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

0:39

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,

0:53

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.

2:16

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,

2:50

particularly peripherally, and that

2:53

corresponds to the same areas of

2:55

diffusion restriction that we saw before.

2:58

So that's very concerning for malignancy.

3:02

So, interestingly, these are bilateral

3:05

ovarian lesions, which look malignant.

3:07

So how common is that to get primary ovarian

3:11

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.

3:21

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

3:31

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.

3:40

And it's usually a GI source.

3:41

So stomach, colon, small bowel, those

3:45

would all be sources for Krukenberg tumors.

3:48

And in this case, you can see that

3:50

the distal sigmoid colon looks

3:53

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

4:18

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

4:29

maybe now metastatic disease to the ovaries.

4:34

Alright, so the patient went to the OR,

4:38

and this is the post-operative scan.

4:42

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

5:04

inferior aspect of the extraperitoneal space,

5:09

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

5:13

And that's concerning for

5:14

peritoneal carcinomatosis.

5:15

So this actually was a metastatic tumor of

5:18

the sigmoid colon with diffuse peritoneal

5:21

involvement, peritoneal carcinomatosis, and

5:23

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.