Answer for BIR CoW 07 April 2019
Endometriotic cyst
Findings
There is large relatively well defined T2 heterointense lesion with hemorrhagic component & soft tissue & fluid component noted in left ovary. The lesion measures 6 (cranio caudal) x 3.4 (antero-posterior) x 5.2 (transverse) cm. hemorrhagic component shows diffusion restriction. Evidence of well defined T2 heterointense lesion noted in right ovary with solid components & follicles displaced peripherally.The lesion measures 2.5 (transverse) x 3.3 (antero-posterior) x 3.3 (cranio caudal. The lesion shows facilitated diffusion. There is layering noted within lesion. another small T2 hypointense lesion measuring 1.6X 1.8 cm noted in the right adnexa Uterus appears enlarged. There well defined T2 hypointense lesion noted in posterior wall uterus within the myometrium. Uterus measures – 6.7 (cranio caudal) x 5.6 (antero-posterior) x 4.3 (transverse) cm. Endometrial thickness – 9mm. Junctional zone measures 6.7mm. Features suggestive of endometriotic cyst involving both ovaries, right adnexa & focal endometrioma of uterine myometrium
Discussion
ENDOMETRIOMA: Localised form of endometriosis and are seen within the ovary. Also known as chocolate cysts or endometriotic cysts. More common in reproductive age group. PATHOLOGY: contains dark degenerated products following repeated cyclical hemorrhage. cysts may be upto 20 cm but they are usually smaller(2-5cm) TYPICAL LOCATIONS Ovaries-75% Anterior/posterior cul-de-sac-70% Posterior broad ligament-50% Uterosacral ligaments-35% Uterus-10% Colon-5% USG: Unilocular cyst with acoustic enhancement with diffuse homogenous ground glass echoes as a result of the hemorrhagic debris.this occurs in 50% cases. Less typical features include -multiple locules. -hyperehoeic wall foci -Cystic-solid lesion -anaehoeic cysts. MRI: T1-hyperintense while acute hemorrhage appears hypointense. Endometriomas with high T1 signal characteriscally do not show loss of signal on T1 fat suppressed sequence,which is important for differentiating it from mature cystic teratoma of ovary. T2-hypointense owing to the presence of deoxy hemoglobin and methemoglobin(shading sign),which is very suggestive of endometrioma. T2 dark spot sign. Old hemorrhage occasionally appears hyperintense. T2 DARK SPOT SIGN: As a result of chronic hemorrhage in endometrioma. Seen within the cyst often against the cyst wall itself (usually the of low T2 signal due to hemosiderin-laden macrophages and fibrous content of the cyst wall) Useful in differentiating endometrioma from hemorrhagic ovarian cyst as both might show high T1 signal and T2 shading. DWI- variable restricted diffusion. T1C-may have wall enhancement The presence of mural nodule suggests malignant transformation.
Findings
There is large relatively well defined T2 heterointense lesion with hemorrhagic component & soft tissue & fluid component noted in left ovary. The lesion measures 6 (cranio caudal) x 3.4 (antero-posterior) x 5.2 (transverse) cm. hemorrhagic component shows diffusion restriction. Evidence of well defined T2 heterointense lesion noted in right ovary with solid components & follicles displaced peripherally.The lesion measures 2.5 (transverse) x 3.3 (antero-posterior) x 3.3 (cranio caudal. The lesion shows facilitated diffusion. There is layering noted within lesion. another small T2 hypointense lesion measuring 1.6X 1.8 cm noted in the right adnexa Uterus appears enlarged. There well defined T2 hypointense lesion noted in posterior wall uterus within the myometrium. Uterus measures – 6.7 (cranio caudal) x 5.6 (antero-posterior) x 4.3 (transverse) cm. Endometrial thickness – 9mm. Junctional zone measures 6.7mm. Features suggestive of endometriotic cyst involving both ovaries, right adnexa & focal endometrioma of uterine myometrium
Discussion
ENDOMETRIOMA: Localised form of endometriosis and are seen within the ovary. Also known as chocolate cysts or endometriotic cysts. More common in reproductive age group. PATHOLOGY: contains dark degenerated products following repeated cyclical hemorrhage. cysts may be upto 20 cm but they are usually smaller(2-5cm) TYPICAL LOCATIONS Ovaries-75% Anterior/posterior cul-de-sac-70% Posterior broad ligament-50% Uterosacral ligaments-35% Uterus-10% Colon-5% USG: Unilocular cyst with acoustic enhancement with diffuse homogenous ground glass echoes as a result of the hemorrhagic debris.this occurs in 50% cases. Less typical features include -multiple locules. -hyperehoeic wall foci -Cystic-solid lesion -anaehoeic cysts. MRI: T1-hyperintense while acute hemorrhage appears hypointense. Endometriomas with high T1 signal characteriscally do not show loss of signal on T1 fat suppressed sequence,which is important for differentiating it from mature cystic teratoma of ovary. T2-hypointense owing to the presence of deoxy hemoglobin and methemoglobin(shading sign),which is very suggestive of endometrioma. T2 dark spot sign. Old hemorrhage occasionally appears hyperintense. T2 DARK SPOT SIGN: As a result of chronic hemorrhage in endometrioma. Seen within the cyst often against the cyst wall itself (usually the of low T2 signal due to hemosiderin-laden macrophages and fibrous content of the cyst wall) Useful in differentiating endometrioma from hemorrhagic ovarian cyst as both might show high T1 signal and T2 shading. DWI- variable restricted diffusion. T1C-may have wall enhancement The presence of mural nodule suggests malignant transformation.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!