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So let's look at a few real-world cases demonstrating diagnostic

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reasoning and potential complications and

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image data biopsies of introdominal lesions.

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So here we have a 66 year old female with history

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of microscopic colitis presenting with 10 days of abdominal distention

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pain and dark stools.

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So unliker typical Colitis symptoms, the pain is

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actually not a alleviated with bowel movements and she

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also notes but 25 pounds of weight loss

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within the last year.

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Her vital signs are within the limits of normal. Her examination is

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notable for some abdominal distention was shifting

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downness.

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Bedside ultrasound confirms societies labs are

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notable for a ca-125 greater than

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2000 here. We see a physician performing a paracentesis and

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the fluid that is aspirated

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the parasitesis yields as clear

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yellow fluid.

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The question for you is the patient's age and extreme

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ca-125 elevation rates suspicion for

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what?

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tuberculosis cholangiocarcinoma

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messenger lymphoma

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Wolverine cancer

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the patient's age in extreme ca-125

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elevation Ray suspicion for ovarian cancer.

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So ca-125 is a particularly strong and

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though often non-specific Mark of neoplastic pathology.

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That is more commonly associated with gynecologic malignancies

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than other options given

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so what are our next steps So the patient's paracentes is

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report is submitted for fluid insideologic analysis.

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Song the serum albumin site is

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gradient is less than 1.1 suggesting non portal etiology

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of cirrhosis.

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The cytology suggests malignant cells of non-matopoietic origin

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requiring further sampling for full characterization.

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The patient is then sent from abdominal CT

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with contrast.

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So what do we see?

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If you thought that there was large volume ascites, then

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you would have been spot on.

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So there's this a regular enhancing nodularity

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around the right pelvic sidewall the

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reproductive organ evaluations, although a little

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limited secondary the street artifact from the bilateral hip

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prosthesis, but something I'm

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turning is there.

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So the patient is referred for transvaginal ultrasound,

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which we see to the right.

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And the impression on that is similar societies with

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low level internal Echoes, but then there's thought to

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be this tubular echogenic soft tissue mass in the right pelvicidal with

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potential thrombosis of the ovarian vein.

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So the question for you, so given this patient's history of

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hip arthroplasty. How would you further the

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characterize the soft tissue mass in our pelvis?

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Would you consider CT without contrast?

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Would you consider MRI?

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How about an fdg pet scan or perhaps

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a contrast enhanced ultrasound?

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So given the patient's history of hip arthroplasty.

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Perhaps you would consider the soft tissue Mass

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evaluation better supported by an MRI an MRI

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of the pelvis both with and without Ivy contrast

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will actually help to elucidate the soft tissue structure of

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the pelvic pathology. Wow, avoiding

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and mitigating the issues concerning streak artifact

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associated with the patient's hip prosthesis.

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So in the reading room, what do we see here?

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What you would have seen?

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Hopefully is this diffuse peritoneal

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enhancement with areas of peritoneality here?

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We see thickening in this

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particular region.

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And on this region as well.

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markedly enhancing area nodularity particularly

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concerning

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There's concern for the right ovary thought to

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have solid components.

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And in this particular region, there's a

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soft tissue deposit in the gastrocolic space that's concerning

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for metastasis to the gastrocolic ligament

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or Elemental caking.

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Question for you. Now, what will be the next best step to confirm the

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underlying cause of this patient societies?

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Would you consider repeat paracentesis?

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Would you submit genetic testing

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of the acidic fluid?

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Would you perform a biopsy of the gastricolic mass?

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What would you?

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Say no further testing is required.

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If you thought but biops seeing the gastricolic mass was the

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next best step you would have been spot on so given that

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this is likely to represent metastasis labsing

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of the mass within the gastricolic ligamists likely

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to Lucid the underlying primary cancer.

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So which intra abdominal structure is the

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gastrocolic ligamental part of is it the less romantic?

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Is it the Miso colon? Is it the Miso

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salvings?

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Or is it the greater momentum?

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If you set the great omentum.

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Kudos you would have been spot on.

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So the ligaments of the granomentum include as we would

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have mentioned previously the gastrocolic ligament gastrophenic

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gastrosplenic splinterino

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and frenicle Splinter

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ligaments.

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So what are our next steps?

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So the patient undergoes a technically successful core

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needle biopsy of the gastrocolic mass. The histologic

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sample is fixed in formalin and sent

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for pathologic analysis.

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The pathology report for the patient's sample Returns

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the next day.

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And in conclusion, we have high grade serious carcinoma

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malarian origin findings consistent with

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primary ovarian cancer.

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The patient is actually informed appropriately for

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diagnosis and she is then connected with a

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dedicated gynecologic oncologic team for further

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treatment.

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She scheduled for further CTE in order to State your

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cancer and then plans appropriate medical

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therapy targeted towards the ovarian neoplasm.