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All right, so this is a 36-year-old who presented with infertility.

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I'm going to scroll through the sagittal

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and the axial and then we're going to get our question done right off the bat.

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So, scrolling through on the sagittal

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we have a very a contracted bladder down here.

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We have these extra kind of T2 bright structures

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going on in the anterior compartment.

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Looking at our middle compartment.

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So our uterus is anteverted and not terribly flexed one way or another.

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There are a couple of more homogeneous, very T2 dark structures in the uterus.

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Notice these are a little bit T2 darker

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than the lesion in the myometrium we saw in the last case.

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And then our posterior compartment,

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at least on this sagittal,

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is a bit of a hot mess.

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It's kind of hard to tell what's what.

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So let's look at that on the axial and see

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if we can get a better sense of what's going on.

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Oh, boy.

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Okay, so here's our uterus which is

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in the midline and pushed fairly far anterior in the pelvis by this structure

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and this structure here, which are our ovaries.

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They are touching each other

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in the midline in the back here, kind of displaced.

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And then we have this tethering of the rectum forwards towards the

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ovaries and the uterus by this T2 dark scar tissue here.

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And then we have a little bit of...

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We have another paraovarian or ovarian little cystic lesion down here.

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Okay, so now that we have a lay of the land on the T2 non fat sat images,

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let's pull up a T1 and look at these things side by side.

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And there's a lot of bright stuff on the T1,

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so we're going to have a lot to talk about here.

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So, these adnexal structures are

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T2 dark and T1 bright.

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Okay.

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And we also have a tubular structure in the right adnexa right here,

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that is also T2 dark and T1 bright.

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So we're going to talk a little bit about what that is.

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And then we see little punctate foci of

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T1 hyperintensity amongst all of this T2 dark stuff

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that's happening in the center and causing all this tethering.

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All right. So now that we've pointed out

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all of the findings, but before talking about what all of these

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things are, can we pull up the next question please?

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So which feature of this case implies the highest severity of endometriosis?

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The presence of kissing ovaries,

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the presence of a hematosalpinx, the presence of both deep and superficial

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morphologies or anterior compartment involvement?

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All right, so I got a couple of votes for hematosalpinx

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I got one vote for kissing ovaries

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and one vote for both deep and superficial morphologies.

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So we'll go through all of those answers

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and talk about why one of them was correct.

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So, kissing ovaries is the name given when

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the ovaries are medialized and touching each other, they're kissing.

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The examples that I've shown in this

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lecture have been kissing posterior to the uterus, although they can also be

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displaced anterior and be in a kissing morphology anterior to the uterus.

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So the presence of endometriomas alone won't cause the ovaries to be moved

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in location like this.

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When they're medialized or kissing each other,

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it actually implies that there's deep

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infiltrating endometriosis and scarring of the ovaries together.

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In this case, we also see that there's deep

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infiltrating endometriosis involving the rectum and the uterus.

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So there's kind of no question that there's DIE in this case.

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But you can imagine, if we didn't have DIE

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involving those other organs and all we saw were the medialization of the ovaries,

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when the ovaries are kissing like that, it implies stage three or stage four.

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And that's the surgical staging

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that the gynecologist use, not a radiologic staging system,

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but

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it involves...

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it implies surgical stage three or stage four endometriosis.

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And in fact has an accuracy of 82%

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for diagnosis of stage four endometriosis,

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and a 79% specificity.

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So kissing ovaries imply the highest degree...

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the highest severity of disease because it implies that there is deep infiltrating

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endometriosis obliterating the space between the ovaries.

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Again, going to be very difficult for

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the surgeon to get back into that area laparoscopically.

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This case does feature a hematosalpinx,

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so this tubular structure here in the right adnexa that's T1 bright

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and T2 dark is a blood filled fallopian tube.

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Hematosalpinx is highly suggestive of endometriosis, though is not specific

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for it necessarily.

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In the setting of endometriosis,

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it implies that there is functional tissue

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in the tube itself that is secreting that blood product.

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Although we don't often see

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nodular areas of glandular tissue, we just see the blood.

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This case also shows

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involvement of the round ligaments of the uterus on both sides.

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So, the round ligaments extend from the kind of anterior lateral corners

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of the uterus on both sides and then extend towards the inguinal canal.

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They're a little bit stretched out because

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of the displacement of the uterus,

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although that is, in this case, subtle, but

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example of anterior compartment involvement.

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The round ligaments.

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So here's the round ligament on one side and here's the round ligament on the other.

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That thickened kind of triangular shape.

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If you remember the case that we looked earlier, we were able to see the round

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ligaments but they were very thin T2 hypointense structures.

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That's what they should look like.

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And then finally, we do have a little bit

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of superficial endometriosis as well along the uterine serosa.

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So in this case, we see all three morphologies of endometriosis.

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Endometriomas,

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deep infiltrating

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endometriosis with obliteration of the rectouterine space and kissing

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ovaries, as well as superficial endometriotic implants.

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This is very, very severe disease.

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Very overwhelming case to look at if you

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don't break it down by compartment and by morphology when you dictate.

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These T2 dark, homogeneously T2 dark structures in the uterus are fibroids.

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And I think that was all I needed to say about this case.

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So in the interest of time, I'm going to keep going.