0:02

Hello and welcome to Case Crunch Rapid Case

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Review for the core exam hosted by Medality.

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In this rapid-fire format, faculty will

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show key images along with a multiple-choice

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question, and you'll respond with your

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best answer via the live polling feature.

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After a quick answer explanation,

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it's on to the next case.

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

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review and previous case reviews by creating a free

0:25

account using the link provided in the chat.

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Today, we're honored to welcome Dr. Erin Gomez

0:30

for a GU Board Prep case review.

0:33

Dr. Gomez is an Assistant Professor of

0:35

Radiology and the Director of the Diagnostic

0:37

Radiology Residency Program at Johns Hopkins.

0:40

Her academic interests include medical student

0:42

and resident education, fundamentals and clinical

0:45

applications of MRI physics, and cross-sectional imaging

0:48

of the female pelvis, with a focus on high

0:50

risk OB imaging and MR evaluation of the placenta.

0:54

We're thrilled she's here today to lead us in this case

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review. Questions will be covered at the end

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if time allows, so please remember to use the

1:00

Q and A feature to submit those questions.

1:03

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

1:06

Dr. Gomez, please take it from here.

1:09

Thanks so much for having me.

1:10

I'm Erin Gomez.

1:11

I'm from Johns Hopkins.

1:12

I'm a body imager.

1:13

I'm thrilled to be here with you today

1:15

to do a genitourinary board review.

1:17

So let's get started.

1:21

Um, so here are the rules of play.

1:23

The multiple-choice questions

1:24

are for everyone via the poll.

1:26

We're gonna keep moving quickly

1:27

so we can do as much as possible.

1:29

I have 35 cases that I would love to get through,

1:32

um, so let's do our best.

1:34

I also wanna say this is a super safe space.

1:36

I judge no one.

1:38

This is the place to practice.

1:39

This is the place to test the waters, and you

1:41

are strong and smart, and I believe in you.

1:45

I have nothing to disclose. When you're

1:48

approaching questions for the board exam,

1:51

one of the things that I think you should ask

1:53

yourself, when you're presented with the images and

1:55

with the content for the questions, things like,

1:58

are the anatomic relationships that I'm seeing normal?

2:00

Is there distorted anatomy here? Is there

2:03

something missing that should be there?

2:05

What are the signal characteristics if there's an

2:07

MRI or a CT or finding that makes the thing that

2:11

you are thinking of the most likely diagnosis?

2:14

Because sometimes they won't

2:15

ask you what's the diagnosis?

2:16

They'll say, what's the thing that makes that the thing?

2:19

What explains the finding?

2:21

Is it, you know, if this is a hemorrhagic

2:22

lesion, is it hematocrit effect?

2:24

Is it a fat-containing lesion?

2:27

The other thing they may ask you

2:28

is, what are you gonna do next?

2:29

So, are you doing another imaging exam?

2:32

Are you adding another sequence?

2:33

Is the patient gonna have tissue taken?

2:36

What would help you differentiate this

2:39

lesion from a different lesion that may

2:41

be similar, may share some features.

2:44

One of the things that they're really gonna

2:45

do to you pretty commonly is, um, ask you

2:48

something that has a physics undertone to it.

2:51

So what's the physics behind the finding?

2:54

Um, how would manipulating some of these different

2:56

imaging parameters change the image or affect it?

2:59

And then if you get stumped, if you are in a place

3:02

where you are feeling lost, um, one of the pieces

3:05

of advice that I'll give you is if you're saying,

3:07

I don't know what that thing is, start describing it.

3:10

Describe it to yourself.

3:11

What are the sequences that I have available to me?

3:13

What are its imaging characteristics?

3:15

And start working from there.

3:17

Okay.

3:19

Let's start with a few warmup questions.

3:22

A few softballs.

3:23

You got this.

3:25

Alright, warmup question number one, name this game.

3:25

93 00:03:30,240 --> 00:03:31,350 Is it Canoodle?

3:31

Qwertle?

3:32

Hurdle?

3:33

Wordle or turtle?

3:43

Okay.

3:44

And it looks like the majority of you got it right.

3:46

This is Wordle.

3:47

Excellent.

3:49

All right, next warm-up question.

3:51

This adorable, porous

3:52

creature's dwelling can be best described as?

3:56

Cranberry under my couch. A bagel on top of

3:58

the fridge. A pineapple under the sea. A mango

4:01

beside a pond, or a coconut behind the hospital.

4:11

Excellent.

4:11

Even more folks represented for this one that is

4:15

SpongeBob, who lives in a pineapple under the sea.

4:18

Next warm-up, which pop diva (pictured right)

4:21

broke the internet last year,

4:23

selling tickets for the ERAS tour?

4:36

Okay.

4:36

We had 95% correct on this one.

4:38

So we have some Swifties in the audience for sure.

4:40

That is indeed Taylor Swift.

4:43

Well done.

4:44

And then last warm-up question for you

4:45

to get to know you a little bit better.

4:47

Um, tell me about yourself.

4:49

Are you a resident studying for the core?

4:51

Are you an attending physician?

4:52

Are you just here for the cases or are you hanging out?

4:55

Let us know.

5:10

Okay.

5:10

Good mix.

5:10

All right.

5:11

Looks like mostly residents, but we've got, um, some

5:13

attendings and some folks who are here for the cases.

5:16

All right, now for the real deal.

5:18

Let's get into it.

5:20

Here's our case one.

5:21

This is a patient with elevated PSA.

5:23

I'm going to let you look at

5:25

this image for a few seconds.

5:26

These are axial T2 weighted images of the pelvis.

5:29

We're at the level of the rectum

5:31

and the symphysis pubis here.

5:37

Okay, here are more images for this patient.

5:40

We have diffusion weighted imaging

5:42

with an accompanying ADC map.

5:43

The average ADC value in this region of interest is

5:46

572, and then these are T1 post-contrast images.

5:54

Okay, so here's your question.

5:56

Which of the following sequences is most important

5:59

in the PI-RADS characterization of this lesion?

6:15

It looks like most of you got this right.

6:16

The answer is diffusion weighted imaging.

6:18

This was a peripheral zone lesion in the prostate gland.

6:21

And so remember for the peripheral zone diffusion is

6:24

gonna be our go-to sequence for the transition zone.

6:27

T2 is gonna be what you lean on

6:29

for your primary RADS categorization.

6:32

Next case, um, this is a patient

6:34

with pain and recent trauma.

6:36

This is a side-by-side scrotal

6:38

ultrasound, gray scale images only.

6:41

I'll let you take a moment to look at these.

6:43

They're labeled right and left,

6:54

and now we have color Doppler images.

6:56

Also a side-by-side comparison

6:57

of the right and left testicle.

6:59

These are transverse images.

7:07

I'll let you take a couple

7:07

more seconds to look at these.

7:15

Okay, here's your question.

7:16

Which feature is most suggestive of testicular rupture?

7:33

Excellent.

7:33

So the majority of you got this question correct.

7:35

The answer is B, disruption of the tunica.

7:38

Let's go back to the images really quickly.

7:40

Um, so this is a patient who had recent trauma.

7:42

We can see already the left testicle

7:44

is enlarged compared to the right.

7:46

It has a lot of peripheral hypoechogenicity

7:50

inferiorly, um, the capsule of the testicle.

7:53

Um, and in tunica albuginea, we don't see it extremely well.

7:56

There is some adjacent complex fluid in the periphery

7:59

of the left testis on the color Doppler images.

8:02

Um, the right testis has normal

8:04

flow, uh, normal architecture.

8:06

The left testis is very heterogeneous.

8:08

There's diminished flow here.

8:10

So this patient who has had recent

8:12

trauma has a testicular rupture.

8:14

And, uh, honestly, this testicle is also hypoperfused,

8:18

so maybe on the way to testicular infarction.

8:21

Um, and so while heterogeneity can be a sign

8:23

that there's edema present, um, absent flow

8:25

can tell you that hypoperfusion is happening.

8:27

Um, and the history and adjacent

8:29

free fluid can also be helpful.

8:31

It's that disruption of the tunica albuginea, um,

8:34

that should sway you towards testicular rupture.

8:37

Next case, this is a patient with pelvic pain.

8:40

We have axial and sagittal CT

8:43

images of the abdomen and pelvis.

8:45

I'll give you a moment to look at

8:47

these images and make the finding.

9:02

Okay.

9:03

Diagnosis, please.

9:05

Is this a tumor, myelolipoma, a serous

9:08

cystadenoma, a Kingberg tumor, a mature teratoma

9:11

with torsion, or a retained foreign body?

9:27

Okay.

9:27

The vast majority of you got this correct as well.

9:29

This is a mature teratoma with torsion.

9:31

Let's go back to this.

9:32

So we have a well-circumscribed pelvic mass.

9:35

It has, um, solid components to it for sure.

9:38

There's a little bit of calcification here.

9:40

There's macroscopic fat in the center

9:42

of the lesion surrounding the lesion.

9:45

There's a lot of free fluid, kind of more than we would

9:47

expect for physiologic free fluid here in the pelvis.

9:50

Um, and since we know that this is a fat and

9:52

calcium-containing lesion, this is almost

9:54

certainly a mature teratoma or an ovarian dermoid.

9:57

This ovary is way too large.

9:59

If I were to put calipers on here, this is probably,

10:01

um, at least five, maybe seven centimeters.

10:04

And so an enlarged ovary with a known

10:06

lesion and free fluid pelvic pain, um,

10:08

this should raise suspicion for torsion.

10:11

So D was the correct answer here.

10:14

All right, case number four.

10:16

This is a patient with scrotal and inguinal pain.

10:19

We have transverse images, side by

10:21

side, images of the testicles here.

10:23

And then this is a closer look at the

10:25

left testicle with, um, color Doppler.

10:30

I'll give you a moment to look at those.

10:35

More images for this case.

10:37

This is also a color Doppler

10:39

image of the left epididymal head.

10:46

Here's the left, um, inguinal canal.

10:49

This is superior to the left testis, and so

10:52

we have gray scale and color Doppler images.

10:55

This is an extra testicular finding.

11:02

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

11:06

And then finally, there's an

11:07

accompanying CT for this patient.

11:09

This is a coronal post-contrast CT of the pelvis.

11:16

Okay, diagnosis please.

11:30

Okay.

11:31

So kind of a mixed bag here.

11:32

Uh, the majority of people

11:33

said of vascular malformation.

11:35

We also got some votes for spermatic cord

11:37

sarcoma, inguinal hernia, and panniculitis,

11:40

which is the correct diagnosis here.

11:42

So what is panniculitis?

11:44

It's inflammation of the spermatic cord.

11:47

Often happens in cases of epididymitis.

11:50

So this patient certainly has epididymitis.

11:53

On the left side, we can see there's

11:55

increased flow within the left testicle.

11:58

The left epididymis is inflamed and engorged looking.

12:02

And then here, so this is actually the spermatic cord.

12:05

It's really epigenic because it's inflamed.

12:08

It's very hypervascular.

12:10

And, um, on the CT, we can see really nicely, um,

12:14

that the left testicle looks a little bit emaciated.

12:17

There's engorgement of the left spermatic cord.

12:19

There's fat stranding surrounding the spermatic

12:22

cord, which is asymmetric compared with the

12:24

right, and there's a left-sided hydrocele.

12:26

Um, so you can often see panniculitis in the

12:28

setting of sort of, um, ascending, uh, genital

12:31

urinary infection, uh, most commonly epididymitis.

12:34

So this is panniculitis, which again

12:36

is inflammation of the spermatic cord.

12:39

Next case, this is a patient with pelvic pain.

12:42

Um, we have a sagittal gray scale

12:45

ultrasound image of the left ovary.

12:47

The calipers here are measuring something

12:49

that's measuring 7.1 by 4.5 centimeters.

12:54

I'll give you a moment to look at it.

12:58

One more image.

12:59

This is color Doppler,

13:02

or sorry, color.

13:07

Okay.

13:08

The patient is 33 years old.

13:10

The lesion in the previous

13:11

images measures 6.5 centimeters.

13:14

What should you do?

13:16

What's your responsibility as the radiologist here?

13:30

Okay, so we're split between follow-up in

13:33

six to 12 weeks and recommend pelvic MRI.

13:36

So for this patient, we can

13:37

follow this up in six to 12 weeks.

13:39

This is a premenopausal patient.

13:41

Um, this lesion is not small, but it's

13:44

not, uh, it's not super big either.

13:47

When we go back and we look at the imaging

13:49

features, um, this is something that

13:51

has a lot of different densities within it.

13:53

We have some stuff in here that almost looks like,

13:55

uh, kind of like a smooth, uniformly hypoechoic, maybe a

13:59

chocolate cyst, but there's some peripheral avascular

14:02

angiogenesis within the dependent portion of this lesion.

14:05

So right off the bat, I'm wondering, is

14:07

this an endometrioma with retracted clot?

14:09

Um, is this a hemorrhagic ovarian cyst

14:11

that's evolving, maybe doing weird things?

14:14

So in a younger person who's premenopausal, um, we can

14:18

follow this up in six to 12 weeks per the SRU criteria.

14:22

Now, let's say the patient's 68 years

14:24

old, the lesion is still 6.5 centimeters.

14:27

What are we recommending now?

14:39

Okay.

14:40

Um, so we're pretty split between recommending

14:42

pelvic MRI and surgical consultation,

14:44

and I'm happy to see that, right?

14:45

Because we are not letting this thing go.

14:47

We're not just leaving it in the body.

14:48

Um, we're not not recommending follow-up.

14:51

This thing has to come out and that's

14:52

because this is a postmenopausal patient and

14:55

the imaging features are the same, right?

14:57

This is something that has hemorrhage within it.

14:59

But because this patient is postmenopausal,

15:01

they should not be ovulating anymore.

15:03

Nothing should be bleeding within the ovary.

15:05

There should not be hormonal stimulus

15:07

for things like endometriosis.

15:10

And so, regardless of what this is, we can't say for

15:13

sure that there's not an underlying mass that has bled.

15:16

Um, and so, um, you know, even if we got a

15:18

pelvic MRI for this thing, given the size

15:20

and the appearance, it's gonna come out.

15:24

Case number six A UB, which stands

15:26

for abnormal uterine bleeding.

15:28

This is a 36-year-old patient.

15:30

We have coronal grayscale and color

15:32

ultrasound images of the cervix.

15:44

Diagnosis, please.

15:47

Is it an abscess infected into both prolapse?

15:51

Fibroid in the cervical canal, relapsed

15:54

endometrial polyp, or cervical carcinoma?

16:09

Okay.

16:09

All over the place here as well.

16:11

Um, the answer to this one is cervical carcinoma.

16:14

So let's go back and review the imaging findings here.

16:17

So we're kind of centered down at

16:18

the level of the cervical canal.

16:20

This is a pretty irregular

16:22

looking lesion here, peripherally.

16:24

It does have some flow within it.

16:26

So this is a soft tissue lesion.

16:28

Um, if we were thinking about an ovarian cyst, I would

16:31

want this to be more smooth in the periphery,

16:32

a little bit more well circumscribed, and we

16:34

shouldn't see any flow internally, although ovarian

16:37

cysts can have proteinaceous or hemorrhagic debris,

16:40

so they can have some complexity within them, um,

16:42

but they shouldn't have any internal vascularity.

16:46

Similarly, a cervical abscess, I would expect

16:48

to see, um, more peripheral hyperenhancement,

16:51

maybe mobilegenic debris within the lesion.

16:54

Um, and then a prolapsed fibroid or

16:56

polyp, I would expect them to be a

16:57

little bit more smooth with a fibroid.

16:59

We may see some Venetian blind artifact

17:02

and with a polyp, we would like to see

17:03

that classic stalk-like vascularity.

17:05

Um, so for this patient who's having a lot of

17:07

bleeding, um, this is a pretty ugly lesion.

17:09

This is a cervical carcinoma and needs to be biopsied.

17:15

Next case, this is a patient with

17:17

pelvic pain and vaginal bleeding.

17:21

We have, um, sagittal T1 post

17:24

contrast images of the pelvis.

17:26

And then we also have diffusion-weighted

17:27

imaging with accompanying ADC map.

17:30

And we'll give you a moment to look at this

17:36

and I encourage you to focus on what's

17:39

happening here regionally as well.

17:51

Okay.

17:52

What features present on these images of a patient

17:54

with cervical cancer qualifies as T4 disease?

17:58

So this may happen to you when

17:59

you're taking these exams as well.

18:01

You know the finding, you know that this

18:02

is a cervical or a vaginal cancer, and then

18:04

they're gonna ask you a question about staging.

18:07

So what constitutes T4 disease in cervical cancer?

18:10

That's the real question, right?

18:21

Excellent.

18:21

Well done.

18:21

The majority of you said bladder

18:23

invasion and that's correct.

18:24

So confinement to the cervix, that's T1B disease.

18:28

And then, um, in the FIGO criteria for staging

18:31

cervical cancer, um, one of the big tie-breakers

18:33

will be involvement of the upper one third

18:35

versus the lower one third of the vagina.

18:37

Upper one third of the vagina is T2 disease, lower

18:40

one third of the vagina is T3 disease.

18:43

Pelvic sidewall abutment is considered

18:45

T3B. Um, but once you start involving

18:48

either the bladder or the rectum, um, or

18:50

structures outside of the pelvis, that's T4.

18:55

Okay.

18:56

Next case.

18:58

Sorry, my, uh, my caption at

19:01

the top is cut off by my zoom.

19:09

So we have a sagittal contrast

19:10

enhanced CT of the pelvis.

19:14

Um, I believe this is a patient

19:16

who had a history of breast cancer.

19:20

That's right, Dr. Gomez.

19:21

Okay, cool.

19:22

Sorry, I was like behind my little zoom bar up there.

19:25

Okay.

19:27

And so here's the finding, right?

19:29

The endometrium looks thickened.

19:31

Um, this patient, uh, has an endometrium that's

19:34

greater in thickness than we would expect for her age.

19:37

Um, so here is the ultrasound for this patient.

19:39

We have gray scale and color sagittal images

19:42

of the EMS, which stands for endometrial stripe

19:52

diagnosis.

19:53

Please.

19:54

What are we seeing here?

20:07

Okay, great.

20:08

So this is an atypical mini, right?

20:09

You'll know her when you see her.

20:10

Um, these are tamoxifen-related

20:12

changes of the endometrium.

20:14

Um, so patients who are receiving tamoxifen,

20:16

tamoxifen for breast cancer, um, will undergo, may

20:19

undergo these classic kind of cystic, um, clustered,

20:23

minimally vascular changes of the endometrium.

20:27

Um, this is not a malignancy, it's

20:29

more of an endometrial hyperplasia that

20:32

happens in the setting of tamoxifen use.

20:35

Um, and so that's the correct answer here.

20:38

Um, certainly.

20:40

It can be challenging to distinguish endometrial

20:43

hyperplasia from an endometrial malignancy.

20:46

Um, and so if somebody, if a patient was coming

20:48

in de novo, they didn't have a history of treated

20:50

breast cancer, um, and you saw these findings,

20:53

you may still take an endometrial biopsy.

20:55

Even in this patient.

20:56

On Tamoxifen, you may take an endometrial

20:57

biopsy, but for the purposes of the core exam,

21:00

if they give you a history of patient with

21:02

breast cancer and they show this, these are

21:04

tamoxifen-related changes in the endometrium.

21:08

Alright, case nine.

21:11

Perhaps a little similar to one we saw earlier.

21:13

We have an axial CT image of the pelvis with contrast.

21:19

I'll give you a moment to look at this.

21:29

And here's the ultrasound.

21:31

This is a sagittal color image of the uterus.

21:45

Okay, what is it?

21:57

Okay, excellent.

21:58

Um, so some of you said mature teratoma, um, and

22:01

we'll talk about that in just a second, but the

22:03

majority of you said lipoma, which is correct.

22:06

Um, so what is a lipomyoma?

22:08

It is a fat-containing fibroid.

22:11

It's a fatty variant of the normal fibroids

22:13

that we see all of the time in the uterus.

22:16

Let's go back to the CT.

22:18

So the first clue here and, and on this single

22:20

slice, I did think it was a little unfair

22:23

just to show you this, 'cause for all the

22:25

world looks like it could be that torsed ovary.

22:28

But I will tell you that this is all myometrium here.

22:30

In the periphery of this, we

22:32

see a little bit of the, um,

22:34

of the right uterine ovarian ligament and the right

22:36

ovarian vascular pedicle here in the right adnexa.

22:39

But I wanted you to know for

22:41

sure that this was in the uterus.

22:42

So that's why I showed you the sagittal gray

22:44

scale and color ultrasound image of the uterus.

22:47

This is myometrium, um, wrapping

22:49

all the way around this lesion.

22:51

It's hyperechoic, right?

22:52

So we know that this is a fatty thing.

22:54

Um, we have color on here.

22:56

It's not a super vascular lesion.

22:58

And so one of the strategies that I want to

23:00

talk to you about for the board exams

23:03

is, um, eliminate the things right away.

23:05

And you know this from taking

23:06

tests your whole lives, right?

23:07

But eliminate the things right

23:08

away that don't make sense.

23:09

So this is probably not an ovarian torsion.

23:11

If we can see myometrium wrapping around this lesion,

23:15

this is, um, uterine, um, and infarcted fibroid,

23:18

um, I would not expect to see as much echogenicity.

23:22

It would probably still look a lot like a

23:25

normal fibroid, maybe with just a little

23:26

bit more hypoechogenicity and edema.

23:30

A liposarcoma, we would expect to see, uh, a lot

23:33

more vascularity and maybe even a little bit more

23:36

irregularity in the periphery of that lesion.

23:39

And again, this is uterine in nature,

23:40

so it is not a mature teratoma.

23:42

So the best answer here is lipomyoma.

23:45

Next case.

23:46

This is a patient with cyclic pelvic pain.

23:49

We have axial T2-weighted and axial T

23:51

1 non-fat saturated images of the pelvis.

23:56

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

24:04

These images are a little bit of an eye test.

24:10

There's a T1 fat SAT pre.

24:12

This is chemical fat saturation.

24:15

And then we have T1 fat sat post.

24:27

And here's the finding.

24:28

If you didn't see it, which MR sequence

24:33

is most specific for this condition?

24:48

Okay, good.

24:48

Excellent.

24:48

Most of you said the T1 FAT sat pre.

24:51

I like those of you who are thinking about the T2.

24:53

If we were looking at an ovarian lesion and we

24:55

were talking about an endometrioma in the ovary,

24:58

um, I'd consider the T2 and some T2 shading

25:01

that we might see on those images fairly specific.

25:04

Um, when we're talking about extra-ovarian

25:06

endometriosis implants, which is what this is,

25:09

the T1 fat sat pre can be very specific.

25:12

So let's go back, right?

25:14

So, um, in this patient's inguinal region,

25:16

we have what just looks like scarring, right?

25:19

It's dark on the T1 and the T2.

25:21

Anything that's dark on both of those, you're

25:23

gonna start thinking about fibrotic tissue.

25:25

We're gonna start thinking about scarring.

25:26

There's desmoplastic change in the periphery here.

25:29

There's some speculation there.

25:32

And we look on this on the T1 fat sat pre,

25:34

there's some bulk here compared with the other side.

25:37

And then there's a tiny focus of intrinsic T1

25:39

hyperintensity in the central aspect of this.

25:42

This enhances an endometriosis implant, and

25:44

their associated growing can definitely enhance.

25:47

We classically think about them enhancing later,

25:50

um, because it's mostly fibrotic change that we're

25:52

looking at, but don't let enhancement dissuade you.

25:55

But the classic finding for endometriosis

25:57

implants, um, is those T1 bright

25:59

powder burn lesions outside of the uterus.

26:02

And so this is endometriosis.

26:06

Okay, case 11,

26:11

we have sagittal T2 weighted images of the pelvis.

26:16

We've given rectal gel and we have asked the patient

26:20

to perform some maneuvers for us on the table.

26:28

I encourage you to make a comparison.

26:31

Between these, uh, this image here and

26:33

this one on the right of your screen.

26:37

Okay, so here's your question.

26:40

In which of these images is the PCL, which

26:43

stands for pubic cidal line, drawn correctly?

26:46

And this is what happens, right?

26:48

You'll be taking the exam and

26:49

you're like, I know what that is.

26:50

I know that's pelvic floor laxity, and

26:52

then this is the question that you'll get.

26:53

So they're gonna ask you to take

26:54

your knowledge a step further.

26:56

That's what's gonna happen on the exam.

27:06

Okay?

27:06

The majority of you said B, but it was close.

27:10

A as well, and B is the correct answer.

27:13

So, um, the pubic cidal line is kind of the

27:17

reference standard that we set for ourselves

27:19

when we are evaluating pelvic floor laxity, we're

27:22

looking to see how far above and how far below

27:25

things are relative to the pubic cidal line.

27:28

The pubic cidal line is drawn from the

27:30

inferior aspect of the symphysis pubis to

27:33

the last joint of the sacrum and coccyx.

27:37

So this last little joint space here

27:38

is where you're gonna stop your line.

27:40

You'll notice that in A, it comes all

27:41

the way down to the tip of the coccyx.

27:44

Okay?

27:46

Alright.

27:47

Case 12.

27:49

Which of the following properties of the

27:51

labeled region accounts for its T2 signal?

27:54

So we have a fat-saturated sagittal T2

27:56

weighted image of the pelvis here.

27:58

The yellow arrow is pointing to the region

28:02

that I would like you to talk about.

28:03

So why does it look like that on the T2?

28:17

Okay.

28:18

Um, I like the folks who said C and D here.

28:21

I think you were getting at the right thing.

28:24

So what region of the uterus is this?

28:26

You can just say it out loud at home, right.

28:28

This is the junctional zone.

28:30

The junctional zone is that layer of the uterus

28:33

that's interposed between the endometrium,

28:35

which is this T2-weighted region in the center.

28:38

And then the myometrium proper, which is this T2-

28:41

heterogeneous layer out here on histology.

28:45

The junctional zone is actually still

28:48

myometrium, but it's really densely compacted.

28:51

Um, and so it has a lower water content than the rest

28:54

of the myometrium, which is what makes it dark on T2.

29:01

Okay.

29:02

Case 13.

29:03

This is a companion case for you.

29:05

We have SAG and axial T2

29:07

weighted images of the pelvis.

29:08

I will give you a moment to take a look at them.

29:18

Here's what I'm looking at.

29:22

Diagnosis, please.

29:35

Okay.

29:35

Excellent.

29:36

You all said adenomyosis.

29:38

That is the correct answer.

29:40

I'm sorry.

29:41

This should be adenomyosis, not

29:43

adenomyosis, but you know what I mean.

29:45

Adenomyosis happens in the gallbladder.

29:46

This is uterine adenomyosis.

29:48

Um.

29:49

Adenomyosis is uh, basically histologically

29:53

the same thing as endometriosis.

29:54

It's when you have atopic glandular

29:56

tissue, um, in the myometrium.

29:58

And so what it's gonna look like for you

30:00

is on T2-weighted imaging of the pelvis.

30:02

The junctional zone, which is that dark

30:03

band we looked at in the previous case,

30:05

is gonna look thickened and indistinct.

29:07

Um, there are numbers out there for upper

30:09

limits of normal of the junctional zone.

30:11

Folks will say 10 to 12 millimeters in thickness.

30:13

They're not gonna measure it for you on the test.

30:15

It's gonna look greater than or equal

30:18

to 50% of the width of the myometrium.

30:21

And it's gonna have these interspersed

30:23

T2 hyperintense cystic foci,

30:26

that's that ectopic glandular tissue.

30:28

So this is adenomyosis, I apologize.

30:32

Alright, case 14, pelvic pain.

30:35

We have axial T1 fat-saturated images, axial T2

30:39

weighted images of the pelvis, and then a coronal

30:41

STIR, um, which is also a fat saturation technique.

30:54

Okay, so what is this thing?

31:08

Okay, awesome.

31:09

I'm so proud of you.

31:10

You almost all of you said endometrioma.

31:12

Um, so they may show you things like this on the core

31:15

exam or on the certifying exam to try to trick you.

31:18

Axial.

31:18

So this thing is walking and talking

31:20

like an endometrioma on the T1 fat

31:22

sat pre and on the axial T2, right?

31:24

Classic features intrinsically G

31:26

T1 hyperintense T2 shading.

31:29

But on the stir, it loses its

31:31

signal, which can, which can.

31:34

Dissuade some people from thinking that

31:36

this is an endometrioma on the test.

31:39

This is indeed an endometrioma.

31:40

And I just want to remind you that

31:42

stir is not specific to fat.

31:45

Remember that stir imaging, we're acquiring

31:47

that by giving a 180-degree RF pulse, followed

31:50

by a 90-degree pulse to generate that signal.

31:53

And then we're reading out at the

31:55

null time of the tissue of interest.

31:57

So for stir imaging, the T1, um, is

31:59

short because we want to null out fat.

32:02

But blood products, particularly within things like um,

32:06

hemorrhagic ovarian cysts and endometriomas, they can

32:09

have T1 relaxation times that are similar to fat.

32:12

So you may see dropout on a stir for a

32:15

lesion that's not necessarily fat-containing.

32:17

This is an artifact, um, that happens

32:20

with blood products on the stir.

32:21

So be on the lookout for it.

32:22

They may try to fool you into thinking that

32:25

an endometrioma is actually a teratoma.

32:27

But I didn't get you so well done.

32:30

All right, next case.

32:32

This is blocked for me, but um, I think it's a patient

32:35

with pelvic pain and like a mildly elevated beta HCG.

32:39

We have a sagittal grayscale image of the

32:42

pelvis, and we are looking at the endometrium.

32:52

What's our diagnosis here?

33:05

Well done.

33:06

The vast majority of you said ruptured ectopic

33:08

pregnancy, and that's the correct answer here.

33:10

Um, so this is a patient who is having pain.

33:13

We are looking directly at the endometrial cavity.

33:16

There is not a gestational sac in sight.

33:18

And then here's the bladder.

33:20

This is way too much free fluid in the pelvis, right?

33:23

This is not physiologic free fluid.

33:25

And what I tell my residents is anytime you see

33:28

free fluid in the pelvis, that looks like you

33:31

went to the beach and you took a jar of water

33:34

and you poured some sand into it and shook it up.

33:36

That appearance is what blood products

33:39

look like in the pelvis on ultrasound.

33:41

So there's kind of this grainy

33:43

appearance to the free fluid here.

33:45

This patient has, um, pelvic hemoperitoneum and so

33:48

given the history, given the beta, um, this is a

33:51

ruptured ectopic pregnancy till proven otherwise, this

33:53

patient went to the OR, they evacuated a liter and a

33:55

half of blood from her pelvis and they did a hysterectomy.

34:01

Next case, patient sent from MFM Clinic, we have

34:04

coronal sag and axial T2-weighted images of

34:08

the abdomen and pelvis showing the gravid uterus.

34:20

And here's the finding.

34:21

So there's an area of myometrial thinning here.

34:23

There's placental signal that extends

34:25

beyond the myometrial contour.

34:27

There's a placental mass here.

34:28

This placenta is somewhat heterogeneous in

34:30

the periphery, and we see placental signal

34:33

that is, uh, looks like it's encroaching

34:35

upon the peri-vesicular fat here posteriorly.

34:38

So how is this condition managed?

34:49

Okay, great.

34:50

Most of you said either a cesarean

34:52

hysterectomy or cesarean section.

34:54

Cesarean hysterectomy is the correct answer here.

34:56

So this was a case of placenta accreta

34:58

spectrum, specifically placenta percreta.

35:01

We have placental tissue that is extending

35:03

beyond the level of the uterine serosa.

35:06

There's potential for invasion of pelvic structures

35:08

here, which we're seeing with the bladder and probably,

35:11

um, you know, even a portion of the vagina perhaps here.

35:14

Um.

35:16

These patients cannot be managed expectantly.

35:18

Um, there is the severe risk for

35:20

peripartum hemorrhage in these cases.

35:22

Uterine artery embolization is done

35:24

for many of these folks, um, but they

35:26

cannot have a vaginal delivery safely.

35:29

If this were a very, very tiny focus

35:31

of only myo-adherent placenta, like one

35:34

centimeter of focus of placenta accreta, you

35:37

may be able to do a partial myomectomy.

35:39

Um, c-section is certainly part of

35:40

this, but unfortunately in these cases,

35:42

uh, the uterus has to be removed.

35:46

Case 17, we have a grayscale ultrasound image of

35:49

the right adnexa, and the sonographer has been

35:53

generous enough to label this right ovary as well.

36:01

What explains the echogenic duration within the lesion?

36:13

Okay, so most of you said the

36:15

presence of hair and that is correct.

36:17

So this is another ovarian

36:19

teratoma or an ovarian dermoid.

36:21

Um, this is what they call the dot

36:23

dash sign of, um, a mature teratoma.

36:26

Uh, so this appearance is characteristic

36:29

of hair mixed with sebum and liquid fat.

36:32

Within the lesion

36:38

Case 18, we have an axial CT image of

36:42

the abdomen at the level of the kidneys.

36:50

This is the same patient we are

36:51

now further down in the pelvis.

36:54

I have a region of interest in the right hemi

36:57

pelvis with an average Hounsfield unit of 42.

37:04

So there's a soft tissue density lesion

37:09

with some fat stranding.

37:13

We're going even further down.

37:15

Here we are at the level of the urinary bladder.

37:18

Here's the left ureter.

37:19

Here's another region of interest

37:21

measuring 66.9 Hounsfield units.

37:24

What best explains the findings present

37:30

Is this a recently passed stone ascending

37:33

urinary tract infection, IgG4 disease,

37:36

urothelial malignancy, or postoperative change?

37:49

Excellent.

37:49

So, urothelial malignancy, right?

37:51

Um, this is a patient, uh, who has a, a

37:55

ureteral cancer until proven otherwise.

37:57

There's hydronephrosis, there's some

37:59

cortical thinning here in the right kidney.

38:01

So this has been going on for a while.

38:03

Um, this is a soft tissue density lesion.

38:06

There's some inflammatory change surrounding it.

38:08

This is way too thick, way too dense, and

38:10

over way too long of a segment of the ureter

38:13

to be related to a recently passed stone.

38:16

Um, IgG4 disease since

38:17

can certainly cause weirdness.

38:19

It can cause soft tissue

38:21

thickening and inflammatory change.

38:23

Um, but for this patient, urothelial malignancy is the

38:25

best answer, and this needs to be investigated further.

38:31

Okay, case 19.

38:32

This is a patient with back pain.

38:33

We have axial contrast-enhanced CT images

38:36

of the abdomen at the level of the kidneys.

38:39

I've dropped a region of interest

38:41

in the left perinephric space and

38:42

it measures 59 Hounsfield units.

38:50

More images, additional axial contrast-

38:54

enhanced CT images of the abdomen.

38:56

Then we also have a coronal post

39:02

diagnosis. Please.

39:13

So we were split between an AML with

39:15

hemorrhage and lymphoma dis infiltration.

39:17

And I like lymphoma as a thought here, right?

39:19

Because lymphoma, it's one of the great mimickers.

39:21

It can do lots of different things.

39:24

Um, there are kind of three different

39:25

appearances that you should think of when

39:27

you think of lymphoma in the kidneys.

39:29

Number one is a solitary renal mass.

39:31

Number two is multiple renal masses.

39:34

And number three is diffuse infiltrative disease.

39:37

So there's definitely a lot of soft tissue

39:39

density here in the left perinephric space.

39:42

The thing that sells this as a bleeding AML is

39:45

there's some fat here in the lower pole, and I'm gonna

39:48

trace my mouse around the outline of this lesion.

39:50

So there's a fat-containing left lower pole

39:52

renal lesion, and we actually see a little

39:54

contrast blush in the periphery of this thing.

39:58

So for rupture would certainly give you fat stranding.

40:01

We often see that in the setting

40:02

of obstructive nephropathy.

40:04

Um, and then post-biopsy hemorrhage.

40:06

Um, could also be a thought here, I guess

40:08

if they were biopsying this AML maybe.

40:11

Um, but these are known to spontaneously

40:13

bleed, and that is the correct answer here.

40:18

Case 20.

40:20

We have two MR images of the abdomen.

40:31

These images were obtained on a 1.5 Tesla magnet, which

40:36

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

40:51

Okay, the majority of you said 4.4

40:53

milliseconds, which is correct.

40:55

Um, so remember that the in-phase images are

40:58

acquired first in in- and out-phase imaging.

41:00

We're taking advantage of the different

41:02

precession frequencies of fat and water protons.

41:05

So for a 1.5 Tesla magnet, um, that's

41:07

gonna be done at 4.4 milliseconds.

41:09

Remember that you will have to adjust your math for a

41:11

three-T magnet, and they may ask you that on the exam.

41:17

Case 21, history withheld.

41:21

We have coronal contrast-enhanced

41:23

images of the abdomen and pelvis.

41:25

We also have an axial and a

41:27

coronal CT for the same patient.

41:39

Which finding on these images favors a diagnosis

41:42

of lymphoma rather than renal cell carcinoma?

41:49

This is from my folks who said lymphoma

41:51

for, uh, the second previous question.

42:03

Excellent.

42:04

So the vast majority of you said

42:06

vascular encasement without occlusion.

42:08

That is the correct answer here.

42:09

So let's look at these images again.

42:11

We have a big infiltrative, left upper pole, renal mass.

42:14

There's a lot of soft tissue here.

42:16

We have extension toward the SOAs muscles.

42:18

We have extension across the midline.

42:19

We have mass effect on the vasculature here.

42:22

One of the words that I like to use

42:23

to describe lymphoma is respectful.

42:26

It's here, it's pushing things out of the way.

42:29

It's causing mass effect.

42:30

It's wrapping itself around vasculature,

42:32

but it's not occluding, right?

42:34

So if you see a big infiltrative soft tissue

42:36

mass anywhere in the abdomen and you see

42:39

encasement without occlusion of the vasculature,

42:42

you should think of lymphoma, right?

42:44

If this were renal cell carcinoma, the thing

42:45

that we would expect to see is what infiltration

42:48

and expansion of the renal vein, right?

42:50

You would expect to see renal vein involvement,

42:52

tumor thrombus present, or at the very least, the

42:54

renal vein is gonna be cut off, um, by this mass.

42:57

So this is a diagnosis of renal lymphoma.

43:00

Well done. Case 22.

43:04

We have T2-weighted axial images of the abdomen.

43:10

This is a T1 pre and a T1 post.

43:19

What's the most common histological

43:21

variety of renal cell carcinoma?

43:23

They will also do this to you.

43:25

You will know the answer.

43:26

You'll look at it and say it's an RCC, and

43:28

then, um, they'll want you to tell them more.

43:41

Excellent.

43:41

So most of you said clear cell,

43:43

and that's the correct answer here.

43:45

These are actually ranked, uh, in

43:47

order from most to least common.

43:49

So clear cell is the most common

43:51

histologic subtype of renal cell carcinoma.

43:53

About 80 to 85% of RCCs are gonna be clear cells.

43:56

Coming up behind that with about 10 to 15%.

43:59

Um, it's gonna be papillary, and then the

44:01

rest of these are anywhere from two to 5%.

44:03

Remember that medullary RCCs, um, are classically

44:06

seen in patients with sickle cell disease.

44:10

Okay.

44:11

Case 23.

44:12

Follow-up ovarian cyst.

44:14

We have a sagittal grayscale ultrasound image

44:16

of the right ovary, and then a transverse

44:19

color ultrasound image of the same ovary.

44:22

I'll give you a moment.

44:24

I will tell you that within the cyst is the

44:27

finding that I would like you to focus on.

44:35

It's here to qualify as struma ovarii.

44:39

What percentage of these tumors

44:41

should be thyroid tissue?

44:53

Okay, so we have a lot of votes for at least

44:55

25% and a lot of votes for at least 10%.

44:59

The answer here is greater than 50%.

45:01

So the dominant type of tissue within the teratoma has

45:04

to be thyroid tissue to classify it as struma ovarii.

45:08

Okay.

45:09

And that's just a tidbit, uh, that you can store

45:12

away in the memory bank. Case 24, we have coronal

45:17

and sagittal contrast-enhanced CT images of

45:20

the abdomen and pelvis with subtle findings.

45:30

Okay.

45:31

What percentage of Krukenberg tumors are bilateral?

45:44

Ooh, this is, this was just a pure

45:46

multiple-choice question here.

45:47

Everyone, uh, shot their shot in

45:49

different, with different answers.

45:51

Pretty evenly distributed here.

45:52

So for test-taking, right?

45:53

20 and 80 are always good answers.

45:56

Um, so the vast majority of

45:57

Krukenberg tumors are bilateral.

45:59

What is a Krukenberg tumor?

46:01

It is a GI primary cancer that

46:03

metastasizes to the ovary.

46:05

So we go back to these CT images.

46:07

Um, the cancer is actually present here on the screen.

46:10

Um, even though the stomach is underdistended,

46:12

it is thickened, it is hyper-enhancing.

46:14

There's kind of this rind of tissue here.

46:17

Lots of different ways that gastrointestinal

46:21

cancers can spread to the ovaries per, you know,

46:23

Kreinberg tumors are very interesting and it

46:25

really depends on the primary cancer present.

46:27

Is it colon?

46:28

Is it small bowel?

46:29

Um, is it stomach?

46:31

Is it, you know, appendix?

46:33

Um, the primary tumor and kind of its

46:35

cancer morphology are going to determine

46:39

how the spread happens to the ovaries.

46:41

So with some gastric cancers, you may be wondering,

46:43

well, this looks pretty confined to the stomach.

46:45

How are we getting to both of the ovaries here?

46:47

They think that for many gastric cancers, the Kreinberg

46:49

tumors actually pass retrograde through the lymphatics.

46:53

Um, and so that's another kind of interesting

46:57

thought exercise that you can do with

46:58

yourself is how did this thing get here?

47:01

So Kreinberg tumors, GI cancer, metastatic to the ovary

47:04

is often gonna look like an enlarged low density cystic

47:07

ovary, and these are bilateral the majority of the time.

47:11

Case 25, we have late arterial phase

47:15

contrast-enhanced images of the abdomen.

47:20

These are CT images.

47:29

What's the most likely diagnosis?

47:41

So the majority of you said pancreatic neuroendocrine

47:43

tumor, which is a great thought, right?

47:45

We have artily-enhancing nodular lesions

47:48

that are present here in the pancreas,

47:50

but this is genital urinary board review.

47:52

This is not GI board review.

47:54

Right?

47:54

And so the key feature that I want you to notice

47:57

on these images is that the left kidney is absent.

48:00

It is no longer with us.

48:01

It has been removed because it

48:03

was, it had renal cell carcinoma.

48:06

And so this is RCC metastatic to the pancreas.

48:09

So other findings on the image will sometimes

48:11

clue you into the diagnosis as well.

48:14

Case 26.

48:15

I feel hopeful that we're

48:16

gonna get through all of these.

48:17

I think we're gonna make it, there's

48:19

an axial contrast-enhanced CT image.

48:23

Of the abdomen, we're kind of just proximal

48:26

to the aortic bifurcation, and this is the

48:28

finding that I want you to be focusing on.

48:33

What is the least likely clinical

48:35

history for this patient?

48:47

Okay, so the majority of you said either vulvar

48:50

melanoma or rectal adenocarcinoma, the small

48:53

majority saying vulvar cancer, and that's right.

48:55

So what I'm really asking you here is I'm showing you

48:58

an abnormal appearing retroperitoneal lymph node here.

49:01

So the real question here is, which one of

49:04

these cancers would not typically spread

49:07

along the retroperitoneal nodal chain?

49:10

So testicular cancer, prostate cancer, we

49:12

think about those, um, spreading to, uh,

49:15

the pelvic sidewall nodes and going up the

49:17

retroperitoneal nodal chain all the time.

49:18

Right?

49:19

Cervical cancer can also do this as can rectal cancer.

49:23

If you think about it, when we're reading rectal

49:24

cancer MRIs, we're looking where we're looking

49:26

in the mesorectal fat pad for lymph nodes there.

49:29

And we're also looking in the

49:30

presacral retroperitoneal space.

49:32

Vulvar melanoma is different.

49:35

This would spread by the superficial inguinal pathway.

49:38

Um, and so that's why, uh, vulvar

49:39

melanoma is the correct answer here.

49:41

This, um, was an image of a

49:43

patient who had testicular cancer.

49:46

Okay?

49:47

Case 27.

49:49

We have sagittal T2-weighted images of the pelvis.

49:54

Um, this is a patient who is pregnant.

49:57

We can see a fetal cranium here.

49:59

Um, there's a lesion present in the uterus.

50:03

The images in the previous slide

50:05

were acquired with which parameters?

50:07

How did we make those?

50:19

Okay.

50:19

The majority of you said long T2, and that's correct because I told you

50:21

earlier these are T2-weighted images.

50:24

So one of the easiest things you can do

50:26

yourself when you're taking

50:28

these exams is to say, which imaging sequences

50:29

are they showing me here with the MRI?

50:31

Um, there are lots of different mnemonics out

50:33

there to help you remember, uh, which imaging

50:38

parameters are gonna produce which MR sequences.

50:40

I like that T2 is a longer number than one.

50:44

So short, short is T1.

50:45

Long, long is T2; long T, short TE is proton density

50:49

weighted imaging, and then a short TR, long TE is nothing.

50:52

It gives you poor contrast.

50:56

Okay, a follow-up question for this case,

50:59

which artifact is present in the axial image?

51:11

So we have two votes here.

51:13

One is for dielectric effect and one

51:15

is for failure of fat suppression.

51:17

So for those of you who said

51:18

dielectric effect, you're correct.

51:19

Dielectric effect is basically a dropout of

51:22

signal in the central aspect of the images.

51:25

Usually when the patient's abdomen is

51:26

large, this can happen with obesity.

51:29

It can also happen in the context of pregnancy.

51:31

Sometimes obesity and pregnancy combined patients

51:33

with liver failure with large volume ascites.

51:36

Um, what happens is you'll see the central

51:38

aspect of the image will look dark.

51:40

This is not failure of fat suppression because these are

51:43

not fat-saturated images, um, Gibbs or Tation artifact.

51:47

Um, it's classically like a duplication

51:50

and you'll see it, um, mostly on neuro

51:52

imaging, kind of like around the spinal cord.

51:55

Fringes.

51:56

This is also known as zebra artifact.

51:58

It's like big rings in the periphery of the images.

52:01

That's from magnetic field inhomogeneity.

52:03

And then wraparound artifact is when your field

52:05

of view is too small and you have intrusion,

52:08

um, of one portion of the image into another.

52:10

So this is dielectric effect in a patient whose

52:13

abdomen, um, exceeded the field of view case 28.

52:19

We have axial CT images of the pelvis in addition

52:23

to a coronal contrast-enhanced pelvic CT.

52:31

Okay, what's the most common

52:32

type of malignant ovarian tumor?

52:44

Excellent.

52:45

Most of you said serous cystadenocarcinoma.

52:48

You are correct.

52:50

Um, so sometimes you'll know the finding,

52:52

you know, based on the images, you'll know,

52:53

oh, this is definitely ovarian cancer.

52:54

There's a big ugly enhancing

52:56

cystic and solid pelvic mass.

52:57

But then you'll just be asked a trivia question.

53:00

So, serous cystadenocarcinoma is the most

53:02

common type of malignant ovarian tumor.

53:04

Um, mucinous is also fairly common.

53:06

Uh, these are less common.

53:08

Think about clear cell carcinoma, a lot

53:10

involving the endometrium and the vagina.

53:12

Um, similarly squamous, we can think

53:13

about, uh, cervix and vagina

53:17

Case 29, axial CT image of the

53:21

upper abdomen with contrast.

53:23

And then coronal companion case, companion image, sorry.

53:31

So where is this centered?

53:33

Think about the imaging features present with

53:37

which underlying syndrome is this tumor associated?

53:52

Okay, so some guesses here.

53:54

We have, uh, von Hippel-Lindau here.

53:57

This is actually Li-Fraumeni, and for

53:59

the sake of time, um, I won't go through

54:01

all of these different, um, syndromes.

54:04

Um, but that was the correct answer for

54:06

this case in the Q&A. We can go through

54:07

it in um, more detail if you'd like.

54:10

Case 30, this is a 91-year-old

54:12

person with vaginal bleeding.

54:15

We have axial and sagittal contrast,

54:18

enhanced CT images of the pelvis.

54:26

And so I'll draw your attention to the

54:29

imaging appearance of the vagina, which

54:32

is what we're seeing here on the sagittal.

54:36

What's the most likely diagnosis?

54:38

Is this a vaginal squamous cell carcinoma?

54:40

An infected ring pessary with an abscess?

54:42

Is it a muscle-invasive bladder cancer,

54:45

vaginal lymphoma, or rectovaginal fistula?

54:57

Okay, so the majority of you said infected

54:59

ring pessary with abscess, and that's what

55:02

I thought too when I first read this case.

55:04

But when you look back, there's

55:05

too much soft tissue here.

55:07

There's too much extensive soft tissue

55:10

thickening and not really enough necrosis or

55:12

cystic change for this really to be an abscess.

55:15

So while you're right, this is a ring

55:16

pessary that's in place here in the vagina.

55:18

Um, for this patient.

55:19

This ended up being a vaginal squamous cell carcinoma.

55:22

Muscle-invasive bladder cancer.

55:23

The bladder really, um, there's a little

55:25

bit of thickening here posteriorly, but it

55:26

is not the dominant mass vaginal lymphoma.

55:29

I don't know if I've ever seen a case of that.

55:31

Um, and then we really don't see, I didn't show

55:34

you anything that looked like diverticulitis.

55:36

Um, so this is a vaginal squamous cell.

55:40

Few more cases left.

55:41

We're in the home stretch.

55:42

Um, this is a patient with a pelvic mass on CT.

55:44

We have T2-weighted axial images of the pelvis.

55:48

We have diffusion and corresponding a

55:50

DWI map also at the level of the pelvis.

55:59

Here's the thing,

56:02

more images.

56:05

This is a T1 post-contrast fat-saturated

56:07

image of the pelvis, and then a SAG T1 post.

56:11

Here's our lesion and there's something here too.

56:15

What's the most likely diagnosis here?

56:19

Is it lymphoma?

56:21

Ovarian fibroma, metastatic cervical, broad ligament

56:25

fibroid or cervicitis with reactive lymphadenopathy.

56:39

Okay, slim majority said metastatic cervical cancer.

56:41

And I like the way you think.

56:43

So we go back to the initial

56:44

images, um, on the diffusion.

56:47

In addition to this, right, um, external iliac slash

56:52

pelvic sidewall node, uh, having a lot of bulk to it,

56:55

a lot of T2 dark signal, a lot of DWI restriction.

56:58

There's diffusion restriction back here in the

57:01

cervix and the posterior lip of the cervix.

57:03

And we can see here on the post-con images,

57:05

there's a weird enhancement pattern here.

57:07

There's almost like a, like an edema

57:10

pattern here present in the cervix.

57:12

Um, and so this is a patient who has a

57:14

cervical cancer with a pelvic node metastasis.

57:19

Next case, this is a patient who is status post

57:22

MDC and we have, um, contrast-enhanced axial

57:28

and coronal and oblique, kind of sagittal,

57:32

um, CT images of the abdomen and pelvis.

57:37

Okay.

57:40

Which of the imaging features make

57:42

placental abruption most likely?

57:55

Okay.

57:56

Um, so we were sort of torn here between hypo

57:59

enhancement of greater than 50% of the placenta and

58:02

then an indistinct placental-myometrial interface.

58:05

Um, late in the pregnancy and with lots of

58:08

different presentation anomalies, you can see

58:10

an indistinct placental-myometrial interface.

58:12

Um, but it's the hypo enhancement of

58:14

greater than 50% of the placenta here.

58:16

So.

58:17

Especially as the pregnancy goes on, third

58:18

trimester, you can see placental heterogeneity.

58:21

It should not be this much.

58:23

So you can see kind of patchy small

58:25

areas of hypoenhancement in the placenta

58:27

as the patient gets ready to deliver.

58:29

Um, and the placenta sort of loses

58:31

or nears the end of its utility.

58:33

Um, but in this patient who has had a trauma, this

58:36

uh, enhancement that we see here, this is the only

58:39

portion of the placenta that's enhancing normally.

58:42

So all the rest of this is a hypoenhancing placenta.

58:46

It's not receiving blood in contrast

58:47

in the way that we would expect it to.

58:49

Um, and so this patient has a

58:51

traumatic placental abruption.

58:52

This patient went for a stat C-section and did okay.

58:57

Okay.

58:58

Third to last case, elevated HCG status.

59:01

Post D&C we have contrast-enhanced arterial and

59:05

venous phase sagittal, um, CT images of the pelvis.

59:09

I'll give you a moment to look at that.

59:22

Okay, and then here's the chest CT.

59:28

Alright, what's the most likely

59:29

diagnosis for this patient?

59:32

Is it GTN metastatic?

59:34

Omata retained products of conception with

59:37

septic emboli, metastatic melanoma involving

59:40

the uterus or uterine and pulmonary AVMs.

59:53

Okay, great.

59:53

So everyone here said gestational trophoblastic neoplasm.

59:56

That is the correct answer.

59:58

For this patient with elevated beta HCG, right?

60:02

There's this really avidly enhancing endometrial lesion.

60:06

We see it's almost kind of indistinct here

60:08

with the posterior aspect of the uterus and the

60:10

uterine fundus has a lot of vascularity to it.

60:13

Even here in the venous phase,

60:14

we see these pulmonary lesions.

60:16

These are metastases.

60:17

Um, and so this is a patient with a gestational

60:20

trophoblastic neoplasm, probably a choriocarcinoma.

60:26

Okay, second to last question, which

60:29

structure is indicated by the red arrows?

60:33

This absolutely happened to me on my board exams.

60:36

They just pointed to a structure

60:38

and they're like, what is that?

60:39

It happened to me, I think three times.

60:41

A few different questions, uh, on the exam

60:43

where it was just straight anatomy, quizzing.

60:53

Okay, great.

60:54

Oh, good for you, you all, almost all of you said

60:56

puborectalis, which is the correct answer here.

60:59

So let's refresh ourselves on,

61:01

uh, pelvic floor anatomy here.

61:03

Right.

61:03

So the puborectus is gonna be this band

61:06

of muscular tissue that wraps around the

61:09

rectum as well as the vagina and the urethra.

61:13

External to that is the pubic hiatus, and then the ab

61:16

terrain is here and we can recognize it, um, as it

61:20

passes and rounds and creates the abator for Raymond.

61:23

Okay, so this is the puborectalis.

61:25

We can see it nicely here, right?

61:26

There's kind of that, um, concomitant anatomy.

61:29

This is urethra, this is vagina, and this is rectum.

61:33

So this is the puborectus.

61:38

Okay, last one.

61:39

36-year-old patient with pelvic pain and fullness.

61:43

We have coronal T2 weighted MR image

61:47

of the abdomen and an accompanying T

61:49

1 fat sat post contrast axial MR.

61:56

Diagnosis, please.

62:07

Okay.

62:08

Um, so most people said a CE cyst diagnosis

62:11

of carcinoma with a colon metastasis.

62:14

Um, and the correct answer here is

62:16

actually rectal cancer with a krukenberg.

62:18

So if we go back, this patient has a

62:20

spiculated, um, rectal sigmoid lesion.

62:24

It's really enhancing.

62:25

It's kind of involving the wall of the colon here.

62:28

Um, ovarian cancer, we think about those lesions

62:31

as being kind of like surface implants, right?

62:34

They kind of glom onto the bowel.

62:36

Um, we think about the, the pattern of peritoneal

62:38

metastatic disease that we can see in ovarian cancer.

62:41

Um, we are seeing really just, um, a, a

62:46

devastating amount of colonic cancer and

62:48

rec, um, colorectal cancer in young patients.

62:51

Um, so this is a case that I read a couple

62:53

weeks ago, um, of a person who has a new

62:55

diagnosis of colorectal cancer and a unilateral,

62:59

um, ovarian metastasis or berg tumor.

63:04

Okay.

63:05

So reminder, these are the things I want you

63:07

to ask yourself when you see these cases.

63:09

Think about anatomic relationships,

63:10

think about signal characteristics.

63:12

What explains this?

63:13

What am I doing next?

63:14

What's gonna help me differentiate

63:16

this from another thing?

63:17

How do they make these images?

63:19

What's the physics behind the

63:20

thing that I'm seeing here?

63:21

And then if you find yourself in a

63:23

pickle, how can I describe these lesions?

63:26

Also, when you go to take your test, um, these

63:29

are like my three tips for anybody taking an exam.

63:31

Snacks, always have like your go-to snacks.

63:34

Everyone has their little snack pack

63:35

that they take with them to an exam.

63:37

Get your snacks, relax.

63:39

Pats on the backs.

63:40

You're gonna be great.

63:41

Thank you so much for your time.

63:43

I will stick around for maybe another

63:44

five minutes to do some Q&A. Um, and

63:47

thanks so much for your attention, Dr.

63:50

Gomez.

63:50

That was incredible.

63:51

You did 35 in an hour, so impressive.

63:53

We did it.

63:55

Amazing.

63:56

Yeah.

63:56

You've got a question in the Q&A box right now.

63:59

Okay.

64:00

If you wanna pop it open or, yeah, I got it.

64:02

Awesome.

64:03

What do you use as your upper limit of normal for

64:05

a postmenopausal patient's endometrial thickness?

64:09

Um, for a patient with postmenopausal

64:11

bleeding, uh, no PMP and just pain.

64:15

Um, I'm guessing that's maybe like,

64:17

uh, I don't know what PMP stands for.

64:20

Um, and patient with no hormonal therapy, so kind of my

64:23

go-to number for, um, postmenopausal patients is five.

64:28

Uh, once things get beyond five

64:30

oh, postmenopausal bleeding.

64:31

Sure.

64:31

Yeah.

64:32

Yeah, no problem.

64:33

Um, it doesn't really matter what the history

64:35

is, you know, if I'm seeing, um, if I'm seeing

64:38

a patient who is, I know is postmenopausal and

64:41

their, uh, endometrial thickness is greater

64:43

than five millimeters, I'm getting concerned.

64:46

Especially if it's not just like

64:48

a nice, smooth sort of genic, uh.

64:52

You know, expected appearance of the endometrium.

64:56

Um, anytime I'm seeing, you know, even things that

64:58

are approaching like seven, eight millimeters, like

65:00

really once we're getting just even a little bit above

65:02

five, um, that's when I, uh, start to get concerned.

65:06

Because the other way to think about it, right, is

65:08

like, um, is like if this was somebody in your family,

65:12

right, what would you want to have done for them?

65:14

And if this was like my mom or, you know, my older

65:16

sister or something, like even, you know, if they

65:18

were having symptoms and, and they had an endometrium

65:21

that looked slightly abnormal, I would want that to be

65:23

investigated, even if it meant that they, you know, got

65:25

an endometrial biopsy just to kind of see that through.

65:29

Okay.

65:29

Another person said, can you

65:30

go over the leiomyoma queso?

65:32

And I like that you spelled it

65:33

like cheese and not like case.

65:35

That's funny to me.

65:36

Okay.

65:38

Let's see.

65:39

Was it number 29?

65:42

I think it was, yeah.

65:43

So what's the lesion here, right?

65:47

What's, so I'll pull this back up again.

65:50

So we have, uh.

65:53

Axial and coronal post contrast images.

65:56

So this lesion is centered in

65:57

the right adrenal gland, right?

66:00

This thing gives me the ick, right?

66:02

It's like a big heterogeneous,

66:05

centrally necrotic lesion here.

66:08

Um, this, uh, you know, when you think about

66:12

like an avidly enhancing, um, adrenal lesion,

66:16

of course, a lot of people think of pheochromocytoma.

66:18

This thing's like a little too big, a little

66:19

too irregular, a little too necrotic for me, uh,

66:22

to really feel comfortable just letting it go.

66:24

As a pheo.

66:25

Um, so my suspicion here is going

66:27

towards adrenal cortical carcinoma.

66:29

So knowing this is an ACC, um, we're gonna think

66:33

about things like Li-Fraumeni syndrome, we're gonna think

66:35

about MEN1, FAP, Beckwith-Wiedemann, um, though,

66:40

you know, if you'd had all those choices and then

66:42

something else, like which of these is not, um,

66:44

but this is, uh, an adrenal cortical carcinoma.

66:48

Does that answer your question?

66:54

I hope so.

66:56

Okay.

66:57

Others, other questions?

67:02

I, I see the, can we go, can you

67:04

explain the Li-Fraumeni syndrome again?

67:06

I think it was asked twice.

67:08

Oh, I see.

67:08

You are probably in the answered section.

67:11

Um, oh, I'm in the answered section.

67:13

Oh, sorry.

67:13

Okay.

67:14

Uh, let's see.

67:15

I was confused if you consider five.

67:17

millimeters abnormal, only if they have

67:18

bleeding and if they're postmenopausal.

67:20

Yeah.

67:20

So in a postmenopausal patient who's

67:22

having bleeding greater than five

67:25

millimeters, um, I'm going to be concerned.

67:29

Right?

67:29

Um, I'm gonna be trying to find an explanation

67:32

for why they're having bleeding, regardless

67:34

of how thick the endometrium is.

67:36

Um, but sort of five millimeters

67:38

and below is acceptable.

67:40

Endometrial thickness for me,

67:42

for a postmenopausal patient.

67:44

Um, you know, if the patient is not having any

67:46

symptoms, right, they're like totally asymptomatic.

67:48

They're not on any medications,

67:50

it's six millimeters, I'm okay.

67:52

Right?

67:52

But if we're at six, seven, eight millimeters and the

67:54

patient is having bleeding, they're having

67:56

symptoms, um, I'm, I'm gonna investigate.

67:59

Yeah.

68:00

Does that answer your question?

68:02

I hope so.

68:04

Cool.

68:05

Awesome.

68:10

Hey, I think, I think we got 'em all.

68:12

Yeah.

68:12

Okay, cool.

68:13

We did it.

68:13

Yay.

68:14

Um, thank y'all so much for having me.

68:16

This was really fun.

68:17

I loved doing board review.

68:18

You're gonna be so great on the exam.

68:20

Um, I wish you the absolute best of luck.

68:24

Dr. Gomez, thank you so much again for doing this.

68:26

Really appreciate all the work this was and

68:28

for, for making it so engaging and you've

68:31

set the record now for getting through 35.

68:32

So we, we, we appreciate it.

68:36

Awesome.

68:36

And thank you so much for everyone, for participating,

68:38

for your questions and for participating in the polling.

68:41

You can access the recording of today's

68:43

case review and previous case reviews

68:45

by creating a free MRIline account.

68:47

And be sure to join us Monday, April 22nd with

68:51

Dr. Melissa Carroll.

68:52

She'll lead us in a rapid review of

68:54

thoracic cases and you can register for

68:56

that at the link provided in the chat.

68:58

Follow us on social media for

68:59

updates for future case reviews.

69:02

Thanks again for learning with

69:03

us and we will see you soon.