0:01

Our next case is of a 49-year-old female who had

0:03

a pelvic MRI for dysfunctional uterine bleeding.

0:07

Again, T2-weighted imaging is going to be

0:09

really important when you're considering the

0:12

uterus and defining the different structures.

0:14

In this particular patient, there are

0:16

going to be a lot of findings.

0:17

We also have a little bit of

0:18

artifact from respiratory motion.

0:20

So we can see here the endometrium is T2 bright.

0:23

I actually have this sort of outpouching or

0:26

bulging right here at the site of prior C

0:28

section scar that's called an isthmocele.

0:30

We'll see some examples

0:31

of that later in the talk.

0:33

We have some T2-bright Nabothian cysts,

0:35

which are extraordinarily common.

0:37

Okay, and we also have multiple

0:39

classic appearing T2-dark fibroids,

0:41

such as one here, another one here.

0:43

These are myometrial-based.

0:45

Then you have these other additional fibroids.

0:47

This one's a little bit more T2 bright with some

0:49

heterogeneity to it, another fibroid over here,

0:52

and then another T2-bright fibroid, slightly

0:55

heterogeneous, but even brighter than this one.

0:57

So your T2-weighted imaging

0:58

alone is not going to be able to

1:00

necessarily tell you what's going on

1:02

exactly what kind of fibroid

1:03

or degeneration this is.

1:05

You refer back to the chart

1:06

that I showed you earlier.

1:07

So you're going to need a little

1:08

bit more images to consider as well.

1:13

This is your T2 fat sat.

1:14

I'm just going to run through this as well.

1:16

This uterus, you can see your Nabothian

1:18

cyst, your endometrium, and your fibroids.

1:21

And in this one in particular, it

1:22

looks a little bit brighter, right?

1:24

And it has this dark spot now

1:25

in this T2 fat-saturated, right?

1:27

Fat-saturated image right here.

1:30

Generally, when you're thinking about

1:31

your in- and out-of-phase T1 images, which

1:34

what we have down here, this is your India

1:36

ink out-of-phase, in-phase is over here,

1:39

we're thinking mostly for dermoids or

1:41

ovarian masses to look for fatty content.

1:43

But if you're trying to figure out

1:45

what kind of fibroid this is, don't

1:48

neglect your in- and out-of-phase.

1:49

You can see right here, here is our

1:52

indeterminate fibroid right here, which

1:54

is T2 bright and dark signal right here.

1:56

If you look when you're out of phase

1:57

versus in phase, there's very

1:59

clearly a drop in signal right here.

2:02

So this contains macroscopic fat and that

2:04

would make this a lipoleiomyoma as well.

2:07

So this is a lipoleiomyoma on MRI

2:10

on a background of multiple other

2:11

fibroids of different subtypes.

2:14

So a couple more sequences

2:15

here, different views.

2:17

You would need contrast to differentiate the

2:19

other T2 bright or mildly T2 bright fibroid.

2:22

We didn't have that in this particular case.

2:24

But another finding I wanted to point

2:25

out is your thickened junctional zone.

2:27

This is a coronal image, so not the best

2:29

one to measure a junctional zone off of.

2:32

But you also have these T2-bright foci

2:35

out here in the corner in a very poorly

2:37

defined structure, not nearly as well

2:39

defined as this fibroid is over here.

2:41

Here we have another different view.

2:43

This was an open book sequence, again, T2

2:47

bright, and you can see these T2-bright foci in

2:50

this somewhat ill-defined structure right here.

2:52

So this is a little bit of adenomyosis.

2:54

So this patient really does have it all.

2:56

They have a lipoleiomyoma, classic

2:58

fibroids, a little bit of adenomyosis as well.

3:02

And then moving on to the ultrasound

3:04

appearance of the same patient, you

3:06

can see a classic fibroid over here.

3:09

Remember, we're in transverse

3:11

here, so the endometrium is going

3:12

to come out in just a moment.

3:13

It's going to be right here.

3:15

That's what all of this bright signal

3:16

is with increased through-transmission.

3:17

That's the endometrium.

3:19

Get a little bit further down and then we see

3:20

this super echogenic structure right back here.

3:23

Maybe even brighter than the adjacent fat.

3:26

And that's going to be your

3:27

correlate for the lipoleiomyoma.

3:29

So again, this patient has it all.

3:31

We've got our fatty fibroid, our

3:32

classic fibroids, and adenomyosis.