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Hello and welcome to Case Crunch Rapid case review

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for the core exam hosted by modality.

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In this rapid fire format,

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faculty will show key images along

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with a multiple choice question

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and you'll respond with your best answer via

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the live polling feature.

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After a quick answer explanation, it's on to the next case.

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You'll be able to access a recording of today's case review

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and previous case reviews

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by creating a free account using the

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link provided in the chat.

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Today. We are honored to welcome Dr. Aaron Gomez

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for a GU Imaging Board prep case review.

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Dr. Gomez is an assistant professor

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of radiology in the Russell H. Morgan Department

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of Radiology and Radiological Science at Johns Hopkins.

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She serves as a director

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of the Diagnostic Radiology

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Residency Program at Johns Hopkins.

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And her academic interests include medical student

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and resident education fundamentals

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and clinical applications of MRI physics

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and cross-sectional imaging of the female pelvis

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with a focus on high risk OB imaging

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and MRE evaluation of the placenta.

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Questions will be covered at the end if time allows,

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so please remember to use that q

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and a feature to submit your questions.

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With that, we are ready to begin today's board review.

1:08

Dr. Gomez, please take it from here.

1:10

Thanks so much for having me.

1:12

I'm happy to be here with you all this evening.

1:14

Um, again, my name's Erin Gomez

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and I'm at Johns Hopkins in Baltimore

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and tonight we'll be doing a geno urinary board review.

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So let's get right into it. A few rules of play.

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Again, the multiple choice questions are

1:25

for everyone via the poll.

1:27

We are going to move quickly so we can do

1:29

as many cases as possible.

1:31

The other thing I wanna say is I know

1:33

that you're all in sort of the delicate

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and vulnerable time preparing for the core exam.

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This is a safe space.

1:38

I am judging no one and you are strong and smart

1:41

and you are going to do great.

1:43

Um, I have nothing to disclose a couple of pointers for you

1:47

as you approach questions that you may see on the core exam

1:51

or core practice questions.

1:52

Look at the anatomy or the anatomic relationships

1:55

that you're seeing normal.

1:57

They may ask you questions about what signal characteristic

2:00

or finding makes X, Y, Z the most likely diagnosis.

2:03

What explains the finding?

2:05

Are there imaging features, um, that you can use

2:07

that are typical of a specific disease entity?

2:11

Other questions may focus on next steps.

2:14

What imaging sequence or maneuver should you perform

2:17

after what you have seen?

2:19

What would help differentiate the disease entity

2:22

that you're seeing from a similar

2:23

or slightly different condition?

2:25

What's the physics behind the finding?

2:27

There is physics behind every corner on this exam.

2:30

And so, um, they may ask you questions about

2:33

how would manipulate certain imaging

2:34

factors change the image?

2:36

How was the image produced?

2:38

Um, what signal characteristics

2:40

or characteristics of the findings have produced

2:42

this because of physics?

2:44

And then last

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but not least, if you get into a situation

2:47

where you're like, I have no idea

2:49

what this is, describe it to yourself.

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First, start listing off the imaging features

2:53

and that may help you eliminate a few answer choices.

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Alright, let's start with a few softballs, you got this.

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So this is warmup. Question number one, who's this guy?

3:16

Alright, well done. You all crushed that one.

3:18

The answer is indeed Mario.

3:20

I hope I'm not dating myself too much with this question.

3:33

All right, well done. So the answer here is bye bye bye.

3:36

This is in sync. I'm glad that I live to fight another year.

3:40

Warmup question number three.

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Okay, excellent. And you nailed this one.

3:52

It is indeed the goat the greatest of all times.

3:55

Last warmup question,

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and this is just so we can get to know who you are, uh,

3:59

and what type of audience we have here this evening.

4:09

Okay, looks like most of you are residents, a few attendings

4:12

and some folks who are just here for the cases.

4:14

Alright, now for the real deal, here's our first case

4:17

as a 29-year-old status post DNC for a molar pregnancy

4:21

with persistently elevated HCG.

4:23

She is not having any vaginal bleeding.

4:26

We have axial and sagittal contrast, enhanced CT images

4:29

of the pelvis as well as a coronal CT chest.

4:32

What is the most likely diagnosis for this patient?

4:42

Great and far and away, the majority

4:43

of you have selected the correct answer choice,

4:45

which is a gestational trophoblastic neoplasm.

4:48

Um, specifically for this patient,

4:51

we would be most worried about a choriocarcinoma.

4:53

There's an enhancing endometrial mass in this patient

4:57

with a known mole and a persistently elevated beta HCG.

5:00

We would be thinking about gestational trophoblastic disease

5:03

in general, but given the presence

5:05

of the lung nodules which are rounded peripheral, uh,

5:08

and look metastatic, we have

5:10

to think about gestational trophoblastic neoplasm.

5:13

This is a follow-up question about GTN, which

5:16

of the following is true?

5:24

Okay, and it looks like we are split between uh,

5:29

answers A and B.

5:30

The correct answer here is A,

5:32

so choriocarcinoma develops more frequently

5:35

in complete moles.

5:36

And the thing that you should remember is that in general

5:39

complete moles, um, are going to confer a much higher risk

5:43

of both invasive mole

5:44

and choriocarcinoma than a partial mole.

5:47

The treatment for gestational hypoblastic disease,

5:49

as we know, is suction DNC

5:51

and then following the beta HCDG to zero.

5:55

Um, but the complications of invasive mole

5:57

and choriocarcinoma happen happen much more frequently in

6:01

complete mole, uh, than impartial mole.

6:04

Next case, this is a 54-year-old

6:06

with a palpable scrotal mass.

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We have color ultrasound images of the right testicle,

6:14

uh, and inferior to the right testicle.

6:17

What is the next best course of action for this patient?

6:28

Okay, the majority of you,

6:30

a little less than half have said D,

6:32

which is the correct answer, MRI

6:34

to further characterize a para testicular mass.

6:36

So if we look at these images, this is the right testicle.

6:40

It's relatively homogeneous in its heterogeneous feed.

6:42

It has normal flow.

6:44

There's a para testicular mass, it's rounded,

6:46

it has a little bit of internal vascularity

6:49

and peripheral flow within it,

6:51

and it's slightly heterogeneous.

6:52

So this is a para testicular lesion.

6:55

Um, this is, uh, the vascularity eliminates the possibility

6:58

of a scrotal hematoma.

7:00

Um, a seminoma would be within the testicle rather

7:03

than adjacent to it.

7:05

A para testicular abscess should not have this solid

7:07

appearance and this degree of internal vascularity.

7:11

And similarly, a testicular infarct should be intra

7:14

testicular rather than para testicular.

7:16

So here are the MR images.

7:18

Um, so these are axial T one weighted images

7:21

and axial T two weighted images at the level of the testes

7:25

and then inferior to the right testes.

7:28

What is the diagnosis?

7:36

Okay, we're all over the place here.

7:38

I don't think there is a clear winner.

7:40

Um, but if we take a look at these images,

7:43

the imaging characteristics, the signal intensity on T one,

7:46

we almo, it almost looks like we're looking at the right

7:49

testicle duplicated here on this more inferior image.

7:52

So this is the right testicle and this is the lesion.

7:54

This is the right testicle, this is the lesion.

7:56

It's slightly T two heterogeneous, but

7:58

otherwise it's the same size, shape,

8:01

and signal intensity as the other testicles.

8:03

And that's just because this is a testicle.

8:05

This is a case of supernumerary testis poly organism

8:09

or supernumerary testis.

8:10

This is a rare congenital anomaly.

8:12

It's when you have more than one testis.

8:14

These are most often located in the scrotum,

8:17

but they can also be within the inguinal canal,

8:19

the retroperitoneum or the abdomen.

8:22

The most common complication

8:23

of this condition is testicular torsion.

8:26

And these are classified based on whether they communicate

8:29

with a ductus deference.

8:31

So type A, which is the most common type of supernumerary.

8:34

Testis is drained by a separate ductus

8:36

and those patients have reproductive potential.

8:39

And then type B uh, is not drained by ductus deens

8:42

and has no reproductive potential.

8:46

Next case, this is a patient with elevated PSA

8:49

and I'm showing you an axial T two weighted

8:51

image of the pelvis.

8:54

Here are some additional images for you.

8:56

This is diffusion weighted imaging, A DC.

8:58

I've put an ROI on here. The average A DC value is 572.

9:02

And then this is a T one post contrast image.

9:08

So which of the following sequences is the most important in

9:11

the PY rads categorization of this lesion?

9:21

All right, the majority has it.

9:23

The answer here is diffusion weighted imaging.

9:25

Um, this was a peripheral zone lesion.

9:28

Remember that we are favoring diffusion weighted imaging

9:31

for lesions in the peripheral zone

9:33

and then we use the T two weighted images

9:35

to drive the pyre scoring

9:37

for lesions in the transition zone in patients

9:40

with suspected prostate cancer.

9:43

Case four, this is a 25-year-old with amenorrhea.

9:47

We have axial on top

9:48

and coronal T two weighted images of the pelvis.

9:53

What's the diagnosis for this patient?

10:02

Okay, the majority of y'all have voted

10:05

for uterine aid genesis, um, and that's a decent guess

10:09

because this patient's uterus is very small.

10:12

But the answer here is pan hypopituitarism.

10:15

So if we look between the urinary bladder,

10:17

which is here anteriorly

10:18

and the rectum, which is here posteriorly,

10:20

there's small amount of pelvic free fluid

10:22

and then there's a very, very tiny uterus here.

10:25

This is the myometrium

10:26

and this is the T two bright endometrial cavity on this

10:29

coronal T two weighted image.

10:30

There are small ovaries, uh, out here later

10:32

and laterally in the pelvis.

10:34

In patients with turner syndrome, which is

10:36

otherwise known as xo, patients will be described

10:38

as having straight gonads.

10:40

These are often undetectable by medical imaging.

10:42

So the fact that we can see small ovaries

10:45

and a uterus, um, makes Turner syndrome less likely, uh,

10:48

because we are able to identify a small uterus.

10:52

Uterine agenesis is not the right answer.

10:55

A patient with vaginal stenosis, we would expect

10:57

to see distension of the endometrial cavity

11:00

with accumulated contents and debris.

11:03

And then because these, uh, gonads

11:06

and the uterus are so small, they are not normal for age.

11:08

So this is a patient with pan hypo pittu.

11:12

Next case, this is a patient with pain and recent trauma

11:15

and I can tell you that this is a scrotal ultrasound

11:19

race scale image.

11:24

These are accompanying color doppler

11:26

images for the same patient.

11:29

This is the right testicle and this is the left.

11:34

Which feature is most suggestive

11:36

of testicular rupture for this patient?

11:45

Excellent. The bees have it.

11:47

So disruption of the tunica is going to be most suggestive

11:51

of testicular rupture.

11:52

Certainly a heterogeneous architecture, a history of trauma,

11:55

and even adjacent hydro seal.

11:57

Those can all give you clues

11:59

that the patient may have a testicular rupture

12:01

with accompanying hypoperfusion or infarct.

12:04

Um, but it's disruption of the tunica.

12:06

That is the definitive imaging finding for this condition.

12:11

Next case, this is a companion case.

12:13

This is a, uh, 30 5-year-old with scrotal and inguinal pain.

12:18

We have a color image of the testicles with level

12:21

of the midline scrotum as well as a spectral doppler image

12:25

of the left testicle.

12:32

Here's an additional image.

12:33

This is the left epidermal head on color imaging.

12:41

This is uh, gray scale.

12:43

These are gray scale and color, uh, images of a structure

12:48

that is superior to the left testis.

12:54

And this is an accompanying CT image.

12:57

So what is the

13:01

diagnosis for this patient?

13:10

Okay, so the, the largest number of votes were

13:13

for vascular malformation.

13:15

The answer here is panniculitis

13:16

and I'm proud of the 15 of you, uh,

13:18

who chose this as an answer.

13:20

Um, so panniculitis is inflammation

13:22

or infection of the spermatic cord.

13:24

And this can happen in severe cases of epididymitis

13:28

as we have with this patient.

13:30

Um, testicular lymphoma, uh, the um, involvement

13:34

of this spermatic cord and EPIs,

13:35

this looks more infectious inflammatory.

13:38

Um, often folks will guess intraoral hernia for this case,

13:41

but because we show, uh, both on those gray scale images

13:44

as well as the ct, that this is indeed the cord panniculitis

13:47

is the correct answer.

13:50

Okay, we have a two part question here.

13:52

We have axial T two fat saturated images

13:56

of the pelvis at the level of the perineum.

13:59

Which structures are highlighted by the white arrows here?

14:03

So this one is slightly uh, superior.

14:07

This one is slightly inferior.

14:09

They've gotten one slice down.

14:19

Okay, well done. The answer here is indeed the

14:22

URA of the clitoris.

14:23

So these are paired

14:24

and they will join together to form the body

14:27

and glands of the clitoris.

14:28

And so my follow-up question

14:30

for you is which structures are highlighted

14:31

by the pink arrows?

14:40

Okay, the majority has it here as well.

14:42

The answer here is the vestibular bulbs.

14:44

Um, so just a quick review of the anatomy of the clitoris.

14:48

Uh, the clitoris, um, has a glands in a body

14:52

and then these paired ura, uh, which come out laterally.

14:55

And this is the erectile tissue of the clitoris.

14:58

And if we see it in cross-section, we can see

15:00

that there's kind this kind of spongy tissue internally.

15:03

And then the vestibular bulbs, this is glandular tissue

15:05

and this kind of drapes around the vaginal orifice.

15:08

Um, and so uh, within here, uh, there's more less spongy,

15:12

less uh, less spongy

15:15

and less vascular tissue that participates in uh, secretion

15:19

and lubrication of the vagina.

15:22

This is a companion case.

15:23

This is a 68-year-old woman

15:25

with clitoral pain and enlargement.

15:27

We have T two weighted images, T one post contrast images,

15:31

a sagittal T two fat sat image

15:32

and diffusion weighted images at the level of the perineum.

15:35

What is the most likely diagnosis for this patient?

15:46

Okay, excellent. So the majority

15:48

of you had gotten the correct answer,

15:49

which is D equatorial hood abscess.

15:51

So this is a T two hyperintense lesion.

15:53

We can see that on the axial and the sagittal image.

15:56

This is the glands of the clitoris here.

15:59

Um, we can see that the image demonstrates

16:01

peripheral enhancement.

16:02

There are a few reactive lymph nodes here in the groin on

16:05

the T one post contrast

16:07

and there's diffusion restriction uh,

16:09

within this lesion which is most consistent with an abscess.

16:13

Next case, this is a 36-year-old with an adnexal mass

16:17

that was first noted on ultrasound

16:20

and um, there is a lesion here in the pelvis.

16:24

What accounts for the appearance of this lesion?

16:27

So there is physics behind every corner.

16:37

Okay, sort of mixed answers here.

16:40

The first step in this question is finding the lesion,

16:42

which is here, right?

16:44

It's this anteriorly located pelvic lesion.

16:46

It's T two hyperintense and T one hypo intense.

16:50

Um, and so this uh, the um, the

16:56

material making up this lesion would have a long T one time,

16:59

which makes it T one dark

17:01

but also a long T two time,

17:02

which makes it T two bright, right?

17:04

So a short T one relaxation time makes things bright.

17:07

That's stuff like gadolinium which results in T one

17:10

shortening and then a long T two relaxation time results in

17:13

things looking bright on T two weighted imaging.

17:15

So whatever the contents

17:16

of this lesion aren't has a long T one relaxation time

17:19

and a long T two relaxation time.

17:21

So what is the best diagnosis here?

17:30

Okay, the votes are for right ovarian cyst.

17:33

Um, and that is the not a the correct answer.

17:36

The the answer here is actually an appendiceal mus

17:39

appendic mucus, excuse me.

17:42

Um, so the ovaries are both shown here

17:44

and this lesion is independent of the ovaries.

17:46

So this is not a right ovarian cyst.

17:49

Similarly, the T one dark appearance makes this less likely

17:52

an endometrioma.

17:54

While this could be a tors uterine fibroid, it is

17:57

so homogeneously T two hyperintense, it would be unlikely

18:01

that this was a degenerated and tors fibroid.

18:04

And then hydro seines,

18:05

this is not really in the right location.

18:07

This is anterior to the uterus

18:09

and the tubes should be seen here lateral

18:11

and extending toward uh, the ovaries.

18:14

And so, um, for this patient, uh,

18:16

if I gave you a scrollable stack, you would see

18:18

that there was a thin isus connecting this up to the cecum

18:21

and this was an appendiceal mucus seal.

18:25

Next question. This is a patient status post

18:28

low anterior resection.

18:29

We were asked to evaluate for a leak at the anastomosis

18:33

by fluoroscopy.

18:34

So in fluoroscopy tissue contrast is generated by what type

18:39

of interaction.

18:45

And these questions can be frustrating on the core

18:47

because you'll see this and you may know the answer

18:49

clinically and then you go to physics question.

18:52

Um, but don't dismay.

18:53

Uh, you have to ask yourself what type

18:55

of images am I looking at?

18:57

How was this image formed? And that can get you a long way.

19:02

So the majority of you have said photo electric effect,

19:05

which is the correct answer.

19:07

Now we'll have the satisfaction

19:10

of the diagnosis which abnormality is present.

19:20

Okay, well done. The majority

19:22

of you have said rectovaginal fistula

19:24

and that's the correct answer here.

19:25

So this is the catheter we have administered radiopaque

19:28

contrast via the rectum and the anastomosis.

19:31

It's somewhere in here we can see the

19:34

a**l rectal anastomosis.

19:36

There is this outpouching along the posterior aspect

19:38

of the rectum and a tract

19:40

that extends all the way toward a triangular structure uh,

19:44

that extends down toward the perineum.

19:46

And so this is a fistulas tract

19:48

that's extending from the rectum to the forex of the vagina.

19:51

And then this is the vagina pacifying with contrast.

19:54

So this is indeed a patient with a rectovaginal fistula.

19:58

Next case, this is a patient with pelvic pain.

20:01

We have a gray scale ultrasound image

20:05

transvaginal based on the shape of the probe

20:07

and this is an image of the left ovary.

20:09

Here is the color image.

20:15

So my question for you is this patient is 33 years old,

20:19

the lesion in the previous images,

20:20

which will give you one more look at that color image.

20:23

I feel like I clicked away a little quickly.

20:26

The lesion in the previous image is 6.5 centimeters

20:29

and the patient is 33.

20:31

What should you do with regards to this lesion

20:36

you are reporting?

20:45

Okay, so we're sort of split here.

20:47

Um, folks have said follow up in six to 12 weeks,

20:51

recommend pelvic MRI or surgical consultation.

20:53

So let's go back to the appearance of the lesion, right?

20:55

Um, it is a relatively heterogeneous lesion.

20:59

There are some low level internal echoes within the lesion

21:03

and then there are some epigenic project which are avascular

21:08

on the color imaging.

21:09

So when I'm looking at this lesion, there are a couple

21:11

of things in my differential.

21:13

This looks like it has some kind

21:15

of hemorrhagic component to it.

21:17

So I'm thinking about um, a hemorrhagic cyst.

21:20

I'm thinking about an endometrioma with a retracted clot.

21:23

Those would be the most common things in this young patient.

21:27

But this certainly also could be

21:30

a hemorrhagic ovarian mass.

21:32

And the vascular components

21:34

of the lesion are obscured by hemorrhage.

21:35

But because the patient is young

21:37

and hemorrhagic cysts are common, we're going

21:39

to give her the benefit of the doubt

21:41

and have her follow up in six to 12 weeks.

21:44

Now what if the patient were 68 years old

21:46

presenting with the same lesion?

21:55

Okay, good. So the majority

21:57

of you have said either recommend pelvic MRI

22:00

or surgical consultation, um,

22:02

and surgical consultation uh, is the answer here.

22:05

You certainly could start with a pelvic MRI

22:07

but this is a big lesion.

22:08

This is going to come out.

22:10

Um, this patient is 68, uh,

22:12

should no longer be menstruating,

22:14

should no longer be having menstrual cycles

22:17

and so the possibility of a hemorrhagic cyst

22:19

or an endometrioma is much less likely.

22:21

This is far and away more likely a hemorrhagic ovarian mass.

22:24

And this requires surgical consultation

22:26

because this needs to come out.

22:29

Next case, this is a patient with pelvic pain

22:32

and vaginal bleeding.

22:34

I have provided you with sagittal T one post contrast images

22:38

of the pelvis as well as DWI with accompanying A DC images.

22:45

I'll give you a second to take a look at those.

22:52

Which feature present on these images of a patient

22:55

with cervical cancer qualifies as T four disease.

23:08

Okay, excellent. So the majority

23:09

of you have said bladder invasion and that is true.

23:12

Um, so cervical cancer, uh, the staging um,

23:17

feels counterintuitive in some cases

23:20

but um, when the disease is confined

23:22

to the cervix you still have a T one tumor

23:25

and then distinguishing TT two from T three disease depends

23:29

on which portion of the vagina if any is involved.

23:32

So upper one third of the vagina close to the cervix,

23:35

that's gonna be a T two tumor.

23:37

Lower one third of the vagina extending

23:39

further away from the cervix.

23:40

That's gonna be T three abutting.

23:43

The pelvic sidewall is a T three B,

23:45

but once you have gone on to invade the bladder

23:48

and um, local regional pelvic organ organs,

23:51

that is T four disease.

23:53

Well done. K 13.

23:56

What type of study has been performed here?

24:01

It's certainly a PET ct, I'll give you that.

24:03

Um, but you will be asked on the core exam to distinguish

24:06

between different types

24:07

of nuclear medicine studies including different PET cts.

24:11

So tell me what we've done here.

24:20

Okay, uh, we have sort of a split crowd between FDG pet CT

24:25

PFMA PET CT and gallium 68 Dotatate PET ct.

24:29

So that's good, right? You eliminated some choices.

24:32

So none of you said sodium fluoride PET

24:34

or copper dotatate pet.

24:36

Um, the answer here is A-P-S-M-A PET CT

24:38

and the way we can tell um,

24:40

is this intense uptake in the salivary glands.

24:43

And then I've given you the clue

24:44

of extensive retroperitoneal

24:46

lymphadenopathy here in this patient.

24:48

Um, with prostate cancer,

24:51

a gallium 68 Dotatate PET ct.

24:54

Um, we should see uptake in the liver

24:56

but also in the pancreas there is mild salivary gland uptake

25:01

in a gallium 68 dotatate scan,

25:03

but it should not be as intense as what we see

25:05

with A-P-S-M-A PET ct.

25:06

Sodium fluoride PET ct, I didn't trick any of you.

25:09

This is for bone lesions.

25:11

Um, and then a copper, uh, 64 dotatate PET ct.

25:15

We should see increased uptake in the spleen.

25:17

Uh, for those next case case 14,

25:22

what is the most likely diagnosis I

25:26

provided you with T one weighted images,

25:28

T one post contrast images

25:30

and T two weighted images of the upper abdomen.

25:42

Okay, um, so the votes here are split between renal lymphoma

25:46

and perinephric hematoma

25:48

and the answer here is renal lymphoma.

25:50

Um, so we have a little bit of uh, low level enhancement.

25:54

It's homogeneous within this crescentic perinephric lesion.

25:58

Um, I would expect

25:59

to see a little bit more intrinsic T one hyperintensity

26:03

perhaps and a little less enhancement in

26:05

a perinephric hematoma.

26:07

Um, we uh, would expect this lesion to be T two hyperintense

26:11

with it if it were a oma.

26:13

Um, this is not the correct look for a putty kidney, uh,

26:16

nor a urothelial carcinoma, the latter

26:18

of which should be more centrally located within the kidney.

26:21

Uh, so this is a case of renal lymphoma.

26:24

Specifically this was a diffuse large B cell

26:27

lymphoma case 15.

26:31

I have provided you with axial post contrast CT images

26:36

of the pelvis and a coronal uh, post contrast CT as well.

26:40

I'll give you a moment to take that in.

26:50

And here is your question.

26:53

What is the most common type of malignant ovarian tumor?

27:00

Sometimes the questions that you'll be presented

27:02

with on the core, you'll see a case

27:04

and you're trying to take in all of the findings

27:06

and then the question is, uh,

27:08

a fact check and this is one of those.

27:16

Okay, great. The most common common type

27:18

of malignant ovarian tumor is indeed

27:20

serous cyst adenocarcinoma.

27:22

This is an easy way to accumulate some points for yourself,

27:25

uh, by memorizing the most common types of malignancies.

27:31

K 16, in addition to there being physics

27:33

behind every corner on this exam, there is anatomy

27:36

behind every corner.

27:37

So the uterine arteries arise from which vessel I've given

27:41

you a coronal CTA MIP of the abdomen and pelvis.

27:53

Okay, excellent. So the uterine arteries indeed arise from

27:56

the anterior division of the internal iliac arteries.

27:59

Um, when you are evaluating the uterine arteries,

28:03

you can look for the bifurcation of the iliacs

28:06

and then the anterior division will send these tiny kind

28:09

of corkscrew branches, um, out toward the uterus.

28:12

They make this characteristic hair pin turn in the pelvis

28:17

before heading to the uterine body.

28:19

So when you see this characteristic hair pin turn, um,

28:23

in a vessel arising from the anterior division

28:25

of the internal iliac arteries,

28:26

these are the uterine case 17.

28:31

This is a premenopausal patient

28:33

with abdominal pain and vaginal bleeding.

28:36

She went to her OB GYN

28:37

and had a vaginal mass on physical exam.

28:41

These are T one post contrast images of the pelvis.

28:44

This is an axial T two weighted image

28:46

and this is a sagittal T two weighted image.

28:49

Um, and I forgot to mention at the beginning

28:50

of this lecture, I know it was on my slide,

28:52

but I'm also faculty for the GU division of the A IRP

28:55

and this is an A IRP case.

28:57

So shout out, um, to my GU division there,

29:02

what is the best diagnosis for this patient?

29:12

Okay, so we're kind of tied between uterine CIA

29:15

and malignant uterine inversion.

29:17

So let's go back to the images right.

29:19

So indeed the uterus is abnormally configured here, right?

29:23

This is the vagina

29:24

and it is encompassing the

29:28

uterus which is inverted on itself.

29:31

So this is the fundus of the uterus and,

29:32

and the uterus is kind of uh, invaginated inward.

29:36

And if we look at the post contrast images, um,

29:39

there's this really heterogeneously enhancing irregular

29:45

a lesion present within the endometrial cavity.

29:47

It's more difficult to appreciate um,

29:50

the T two weighted images,

29:51

but this is indeed a case of malignant uterine inversion.

29:55

For those of you who said dementia, I like the way

29:58

that you're thinking uterine dementia is the most severe

30:02

form of pelvic organ prolapse in which the uterus,

30:07

um, completely exits the vagina, uh,

30:10

and protrudes from the vaginal orifice.

30:13

So if we go back to the T two weighted image here, um,

30:15

even though the uterus is within the vagina,

30:18

it has not protruded from the inus,

30:20

you'll typically see the uterus extending below the level

30:23

of the perineum in patients with true complete proa.

30:28

These are the path images for this patient.

30:30

This ended up being an undifferentiated

30:33

endometrial carcinoma.

30:34

We can also see the ovaries

30:36

and tubes, um, kind of stuck

30:38

to the uterus here in this image.

30:40

And then this is the lesion, uh,

30:41

and we can see that on the histopath.

30:43

There's infiltrating tumor here, uh, which is um,

30:47

involving the cervix.

30:50

My next patient has constipation, diarrhea,

30:53

and unintentional weight loss.

30:55

And I've provided you with statal

30:57

and coronal CT images with friendly arrow signs, uh, as well

31:01

as an axial CT post contrast image.

31:04

So I'll give you a moment to take a look.

31:15

What is the least likely clinical history for this patient?

31:18

Um, I will encourage you to read carefully, right?

31:20

So sometimes they'll try to get you with these,

31:22

which is the least likely answer, just be careful.

31:25

Um, it's sort of it taboo

31:27

or maybe a little poor form to write questions that say

31:29

what is the least likely?

31:30

Um, but that is the question here.

31:32

And you may see these, uh, even though they are supposed

31:35

to show you fewer of those.

31:37

So what is the least likely clinical

31:41

history for this patient?

31:48

Okay, good. Yes, exactly. You did it.

31:51

So the answer here is stigmata of prior lymph angiogram.

31:53

That's the thing that this would not be right.

31:56

So let's go back. This patient has an enlarged uterus.

31:59

There is a big mamma fibroid here in the uterine body

32:02

and there are all of these partially calcified soft tissue

32:05

masses in the end, in the per in the peritoneal cavity, um,

32:10

predominantly involving the anterior

32:12

abdomen and the omentum.

32:14

So when you see a calcified peritoneal lesions, you have

32:17

to think about things like treated malignancy

32:19

that would include both lymph nodes in the setting

32:21

of lymphoma or peritoneal implants like in a patient had a

32:25

who had ovarian cancer.

32:27

Um, you could also have treated infectious

32:30

or inflammatory conditions like tuberculous peritonitis.

32:33

What this patient had previously was more more ation

32:37

of uterine fibroids.

32:38

Morcellation was a technique for the removal

32:41

of uterine fibroids that was very in vogue in the 2010s

32:45

and early two thousands

32:46

where they would use a little machine

32:48

to grind up uterine fibroids instead of um, resecting larger

32:52

for fibroids through a bigger incision in the abdomen.

32:54

The morcellator unfortunately, um,

32:57

would often drop little pieces

32:59

of the fibroids into the per into the peritoneal cavity

33:02

and these can set up their own supply

33:03

and become little parasitic or metastatic omata.

33:07

A lymph angiogram would not give us

33:09

this distribution of hyper density.

33:11

We would expect to see um,

33:13

hyper density along the lymphatic channels.

33:16

Most commonly you see this in the retroperitoneum

33:18

or the thoracic duct Sker Kylie regions.

33:23

So this was a patient with disseminated peritoneal al

33:26

mytosis and these are the histopath specimens.

33:29

We can see all of this studying with these numerous omental

33:32

and uterine Oma implants.

33:35

Case 19. This is a 71-year-old with palpable labial masses.

33:40

We have gray scale and color ultrasound images

33:44

of the labia bilaterally

33:48

and we are at the level of the vaginal introitus.

33:53

Which of the following additional findings would indicate

33:57

benignity of this lesion?

34:06

Great. Um, so slow flow within the lesions is

34:09

the correct answer here.

34:11

Um, so these are labial varis

34:14

and what I'm not showing you here is a cine clip

34:16

where we can almost see like a ru low sign, um, accumulating

34:20

uh, red blood cells and very slow flowing blood

34:23

within these lesions.

34:24

Um, if we saw regional adenopathy

34:27

or a surgical a cervical lesion,

34:28

we would be thinking about metastatic malignancy If we saw

34:32

soft tissue nodularity within this lesion

34:35

or had it really rapidly grown, um,

34:37

we would also be thinking about a malignant labial lesion,

34:41

um, but slow flow within the lesion that implies that

34:44

that is a benign vascular finding

34:45

and this is indeed labial varis.

34:48

This patient went on to have embolization

34:50

with interventional radiology

34:51

and had resolution of the masses and her symptoms.

34:55

Case 20. This is a patient with intermittent pelvic pain

34:58

and a pelvic mass who presented

35:00

with acute severe abdominal pain.

35:02

This is another A IRP case

35:04

and I have shown you a coronal CT image as well as

35:09

sagittal T two and T one post contrast images

35:12

of the abdomen and pelvis.

35:14

And I have given you handy dandy aero signs

35:17

for this case as well.

35:21

Diagnosis bleeds.

35:30

Okay, and the majority

35:31

of you have said uterine torsion which is

35:33

the correct answer here.

35:34

Um, this is the gross path specimen for this patient.

35:37

Um, you can see the engorged

35:40

and tortuous uh vessels here surrounding the uterus

35:43

and this patient had a 24 centimeter OMA which was the

35:47

lead point for the torsion.

35:48

We can see swirling of the vessels, um, both here on the CT

35:52

and on the T two

35:54

and there's a relative lack of enhancement, um,

35:56

of the uterus and the fibroid on the post contrast images

36:01

case 21, we have an axial

36:06

CT image of the pelvis.

36:11

Here's the accompanying ultrasound image

36:18

diagnosis please.

36:26

Okay, so the answer here is a lipo leiomyoma

36:29

and the majority of you got this.

36:30

We go back to the ct.

36:32

This is a fat containing lesion within the uterus.

36:35

Um, and when we go to the ultrasound image, it's confirmed

36:39

as intrauterine because the image is labeled sagittal uterus

36:42

and we see this, uh, intensely uniformly echogenic uh,

36:46

intrauterine lesion and fat is bright on ultrasound.

36:50

So this is a lipo leiomyoma which is a benign fatty variant

36:55

of uterine fibroids case 22.

36:58

This is a 33-year-old patient status post recent C-section.

37:01

She had an atonic uterus after delivery

37:04

and that required uterine artery embolization.

37:07

She is now coming in with abdominal pain

37:10

and thick dark vaginal discharge.

37:12

We have axial CT images of the pelvis.

37:15

There is contrast on board here

37:18

and then a gray scale transabdominal uh, image

37:21

of the uterus on ultrasound

37:28

here are accompanying MR images for this patient.

37:32

Here is a sagittal T two weighted image.

37:35

We also have a T one post subtraction image as well as

37:40

a standard axial T one post.

37:45

What is the diagnosis for this patient?

37:54

Okay, sort of all over the board here,

37:56

but the answers that got the two, the two answers

37:58

that got the most votes are uterine infarction

38:01

and endometritis and this is a case of uterine infarction.

38:05

Um, so this patient ended up undergoing a hysterectomy.

38:10

Uterine infarction is one of the rarest complications

38:12

of uterine artery embolization.

38:14

Um, it happens very, very infrequently, uh,

38:17

but unfortunately that was the case for this patient

38:20

and for those of you asking, well why not endo metritis,

38:24

it is the global lack of enhancement here within the uterus.

38:28

Um, on the post contrast images that make the diagnosis

38:31

of uterine infarction the answer here, it is okay

38:34

to have a small amount of gas

38:36

and blood products within the endometrial cavity following

38:39

vaginal or cesarean delivery.

38:41

Um, but unfortunately it's the global hypo enhancement

38:43

that makes infarction the, I'm sorry.

38:46

Next question. We have sagittal T two weighted images

38:50

of the pelvis, uh, for a patient with pelvic floor laxity,

38:53

in which of the following images

38:56

is the PCL drawn correctly?

39:07

Okay, we have votes for A and for B

39:11

and the answer here is B.

39:13

So the PCL

39:14

or pubal cidal line, it's a line

39:17

that we use when we are evaluating MRI of patients

39:20

with pelvic floor dysfunction and pelvic floor laxity.

39:24

This study is a dynamic pelvis, MRI sometimes also called uh

39:29

uh Mr Defecography.

39:31

And the way that you draw the pubic cidal line is you go

39:33

from the inferior aspect of the pubic synthesis

39:36

to the last cidal joint.

39:39

So, uh, image A shows the line at the tip of the coccyx,

39:44

but it's the last cidal joint that you wanna extend the line

39:48

to when you're drawing the PCL.

39:51

Page 24. Which of the following properties

39:55

of the labeled region accounts for its T two signal?

39:58

And we should be pointing here,

40:02

the arrow is a little misplaced

40:03

but should be pointing to this region.

40:07

So what property of this region accounts

40:10

for its appearance on T two?

40:19

Okay, excellent. So the answer here is D, low water content

40:23

and dense myocytes.

40:24

This is the junctional zone of the uterus.

40:26

We can see all of the layers

40:28

of the uterus very beautifully here on this sub T two.

40:30

This is the T two bright endometrium.

40:32

This is the T two dark junctional zone.

40:34

This is the T two bright

40:35

and somewhat heterogeneous myometrium.

40:37

And the CI rosa is this thin black line on

40:39

the outside of the uterus.

40:40

The junctional zone, um, is part

40:44

of the myometrium technically,

40:46

but the myocytes in this region are so densely packed, uh,

40:50

that the water content within this region is lower.

40:53

And so that lends this region

40:55

to its T two dark appearance on MRI case 25.

41:00

This is a companion case for you.

41:03

I provided you with sagittal

41:05

and axial T two weighted MR images of the pelvis

41:09

and I've given you a handy dandy arrow sign.

41:13

What is the most likely diagnosis for this patient?

41:23

Excellent. So the majority of you have said adenomyosis

41:25

which is the correct answer here.

41:27

Um, so adenomyosis is when you have ectopic endometrial

41:30

glandular tissue within the junctional zone of the uterus

41:33

or within the myometrium of the uterus.

41:35

This can lead to a thickened

41:36

and indistinct junctional zone

41:38

with interspersed T two bright cystic foci.

41:41

That is the ectopic endometrial glandular tissue

41:45

case 26 pelvic pain.

41:47

We have axial T one fat saturated non-contrast images

41:51

and axial T two and a coronal stir image of the pelvis.

42:02

What is the most likely diagnosis?

42:11

Well done. I had a couple of folks say mature teratoma

42:15

or lipoma.

42:16

Um, but the majority of you said endometrioma

42:18

and that is the correct answer here.

42:20

I wanna drill down on this for just a second.

42:23

So stir images are fat saturated images

42:26

but I wanna remind you

42:28

that stir imaging is not specific to fat, right?

42:31

Remember that when we do stir imaging we are acquiring these

42:35

images by giving a 180 degree RF pulse followed

42:39

by a 90 degree pulse to generate signal

42:41

and then we read out at the null time

42:43

of a tissue of interest.

42:45

And so for stir, the T one is short

42:47

because we wanna null out fat

42:49

but hemorrage variances endometriomas,

42:52

these can have T one relaxation times that are similar

42:55

to fat and that can give you signal dropout on a stir.

42:59

So if this is walking like an endometrioma

43:03

and talking like an endometrioma

43:04

with intrinsic T one hyperintensity

43:06

and T two shading, do not allow the stir to sway you.

43:10

Uh, because sometimes the T one relaxation times, uh,

43:13

when there are blood products on board can make

43:15

a lesion look dark.

43:16

On stir case 27 patient sent from

43:21

maternal fetal medicine clinic, we have coronal sagal

43:24

and axial T two weighted MR images

43:27

of the abdomen and pelvis.

43:32

I'll give you a moment to look at these

43:38

couple of arrows to aid you in your interpretation.

43:43

How is this condition managed?

43:45

What do we do for patients who have this condition?

43:56

Excellent. So we were sort of split

43:58

between cesarean hysterectomy

43:59

and cesarean section Cesarean

44:02

hysterectomy is the answer here.

44:03

This is a patient with placenta accreta spectrum.

44:06

In this case in particular the placenta ex is extending

44:09

beyond the boundary

44:11

of the uterus here this is placenta perreta.

44:13

These cases require resection of the uterus, um, following

44:18

cesarean delivery of the fetus through the fundus.

44:21

So cesarean hysterectomy is the correct answer here.

44:24

Case 28, we have a right a NAL ultrasound image a focused

44:29

on the right ovary.

44:31

We'll give you a moment to take a look at this.

44:37

What explains the echogenic striations within the lesion?

44:49

Excellent. So this is the dot dash sign of a mature teratoma

44:53

and that's due to the presence

44:54

of hair within the lesion case 29.

44:59

We have multiple images here.

45:01

This is the first we have an axial CT image at the level

45:05

of the kidneys coming further down to the level

45:09

of the pelvis, I've placed a region

45:11

of interest on this structure here in the right hemi pelvis

45:14

average hos field units here are 42.

45:20

Even further down I've taken another region of interest.

45:24

Average hounds field units here 67

45:27

and here we are at the level of the urinary bladder.

45:30

What best explains the findings present on these images?

45:41

Wonderful. So the answer here is urothelial malignancy.

45:44

So we have a thickened distal right ureter in this case.

45:48

Um, it is measuring soft tissue density on the images.

45:52

Uh, this is way too thick for a recently passed stone

45:55

or a UTI IgG four disease.

45:58

We expect to see um, entrapment of the ureters

46:01

by soft tissue in the retroperitoneum.

46:03

Um, and we don't have any indication on the rest

46:05

of the images this patient had had a surgery case 30.

46:09

This is a patient with back pain.

46:11

I've given you two axial post contrast images, CT images

46:16

of the abdomen at the level of the kidneys.

46:18

And the region of interest I have placed here is

46:20

59 pounds filled units.

46:23

Additional images for you, we have other axial

46:27

and a coronal post con CT image of the abdomen and pelvis.

46:32

Diagnosis please.

46:41

Excellent. So if we go back,

46:43

there is a fat containing lesion in the

46:45

lower pole of the left kidney.

46:46

There's a big perinephric hematoma

46:49

and there's a focus of active bleeding here.

46:51

So this is a patient, uh, who has an angiomyolipoma

46:54

with hemorrhage case 31.

46:58

We have two MR images of the abdomen, uh, at the level

47:03

of the liver and the adrenal gland.

47:06

These images were obtained on a 1.5 Tesla magnet,

47:10

which echo time was used to acquire the in phase images.

47:21

Okay, I got some

47:23

of you the answer here is B 4.4 milliseconds.

47:26

Um, so remember the out

47:27

of phase images are acquired first at 1.5 Tesla at 2.2

47:31

milliseconds and then the endphase images at

47:34

4.4 milliseconds.

47:36

Next case we're gonna keep moving here.

47:40

I've given you axial T two weighted images

47:43

and then T one pre

47:44

and post contrast images of the abdomen

47:47

of the level of the kidneys.

47:49

What's the most common histological variety

47:51

of renal cell carcinoma

48:00

well done.

48:01

So clear cell is the most common histological variety

48:05

and this is just a straight up knowledge check.

48:08

Next case follow up ovarian cyst.

48:11

Um, we have a gray scale transvaginal ultrasound

48:15

image of the right ovary.

48:16

We also have a color, uh,

48:19

image here accompanying the gray scale.

48:21

Given you some handy dandy arrow signs here.

48:26

To qualify as stroma ov eye, what percentage

48:29

of these tumors should be thyroid tissue?

48:39

Okay, so the majority of you said at least 25% we gotta do a

48:42

little bit more greater than 50%.

48:44

Um, if we take a look at this ovarian lesion,

48:46

if you put this in the thyroid gland,

48:48

you would call this the color cyst all day long

48:50

with these come tail artifacts.

48:52

Um, so this is a variant of mature teratoma

48:55

that can contains thyroid tissue

48:56

and to qualify as stroma ovary eye, greater than 50%

49:00

of the lesion has to be ectopic thyroid.

49:03

Next case, which artifact is present

49:06

in this axial T two weighted MR image of the abdomen?

49:18

Okay, excellent. So the answer here is dielectric effect.

49:21

Um, there's no wraparound in this image.

49:23

We don't see intrusion of any other body parts.

49:26

More fringes are that, um, kind of ripples on a pond effect

49:29

that you see in the periphery of images, Gibbs

49:33

or truncation artifact.

49:34

Uh, we often see, um, on spinal imaging, uh,

49:38

this is not a fat suppression image,

49:40

not a fat suppressed image.

49:41

So we don't have failure of fat set here,

49:43

but this darkness here in the center of the image is

49:46

because the patient's abdominal circumference exceeds our

49:49

field of view and we have signal loss centrally.

49:51

This is dielectric effect

49:52

and we see this in obese pre, uh, obese patients,

49:55

but also pregnant patients

49:56

and patients with large volume of abdominal pelvic ascites.

50:01

Last few cases here, case 35, this is a 91-year-old

50:04

with vaginal bleeding.

50:06

We have axial

50:07

and sagittal contrast enhanced CT images of the pelvis.

50:14

Give you just one moment.

50:17

What is the most likely diagnosis? Okay,

50:27

so the majority of you have said infected ring pessary

50:30

with abscess, but there is soft tissue here

50:33

for this lesion, right?

50:34

There's too much here to be abscess.

50:36

I don't see any gas within this.

50:39

I mean, so this ended up being a vaginal

50:41

squamous cell carcinoma.

50:43

Second to last case, this is a 30, uh,

50:46

this is a young woman status post MVC

50:49

and I've given you multiple axial, uh, coronal

50:52

and sagittal contrast.

50:54

Enhanced CT images of the abdomen and pelvis.

50:58

It is a grave uterus.

51:00

Which imaging features make placental abruption most likely.

51:11

Okay, good. The majority of you said hypo enhancement

51:14

of greater than 50% of the placenta.

51:17

And that's the correct answer here.

51:19

Actually, even when you see hypo enhancement of at least 25%

51:22

of the placenta, you can raise concern

51:24

for placental abruption, um,

51:26

but greater than 50%, that is a surgical emergency.

51:29

This patient and the fetus went to surgery for e c-section

51:32

and both mother and baby survived.

51:35

Last case for you. Which structure is indicated

51:37

by the red arrows?

51:39

Remember, there is physics and anatomy behind every corner.

51:50

Wonderful. And the vast majority

51:52

of you picked the correct answer, which is pupil ect.

51:55

Um, just a reminder that the, um, PTUs muscle contracts,

52:00

uh, during squeezing

52:02

or stress of the pelvic floor musculature.

52:04

Um, and so it acts as this kind of band

52:07

around the rectum and upper vagina.

52:10

So reminder, these are the questions you should be asking

52:13

yourself when you are seeing images

52:15

and multiple choice questions for the core exam

52:18

or when practicing.

52:19

Um, are these anatomic relationships normal?

52:22

What finding or characteristic explains this

52:24

or makes this the most likely diagnosis?

52:26

What are my next steps?

52:28

What would help me make this the strongest

52:29

choice in my differential?

52:31

What is the physics? What is the anatomy

52:34

and how can I describe this if I'm feeling totally lost?

52:38

Final thoughts for you.

52:39

Go into your exam day with your snacks.

52:41

You know what your testing snacks are, take them with you,

52:45

relax, give yourself some pats on the backs.

52:47

You're going to be great.

52:49

Thank you for your time

52:50

and I'm happy to answer any questions that you may have.

52:54

Dr. Gomez, that was, that was awesome.

52:55

You got through 37 cases, you did job well done.

52:58

I have to ask though, what is your, your study snack?

53:02

My study snack is Cheez-Its and a blue Powerade. Ooh,

53:05

So good.

53:07

So good. Um, we do have a couple questions in the Q

53:10

and a box if you wanna pop that open. Yeah,

53:13

Sure. Take

53:14

A look. Um, I'm

53:15

also happy to read them to you.

53:16

Let me pull 'em up. Let's see, what would be the rads,

53:21

let's see, the first one said, what would be the rads

53:23

for the postmenopausal endometrioma, uh,

53:26

versus hemorrhagic cyst?

53:28

Thanks. Um, you know, I I feel like, um,

53:32

to be completely honest with you, I am not an RADS expert

53:36

and I have to look up the calculator every time.

53:39

Um, but we see blood within the lesion.

53:42

There wasn't any vascularity, uh, within those projections.

53:46

And so, um, it probably would've received a, a fairly low

53:49

or a score from me interpreting those images.

53:53

Someone said my questions are tough. I'm sorry.

53:57

Um, but I'm, this is to prepare you, this is to steal you

54:01

and make you stronger.

54:03

Um, let's see. There is a question.

54:06

Can you explain the T one and T two physics question again?

54:09

Are we talking about the relaxation time question?

54:12

We can go back to that one.

54:14

Sorry to dizzy you

54:16

and take you back in time through my slides.

54:18

I think that was the appendiceal mucosal question,

54:21

which was fairly early on.

54:24

So, um, so

54:26

what I'm asking you here is do you see the lesion

54:30

and then once you have identified

54:31

that this is a T two hyperintense

54:33

and T one hypo intense lesion, um, what accounts

54:37

for the appearance of the lesion?

54:39

So, um, things that are going

54:42

to be bright on T two weighted image, they're going images,

54:45

they're gonna have a long T two relaxation time things

54:48

that are gonna be bright on T one.

54:50

They're gonna have a short T one relaxation time.

54:52

And the way that I remember that is

54:54

that gadolinium based contrast results in T one shortening.

54:57

And so this lesion, the characteristics of this lesion are

55:01

that it has a t long T one relaxation time

55:03

and a long T two relaxation time.

55:05

I hope that helps. Let's go to the labial Varice case again.

55:11

Uh, which somebody had questions about, oh wait,

55:13

there was one about the PSMA PET CT first.

55:15

Um, so somebody said, how do you differentiate

55:17

between gallium 68 and PSMA?

55:20

So for me, um, the

55:23

salivary gland uptake in A-P-S-M-A PET CT is much,

55:26

much more intense than the gallium 68 dotatate.

55:29

Also on a gallium 68,

55:31

you're gonna have uptake within the pancreas.

55:33

So that's the distinguishing factor

55:35

and those are the two things that I

55:36

kind of look for right away.

55:39

Um, let's see, in that appendiceal mucosal question,

55:42

the appendiceal mucosal is generating a lot

55:45

of controversy here.

55:47

Uh, why is the bladder bright on T one?

55:51

There's probably some excreted contrast within

55:54

the urinary bladder here.

55:56

Um, ladder here or this may be artifactual.

56:02

And then let's go to the labial es question one more time.

56:07

Let me just for the sake of time here, escape

56:10

and try to find it.

56:14

Here we go. Okay.

56:16

So we have, um, hypo, coic labial masses.

56:21

And when we look in the periphery of the lesion,

56:23

there are all of these tortuous vessels leading

56:25

up to and wrapping around.

56:27

And what I haven't shown you is

56:28

that on syn imaging there's really,

56:30

really slow flow within these lesions.

56:34

So slow flow within the lesions would sway me, uh,

56:37

that this was a benign entity.

56:39

And that is what happened

56:40

to me when I saw this patient in the clinic.

56:42

If I had seen bulky regional adenopathy in her groin

56:46

or within her pelvis, if I had seen,

56:48

if we had done a pelvic ultrasound, a cervical lesion,

56:51

soft tissue nodularity or vascularity within this lesion,

56:56

or if this had grown rapidly, um, over a period of time,

57:00

I would be suspicious that there was a malignant

57:02

process happening here.

57:04

Okay. And then there's a question about the

57:07

clitoral anatomy.

57:09

MRI. So let's go back to that,

57:15

that one, it's here.

57:17

Okay. So these are the cura

57:22

of the clitoris, right?

57:23

So they kind of come down like these paired tails.

57:27

Um, and they're gonna run almost along the inner edges

57:31

of the inferior pubic ray eye.

57:34

So these are the cura singular is cruse of the clitoris,

57:38

and they join together to form the ctor body

57:42

and then they terminate in the glands

57:44

or head of the clitoris.

57:46

And then, so this is the erectile tissue of the clitoris.

57:49

This is the part that becomes engorged with arousal.

57:52

And then these are the vestibular bulbs here.

57:54

And you'll see they kind of wrap around the vaginal inus,

57:58

which we can see down here.

58:01

The vestibular bulbs are the glandular tissue

58:03

and they aid in lubrication.

58:05

And this is a pretty picture that also shows.

58:08

So this is the glands, this is the, um, body

58:11

of the clitoris, and then these are the cura here.

58:14

We can also see the cura here, right?

58:17

And then the bodies come up like this

58:19

and then the vestibular bulbs kind of drape around

58:21

that glandular tissue around the vaginal introitus.

58:27

Let's see, somebody said, why are, um,

58:32

why are copper and gallium dotatate different distributions?

58:35

It seems like they should be the same

58:38

distribution of dotatate.

58:39

That is beyond the scope of my expertise.

58:41

And I'm sorry that I don't have a better

58:43

answer to that question.

58:45

Um, but I do know that for the copper you expect

58:48

to see more uptake within the spleen.

58:55

Okay, I think you got 'em all.

58:56

Okay. We did it. We did it.

58:58

Well, thank you so much Dr. Gomez.

59:00

That was amazing. 37 cases.

59:02

Yes, we did it. Thanks so much for having me. Of

59:05

Course. Thank you so much

59:06

for, for putting together this case

59:08

review and for being here tonight. We really appreciate

59:10

It. Yeah, it's been

59:11

my pleasure. Uh, thank you all again.

59:14

Yeah, for sure. And yeah, for everyone else out there,

59:16

thank you so much for participating.

59:18

You can access the replays of previous reviews

59:22

by creating a free account.

59:23

And be sure to join us next Monday, April 14th. Dr.

59:27

Mahesh is going to be back

59:28

to lead us in another physics review this time covering ct.

59:31

You can register for that at the link provided in the chat.

59:34

Follow us on social media for updates on future meetings.

59:38

And thanks again for learning with us

59:40

and we'll see you next time.