Interactive Transcript
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All right, so here is another
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case of complex ovarian masses.
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So again, before we get into the findings, let's
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just take a quick look at the T2-weighted images
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in the sagittal plane, and you can see that the
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endometrial cavity is a little bit distended.
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This is a postmenopausal woman.
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So it looks like there's probably some
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fluid layering there and maybe a bit
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thickened, but we can take our time
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to evaluate that a little bit more.
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For now, let's just focus on the major
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abnormality, which is the presence of these
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bilateral, very, very large ovarian masses.
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And you can see that they're quite
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complex on tissue-weighted images.
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So the one on the left has a rim of low
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T2 signal, there's a lot of high T2 signal
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centrally, and then some peripheral follicles.
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So, in a reproductive-age woman, you know,
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this would actually be a pretty good appearance
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for a potential torsion, which, with the
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high T2 signal centrally, low T2 signal
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peripherally, and a few peripheral follicles.
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But that doesn't really fit our clinical
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presentation here or the patient's
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demographics, and then bilateral would be
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obviously less common for torsion as well.
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So we've got complex lesions in the pelvis.
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We do need to make sure these
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are arising from the ovaries.
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So let's just make sure that
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we don't see normal ovaries.
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So we'll scroll through quickly.
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And I don't see a normal ovary.
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It looks like the ovarian vessels
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are leading right towards this
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mass and probably the same thing.
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Yep.
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On the right side.
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So these are definitely arising from the ovary.
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Okay, so let's just take a look at the other.
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sequences here.
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So I'm going to just scroll through
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the diffusion-weighted images now.
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I'm just moving towards the high
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B-value images, which are here.
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So notice that those nodular areas of low T2
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signal that were involving the peripheral aspect
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of the left ovary, if we look at those on DWI,
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we've got one that's pretty nodular looking.
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And then we've got that whole rim that
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maintains high signal on high B-value
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images and low signal on the ADC map.
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So this is diffusion restriction
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surrounding that rim and in that nodule.
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So this is not great.
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This is not really a good sign for this patient.
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So another finding that is concerning
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for possible malignancy in this patient.
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Okay, so we've got pre- and post-contrast now.
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So on the right, there's enhancement of
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internal cystic areas and some maybe small nodules
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within the lesion and the left-sided mass.
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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.
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So, interestingly, these are bilateral
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ovarian lesions, which look malignant.
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So how common is that to get primary ovarian
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lesions, which are bilateral and malignant?
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It's not impossible.
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So it's probably maybe 10 to 15 percent
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of cases, depending on the pathology.
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But if you have bilateral ovarian lesions,
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you need to also think about other sources.
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So you probably are familiar with
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the term Krukenberg lesions, but that
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term is typically referred to as
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applying to lesions that have landed
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on the ovaries from a source
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elsewhere in the peritoneal cavity.
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And it's usually a GI source.
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So stomach, colon, small bowel, those
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would all be sources for Krukenberg tumors.
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And in this case, you can see that
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the distal sigmoid colon looks
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very thickened and heterogeneous.
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There's some high T2 signal within the wall.
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There's pretty thickened
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enhancement on post-contrast images.
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So normally, the wall of the colon should be
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fairly thin and imperceptible, but we've got
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this long segment area of thickening that
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looks concerning for a possible malignancy.
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And then there are also these little nodules that
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are along the surface of the sigmoid colon,
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which are concerning for peritoneal deposits.
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All right, so we are suspicious that potentially
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there's an abnormality in the sigmoid colon and
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maybe now metastatic disease to the ovaries.
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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
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in the abdomen, there's an NG tube in
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the stomach, there's a lot of dilated
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small bowel, probably due to ileus.
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And we've now resected that
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portion of the sigmoid colon.
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And now we're starting to get into some really
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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
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peritoneal carcinomatosis.
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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.
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So in this case, when you see those bilateral
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ovarian masses and that thickened sigmoid
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colon, you might want to suggest tumor markers
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like CEA, as well as CA 125, to determine if
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there's a GI source for those ovarian lesions.
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