0:01

All right, so I'm going to show you

0:03

another case of a complex ovarian lesion.

0:06

So again, I'll start on the

0:07

sagittal T2-weighted images here.

0:10

So this is an older patient in her 60s.

0:12

So right away on the sagittal images,

0:14

again, they're really good to just get

0:16

a quick overview of what's going on. So

0:19

we can see that the uterus is kind of

0:22

anteverted or just midline in location.

0:25

We can see that there's a low T2 signal mass,

0:29

which is protruding into the endometrium.

0:31

This is probably a subendometrial

0:32

fibroid, just based on the low T2 signal.

0:35

There's a few cervical cystic structures

0:37

here, and you can see that the pelvic

0:40

floor is sagging on this image.

0:43

So instead of being flat

0:45

or concave, it's convex.

0:47

So this patient has a rectocele

0:50

and a cystocele already.

0:52

So the bladder is sagging, the rectum is

0:54

sagging, and the pelvic floor is sagging.

0:56

So obviously these are not the patient's

0:58

most serious problems, but just giving

1:01

you an example of what we can see just on

1:03

a quick overview of the sagittal images.

1:08

So we know that there's obviously some

1:11

really heterogeneous, bizarre-looking mass,

1:14

which we have to now characterize further.

1:17

So now we're going to look at the ovaries.

1:19

So can we find a right ovary?

1:21

Well, I think we can start to see the

1:24

shape of the right ovary here, but

1:26

again, this is a postmenopausal woman,

1:28

so we're not going to see ovaries, but.

1:31

Just based on the location and the size and the

1:34

shape, I think we can safely say that we have

1:37

a normal looking right ovary here, so it's just

1:40

anterior to the external iliac vessels here.

1:45

And here we've got the uterus.

1:47

Now can we see a normal left ovary?

1:50

Let's look, let's just follow the

1:52

ovarian vessels, follow them, follow

1:54

them, follow them, and they kind of

1:56

terminate in this big heterogeneous mass.

1:59

Okay, so I think we can safely say that the left

2:02

ovary is abnormal and enlarged due to this mass.

2:06

So what are the characteristics of this mass?

2:08

Well, it's got very heterogeneous T2 signal.

2:11

We have an area that's low

2:13

T2 signal on the ADC map.

2:15

Also, pretty low signal on the T2-weighted

2:20

images, but kind of intermediate signal on

2:23

the high B-value diffusion-weighted images.

2:26

So that may represent an area of restriction.

2:29

So that's a bit concerning for high cellularity.

2:32

All right, so now I will show you the

2:34

pre- and post-contrast weighted images.

2:36

So bottom left, this is pre-contrast,

2:39

and then bottom right is post-contrast.

2:41

So you can see that there's some enhancement

2:45

of the small locules, and a particular concern

2:48

is the presence of nodular enhancement.

2:52

So that's concerning for an ORADS5 lesion.

2:57

This low T2 signal area that's persistent

2:59

on the multiple sequences may represent

3:02

an area of calcification, but this

3:05

nodular enhancement is pretty worrisome.

3:09

And we've got some more findings here.

3:12

So I'll just show you inversion

3:15

recovery, which I usually obtain

3:18

routinely for my pelvic patients.

3:21

And again, it's very useful to look for

3:23

edema and lymphadenopathy and fluid.

3:26

And then in this case, it's also helpful

3:28

to look at the bone marrow because in this

3:31

patient, we've got some abnormal marrow

3:34

signal here in the right pubic tubercle.

3:38

And then as we scroll more superiorly,

3:40

it looks like there's probably a

3:42

fracture here of the pubic ramus.

3:46

And then we've got some high T2 signal of the

3:49

left sacral ala and the right sacral ala here.

3:56

So let's go back to those post-contrast

3:58

images and take a look at those areas.

4:00

So look at that enhancement of

4:02

the sacral ala bilaterally.

4:04

So probably due to insufficiency

4:06

fractures in this patient, or if she

4:08

had previous radiation therapy, that

4:10

could account for what we're seeing.

4:13

But the pubic ramus, it looks like there's

4:17

definitely a fracture there extending to the

4:19

tubercle, and there's a lot of high signal

4:21

and enhancement of the adjacent musculature.

4:24

So superior and inferior

4:26

pubic rami are both fractured.

4:28

So in this case, we're not sure if this is due

4:30

to metastatic disease with pathologic fractures

4:34

or another etiology, but you definitely have

4:38

your guard up seeing those findings in this

4:40

patient with presumed ovarian malignancy.