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0:01

All right, so here is another

0:02

case of complex ovarian masses.

0:05

So again, before we get into the findings, let's

0:08

just take a quick look at the T2-weighted images

0:10

in the sagittal plane, and you can see that the

0:14

endometrial cavity is a little bit distended.

0:17

This is a postmenopausal woman.

0:19

So it looks like there's probably some

0:21

fluid layering there and maybe a bit

0:23

thickened, but we can take our time

0:25

to evaluate that a little bit more.

0:28

For now, let's just focus on the major

0:30

abnormality, which is the presence of these

0:33

bilateral, very, very large ovarian masses.

0:37

And you can see that they're quite

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complex on tissue-weighted images.

0:41

So the one on the left has a rim of low

0:45

T2 signal, there's a lot of high T2 signal

0:48

centrally, and then some peripheral follicles.

0:50

So, in a reproductive-age woman, you know,

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this would actually be a pretty good appearance

0:57

for a potential torsion, which, with the

0:59

high T2 signal centrally, low T2 signal

1:01

peripherally, and a few peripheral follicles.

1:05

But that doesn't really fit our clinical

1:07

presentation here or the patient's

1:09

demographics, and then bilateral would be

1:12

obviously less common for torsion as well.

1:16

So we've got complex lesions in the pelvis.

1:20

We do need to make sure these

1:21

are arising from the ovaries.

1:22

So let's just make sure that

1:23

we don't see normal ovaries.

1:25

So we'll scroll through quickly.

1:29

And I don't see a normal ovary.

1:30

It looks like the ovarian vessels

1:33

are leading right towards this

1:35

mass and probably the same thing.

1:37

Yep.

1:38

On the right side.

1:38

So these are definitely arising from the ovary.

1:41

Okay, so let's just take a look at the other.

1:45

sequences here.

1:45

So I'm going to just scroll through

1:48

the diffusion-weighted images now.

1:50

I'm just moving towards the high

1:52

B-value images, which are here.

1:54

So notice that those nodular areas of low T2

1:58

signal that were involving the peripheral aspect

2:01

of the left ovary, if we look at those on DWI,

2:05

we've got one that's pretty nodular looking.

2:08

And then we've got that whole rim that

2:10

maintains high signal on high B-value

2:13

images and low signal on the ADC map.

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So this is diffusion restriction

2:18

surrounding that rim and in that nodule.

2:20

So this is not great.

2:21

This is not really a good sign for this patient.

2:25

So another finding that is concerning

2:28

for possible malignancy in this patient.

2:31

Okay, so we've got pre- and post-contrast now.

2:35

So on the right, there's enhancement of

2:39

internal cystic areas and some maybe small nodules

2:44

within the lesion and the left-sided mass.

2:48

Definitely shows nodular enhancement,

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particularly peripherally, and that

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corresponds to the same areas of

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diffusion restriction that we saw before.

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So that's very concerning for malignancy.

3:02

So, interestingly, these are bilateral

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ovarian lesions, which look malignant.

3:07

So how common is that to get primary ovarian

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lesions, which are bilateral and malignant?

3:14

It's not impossible.

3:15

So it's probably maybe 10 to 15 percent

3:19

of cases, depending on the pathology.

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But if you have bilateral ovarian lesions,

3:23

you need to also think about other sources.

3:27

So you probably are familiar with

3:28

the term Krukenberg lesions, but that

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term is typically referred to as

3:32

applying to lesions that have landed

3:36

on the ovaries from a source

3:37

elsewhere in the peritoneal cavity.

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And it's usually a GI source.

3:41

So stomach, colon, small bowel, those

3:45

would all be sources for Krukenberg tumors.

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And in this case, you can see that

3:50

the distal sigmoid colon looks

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very thickened and heterogeneous.

3:55

There's some high T2 signal within the wall.

3:58

There's pretty thickened

4:00

enhancement on post-contrast images.

4:03

So normally, the wall of the colon should be

4:05

fairly thin and imperceptible, but we've got

4:08

this long segment area of thickening that

4:11

looks concerning for a possible malignancy.

4:14

And then there are also these little nodules that

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are along the surface of the sigmoid colon,

4:21

which are concerning for peritoneal deposits.

4:24

All right, so we are suspicious that potentially

4:27

there's an abnormality in the sigmoid colon and

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maybe now metastatic disease to the ovaries.

4:34

Alright, so the patient went to the OR,

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and this is the post-operative scan.

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So you can see there's a lot of fluid

4:44

in the abdomen, there's an NG tube in

4:48

the stomach, there's a lot of dilated

4:50

small bowel, probably due to ileus.

4:54

And we've now resected that

4:55

portion of the sigmoid colon.

4:58

And now we're starting to get into some really

5:00

concerning-looking enhancement along the

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inferior aspect of the extraperitoneal space,

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so pre-vesicle space, and also in the pelvis.

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And that's concerning for

5:14

peritoneal carcinomatosis.

5:15

So this actually was a metastatic tumor of

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the sigmoid colon with diffuse peritoneal

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involvement, peritoneal carcinomatosis, and

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bilateral Krukenberg tumors of the ovary.

5:26

So in this case, when you see those bilateral

5:29

ovarian masses and that thickened sigmoid

5:32

colon, you might want to suggest tumor markers

5:34

like CEA, as well as CA 125, to determine if

5:38

there's a GI source for those ovarian lesions.

Report

Faculty

Zahra Kassam, MD, FRCPC

Associate Professor of Medical Imaging, Division Head of Body Imaging

Western University

Tags

Ovaries

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

CT

Body

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