0:01

Okay, so we've seen a few

0:03

patterns of endometriosis.

0:05

So I just wanted to summarize what your

0:08

approach should be when evaluating patients

0:11

with this disease to get maximum yield.

0:13

So firstly, use the compartment model.

0:16

So remember to look at the anterior, the

0:18

middle, and the posterior compartments.

0:21

And then this is what we tend to normally do

0:23

anyway because we're so conditioned to look

0:26

for ovarian lesions or endometriomas.

0:29

And remember that those develop

0:31

because of hemorrhage of variable age.

0:34

And then remember to also look around

0:36

the ovary that Candle wax phenomenon,

0:39

that we saw on the last case.

0:41

And then don't forget to look for extra

0:43

ovarian disease, because this can be the only

0:46

manifestation of a patient with endometriosis

0:49

in a pretty large subset of patients.

0:52

So we want to look at those areas that are

0:54

blind to the laparoscopist, that are visible

0:57

to the radiologist, and this is the value add

1:00

of MRI imaging in patients with endometriosis.

1:03

And.

1:04

Quite specifically, we're looking at the deep

1:06

or solid infiltrative type of endometriosis.

1:09

And in terms of the signal characteristics,

1:11

remember that extra-ovarian manifestations

1:14

of endometriosis usually show fibrosis,

1:17

which shows up as low signal on T2 images.

1:20

You might see a little focus of high T2

1:23

signal, like we saw on the last case as well.

1:26

So just to close off endometriosis, this is an

1:29

example of a patient with extra-ovarian disease.

1:32

So this patient had subcutaneous endometrioma.

1:36

And this is actually not uncommon,

1:38

particularly in patients who've

1:40

had caesarean sections previously.

1:42

So I've seen maybe five or six of these

1:44

now, where the patient has cyclical

1:46

pain and an abdominal wall mass.

1:48

You can see on the CT the right rectus sheath

1:53

is enlarged and has a mass-like appearance.

1:55

And what's kind of neat is that the margins

1:59

of the deposit that's in the subcutaneous

2:01

tissue are very similar to the peritoneal

2:04

deposits that we saw on the last case.

2:06

So you've got this irregular-looking mass

2:08

with angular margins, and it's really the

2:11

history and the MRI signal which gives

2:14

you the diagnosis in this sort of case.

2:16

So you probably will see one of

2:18

these at some point in your career.

2:20

And then finally, another MRI pearl, which

2:23

we talked about earlier, and we saw in one

2:25

of the earlier cases, was that the presence

2:28

of hematocysts should be considered a

2:30

specific finding for pelvic endometriosis.

2:34

So, in about 30 percent of patients

2:36

with endometriosis, we might see dilated

2:40

tubes containing hemorrhagic material,

2:42

like we see in this image here with the

2:44

high T1 signal in the dilated left tube.

2:47

And interestingly, this may be the only

2:50

finding in some women with endometriosis.

2:53

So we really have to be aware of this

2:55

finding and recognize that its presence

2:58

suggests that it's not a disease.

2:59

The diagnosis of endometriosis, even in the

3:01

absence of other findings such as endometriomas.

3:05

Another point to remember is that we may

3:07

not see T2 shading as the endometriotic

3:10

implants are often on the outside

3:12

of the tube rather than inside it.

3:15

So the hemorrhage that you see inside the

3:17

tube is often a reaction to the irritation

3:20

from implants on the outside surface.