{
    "Contributors": "MIMIC",
    "Source": "MIMIC-IV",
    "URL": "https://www.physionet.org/content/mimic-iv-note/2.2/",
    "Categories": [
        "Summarization"
    ],
    "Definition": [
        "Summarize the MRI imaging diagnostics' detailed findings for the Pelvis into a concise conclusion."
    ],
    "Reasoning": [],
    "Input_language": [
        "English"
    ],
    "Output_language": [
        "English"
    ],
    "Instruction_language": [
        "English"
    ],
    "Domains": [
        "Medicine",
        "Clinical Reports",
        "MRI",
        "Pelvis"
    ],
    "Positive Examples": [],
    "Negative Examples": [],
    "Instances": [
        {
            "input": "UTERUS AND ADNEXA:\n2.6 x 1.5 cm mass is identified in the endometrium, demonstrating restricted\ndiffusion, similar to ___.  There is no measurable enhancement.\nThe uterus is anteverted and measures 9.0 x 6.3 x 6.3 cm.\nThe junctional zone is not thickened.\n\nThe ovaries are unremarkable for age.  3.9 x 2.3 cm cystic lesion in the left\nadnexa, superior to the left ovary is slightly larger compared to ___ (previously 2.9 x 2.5 cm), likely reflecting left hydrosalpinx.  No\nworrisome features.\n\nTrace pelvic free fluid is within physiologic limits.Mild smooth thickening of\nuterosacral ligament is again noted, consistent with postradiation change.\n\nLYMPH NODES: Prominent right external iliac lymph nodes measuring up to 1.2 cm\nin short axis (05:19) is unchanged.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning bone lesion is identified. \nThe increased T2 signal within the lower lumbar and sacral bone marrow likely\nreflect postradiation change.  2.5 x 2.8 x 7.2 cm lesion with intermediate T1\nand T2 signal in the medial aspect of left gluteus maximus is unchanged and\nlikely reflect chronic hematoma.",
            "output": "1. Stable treated endometrial mass demonstrating restricted diffusion, similar\nto ___ however without measurable enhancement.\n2. Left hydrosalpinx without complex features, slightly larger than before."
        },
        {
            "input": "There is increased signal at the insertion of the rectus abdominus adductor\naponeurosis onto the pubic symphysis with reactive marrow edema, right side\nworse than left.  There is trace fluid signal on the right extending between\nthe tendon and the pubic symphysis, suggestive of a partial tear (03:23;\n06:30).  There is also edema within the adductor muscles on the right side,\nbest seen on series 3, image 24.\n\nA small mildly lobulated T2 hyperintense focus extending superiorly from the\nanterior joint space along the left iliopsoas tendon may represent a small\nganglion cyst versus extension of joint fluid (03:17).  The femoroacetabular\njoints are congruent bilaterally.  There is no significant joint effusion. \nThere is a 5 mm T2 hyperintense focus abutting the right posterior labrum,\nraising suspicion for a labral tear with a small associated paralabral cyst\n(03:14).\n\nThere is no bone marrow signal abnormality.  The visualized muscles and\ntendons are otherwise within normal limits.  Limited evaluation of the pelvic\nstructures does not reveal gross abnormalities.",
            "output": "1. Fluid signal at the insertion of the rectus abdominus adductor aponeurosis\nonto the pubic symphysis with reactive marrow edema, bilaterally but more\nprominent on the right side.  Findings are consistent with a \"sportsman's\nhernia\".\n2. A small right posterior paralabral cyst, raises suspicion for an occult\nlabral tear."
        },
        {
            "input": "No bone marrow edema signal to suggest contusion or fracture about the sacrum/\ncoccyx or elsewhere about the pelvic girdle.  No spondylolisthesis is\nidentified.  Minimal subchondral bone marrow edema pattern seen surrounding\nthe upper most portion of the left SI joint is noted, likely degenerative \n(06:15).  SI joints are otherwise within normal limits.  No soft tissue edema\nis seen about the coccyx.\n\nThere is a small amount of fluid in the bilateral hip joints.  No hip joint\neffusion.  No significant degenerative changes of the bilateral hip joints.\n\nMuscles are normal signal and bulk.  There is trace edema at the bilateral\ngreater trochanters.  There is mild tendinosis of the left gluteal tendons. \nNo greater trochanteric bursitis.\n\nRemaining visualized tendons are intact.\n\nLimited assessment of intrapelvic soft tissue structures shows no free fluid\nor enlarged iliac lymph nodes.\n\nThe uterus is retroflexed, better demonstrated on sagittal images from the\nL-spine MRI performed on ___.  There is a T1 and STIR hypointense\nlesion in the region of the right adnexa, measuring approximately 1.6 x 1.1 x\n23.1 cm, may represent a pedunculated fibroid, broad ligament fibroid,\nendometrioma, or fibrous ovarian lesion.",
            "output": "1.  Trace edema surrounding the uppermost left SI joint, likely degenerative.\n\n2.  Otherwise, the sacrum and coccyx are within normal limits.  No acute\nfracture or spondylolisthesis detected.  No bone marrow edema signal to\nsuggest contusion.  No surrounding soft tissue edema.\n\n3.  Rounded 15.6 mm lesion in the right adnexa, hypo intense on both T1 and\nSTIR images, raises the possibility of a fibrous ovarian lesion (e.g.  ovarian\nfibroma ___ lesion).  The differential diagnosis includes a\npedunculated or broad ligament fibroid or possibly an endometrioma.  Dedicated\npelvic ultrasound is recommended for further characterization.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 16:52 into the Department of Radiology\ncritical communications system for direct communication to the referring\nprovider.\n\nRECOMMENDATION(S):  Low T2 signal right ovarian adnexal lesion.  Dedicated\npelvic ultrasound is recommended for further characterization."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nPreviously demonstrated mass in cervix is no longer visualized.  There is\nreconstitution of normal T2 signal the cervical stroma, except small area of\nabnormal T2 hyperintensity, which is likely posttreatment change.  No\nrestricted diffusion is present.  A cervical mass is not demonstrated and\ndifficult therefore not measured.\nT2 hypointensity bilateral parametrium and surrounding the right ureter likely\nreflects fibrosis related to treatment.\nThe endometrium is now within normal limits for age suggestive of improvement\nof prior uterine corpus obstruction.\nThe junctional zone is not thickened.\n\nPreviously seen nodules in the right adnexum are no longer visualized.  Left\novary has been removed.  The right ovary appears small with a hypointense T2\nrim which could be due to postradiation changes.\n\nTrace pelvic free fluid is within physiologic limits.\n\nSmall amount of presacral edema is noted, likely related to treatment.\n\nLYMPH NODES: The largest lymph node is located in the left external iliac\nregion and measures 1.1 cm, slightly smaller than before (previously 1.3 cm). \n1.0 cm right external iliac lymph node is also smaller (previously 1.5 cm). \nPreviously noted prominent left internal iliac lymph node is not demonstrate.\n\nBLADDER AND DISTAL URETERS: Right ureteral stent is in place.  Thickening of\nthe right bladder wall likely reflect posttreatment change.\n\nVASCULATURE: Iliac and femoral vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Increased T2 hyperintensity of the bone\nmarrow likely reflect posttreatment changes.",
            "output": "1. Excellent treatment response of cervical cancer and pelvic adenopathy. A\ncervical mass is not well visualized and therefore not measured.\n2. Post treatment changes are noted, including fibrotic changes in the\nparametrium and surrounding the right ureter.  Right ureteral stent is\npresent."
        },
        {
            "input": "There is generalized heterogeneity of the marrow signal with a \"salt and\npepper\" appearance in keeping with known multiple myeloma.  In the right\nposterior iliac wing, there is a 2.4 (AP) x 1.4 (TV) x 2.0 (cc) cm lesion\n(04:18) which is isointense to muscle on T1 weighted images and hyperintense\non T2 weighted images likely reflecting a myelomatous deposit. The lesion\nthins the overlying cortex but there is no definite soft tissue extension.\nThere is a trace amount of surrounding edema.  An additional 6 mm lesion is\nnoted superiorly.  In the right subtrochanteric region, there is faint T2\nhyperintense signal in the femur are (05:11) without corresponding fracture\nline or T1 signal hypointensity. This may relate to the known myeloma. There\nis a compression deformity of the L2 vertebral body.\n\nThere is no avascular necrosis in the femoral heads.\n\nThere is trace fluid within both hip joints, likely physiologic.\n\nTrace edema about both greater trochanters is likely physiologic.\n\nThe muscles are symmetric in appearance.\n\nThere is a subchondral cyst within the left acetabulum measuring 7 mm.\n\nThe sacroiliac joints and pubic symphysis are unremarkable.\n\nThe examination is not dedicated to evaluation of the labrum.  No large\nparalabral cyst is appreciated.\n\nThe examination is not dedicated to evaluation of the pelvic contents.  There\nis diverticulosis.",
            "output": "Findings consistent with known myeloma with discrete lesions in the right\niliac bone and possibly the right subtrochanteric region.  Alternatively, the\nfindings in the subtrochanteric region could reflect stress related changes."
        },
        {
            "input": "There is no bone marrow signal abnormality.  The femoroacetabular joints are\ncongruent bilaterally.  There is no joint effusion.  There is extensive\ndiffuse subcutaneous edema, most prominent along the gluteal regions\nbilaterally, right greater than left.  Immediately inferior to the right\nischial tuberosity, there are ill-defined inflammatory changes in the fat the\ncentered around a small fat lobule without fluid signal in this region likely\nrepresenting fat necrosis (08:36).  There is enhancement and edema surrounding\nthe left hamstring tendons, which may represent tendinosis.  There is no\nevidence of rim enhancing fluid collection in the soft tissues suggest abscess\nformation.",
            "output": "1. No MRI evidence of osteomyelitis, osseous metastatic disease, or soft\ntissue abscess formation.\n2. A small focus of inflammatory change within the fat posterior to the right\nischial tuberosity is likely due to fat necrosis.\n3. There is extensive subcutaneous edema is most prominent along the gluteal\nregions bilaterally.  This can be seen with cellulitis and should be\nclinically correlated."
        },
        {
            "input": "The patient has had prior surgery with S1-S2 laminectomy and presumed removal\nof a meningeal cyst.  There is a bony defect seen at site of prior surgical\nresection (07:17), similar in appearance when compared to the prior CT. \nSeveral of the patient's prior MRIs of the lumbar spine did not include this\narea on the axial images however what is seen, appears broadly similar.  There\nis fluid signal intensity material filling the post operative defect, it is\nnot clear whether this represents recurrence of patient's meningeal cyst\nversus a postoperative seroma.  Contiguity with the CSF is difficult to\nevaluate on the current study.  Recommend repeat imaging, dedicated to the\nsacrum with and without contrast.\n\nOtherwise, the visualized bony structures are unremarkable in appearance.  No\nfracture seen.  There are mild degenerative changes in the bilateral hip\njoints.  No joint effusion seen.  Mild tendinosis of the proximal hamstring\ntendons bilaterally.  Mild gluteal tendinosis bilaterally, slightly worse on\nthe left than the right.  The muscles of the pelvic girdle are symmetric and\notherwise unremarkable in appearance.\n\nEvaluation of the pelvic parenchymal structures is limited.  No free fluid in\nthe pelvis, no pelvic lymphadenopathy.  Probable tiny fibroids in the uterus. \nVisualized bone marrow signal is unremarkable.",
            "output": "Postoperative changes in the upper is sacrum with fluid signal intensity\nmaterial tracking through the surgical defect.  This may reflect a\npostoperative seroma but is difficult to evaluate any contiguity with the CSF\nspace on the current study.  Recommend repeat MRI, dedicated to the sacrum\nwith and without contrast.\n\nBilateral gluteal tendinosis, worse on the left.  Bilateral hamstring\ntendinosis.\n\nMild degenerative changes in the bilateral hip joints.\n\nTiny fibroids in the uterus."
        },
        {
            "input": "Note is made of a gross right hydronephrosis with a right\nhydroureter down to the ureterovesical junction.  A lesion of high signal\nintensity on T2-weighted imaging is seen in the lower pole of the left kidney,\nlikely consistent with a cyst and measures 16 mm.\n\nThere is increased signal intensity within the right psoas muscle extending\ndown to the right iliacus on the T2-weighted imaging.  There is increased\nsignal intensity on the T2-weighted imaging in the right sacral ala as\nidentified on the previous MRI.  A curvilinear low-signal intensity line runs\nthrough this high signal within the right sacrum, and the appearances may be\nconsistent with the previously identified right sacral fracture.  Post\nadministration of contrast, there is enhancement within the right iliopsoas as\nwell as in the right sacral ala, which may be consistent with edema.  A well-\ncircumscribed lesion of high signal intensity on T2-weighted imaging within\nthe right iliac bone is identified that measures 8.5 mm on T2-weighted\nimaging.  It is of intermediate to increased signal intensity on T2 and\ndemonstrates contrast enhancement.  The findings for this lesion are non-\nspecific, and this was also identified on the previous MRI.\n\nSome degenerative change is noted in the lumbar spine with degenerative disc\ndisease at the L5-S1 level.\n\nSome free fluid is identified in the pelvis.  Note is made of sigmoid\ndiverticulosis without evidence of diverticulitis.\n\nNote is made of a lesion of low signal intensity on the T1-weighted imaging\nthat is of high signal intensity on the T2-weighted imaging that demonstrates\nenhancement post administration of contrast in the right L5 exit neural\nforamen that measures 9 mm x 7 mm.  This may represent a lesion of the right\nL5 nerve sheath versus enhancement of the nerve root itself.\n\nNo evidence of any significant retroperitoneal lymphadenopathy.\n\n2D and 3D reformations provided multiple perspectives for the dynamic series.",
            "output": "1.  Right sacral ala fracture identified as before with high signal on T2-\nweighted imaging and enhancement post contrast.\n2.  Edema and enhancement within the right iliopsoas muscle, which may\nrepresent changes secondary to radiation due to the more focal nature of\nenhancement or alternatively may be secondary to nerve compression from the\nright L5 lesion.\n3.  Non-specific right iliac lesion, which is unchanged.\n4.  Severe right hydronephrosis with right hydroureter to the level of the\nright vesicoureteric junction.\n5.  Enlarged enhancing right L5 nerve root in the exit foramen. Differential\nincludes post-radiation changes versus metastatic disease."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nPatient is status post bilateral salpingo-oophorectomy.  In the right lower\nquadrant, just inferior to the right kidney and between the right iliacus\nmuscle on the right psoas muscle which is displaced medially, there is a 6.6 x\n5.7 x 6.5 cm lobulated T2 hyperintense mass which enhances heterogeneously and\nrestricts diffusion (3: 35; 04:10; 05:17).  There is no fat plane between this\nmass and the right iliacus and psoas muscles.  The cortex of the right iliac\nbone appears intact.  Additionally, this mass abuts a loop of bowel anteriorly\nwhich it has broad-based contact with (1203:30).  There is trace edema in the\nright lower quadrant inferior to the mass.\n\nThe uterus is anteverted and measures 3.2 x 1.5 x 2.7 cm.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened\n\nLYMPH NODES: No inguinal lymphadenopathy.  A reported 6 mm right external\niliac node which had uptake on recent FDG scan is not seen.\n\nBLADDER AND DISTAL URETERS: Normal.\n\nRECTUM AND INTRAPELVIC BOWEL: A loop of bowel in the right lower quadrant\nabuts the right lower quadrant mass.  Additional loops of small and large\nbowel are unremarkable.\n\nVASCULATURE: Patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The cortex of the right iliac bone\nadjacent to the mass in the right lower quadrant appears intact.  No\nsuspicious osseous lesions.",
            "output": "1. 6.6 cm right lower quadrant mass suspicious for recurrent ovarian cancer. \nThis mass lies between the right iliacus and right psoas muscles which it\nabuts without a preserved fat plane, however the cortex of the right iliac\nbone appears intact.  Additionally, the mass abuts a loop of bowel anteriorly\nwhich it has broad-base contact with and early invasion or adhesion cannot be\nexcluded.\n2. A reported FDG avid right external iliac node seen on recent outside PET-CT\n(images not available for review), is not definitely seen on this MRI\nexamination."
        },
        {
            "input": "The right lower abdominal/upper pelvic mass is incompletely imaged, as the\nsuperior aspect of the mass is in the lower abdomen and just beyond the\nsuperior border of the scan range.\n\nInterval decrease in size of right-sided pelvic mass now measuring 3.7 x 4.5 x\n2.7 cm (series 2, image 25).  The mass is now mildly and heterogeneously T2\nhypointense, with persistent enhancement consistent with fibrosis and\ntreatment response to radiation therapy.\n\nOn the previous examination, the mass was 6.6 x 5.7 x 6.5 cm, significantly\nmore hyperintense on T2W and T2FS images, and had more homogenous\nhypoenhancement.\n\nThere is surrounding bone marrow and muscular edema.  No overt invasion of the\nright iliac bone, though involvement of the adjacent musculature is difficult\nto assess given the limitations of the imaging.\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and diminutive, measuring 3.3 x 1.5 cm.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nPatient is status post bilateral salpingo-oophorectomy.  No evidence of\nabnormal enhancement or soft tissue mass in the surgical bed.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No evidence of pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable\n\nRECTUM AND INTRAPELVIC BOWEL: Stool-filled sigmoid colon.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No evidence osseous lesion.",
            "output": "The right lower abdominal/upper pelvic mass is incompletely imaged, as the\nsuperior aspect of the mass is in the lower abdomen and just beyond the\nsuperior border of the scan range.  In order to encompass the target lesion on\nfuture examinations, imaging should include both the lower abdomen as well as\nthe pelvis.\n\n1. Notable interval decrease in size of right pelvic mass now measuring 3.7 x\n4.5 x 2.7 cm with T2 hypointense appearance and persistent enhancement\nconsistent with fibrosis/response neoadjuvant radiation.  Relationship with\nadjacent structures is difficult to determine as the lesion is incompletely\nvisualized as noted. Repeat imaging of the low abdomen to the pelvis can be\nobtained if further characterization is needed.\n2. Status post bilateral salpingo oophorectomy.  No evidence of abnormal\nenhancement or soft tissue mass in the surgical bed."
        },
        {
            "input": "Please note that this study is not specifically tailored to evaluate the\nprostate.  The prostate gland has decreased in size, 3.9 x 3.5 x 3.9 cm,\npreviously 5.7 x 5.1 x 5.4 cm on outside MRI of the pelvis from ___.\n\nThere is diffuse wall thickening and trabeculation of the bladder.  There is a\nlinear focus of enhancement in the subcutaneous tissues of the anterior\nmidline pelvis extending to the anterior bladder wall (series 1502, image 57),\npostoperative in nature from prior suprapubic catheter.\n\nThere is a 1.0 x 0.6 cm left pelvic sidewall lymph node (series 1501, image\n52), decreased in size compared to CT of the abdomen/pelvis from ___, previously 2.1 x 1.9 cm.  Bilateral external iliac lymph nodes have also\ndecreased in size, for example a 0.9 x 0.8 cm node on the right (series 1501,\nimage 36), previously 1.6 x 1.3 cm, and a 1.3 x 0.6 cm node on the left\n(series 1601, image 43), previously 1.6 x 1.3 cm.  A 1.6 x 1.1 cm left\npara-aortic node at the level of the aortic bifurcation remains unchanged in\nsize (series 5, image 1), previously 1.4 x 1.1 cm.  A 1.2 x 1.0 cm right\ncommon iliac node (series 5, image 8), has decreased in size, previously 1.5 x\n1.4 cm.\n\nThere is marrow replacement of the entire left femoral neck and a portion of\nthe femoral head with corresponding enhancement and restricted diffusion,\ncompatible with osseous metastasis.  There is no evidence of left hip fracture\nat this time.  There is a 1.9 x 1.8 cm enhancing, diffusion restricting lesion\nin the subtrochanteric left proximal femur, also compatible with a metastasis.\nThere is also metastatic involvement of the right acetabulum, involving the\nentire anterior wall and a portion of the posterior wall.  There are\nadditional metastases in the pelvis, with a few representative examples\nincluding a 2.9 x 1.6 cm lesion in the left ilium adjacent to the sacroiliac\njoint (series 1503, image 22), a 1.4 x 1.4 cm lesion in the right sacrum\n(series 1503, image 22), and a 0.9 x 0.7 cm lesion in the left sacrum (series\n1503, image 14).  There are also metastases in the visualized lumbar spine,\nfor example a 1.3 x 1.1 cm lesion in the L5 vertebral body (series 1503, image\n2).",
            "output": "1.  Osseous metastasis replacing the entire left femoral neck and a portion of\nthe femoral head.  No evidence of left hip fracture at this time. CT would be\nmore accurate a determining degree of cortical bone loss and risk of\npathologic fracture.\n\n2.  Additional osseous metastases within the subtrochanteric left proximal\nfemur, right acetabulum, pelvis, sacrum and visualized lumbar spine as\ndescribed.\n\n3.  Significant decrease in size of the prostate gland since the outside MRI\nof the pelvis from ___ (please note that this study is not\nspecifically tailored to evaluate the prostate).\n\n4.  Overall decrease in size of retroperitoneal and pelvic lymphadenopathy\nsince the prior CT of the abdomen/pelvis from ___."
        },
        {
            "input": "RECTUM/ANUS/INTRAPELVIC BOWEL:  Foci of signal void/susceptibility artifact\nare seen along the anterior midline (12 o'clock) aspect of both the internal\nand external anal sphincters, including a linear focus extending in the\nanteroposterior direction towards the vagina, consistent with postsurgical\ndefect from prior fistula excision and sphincteroplasty.  Surrounding the\nlinear foci of signal void is thin T2 hyperintense signal and slight\nhyperenhancement, consistent with granulation tissue.  There is no evidence of\npersistent, fluid-filled fistulous tract.  No evidence of focal fluid\ncollection.  Elsewhere, no evidence of new fistula.  The imaged loops of\nintrapelvic large and small bowel are within normal limits.\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7.5 x 3.0 x 4.2 cm.  There is enhancing\nexophytic 8 mm fibroid at the fundus (03:21).\nThe endometrium is normal in thickness for age and measures 6 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nThere is no significant free pelvic fluid.\n\nLYMPH NODES: There is a 4 mm left internal iliac lymph node.  No\npathologically enlarged pelvic or inguinal lymph nodes.\n\nBLADDER AND DISTAL URETERS: The bladder and terminal ureters are within normal\nlimits.\n\nVASCULATURE: Imaged pelvic vasculature is normal in caliber and patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious foci of abnormal marrow\nsignal are seen.",
            "output": "Post-surgical changes related to prior resection of trans-sphincteric\nrectovaginal fistula and repair/sphincteroplasty, without evidence of residual\nfluid-filled fistulous tract.  No focal fluid collection."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Rectum, visualized small and large bowel are\nunremarkable.  No wall thickening or edema.  No obstruction.\n\nBLADDER AND DISTAL URETERS: Bladder is well distended and thin-walled.  Distal\nureters are unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate and seminal vesicles are\nunremarkable.  Small amount of intrinsic T1 hyperintensity is noted within the\nscrotum, consistent with scrotal hematoma as seen on same day ultrasound. \nBilateral testicles are intact.\n\nPENILE: There is irregularity of the left corpora cavernosa and left tunic\nalbuginea along the inferomedial base with early asymmetric arterial\nhyperenhancing of the left corpora cavernosa.  (10: 28, 29; 11:69)\n\nLYMPH NODES: No inguinal or pelvic sidewall lymph node enlargement.\n\nVASCULATURE: Patent vasculature.  No aneurysmal dilatation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No abnormal bone marrow signal.  Soft\ntissues are unremarkable.",
            "output": "1.  Findings worrisome for disruption of ___ albuginea along inferomedial\nbase of left corpora cavernosa with early asymmetric arterial hyper\nenhancement of left corpora cavernosa.\n2.  Small scrotal hematoma.  Intact bilateral testicles.\n\nNOTIFICATION:\n\nThe findings were discussed with ___, M.D. by ___, M.D.\non the telephone on ___ at 12:23 pm, 5 minutes after discovery of the\nfindings."
        },
        {
            "input": "Left hip:  The patient is status post left total hip arthroplasty.  Accounting\nfor hardware-related artifact, there is T1 intermediate/hyperintense contents\nexpanding the pseudocapsule which may represent hemorrhagic or proteinaceous\nmaterial.  Fluid is suboptimally assessed on these artifact-degraded images.\n\nRight hip:  There is heterogeneous marrow signal and collapse of the right\nfemoral head consistent with avascular necrosis.  There is extensive marrow\nedema extending from the femoral head inferiorly into the proximal femoral\ndiaphysis.  A moderate right femoroacetabular joint effusion is noted.  In\naddition, there is periarticular edema identified within the hip adductors and\nquadratus femoris musculature.\n\nA moderate amount of fluid is seen within the right ischial bursa, with\npartial tears of the right hamstring origins.\n\nPelvic bones:  Foci of STIR hyperintensity throughout bilateral sacral alae\nand iliac bones are consistent with combination of post radiation\nosteonecrosis and probable bilateral chronic sacral ala insufficiency\nfractures.\n\nPelvic soft tissues:  The patient is status post pelvic exenteration with\nright and left lower quadrant ostomies identified.\n\nThere is mild presacral fluid.\n\nLimited assessment of the lower lumbar spine is grossly unremarkable.",
            "output": "1. Right femoral head AVN with partial femoral head collapse.  A right hip\njoint effusion periarticular edema may be reactive however infection is not\nexcluded in the appropriate clinical context.\n2. Status post left total hip arthroplasty with nonspecific proteinaceous or\nhemorrhagic material expanding the pseudocapsule.\n3. Post radiation changes within the sacrum, including bone infarcts and\nprobable chronic insufficiency fractures.\n4. Partial right hamstring origin tears with associated right ischial\nbursitis.  ."
        },
        {
            "input": "The patient is status post pelvic exenteration with bilateral ostomies in the\nlower quadrants.\n\nThe sacral plexus is normal in appearance.\n\nThere is asymmetric low signal intensity on T1 along the left pelvic sidewall,\nabutting a left pelvic small bowel loop (series 4, image 11).  The sciatic\nnerve traverses this region.  Along the greater sciatic notch, the sciatic\nnerve appears mildly thickened (series 4, image 14), compared to the\ncontralateral side.  As noted on previous exam, there is marked expansion of\nthe left hip joint with T1 relatively hyperintense material which may reflect\nproteinaceous or hemorrhagic debris.  This may have mass effect on the sac\nnerve as it extends posterior to the left hip joint with some additional\nperiarticular fibrosis likely also contacting the sciatic nerve itself. \nSciatic nerve appears slightly hyperintense laterally to the ischial\ntuberosity compared to the contralateral side on fluid sensitive images\n(series 5, image 28).\n\nHypointense signal on T1 weighted imaging of the right femoral head and neck\nwith increased signal intensity on fluid sensitive sequence.  Irregularity of\nthe articular surface of the femoral head.  These findings are consistent with\navascular necrosis.  Stable small right hip joint effusion, likely reactive.\n\nSI joints demonstrate STIR hyperintense signal within the sacral alae\nbilaterally and iliac bones, consistent with bone infarcts, most likely\nrelated to prior radiation therapy.  Likely superimposed changes of previous\ninsufficiency fractures in the bilateral sacral ala also.  Tarlov cysts in the\nsacrum.\n\nEdema is noted within the left iliacus muscle and likely related to the left\nhip process.  Partial bilateral hamstring origin tendon tears.",
            "output": "1. Left sciatic nerve asymmetry with some expansion of the greater static\nnotch, and high signal on fluid sensitive images lateral to the ischial\ntuberosity are compatible with neuropathy.  This is likely due to combination\nof surrounding scar tissue at the left pelvic sidewall and adjacent to the\nleft hip arthroplasty in addition to some possible mass-effect related to\nexpansion of the postsurgical left hip pseudocapsule.  (Left hip pseudo\ncapsule is expanded with T1 hyperintense proteinaceous or hemorrhagic material\nas noted on previous study).\n2. Sacral plexus is normal.\n3. Stable right femoral head avascular necrosis with partial collapse and\neffusion the right hip.\n4. Signal changes involving the bilateral sacral alae and adjacent iliac bones\nlikely reflect combination of radiation changes, osteonecrosis and\nsuperimposed previous sacral alar insufficiency fractures.  These are similar\nto previous exam."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.1 x 4.5 x 5.3 cm..\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is not thickened.\nMultiple intramural uterine fibroids, largest in the fundus measuring 3.0 cm.\n\nCervical nabothian cysts noted.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nLYMPH NODES: The liver is homogeneous in signal characteristics.  There is no\nchemical shift on the in or out of phase sequences to suggest the presence of\nhepatic steatosis or iron deposition. The liver contours are smooth.  No solid\nor cystic lesions.\n\nBLADDER AND DISTAL URETERS: The bladder is moderately well distended without\nwall thickening or mass.  Small urachal remnant is noted.\n\nRECTUM AND INTRAPELVIC BOWEL: The GI tract is of normal caliber in the pelvis.\nNo evidence of rectal prolapse.\n\nVASCULATURE:  Abundant and dilated venous vasculature in the lower pelvis,\nparticularly posterior to the urethra.  (04:14).\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal\nsignal characteristics.  No concerning osseous lesions.  Sacral Tarlov cysts\nincidentally noted.",
            "output": "1.  Abundant and dilated venous vasculature in the lower pelvis, particularly\nposterior to the urethra, which likely corresponds to palpable abnormality.\n2. No evidence of sub-urethral solid mass.\n2.  Leiomyomatous uterus."
        },
        {
            "input": "There is no evidence of thrombus within the femoral, common femoral, external\niliac, common iliac, and IVC.  Bilateral common iliac and external iliac veins\nare significantly narrowed.\n\nA 1.1 cm simple cyst is seen in the inferior pole of the right kidney (03:44).\nOn postcontrast images, there is no definite non enhancement of this lesion.\n\nThe urinary bladder and bilateral distal ureters are within normal limits. The\nvisualized colon and small bowel demonstrates normal caliber and wall\nthickness There is no free fluid in the pelvis.  The study is not tailored to\nevaluate the prostate but the prostate and seminal vesicles appear grossly\nunremarkable.  There is no pelvic or inguinal lymphadenopathy.",
            "output": "1.  No evidence of venous thrombosis.\n2.  Incidental finding of a 1.1 cm cyst in the lower pole of the right kidney.\nEnhancement within the cyst cannot be ruled out and a outpatient ultrasound is\nrecommended for further evaluation.\n\nRECOMMENDATION(S):  Renal ultrasound is recommended for further evaluation of\na 1.1 cm cyst in the lower pole of the right kidney."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Intrapelvic bowel loops are unremarkable.\nEnhancing intersphincteric fistula tract begins at the left anterolateral\naspect of the rectum at approximately 2 o'clock, extends through the left\nischioanal fat, and appears to exit at the medial left gluteal cleft. The\nfistula does not cross the external sphincter, but abuts it and there is some\nassociated inflammation of the overlying muscle.\n\nNumber of fistulas: 1\n\nINTERNAL ANAL OPENING:\n\nLocation (quadrant and clock face) in supine position: Left anterolateral at 2\no'clock\nDistance from anal verge:  1.6 cm\nRelation to the internal sphincter: Lower third of sphincter\n\nFISTULA TRACT:\n\nMaximum tract diameter:  5 mm\nFistula type (___ classification):  Intersphincteric\nSecondary branches: None\nExit site: Left gluteal cleft\nHyperintensity of the tract on T2: Moderate\nEnhancement of the tract: Central enhancement with high signal intensity on T2\ncompatible with granulation tissue\n\nOTHER FINDINGS:\n\n\n\nAbscess: No\nRectal and sigmoid wall inflammation: No\nPresence of ___, drains or prior surgery: No\n\n\nBLADDER AND DISTAL URETERS: Bladder is unremarkable.  There is small volume\npelvic free fluid.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Prostate, seminal vesicles, and\nscrotum are unremarkable.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions.",
            "output": "1. Intersphincteric perianal fistula tract extends from the 2 o'clock position\nof the anus and appears to exit along the left gluteal cleft.  No associated\nfocal fluid collection.\n2. Nonspecific small volume pelvic free fluid."
        },
        {
            "input": "There is T1 hypo intensity involving the right sacral ala and right iliac bone\nadjacent to the sacroiliac joint with destruction of the cortex and bone\naround the joint.  There is a small right sacroiliac joint effusion. There is\nsoft tissue edema in the right presacral region including a peripherally\nenhancing soft tissue fluid collection which measures approximately 11 x 25 mm\non STIR, with central non-enhancing fluid component on post contrast imaging\nmeasuring approximately 12 x 5 mm (series 8, image 34) along the anterior\ninferior right sacroiliac joint (series 4, image 10).  In addition, there is a\nsmall amount of fluid/phlegmon along the posterior inferior joint line (series\n6, image 18). There is muscle edema seen within the paraspinal muscles right\nmore than left, right gluteus maximus and medius muscles and to a greater\nextent within the right piriformis muscle.  The muscle edema extends\nsuperiorly along the iliacus and iliopsoas muscles. The previously seen drain\non prior CT is partially visualized on this examination and there is mild\nenhancement of the tissues surrounding the pigtail without a well defined\nfluid collection seen.\n\nWithin the right sacral ala there is a linear hypointensity and possible small\nsuperimposed nondisplaced fracture cannot be excluded (series 6, image 16).\n\nNo left sided sacroiliac effusion. There is a mild amount of subchondral edema\nalong the anterior left SI joint in both the sacrum and iliac bone (series 6\nimage 14 -15) associated with mild T1 hypointense signal and mild cortical\nirregularity.\n\nThere is a small amount of free fluid in the pelvis, likely physiologic.\nRemaining pelvic soft tissues are grossly unremarkable.",
            "output": "1. Findings consistent with septic sacroiliitis on the right with a small\njoint effusion and small soft tissue collection along the inferior joint line\nmore prominent anteriorly. There is extensive intramuscular edema surrounding\nthe joint as described above.\n\n2. Within the right sacral ala there is a linear hypointensity and possible\nsmall superimposed nondisplaced fracture cannot be excluded (series 6, image\n16).\n\n3. Mild sacroiliitis of the  left SI joint without findings to suggest\ninfection."
        },
        {
            "input": "Compared to prior examination there is increased bone marrow edema pattern\nseen within the right sacral ala and right iliac wing posteriorly.  There are\nheterogeneous areas of hypointense signal within the bone marrow edema which\nmay represent non vascularized bone (series 7, image 12).  In addition, there\nhas been interval increase in the degree of right sacroiliac joint widening\nmost markedly at the anterior superior joint space.  This reflects a\ncombination of synovitis and inflammatory phlegmon and nonenhancing fluid, for\nexample the largest area measuring 8 mm along the anterior aspect of the joint\n(series 9, image 25).  There is a small area of non enhancement along the\nposterior joint (series 100, image 18) which does not have a STIR hyperintense\ncorrelating signal and may represent devitalized bone fragments.\n\nThere is increased subchondral bone marrow edema at the left sacroiliac joint\ncompared to prior study.  There is slightly more cortical destruction along\nthe anterior inferior joint (series 7, image ___.  No joint effusion. \nThere is minimal edema in the soft tissues along the anterior joint line.\n\nAgain seen is presacral edema and intramuscular edema involving the\npiriformis, obturator internus, iliacus, and to a lesser degree the gluteal\nmuscles.  No evidence of well defined peripherally enhancing soft tissue fluid\ncollection.\n\nThere is a small amount of free fluid in the dependent portion of low pelvis.\n\nThere is a small amount of fluid in the bilateral hip joints.",
            "output": "1.  Again seen are findings consistent with septic sacroiliitis on the right\nwith increased destruction of the joint predominantly along the anterior and\nsuperior aspect.  There is hyper enhancing within the widened joint with a\nsmall amount of fluid.  There are areas of non enhancing bone, which may be\ndevitalized.\n\n2.  There is worsening sacroiliitis of the left SI joint with increased\nsubchondral bone marrow edema pattern and cortical destruction along the\nanterior joint line.\n\n3.  Presacral edema and prominent intramuscular edema involving the right\npiriformis, trace internus, and gluteal muscles.  No soft tissue well-defined\nperipherally enhancing fluid collection."
        },
        {
            "input": "Of note, this study was tailored for evaluation of the sacrum and the anterior\npelvis was not fully imaged.\n\nThere is a rim enhancing fluid collection in the deep aspect of the right\niliacus muscle measuring approximately 7.2 x 7.9 x 2.5 cm.  This fluid\ncollection extends from the right sacroiliac joint where there is a moderate\neffusion with erosive changes of the right sacroiliac joint and surrounding\nbone marrow edema and enhancement consistent with osteomyelitis.  The fluid\ncollection demonstrates a rim of high T1 signal, which could reflect the\npresence of methemoglobin i related to hemorrhage or proteinaceous fluid\n(18:13).\n\nThe hyperintense STIR signal surrounding the anterior aspect of the left SI\njoint is not significantly changed compared to ___.  No left SI\njoint effusion.\n\nThere is no hip joint effusion bilaterally.  There is hyperintense STIR signal\nand enhancement within the right piriformis muscle, similar to prior study\n(04:11, 06:21).\n\nLimited assessment of intrapelvic soft tissue structures shows trace focally\nfree fluid, within physiologic limits",
            "output": "New rim enhancing fluid collection in the deep aspect of the right iliacus\nmuscle.  The fluid collection extends from the right sacroiliac joint were\nthere is a moderate effusion with erosive changes and surrounding\nosteomyelitis.\n\nIncreased signal on the right piriformis muscle, similar prior study, most\nlikely representing myositis.\n\nNo significant change in left sacroiliitis involving the anterior aspect of\nthe SI joint without a joint effusion.\n\nNOTIFICATION:   The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 10:34 AM, 5 minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 4.0 x 11.1 x 3.9 cm.  The endometrium is\nnormal in thickness for age and measures 6mm.  The junctional zone is not\nthickened.  Multiple nabothian cysts are seen in the cervix.\n\nThere is a large infiltrative solid cystic heterogeneously enhancing mass in\nthe pelvis.  Normal ovaries are not seen separate from this mass, which\nmeasures approximately 17.5 x 15.9 x 18.3 cm (trv x ap x cc).  Solid\ncomponents of this mass show evidence of diffusion restriction and\nenhancement.  The cystic components show a few areas of internal hemorrhage. \nMultiple surrounding solid heterogeneously enhancing peritoneal nodules are\nseen the visualized parts of the abdomen and pelvis.\n\nThere is evidence of nodularity in the visualized parts of the omentum\nconcerning for peritoneal carcinomatosis. There is evidence of mild ascites\nand free pelvic fluid.\n\nLYMPH NODES: Multiple enlarged pelvic lymph nodes are seen, for example left\nobturator measuring 1.8 cm, left external iliac measuring 2.2 cm (series 4\nimages 20 and 27).\n\nRECTUM AND INTRAPELVIC BOWEL: Limited assessment of the bowel loops.  Multiple\ntumor nodules are seen intimately associated with the serosal aspect of the\nsigmoid colon and the visualized bowel loops.  There is no evidence of\nproximal dilated bowel loops in the visualized parts of the lower abdomen and\npelvis.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is under filled.  There is no\nevidence of hydroureter.\n\nVASCULATURE: The iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no abnormal marrow signal.  No\nsoft tissue abnormality.",
            "output": "Findings consistent with metastatic ovarian neoplasm of epithelial origin\nlikely serous adenocarcinoma with pelvic lymphadenopathy and peritoneal\ncarcinomatosis."
        },
        {
            "input": "MRV: There is wall to wall enhancement of the pelvic vasculature without\nevidence of venous or arterial thrombus. Intravascular flow is preserved in\nthe distal IVC, common iliac, external iliac, internal iliac, and common\nfemoral veins. The aorta is normal caliber throughout. The SMA, ___, and their\ndistal branches are well opacified. Bilateral single renal arteries are well\nopacified.\n\nMRI: The kidneys are unremarkable. The bladder appears normal. The prostate\ngland and seminal vesicles are unremarkable. Colonic diverticulosis. The\nimaged portions of small and large bowel are otherwise unremarkable. No pelvic\nsidewall or inguinal lymphadenopathy. There is fat in the left inguinal canal.\nNo free pelvic fluid. The bone marrow signal is normal.",
            "output": "Normal pelvic MRV.  No evidence of pelvic vein DVT."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Normal.  No evidence of proctitis.\n\nNo free pelvic fluid.\n\nBLADDER AND DISTAL URETERS: Mildly distended bladder is unremarkable.  No\nevidence of distal hydroureter.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: There is mild nodular glandular\nhypertrophy involving the central zone and mid gland with homogeneous\nenhancement, reflecting benign prostatic hyperplasia.  The seminal vesicles\nappear within normal limits.  The visualized testicles and epididymi are\nwithin normal limits.\n\nLYMPH NODES: No inguinal or pelvic lymphadenopathy.\n\nVASCULATURE: Grossly patent internal and external iliac vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is very low marrow signal within\nthe visualized pelvis and proximal femurs on T1 and T2 weighted imaging, which\nmay represent sequela of iron deposition associated with prior transfusions. \nLess likely these finding is reflect significant red marrow reconversion.\n\nThere is a 3 cm linear T2 hyperintense enhancing tract along the right aspect\nof the gluteal fold, extending to the anal canal at the 6 o'clock position\n(series 1002, image 68).  This likely represents a low intersphincteric\nperianal fistula.  There is no associated perianal abscess.  The ischioanal\nfat is preserved.",
            "output": "1. Low intersphincteric perianal fistula at the 6 o'clock position, extending\nalong the right gluteal fold.  No perianal abscess.\n2. Very low bone marrow signal throughout the pelvis and proximal femora\nsuggestive of iron deposition related to prior blood transfusions. \nSignificant red marrow reconversion is felt to be less likely.\n\nRECOMMENDATION(S):  Direct inspection to assess for presence of external\nopening to the fistula along the right gluteal cleft.\n\nNOTIFICATION:   The findings were discussed with ___, M.D. by\n___, M.D. on the telephone on ___ at 5:57 pm, 15 minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 7.0 x 5.9 x 6.9.  There is a 3.9 x 3.8\ncm mildly T2 hyperintense enhancing lesion in the posterior aspect of the\nuterine body.  Multiple susceptibility foci are noted within and about this\nlesion, which may be sequela of prior surgery and or prior hemorrhage..\nThe endometrium is normal in thickness for age and measures 8 mm.\n\nThe right ovary is visualized and appears within normal limits with a corpus\nluteum within it.\nThe left ovary is visualized and appears within normal limits.  There is a 1.4\ncm simple left paraovarian cyst (06:13)\n\nAgain noted are multiple enhancing masses throughout the pelvis, including a\n3.3 x 2.6 cm lesion in the left side anterior to the sigmoid colon (06:23), a\n5.0 x 2.5 cm lesion located anteriorly in the pelvis (06:25) and a 1.5 x 1.0\ncm lesion in the midline (1102:16).  Note is made of a predominantly necrotic\nright upper pelvic mass measuring approximately 5.8 x 4.2 cm on coronal images\n(11:5), that demonstrates a peripheral enhancing solid component, notably\nwithin its superior aspect.  Of note, edema and inflammatory changes are noted\nadjacent to this mass.  Additional smaller nodularities are also noted within\nthe pelvis (06:26).\n\nThere is small to moderate amount of pelvic free fluid.\n\nLYMPH NODES: No enlarged pelvic lymph node is seen.\n\nBLADDER AND DISTAL URETERS: The bladder is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and visualized bowel is unremarkable.\nThe appendix is not definitely seen.\n\nVASCULATURE: The iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous in the lesion is\nseen.",
            "output": "Uterine lesion is redemonstrated along with multiple pelvic masses and\nascites.  Of note, a dominant partially necrotic mass is noted in the right\nlower quadrant associated with adjacent inflammatory changes.\n\nDifferential considerations include disseminated peritoneal leiomyomatosis,\nhowever leiomyosarcoma, either multifocal or arising through degeneration of a\nbackground peritoneal leiomyoma is possible.  Alternative benign and malignant\nperitoneal lesions are also not excluded but considered less likely given\nsimilarity of peritoneal lesions to uterine lesion in signal characteristics,\nand patient age.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 2:44 pm, 10 minutes\nafter discovery of the findings."
        },
        {
            "input": "Carcinoma of the Vulva\nIA: Tumor confined to the vulva or perineum, ? 2cm in size with stromal\ninvasion ? 1mm, negative nodes\nIB: Tumor confined to the vulva or perineum, > 2cm in size or with stromal\ninvasion > 1mm, negative nodes\nII: Tumor of any size with adjacent spread ___ lower urethra, ___ lower\nvagina, anus), negative nodes\nIIIA: Tumor of any size with positive inguino-femoral lymph nodes: (i) 1 lymph\nnode metastasis greater than or equal to 5 mm or (ii) ___ lymph node\nmetastasis(es) of less than 5 mm\nIIIB   (i) 2 or more lymph nodes metastases greater than or equal to 5 mm or\n(ii) 3 or more lymph nodes metastases less than 5 mm\nIIIC      Positive node(s) with extracapsular spread\n___       (i) Tumor invades other regional structures ___ upper urethra, ___\nupper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone, OR (ii)\nFixed or ulcerated inguino-femoral lymph nodes\nIVB       Any distant metastasis including pelvic lymph nodes\n\n\n\nUTERUS AND ADNEXA:\n\nThe fibroid uterus is anteverted and measures 10.6 x 5.2 x 7.6 cm.  There is a\n0.8 x 0.8 cm T2 hypointense homogeneously enhancing intramural fibroid within\nthe anterior uterine fundus.  No subserosal component.  No intracavitary\nfibroids.  (03:15).\nThe endometrium is normal in thickness for age and measures 0.4 cm.\nThe junctional zone is thickened consistent with adenomyosis.\n\nThe ovaries are not visualized.\n\nNo pelvic free fluid.\n\nLYMPH NODES: There are 2 enlarged centrally necrotic left external iliac and 3\nleft inguinal lymph nodes, largest measuring up to 1.7 x 1.4 cm and 2.2 x 1.8\ncm respectively.  (4:24, 30).\n\nBLADDER AND DISTAL URETERS: Bladder is decompressed.  Distal ureters are\nunremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Sigmoid diverticulosis noted.  Rectum and\nadditional visualized small large bowel are unremarkable without obstruction.\n\nVASCULATURE: Patent vasculature.  No aneurysmal dilatation.\n\nOSSEOUS STRUCTURES: No suspicious osseous lesions.\n\nSOFT TISSUES: Along the left labia there is a subtle 0.4 x 0.7 cm (AP x TV)\nmildly T2 hypointense lesion which demonstrates restricted diffusion and\nheterogeneous hyper enhancement which corresponds to the FDG avid area noted\non ___ consistent with patient's known vulvar carcinoma. \n___ 08:39).  This lesion is located inferior and seperate from the\nclitoris.  Located just inferior to the soft tissues are otherwise\nunremarkable.",
            "output": "1.  Enhancing 0.7 x 0.4 cm lesion along left labia is consistent with\npatient's known vulvar cancer and corresponds to FDG avid abnormality seen on\nsame day FDG PET.  Imaging stage IVB given necrotic left external iliac\nlymphadenopathy in addition to left inguinal lymphadenopathy.\n2.  Fibroid uterus.\n3.  Adenomyosis."
        },
        {
            "input": "Bones: The patient is status post left hip disarticulation.  Fluid is seen\nwithin the left acetabulum measuring approximately 4.1 x 2.7 x 3.0 cm. Fat and\nsoft tissue along the medial wall of the acetabulum likely represents soft\ntissue filling the acetabulum.  There is mild peripheral enhancement of the\nfluid collection, however there is no adjacent reactive bone marrow changes.\n\nAlignment of the pelvis appears preserved.  No fractures identified.\n\nWithin the intertrochanteric region on the right proximal femur there is a 2.3\nx 2.2 cm rounded lesion which appears to have stippled internal fat and\ndemonstrates stippled enhancement (image 7: 40 and 10:40). This was partially\nimaged on localizer images from ___ and appears unchanged in size.\n\nMild degenerative changes of the pubic symphysis.  Moderate degenerative\nchanges of the lower lumbar spine, partially imaged.\n\nSoft tissues: There is mild edema and enhancement of the muscles at the distal\nstump.  Mild subcutaneous edema of the distal stump.  There is mild edema\nwithin the left iliacus muscle and deep to it.  There is mild edema within the\ngluteus medius and minimus muscles and left piriformis muscle. There is mild\nedema deep to the right iliacus muscle. Mild bilateral hamstring tendinosis.\n\nThere is an enlarged enhancing lymph node of the inferior left inguinal region\nmeasuring 2.5 x 1.7 cm, and previously measured 1.2 x 1.2 cm on ___. \nThere is no definite fatty hilum.\n\nRight fat containing inguinal hernia.",
            "output": "1.  Status post left hip disarticulation.  Fluid collection in the left\nacetabulum and mild-to-moderate muscle edema and soft tissue edema about the\nleft hip is likely postsurgical\n2.  Prominent left inguinal lymph node has increased in size since exam on ___.  While this could be reactive this is most concerning for spread of\ndisease and is amenable to percutaneous tissue sampling.\n3.  Rounded lesion of the right proximal femur with stippled internal fat and\nstippled enhancement may represent focal red marrow conversion or a\nhemangioma.  This was partially imaged on localizer images from ___\nand appears unchanged in size.  This can be followed on subsequent exams.\n\nNOTIFICATION:   The findings were emailed to ___ by ___, M.D. on\n___ at 1:35 pm, 2 minutes after discovery of the findings."
        },
        {
            "input": "Again, the patient is status post left hip disarticulation.  There has been\ndecrease in the amount of fluid seen within the left hip acetabulum.  However,\nthere is still soft tissue within the acetabulum with increased STIR signal\nthat enhances with similar appearance to the prior study.  No adjacent\nreactive bone marrow edema.\n\nAgain noted is a rounded lesion in the right proximal femur in the\nintertrochanteric region measuring up to 2.3 cm (04:32) that is mildly\nhypointense on T1 and hyperintense on STIR.  This lesion is brighter than\nmuscle, likely representing red marrow conversion and is unchanged from the\nprior studies.\n\nSince ___, there is a new mass measuring 4.7 x 4.2 x 4.2 cm in the\nleft hemipelvis causing mass effect on the adjacent the left external iliac\nvasculature.  This lesion is T2 hyperintense, T1 hypointense, and avidly\nenhances.  It comes in contact with the left hip acetabulum without evidence\nof invasion.  It corresponds to an FDG avid lesion seen on recent PET-CT.\n\nAdditionally, there are two STIR hyperintense, T1 hypointense, enhancing\nlesions in the subcutaneous tissues of the left hip (9: 25 and 28) which\ncorrespond to FDG avid lesions seen on recent PET-CT.  These lesions measure\n2.7 x 1.3 x 1.3 cm and 1.7 x 1.1 x 1.2 cm.  Findings are compatible with\nmetastatic foci.\n\nThere are several enhancing lymph nodes in the left groin, the largest\nmeasuring 2.2 x 1.4 cm, this is increased from the prior study of ___.  The previously noted enlarged left inguinal lymph node was excised and\nno longer visualized.\n\nThere has been interval decrease in edema of the musculature of the left hip\nwith increased fatty atrophy.  No other significant interval change.",
            "output": "4.7 cm enhancing mass in the left hemipelvis causing mass effect on the\nadjacent left external iliac vasculature and corresponds to the FDG avid\nlesion seen on recent PET-CT.  Two additional enhancing lesions in the soft\ntissues of the left hip correspond to FDG avid lesions.  Findings are\ncompatible with metastatic disease.\n\nThere is again left groin lymphadenopathy, the largest measuring up to 1.4 cm\nin short axis, increased in size from the prior MRI."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.9 x 3.7 x 5.1 cm.  There is a\nlobulated 7.1 x 4.6 x 7.1 cm T2 hyperintense enhancing lesion arising from the\ncervix with restricted diffusion extending into the lower uterine segment and\ninto the upper two thirds of the vaginal canal, invading the anterior and\nposterior vaginal walls (12:66).  Additionally, there is extension of the\ntumor into the parametrium bilaterally (1101:53, 54).  The mass is obstructing\nthe endocervical canal, with secondary fluid distention of the endometrial\ncavity (1101:59).\n\n\nBLADDER: There is  wall thickening along with irregularities and restricted\ndiffusion along the posterior bladder wall, suggesting invasion (04:11 ;\n12:7).\n\nNote is made of a urethral diverticulum.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nThere is trace pelvic free fluid.\n\nLYMPH NODES:  Multiple enlarged heterogeneous pelvic lymph nodes are\nsuggestive of tumor involvement.  For example, there is a 1.4 x 1.0 cm right\ninguinal necrotic lymph node (03:23).  Another example includes a 1.9 x 1.2 cm\nheterogeneous left external iliac lymphadenopathy (03:10) that was intensely\nFDG avid on prior PET-CT.  A 0.8 x 0.8 cm  right internal iliac lymph node\n(03:10) and a 0.9 x 0.6 cm right external iliac node (3:8) that were mildly\nFDG avid on prior PET-CT are also concerning for tumor involvement.  A 1.0 x\n0.7 cm heterogeneous presacral lymph node on the right was also mildly FDG\navid (3:9).  Of note, multiple subcentimeter perirectal nodes are concerning\ndue to their quantity rather than their size.\n\nRECTUM AND INTRAPELVIC BOWEL:  The rectum is unremarkable.\n\nVASCULATURE: The bilateral iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES:  There is heterogeneity of the pelvic\nbones associated with focal areas of enhancement in the left hemisacrum and\nright acetabulum (1102:47,74; 80) that are concerning for metastatic disease.",
            "output": "1.  7.1 cm cervical mass extending into the lower uterine segment and into the\nupper two thirds of the vaginal canal, invading the anterior and posterior\nvaginal walls and extending into the parametrium bilaterally.  Wall thickening\nand effacement of the fat plane along with restricted diffusion along the\nposterior bladder wall is suggestive of bladder wall invasion by tumor.  MR\nstaging:  Stage IV.\n2.  Multiple enlarged and morphologically abnormal pelvic lymph nodes\nconsistent with metastatic involvement.\n3.  Foci of signal abnormality and enhancement in the left hemi sacrum and\nright acetabulum concerning for metastatic disease."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.0 x 3.4 x 4.8 cm.\n\nA 3.6 x 1.8 x 3.0 cm lobulated T2 hyperintense enhancing lesion arising from\nthe cervix with restricted diffusion has intervally decreased in size when\ncompared to prior.  It extends into the lower uterine segment as well as the\nupper ___ of the vaginal canal (series 15, image 53).  It demonstrates\nrestricted diffusion on the DWI sequences with corresponding low signal\nintensity on the ADC maps.  There is a small amount of fluid in the\nendometrial cavity.\n\nThere is linear T2 hypointense signal within the parametrium bilaterally\nwithout corresponding diffusion restriction or abnormal enhancement, most\nlikely due to fibrosis.  There is however T2 isointense signal in the left\nparametrium with corresponding diffusion restriction (series 8, image 17,\nseries 5, image 22, series 9, image 20 and series 900, image 20), compatible\nwith parametrial extension of tumor.  The tumor does not extend into the\npelvic sidewalls.  The previously described thickening of the posterior\nbladder wall is not visualized and there is a clear fat plane between the\ncervix and bladder.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nNo free fluid in the pelvis.\n\nLYMPH NODES: Interval improvement in multiple enlarged heterogeneous pelvic\nlymph nodes.  For example the previous described necrotic right inguinal lymph\nnode has intervally decreased in size, currently measuring 5 mm.  The right\ninternal iliac lymph node has decreased in size, currently measuring 6 mm\n(series 5, image 15).  The left internal iliac lymph node measuring 5 mm\n(series 5, image 16) has decreased in size from prior.  No new suspicious\npelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Previously described wall thickening along the\nposterior bladder wall is no longer seen.  There is a clear fat plane between\nthe cervix and bladder.  The bladder is otherwise decompressed which limits\nproper evaluation, however no gross mass lesions.  Note is made of a small\nperiurethral diverticulum along the mid urethra.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Visualized portions of the iliac vessels are normal in caliber\nand patent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Hypointense signal on the T1 weighted\nimages within the right acetabulum (series 11, image 34) with heterogeneous\nenhancement (series 1401, image 69) is highly suspicious for metastatic\ndisease.  No new suspicious bony lesions.\n\nThere is linear enhancement of the vaginal mucosa bilaterally at the introitus\n(series 1402, image 127) new from prior with a small nonenhancing 9 mm cystic\nlesion in the right labia majora (Series 5, image 39).  This could be related\nto postradiation changes versus infection.  Correlation with physical exam is\nrecommended.",
            "output": "1.  Interval decrease in size of a cervical mass that extends into the lower\nuterine segment and upper ___ of the vaginal canal, currently measuring 3.6 cm\nin maximal diameter.  There is minimal extension into the left parametrium.\n2.  Previously-described thickening of the posterior bladder wall is not\nvisualized on today's study with a clear fat plane between the cervix and the\nbladder wall.\n3.  Interval decrease in size of multiple enlarged pelvic lymph nodes.\n4.  Unchanged focal lesion in the right acetabulum, concerning for metastatic\ndisease.\n5.  Linear vaginal mucosal enhancement with a small 9 mm cystic lesion in the\nright labia majora which is nonspecific, without obvious aggressive features. \nFindings could be related to postreatment change, infection, or trauma. \nCorrelation with physical exam is recommended to exclude any neoplastic\nfeatures."
        },
        {
            "input": "The uterus is anteverted and measures 11.2 x 6.6 x 8.8 cm.  There are foci of\nsusceptibility in the lower uterine segment and in the lower abdominal wall,\nfrom clips from prior C-section. The junctional zone is diffusely thickened up\nto 17 mm and contains multiple cystic foci of T2 hyperintensity (03:16,\n04:21), which are hyperintense on T1WI, indicating blood products (09:58). \nThis is consistent with adenomyosis.\nIn the fundus on the left there is a 1.9 cm intramural T2 hypointense mass,\nconsistent with fibroid (04:19).  The fibroid enhances homogeneously.\nThe endometrial stripe is also normal in thickness measuring 7 mm.\nThe uterus the supplied from bilateral uterine arteries.\nThere are multiple nabothian cysts in the cervix. The vaginal canal is grossly\nnormal.\n\nBoth ovaries are well visualized and are normal in size and appearance without\nevidence of mass. There is minimal free fluid in the pelvis. The partially\ndistended bladder is grossly unremarkable. The visualized bowel loops are\nwithin normal limits. There is no significant pelvic or inguinal\nlymphadenopathy. The osseous structures are unremarkable.",
            "output": "Diffuse thickening of the junctional zone with cystic changes, consistent with\nadenomyosis.\n1.9 cm left uterine intramural fibroid.\nArterial supply to the uterus from the uterine arteries without ovarian supply\nevident."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and anteflexed and measures 10.8 x 6.2 x 7.2 cm. \nWhen measured in similar planes, it previously measured 11.8 x 7.5 x 8.8 cm. \nSince the prior exam, the patient has undergone a uterine artery embolization.\nThere is carneous degeneration in the junctional zone which is no longer\nenhancing, compatible with post treatment changes.  The area of degeneration\nmeasures approximately 5.3 x 4.7 x 4.7 cm.  The region of adenomyosis\npreviously measured 6.1 x 6.9 x 5.6 cm (though the borders were indistinct, so\nit was difficult to accurately measure).  The previously identified left\nfibroid has also slightly decreased in size.  It measures 1.7 x 1.7 x 1.2 cm. \nIt previously measured 1.8 x 1.7 x 1.9 cm.  The fibroid has also undergone\ncarneous degeneration and is no longer enhancing.  No complications are\nidentified.\n\nThe endometrium is normal in thickness for age and measures 4 mm. The the\ncervix is normal other than multiple nabothian cysts.\n\nThe ovaries are normal.  The corpus luteum is noted on the right.\n\nA small amount of pelvic free fluid is noted, and within physiologic limits.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are normal.\n\nRECTUM AND INTRAPELVIC BOWEL: There is sigmoid diverticulosis without evidence\ndiverticulitis.  The imaged portions of the small bowel are normal.\n\nVASCULATURE: The arterial vasculature is normal in caliber without evidence of\nan aneurysm.  The venous vasculature is patent without evidence of a thrombus.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are mild multilevel degenerative\nchanges in the lower spine with disc degeneration in small bulges at L4-5 and\nL5-S1.  There are no concerning osseous lesions.  Susceptibility artifact in\nthe anterior abdominal wall likely represents clips from a prior C-section. \nThe soft tissues are otherwise unremarkable.  There is no hernia.",
            "output": "Post treatment changes from a uterine fibroid embolization, as described\nabove."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.2 x 3.4 x 2.6 cm.  A 1.5 cm partially\nexophytic fibroid is incidentally noted (4:20).\nThe endometrium is homogeneous and normal in thickness for age. The junctional\nzone is not thickened.\n\nThe ovaries are not visualized.  A nonenhancing homogeneously T1 and T2\nhyperintense right adnexal mass measures 6.9 (AP) x 4.9 (TV) x 5.2 (SI) cm,\npreviously 5.0 x 3.6 x 4.0 cm on a CT scan from ___.  Increased T1\nsignal is likely due to proteinaceous contents.  There are no concerning\nfeatures such as mural nodularity, enhancement, or invasion of adjacent\nstructures.\n\nThere is no intrapelvic free fluid.\n\nLYMPH NODES: There is no intrapelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder is moderately distended, and appears\nnormal.  There is mild mass effect along the superior aspect of the bladder\nfrom the adnexal cystic lesion.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic loops of small and\nlarge bowel are within normal limits.\n\nVASCULATURE: The iliac vessels are patent and normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no bone marrow signal\nabnormality.  There is a small fat containing left inguinal hernia (series 5,\nimage 3, series 3, image 25).",
            "output": "6.9 cm benign-appearing right adnexal cystic lesion.  Given gradual\nenlargement since ___, a low-grade neoplasm such as a borderline tumor\nremains on the differential.  If continued non-surgical follow-up is desired,\nultrasound or MRI can be performed in ___ year."
        },
        {
            "input": "There is extensive ascites seen throughout the abdomen and pelvis, similar to\nthe prior CT scan.\n\nThere has been improvement of the right iliacus hematoma since the previous CT\nscan.  There is only faint edema within it and it has decreased in size.\n\nThere is no abnormal edema within the right hip adductors to suggest a focal\ntear.  There is symmetric signal intensity within the adductor, gluteal, and\nthigh muscles bilaterally.\n\nThere is normal marrow signal within the proximal femurs bilaterally.  There\nare areas are red marrow seen throughout both proximal femurs.  There are no\nsigns for avascular necrosis or stress fracture. The marrow signal throughout\nthe rest of the pelvis is relatively preserved.  There is normal signal at the\nsacroiliac joints and lower lumbar spine.\n\nThere is a inguinal canal hernia with ascites fluid extending into the canal. \nThere is no inguinal or pelvic lymphadenopathy.",
            "output": "1.  No signs for muscle injury about the hips including the adductor muscles. \nThere has been near complete resolution of the hematoma within the right\niliacus muscle.  Only faint edema is seen.\n2.  Prominent ascites.  Portion is seen extending into the left inguinal\ncanal."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 6.5 x 9.3 x 7.2 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Distorted by the uterine fibroid.  No endometrial thickening.\nJunctional zone: Distorted by the uterine fibroid, however the visualized\nportion is not thickened.\n\nFIBROIDS:\n\nFibroid burden: One.\nFibroid enhancement: Homogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\nnone\n\nThe three dominant fibroids are:\n1.      Size 5.4 x 5.3 x 5.1 cm homogeneously enhancing, Intramural with less\nthan 50% submucosal component, at the anterior corpus with thinnest portion\noverlying myometrium measures 5 mm.\n\n\nOVARIES:\nUnremarkable.\n\nThere is no intrapelvic free fluid.",
            "output": "5.4 cm anterior intramural uterine fibroid with less than 50% submucosal\ncomponent.  The thinnest portion overlying myometrium measuring 5 mm."
        },
        {
            "input": "3.6 x 2.2 x 0.8 cm (CC by transverse by AP ___ T2-hyperintense\ncollection with hyperenhancing thick walls is similar in configuration and\nlocation to ___.  The collection now contains a small amount of gas.\nThis collection is located in the midline, centered slightly to the left, and\nis interposed between the rectum and the prostate gland.  The collection\nextends from the posterior aspect of the prostatic apex to the posterior\naspect of the seminal vesicles. There is significant diffuse contiguous\nenhancement of the adjacent left perirectal region and presacral tissues,\nincluding the mesorectal fascia, which limits evaluation for an enhancing\nfistulous tract. There is diffuse edema of the rectal wall, but no defect or\nfistula is identified.\n\nThere are small mesorectal reactive nodes.  Small inguinal, external iliac,\nand pelvic sidewall nodes.  No free pelvic fluid.  The bladder is\nunremarkable. No inguinal hernia. The bone marrow signal is normal.",
            "output": "3.6 x 2.2 x 0.8 cm midline pelvic fluid collection interposed between the\nrectum and the prostate gland, similar in size to ___. The\ncollection now contains gas, but diffusely enhancing phlegmonous appearance of\nthe left perirectal region limits evaluation for fistula. Followup imaging is\nrecommended after appropriate therapy."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe fibroid uterus is anteverted and measures 13 x 16.4 x 9.5 cm.  Four\ndominant T2 hypointense, heterogeneously hypoenhancing fibroids are described\nbelow:\n\n1. Subserosal with less than 50% intramural component measuring 5.9 x 7.2 x 5\ncm within the posterior central uterine fundus (03:19).\n2. Subserosal with less than 50% intramural component measuring 8.8 x 7.5 x\n8.9 cm within the anterior central uterine body (03:26).\n3. Subserosal with less than 50% intramural component measuring 7.1 x 6.8 x\n6.4 cm along the left lateral lower uterine segment (03:32).\n4. Exophytic subserosal fibroid along the lateral right uterine body measures\n4.8 x 3.3 x 3.7 cm, which demonstrates low level enhancement that follows\nsimilar signal characteristics to the uterine fibroid which has mildly\nincreased in size since ___ (previously 2.6 x 4.1 cm) (3:19). A\nbranch of the uterine artery is seen traversing into this lesion, confirming\nuterine origin.\nNo intracavitary fibroids noted.\n\nThe endometrium is within normal limits measures 3 mm.\nThe junctional zone is within normal limits.\n\nSusceptibility artifact along bilateral adnexa from prior tubal ligation noted\n(16:36).  The ovaries are not visualized which is expected in a post\nmenopausal patient.\n\nNo pelvic free fluid.\n\nLYMPH NODES: Inguinal or pelvic side wall lymph nodes are not enlarged.\n\n\nVASCULATURE: Patent vasculature.  No aneurysmal dilatation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No aggressive osseous lesions.",
            "output": "Fibroid uterus as described above."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 4.4 x 5.1 x 9.7 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 10 mm\nJunctional zone: 7 mm without focal thickening.\n\nFIBROIDS:\n\nFibroid burden: 2\nFibroid enhancement: Homogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n1.  none\n\nThe three dominant fibroids are:\n1.      size 0.4 x 0.9 x 0.9 cm homogeneous enhancement, subserosal with less\nthan 50% intramural component, anterior fundus\n2.      size 1.4 x 1.8 x 1.6 cm homogeneous enhancing, 100 % intramural,\nposterior fundus\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.  No hypertrophied gonadal\narteries are identified.\n\nOVARIES:\nNormal size with normal follicular activity bilaterally.\n\nThere is no intrapelvic free fluid.\n\nSmall fat containing paraumbilical hernia.",
            "output": "1. Two homogeneously enhancing uterine fibroids, the largest intramural\nmeasuring 1.8 cm at the uterine fundus as detailed above.  No submucosal or\npedunculated fibroids.\n2. Normal junctional zone."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.5 x 4.1 x 4.5 cm (157 cc), previously\n9.7 x 4.4 x 5.1 cm (217 cc).  A C-section scar is noted.  There is excellent\ntreatment response with decreased fibroid size and loss of enhancement.  For\nexample, a submucosal fibroid measures 0.8 x 0.5 x 0.7 cm (series 3, image\n12), previously 1.4 x 1.8 x 1.6 cm.\nThe endometrium is normal in thickness for age and measures 5 mm.\nThe junctional zone is not thickened.\n\nThe ovaries are unremarkable.\n\nThere is no free fluid in the pelvis.\n\nLYMPH NODES: No lymphadenopathy.\n\nRECTUM AND INTRAPELVIC BOWEL: No bowel obstruction.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue\nlesions.  The patient is status post mesh repair and ventral hernia\nrecurrence.",
            "output": "Excellent treatment response of fibroid embolization."
        },
        {
            "input": "There is subtle focal thickening in the dome of the urinary bladder to the\nleft from midline (1703:48), which appears non specific.  It corresponds to a\nfocus of abnormality seen on prior outside CT from ___.\n\nThere does not appear to be relation to nearby large or small bowel\nstructures.  The visualized bowel loops are within normal limits.\n\nThere is no evidence for a fistula between the bowel and the pelvic\nstructures.  No air is seen within the bladder.\n\nThe uterus is normal in size and appearance without evidence of focal mass.\nThe cervix and vaginal canal are also normal in appearance.\n\nBoth ovaries are well visualized and are normal in size and appearance without\nevidence of mass.  Small, sub-cm follicles are seen within both ovaries\nwithout a dominant cyst.\n\nThere is small amount of free fluid in the pelvis.  Subcutaneous soft tissue\nthird spacing is also notable.\n\n There is no significant pelvic or inguinal lymphadenopathy. The osseous\nstructures are unremarkable.",
            "output": "1.  No evidence of fistulous disease.\n\n2.  Subtle and nonspecific focal thickening in the dome of the urinary bladder\nto the left from midline.  This does not appear to be arising from a\nfistulizing process.\n\nRECOMMENDATION(S):  Suggest cystoscopy for further evaluate of the bladder\nabnormality."
        },
        {
            "input": "MRA:  There is normal patency and appearance of the IVC, the common iliac\nveins as also the external and internal iliac veins bilaterally.  No evidence\nfor DVT.  No arterial abnormalities.\n\n\nMRI:  A incompletely imaged cystic renal lesions are identified in the lower\npole of the right kidney measuring 5 mm.  They most likely represent simple\nrenal cysts.  A T2 bright lesion is identified in the lower pole left kidney\nmeasuring 8.2 mm.  The lesion is hypointense on the precontrast T1 weighted\nimages and no enhancement is identified.  This most likely presents an renal\ncysts.  The visualized portion of the small large bowel unremarkable.  The\nappendix is normal.  A 1.8 cm dominant follicle is identified within the left\novary, within normal limits based on the age of the patient.  The urinary\nbladder is are unremarkable.  No bony abnormalities.",
            "output": "1.  No evidence for DVT in the pelvic veins or IVC.  2.  Bilateral small T2\nbright nonenhancing lesions most likely presenting renal cysts."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Partially visualized sigmoid colon appears thick\nwalled, similar to the study performed in ___ (series 4, image 12). \nFurthermore, there is wall thickening and mild mucosal hyperenhancement in the\nrectum and distal sigmoid colon.  These changes are likely related to active\nIBD flare confirmed with sigmoidoscopy.  Previously described left\ntrans-sphincteric perianal fistula has healed.  No residual enhancing or fluid\ncomponents are seen.  No new perianal fistula is identified.\n\nBLADDER AND DISTAL URETERS: Normal.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.\n\nLYMPH NODES: Scattered mesorectal and presacral lymph nodes, mildly bulky,\nlikely reactive in nature (series 6, images 1 through 6).\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No marrow replacing process.",
            "output": "Thick-walled partially visualized sigmoid and rectum, with evidence of mucosal\nhyperenhancement and increased signal on T2-weighted imaging suggesting active\ninflammation.  This extends to the anorectal junction but the anus itself is\nessentially normal in this study.  These changes are likely related to active\ninflammatory bowel disease flare confirmed with sigmoidoscopy.  There is\nreactive mesorectal and presacral lymphadenopathy, as above.\n\nPreviously described left trans-sphincteric perianal fistula has healed.  No\nresidual enhancing or fluid components.  No new perianal fistula."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: The visualized loops of small and large bowel\nare relatively featureless with mild apparent wall thickening and prominence\nof the Vasa recta consistent with known inflammatory bowel disease. Arising at\n2 o'clock, approximately 2 cm above the anal verge, is a transsphincteric\nperianal fistula composed primarily of enhancing granulation tissue with a\ntrace central fluid signal intensity component.  This extends inferiorly along\nthe left aspect of the distal rectum and exits along the medial left gluteal\nfold.  There is a component of inflammation that extends within the left\naspect of the external sphincter muscle itself.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable\n\nLYMPH NODES: No suspicious lymphadenopathy.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesion.",
            "output": "1. Transsphincteric perianal fistula composed primarily of enhancing\ngranulation tissue with a trace central fluid component arising at 2 o'clock,\n2 cm above the anal verge and exiting along the medial left gluteal fold with\nassociated inflammatory change within the left aspect of the external\nsphincter muscle itself.  No drainable fluid collection or frank abscess.\n2. Featureless appearance of the visualized colon in keeping with known\ninflammatory bowel disease."
        },
        {
            "input": "There are multiple and extensive areas of marrow signal abnormality evident\npredominantly in the right iliac bone (40:20) but also involving the left\niliac bone (4B: 22) and the left proximal femur (4B: 34). There is near\ncomplete replacement of the marrow of the intertrochanteric left femur. All\nthese areas demonstrate abnormally low signal intensity on T1 weighted\nsequences. There is no loss of signal on out of phase compared to inphase T1\nweighted sequences to suggest the presence of erythropoietic marrow and all of\nthese areas demonstrate diffuse enhancement following contrast administration\n(11:13, 15, 12). Around the right iliac bone anterior there is extensive soft\ntissue edema (6:9) with associated hyper enhancement following contrast\nadministration (10:9). The appearances are very concerning for a marrow\ninfiltrative process such as metastatic disease.\n\nAdditional abnormalities are evident in the spine although incompletely\nvisualized on this nondedicated study. There is a mottled appearance to L4\n(08:13) with heterogenous enhancement following contrast administration\n(11:13). Similar this abnormal signal and hyper enhancement in the posterior\nelements of L5 (11:10, 10:2).\n\nAn additional lesion is seen in the left parasymphyseal region (11:19)\nextending into the superior pubic ramus.\n\nThere is a small amount of free fluid in the pelvis. No pelvic lymphadenopathy\nseen.",
            "output": "1. Multiple enhancing lesions throughout the visualized marrow as described.\nThe appearances are very concerning for metastatic disease and correlation\nwith any known primary is recommended.  Lymphoma or leukemia could have a\nsimilar appearance. There is a soft tissue component extending from the right\niliac bone lesion. There is involvement of both the right and left iliac\nbones, the left proximal femur and L4 and L5.  Although considered much less\nlikely possibilities, in the appropriate clinical setting, granulomatous\ndisease or Brown tumors of hyperparathyroidism might give rise to a similar\nappearance.\n\nNOTIFICATION:   The impression above was entered by Dr. ___ on\n___ at 10:17 into the Department of Radiology critical communications\nsystem for direct communication to the referring provider."
        },
        {
            "input": "Compared to MRI from ___, the extent of bone marrow signal abnormality\nthat was previously seen in the right and left pelvis, proximal left femur,\nleft superior pubic ramus, and presumptive L3 and L5 vertebral body as\nimproved in size and conspicuity in all locations. There are patchy areas of\nbone marrow edema and faint enhancement within the ilial bones, left femoral\nneck and shaft, around the symphysis pubis and in L3 vertebra.  No new foci of\nabnormal marrow signal is identified. There is residual deformity of the L3\nand L5 vertebral bodies, not fully evaluated on this exam. There is no\nevidence of new fractures.\n\nThere are no findings suggestive of femoral head osteonecrosis. There is no\nfemoral acetabular joint effusion.  Bony buttressing at the femoral head neck\njunctions is noted on both sides -- in the appropriate clinical setting, this\nconfiguration can be associated with femoroacetabular impingement.\n\nMuscles and tendons about the pelvic girdle are within normal limits. No soft\ntissue masses or muscle signal abnormality is detected.\n\nLimited assessment of the intrapelvic soft tissue structures is grossly\nunremarkable. No free fluid or enlarged iliac lymph nodes are identified.\nScattered nonenlarged inguinal lymph nodes are noted bilaterally.",
            "output": "1. Previously seen bone marrow signal abnormality in the pelvis, left proximal\nfemur and lower lumbar spine is smaller and less conspicuous at all sites,\nconsistent with response to therapy.  Residual deformity of the presumptive L3\nand L5 vertebral bodies again noted.\n2. No evidence of femoral head osteonecrosis identified."
        },
        {
            "input": "The focus of FDG avidity seen adjacent to the left anterior acetabulum on the\nPET-CT dated ___ appears to correspond to a enhancing distal\nleft external iliac chain lymph node, which measures 7 mm in short axis on\ntoday's examination (series 13, image 14).  This lymph node was not visualized\non the CT abdomen and pelvis dated ___.  In addition, it  appears to\nhave slightly decreased in size since ___.\n\nBone marrow signal is within normal limits throughout.  There is no suspicious\nenhancement of bone.  No evidence of acute fracture.\n\nEnhancement is seen at the origin of the right hamstring tendons, which is\nlikely due to degenerative tendinosis (series 13, image 26).  Enhancement is\nalso seen at the insertion of the left gluteal tendons (gluteus medius and\nminimus) on the greater trochanter (series 13, image 18), which is also likely\ndue to degenerative tendinosis.  No suspicious soft tissue enhancement.\n\nSigmoid diverticulosis is demonstrated.  No other abnormalities within the\npartially visualized abdomen and pelvis.",
            "output": "1. The focus of FDG avidity adjacent to the left anterior acetabulum on the\nPET-CT dated ___ appears to correspond to a distal left external\niliac chain lymph node, which measures 7 mm in short axis.  On review of prior\nimaging, this lymph node had an interval increase in size from ___ to\n___.  Although this lymph node is currently in nonenlarged,\nlymphomatous involvement remains possible given FDG avidity.\n2. Bone marrow signal is within normal limits without evidence of suspicious\nosseous lesions.\n3. Tendinosis at the origin of the right hamstring tendons on the right, and\nof the insertion of gluteus minimus and medius tendons on the left.\n4. Diverticulosis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.4 x 5.0 x 5.8 cm.  A 1.1 cm T2\nhypointense enhancing lesion along the posterior mid uterus is consistent with\na fibroid (04:14).  The endometrial polyp seen on the prior ultrasound is not\nclearly identified on today's exam.\nThe endometrium is normal in thickness for age and measures 0.7 cm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\n\nThere is a large left ovarian cyst measuring 7.3 x 5.3 x 7.3 cm TV x AP x CC\n(04:24).  There is no internal nodularity or papillary projections.  The\nposterior wall of the cyst is thickened, although this likely represents a\nrind of normal left ovarian parenchyma, which contains other small follicles\n(04:25).\n\nNo pelvic free fluid. T2 hypointense thickening of the peritoneal lining can\nbe seen in the setting of endometriosis.\n\nLYMPH NODES: No pelvic sidewall or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions are\nidentified. Soft tissues are unremarkable.",
            "output": "1. 7.3 cm left ovarian cyst without concerning features.  Apparent thickening\nof the posterior cyst wall likely represents the normal left ovarian\nparenchyma that is thinned by the cyst.\n2. Previously seen endometrial polyp is not definitely visualized on the\ncurrent exam.\n3. 1.1 cm posterior subserosal fibroid.\n4. Thickening of pelvic peritoneal lining may suggest underlying\nendometriosis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.9 x 3.9 x 5.5 cm.  Along the anterior\nlower uterus, there is a 33 x 37 x 19 mm T2 hypointense lesion which is\nhypoenhancing (3, 11 and 1402, 56).  There is a rim of surrounding myometrium.\nThis is compatible with an intramural fibroid.  The myometrium is otherwise\nquite heterogeneous, likely due to multiple smaller ill-defined fibroids. \nThere are distorting the endometrium, which is not well evaluated.  There is\nno evidence of endometrial thickening.\n\nScarring is noted along the posterior aspect of the uterus (3, 15).  There is\nno associated tethering of the adjacent bowel.  This is nonspecific, and may\nbe from a prior surgery or possibly old endometriosis.  There is no\nendometrial deposits or endometriomas noted elsewhere in the pelvis.\n\nThe cervix and vaginal canal are within normal limits.\n\nThe right ovary is normal with several tiny follicles.  The left ovary is also\nnormal.  No follicles are noted on the left.\n\nThere is no free fluid in the pelvis.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS:  The bladder is not fully distended, which limits\nevaluation.  Within the limitations, there is no focal thickening or evidence\nof a mass.  The distal ureters are normal.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic bowel loops are\nwithin normal limits.  There are no focal inflammatory changes.\n\nVASCULATURE: The pelvic arterial vasculature is normal without evidence of an\naneurysm or significant stenosis.  The pelvic veins are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning osseous lesions. \nModerate degenerative changes are noted at a L5-S1, where there is disc\ndegeneration and endplate changes.  There is no large disc bulge.  The soft\ntissues are unremarkable.",
            "output": "1.  Fibroid uterus; specifically, the abnormality seen on the prior ultrasound\ncorresponds to an intramural fibroid in the lower uterine segment.\n2.  Normal ovaries."
        },
        {
            "input": "There is a complex network of perianal and perirectal fistulas that\ncommunicate intersphincterically.\n\nThere is a dominant tract that arises from the 3:00 position of the lower\nrectum (11:57), approximately 4-cm above the anal verge with posterolateral\nand inferior branches.  The posterolateral branch extends transphincterically\ninto a T2 hyperintense collection in the left puborectalis muscle, measuring\n3.8 cm x 2.7 cm, series 11, image 55, which is both larger and more enhancing\nrelative to the prior study. Although there are punctate non-enhancing pockets\nof fluid in this collection, the bulk of this lesion enhances avidly,\npredominately granulation tissue, and no drainable collection is identified. \nThe inferior branch courses intersphincterically and exits the left gluteal\nfold, and contains ___ (11:75).\n\nA second dominant tract arises from the 9:00 position of the lower rectum\n(11;57) and has anterior, inferior, and posterolateral branches. The\nposterolateral branch is transphincteric and ends blindly within the right\nlevator ani, which is avidly enhancing, worsened since the prior examination\n(series 11 image 55), without fluid collection.  The inferior branch is\nintersphincteric, and extends to the right gluteal fold.  The anterior branch\nprojects 10 mm towards the posterior vaginal wall and ends blindly without\nfistulization to the vagina, unchanged since the prior examination (10;60).\n\nThe internal and external anal sphincters are both markedly attenuated and\nedematous, with inflammation throughout the intersphincteric space.\n\nNumerous enhancing prominent mesorectal and perirectal lymph nodes measure up\nto 0.8 cm and are similar to the prior exam. Extensive wall thickening with\nhyperenhancement of the mucosa, and adjacent inflammatory changes involving\nthe rectum and sigmoid colon are consistent with active proctocolitis. A 1.3\ncm x 1.5 cm right posterior fundal fibroid denoted by low signal intensity on\nT2 weighted sequences is overall similar to the prior exam. The endometrium is\nnormal. A tiny nabothian cyst is present. Susceptibility artifacts arise from\nthe bilateral Essure devices, confirmed on a comparison CT from ___.\n\nThe bladder is normal.  Normal T1 marrow signal is identified.",
            "output": "1. Interval worsening of a complex network of perirectal fistulas as described\nabove, with involvement of bilateral levator ani and extension to the right\nand left gluteal folds, overall worse since the ___ MRI.  No\ndrainable fluid collections.\n2. A blind-ending right anterior tract extends into the posterior vaginal wall\nwithout a communicating rectovaginal fistula, unchanged in configuration.\n3. Numerous enlarged mesorectal and perirectal lymph nodes.\n4. Active proctocolitis.\n\nNOTIFICATION:  ___ were d/w Dr. ___ by Dr. ___ by phone at 4:10p\non the day of the exam."
        },
        {
            "input": "The uterus is anteverted with a single intramural fibroid again identified\nwithin the posterior wall of the upper uterine segment. This has maximum\ndiameter of 1.4 cm (04:19). Linear susceptibility artifact at the uterine\ncornua bilaterally are compatible with bilateral Ensure devices. The remainder\nthe uterus, cervix, bladder, and urethra are unremarkable.\n\nAs was seen previously, there is evidence of active proctitis with rectal wall\nthickening and mucosal hyperemia. The surrounding mesorectal fat demonstrates\nfibrofatty proliferation and increase in number of rectal vessels, signs\nindicating chronicity. There are also numerous perirectal lymph nodes,\npresumably reactive in etiology.\n\nThere is extensive complex perianal fistulous disease, described superior to\ninferior below.  At the level of the anorectal junction, there are multiple\ntranssphincteric defects including bilateral posterior lateral defects which\ncoalesce posteriorly. This circular tract extends just above the puborectalis\nmuscle and involves the levator sling. It communicates with a large pocket of\nT2 hyperintense material along the posterior pelvic floor, slightly greater on\nthe left than the right. Transversely this extends from the posterior aspects\nof each obturator internus muscle, measuring 8.9 cm in diameter. Posteriorly\nthere is extension to the coccyx. As compared to previously there is no\ndecreased fluid, nonenhancing component, with almost the entirety of this\nmaterial enhancing, indicating phlegmon. (07:11).\n\nThe perianal disease tracts inferiorly circumferentially along the\nintersphincteric space with multifocal defects within the internal sphincter\nand external sphincter resulting in loss of the normal sphincter architecture.\n\nA component extends anteriorly on the right and results in posterior tethering\nof the vagina.  While involvement of the serosal surface of the vagina is\nsuspected, there is no evidence of fistulous communication to the vaginal\nlumen.\n\nMost inferiorly, there appear to be three ramifications that exit to the\nbuttock skin surface, one on the are right and two on the left (one of which\ncontains a ___. No significant fluid is seen along the course of any of\nthese tracts.\n\nInguinal lymphadenopathy is unchanged and presumably reactive in etiology.\nVisualized osseous structures are within normal limits.",
            "output": "Re-demonstration of numerous complex perianal fistulas, with extension to and\njust above the levator ani. The degree of associated inflammation and\npreviously seen fluid components have decreased as compared to the most recent\nprior examination. There is no drainable fluid collection."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 10.6 cm (AP) x 7.8 cm (TV) x 10.4 cm\n(length)\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 5 mm.  There is an intrauterine device\nwhich appears to be in the endometrial cavity, although exact positioning is\nhard to determine on MRI.\nJunctional zone: 18 mm, consistent with adenomyosis.\n\nThere is scarring of the uterus anteriorly, consistent with previous cesarean\nsection.\n\nFIBROIDS:\n\nFibroid burden: ___\nFibroid enhancement: Heterogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n1.      none\n\nThe three dominant fibroids are:\n1.  Size: 9.0 cm x 7.5 cm x 6.9 cm avid enhancement, 100 % intramural,\nlocation inferior fundus\n2.  Size: 6.4 cm x 5.3 cm x 5.1 cm avid enhancement with central necrosis, 100\n% intramural, location superior fundus\n3.  Size: 3.4 cm x 3.1 cm x 3.3 cm avid enhancement, exophytic subserosal,\nlocation superior fundus\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nNormal size with normal follicular activity on the right.\n\nThe left ovary contains a 3.3 cm x 3.4 cm T2 hyperintense lesion with an\ndebris-fluid level which contains mildly high T1 contents seen, suggesting\nthis is a hemorrhagic cyst.  Adjacent to this, there is a circumferentially\nhigh T1 lesion, measuring 1.7 cm x 1.1 cm, likely representing a hemorrhagic\ncorpus luteal cyst.\n\nThere is a physiologic amount of intrapelvic free fluid.\n\nThere is mild asymmetric thickening of the ureterosacral ligament, suspicious\nfor deep endometriosis.",
            "output": "1. Multiple fibroids are seen, measuring up to 9.0 cm x 7.5 cm x 6.9 cm as\ndescribed above.\n\n2.  Asymmetric mild thickening of the ureterosacral ligament, suspicious for\ndeep endometriosis.\n\n3. Thickened junctional zone up to 18 mm, consistent with adenomyosis.\n\n4. Left ovarian 3.4-cm hemorrhagic cyst and hemorrhagic corpus luteal cyst."
        },
        {
            "input": "The uterus is within normal limits for postmenopausal status, measuring 6.0 cm\nlongitudinally by 2.2 cm anteroposterior by 4.1 cm transverse, with\nanteverted, anteflexed orientation. The junctional zone is normal in\nthickness. There is minimal focus of T2 hyperintensity within the endometrial\ncavity, less than 3 mm in thickness. There is no distension of the endometrial\ncavity to suggest a polyp or endometrial mass. The cervix and vaginal canal\nare within normal limits.\n\nThe ovaries are very small and not easily distinguished from adjacent bowel.\nThere is no free fluid in the pelvis. The partially distended bladder is\ngrossly unremarkable. The rectum and distal sigmoid colon are within normal\nlimits. There is no pelvic or inguinal lymphadenopathy.\n\nThe osseous structures are unremarkable.",
            "output": "No evidence of endometrial polyp or mass. Minimal T2 hyperintense signal in\nthe endometrial cavity most likely reflects a small focus of residual\nendometrial tissue post ablation, but no fluid distending the canal."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.6 x 3.3 x 4.6 cm.  Although no\ndiscrete myometrial lesions are visualized, the anterior myometrium appears\nbulky with low T2 signal intensity, possibly representing small fibroids.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There is a borderline enlarged left external iliac lymph node\nmeasuring 1.5 cm in short axis (series 3, image 6).  No new pelvic or inguinal\nlymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder is moderately distended and normal in\nappearance.\n\nRECTUM AND INTRAPELVIC BOWEL: Partially imaged pelvic small and large bowel\nare unremarkable in appearance.\n\nVASCULATURE: No retrograde or anterograde flow is visualized within the\ngonadal veins on the time of flight images, likely due to their small caliber,\nas demonstrated on the CT abdomen and pelvis dated ___.  Otherwise,\nthe pelvic vessels appear patent and normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Surrounding soft tissues are unremarkable\nin appearance.  No suspicious osseous lesions.",
            "output": "1. Neither retrograde nor anterograde flow is visualized within the gonadal\nveins on the type of flight images, likely due to their small caliber, similar\nto the CT abdomen and pelvis dated ___.\n2. Bulky anterior myometrium with low T2 signal intensity without discrete\nlesions, possibly representing small fibroids.\n3. Borderline enlarged left external iliac lymph node measuring up to 1.5 cm\nin short axis, unchanged since the CT dated ___, nonspecific."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe uterus is anteverted and measures 11 x 11 x 9 cm.\n\nLarge fibroid projects into and displaces  the endometrial cavity measures\napproximately 4 (AP) x 8 x 8 cm. This mass shows low signal on T2 weighted \nimages and intermediate signal on T1 weighted images and no significant\nenhancement. Endometrium is seen above, below, and posteriorly to this\nfibroid.  These findings are consistent with a  broad based submucosal\nanterior uterine body fibroid that pushes into the endometrial cavity. When\ncompared to exam from ___ this fibroid is smaller and projects more into the\nendometrium.\n\nOff the posterior uterine body there is a pedunculated subserosal fibroid\nwhich measures 5.5 x 5.5 cm in greatest axial dimension.  This shows expected\nlow signal on T2 weighted images and no enhancement.\n\nOther smaller fibroids are also noted most of which are intramural none of\nwhich show significant enhancement.  Addition, there is a small subserosal\nfibroid at the fundus which does not show enhancement.\n\nThe fibroids do not demonstrate enhancement consistent with prior embolization\n\nEndometrium is distorted by the submucosal large fibroid as described above\nbut is not thickened.  An IUD is in place.\n\nThe junctional zone is not well seen.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nNo free pelvic fluid.\n\nLYMPH NODES: There are several enlarged pelvic lymph nodes which are new since\n___. A left internal iliac lymph node measures 1.2 cm in short axis.  Right\nobturator lymph node measures 1.1 cm in short axis. Right internal iliac lymph\nnode measures 1.2 cm in short axis.\n\nBLADDER AND DISTAL URETERS: Normal\n\nRECTUM AND INTRAPELVIC BOWEL: Normal\n\nVASCULATURE: Normal\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Normal bone marrow signal.",
            "output": "1.  Large submucosal fibroid with a broad base of attachment to the anterior\nuterine wall projects into and displaces the endometrial cavity; it is smaller\nwhen compared to ___.  There is also a subserosal exophytic fibroid off the\nposterior aspect of the uterus.  Neither of these fibroids show significant\nenhancement\n\n2.  There are 3 enlarged pelvic nodes, new from ___.  This is unclear in\netiology and may be reactive.  Followup MRI should be performed in 3 months.\n\n The impression and recommendation above was entered by Dr. ___\n___ on ___ at 10:38 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider.\n\nRECOMMENDATION(S):  MRI of the pelvis should be performed in 3 months.\n\nNOTIFICATION:   The findings were discussed with Dr. ___. by\n___, M.D. on the telephone on ___ at 11:16 AM, 45\nminutes after discovery of the findings."
        },
        {
            "input": "Tumor:  The primary component of the tumor is annular, with an apple-core like\nappearance involving the mid rectum (5:26).  There is a large mucinous\ncomponent that appears more de-differentiated, which fills the mesorectal\nspace and extends into the mesentery of the sigmoid colon (5:16).  There is no\ndistinct fat plane between components of the mass and the uterus.\n\nDistance from anal verge (AV) (mm): 2.4\nExtends cranio-caudally (CC) (mm):  6.6 cm\nDistal edge lies:  15 mm below puborectalis sling\nUpper border lies: at peritoneal reflection\n\nSTAGING\nInvading tumor edge: 5:00 to 11:00 positions\nMuscularis propria:  extends through\nExtramural spread (mm): > 5 cm\nExtramural venous invasion (EMVI):  yes, there is extensive EMVI, with\nextension up the left gonadal vein, beyond the imaged field-of-view.\nPeritoneal reflection: Involved\nAdjacent pelvic organs ___, prostate, vagina): There is a long segment of\ndirect contact between the posterior aspect of the mass and the puborectalis\nsling (5:27).\n\nCRM (Circumferential resection margin): 0 mm\n\nMinimum tumor distance to MRF:  less than or equal to 1mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: At and above tumor\nMesorectal lymph nodes - heterogeneous signal: yes\nMesorectal lymph nodes - capsular irregularity: yes\nMesorectal lymph nodes:  N2 ( >4)\n\nPelvic side wall nodes:  yes, right external iliac node measuring 2.3 x 1.5 cm\n(11:22)\nIf Yes to Pelvic side wall nodes (location): right\nIf Yes to Pelvic side wall nodes (type): malignant\n\nStaging Assessment: T4b\nExtramural spread (mm): > 5 cm\nCRM:   involved\nEMVI:  positive\nLocation: mid rectal tumor\nNodal:  N2\nMetastasis: M1\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and contains a large 4.8 cm partly calcified fibroid,\nwhich distorts the endometrium.\n\nThe ovaries are not distinctly seen.\n\nBLADDER: Unremarkable.\n\nVASCULATURE: Redemonstration of large occlusive thrombus in the right external\nand internal iliac, common femoral, femoral and greater saphenous veins,\nlikely representing bland thrombus.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious lesions.",
            "output": "1. T4b, N2, M1, 6.6 cm annular rectal mass with a large\nde-differentiated-appearing mucinous component filling the mesorectal space\nwith direct extension into the sigmoid colon mesentery and extensive EMVI with\ntumor thrombus extending up the left gonadal vein.\n2. Redemonstration of large occlusive, probably bland thrombus in the right\nexternal and internal iliac, common femoral, femoral and greater saphenous\nveins."
        },
        {
            "input": "Tumor:  As previously, the central component of the tumor is annular in\nconfiguration with an apple-core appearance of the mid rectum (04:28). \nCompared to prior, there is substantial interval increase in the degree of\nannular thickening.  The tumor demonstrates decreased T2 hyperintensity, now\nintermediate, and decreased enhancement involving greater than 50% of the\ntumor.\n\nRedemonstrated is a large mucinous component of the tumor which fills the\npresacral space and bulges anteriorly against the posterior wall of the uterus\nand into the mesentery surrounding the sigmoid colon.  Compared to prior, this\nmucinous component appears substantially less bulky.\n\nDistance from anal verge (AV) (mm): 2.6 cm\nExtends cranio-caudally (CC) (mm): 7.0 cm\nDistal edge lies:  15 mm below puborectalis sling\nUpper border lies: at peritoneal reflection\n\nSTAGING\nInvading tumor edge: From 5 o'clock to 11 o'clock\nMuscularis propria:  extends through\nExtramural spread (mm):  > 10 mm\nExtramural venous invasion (EMVI):  yes\nPeritoneal reflection: Involved\nAdjacent pelvic organs ___, prostate, vagina): Enhancement of the\npuborectalis sling is suggestive of a reactive inflammatory process or direct\ntumor invasion.\n\nCRM (Circumferential resection margin): 0 mm\n\nMinimum tumor distance to MRF:  less than or equal to 1mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: At and above tumor\nMesorectal lymph nodes - heterogeneous signal: yes\nMesorectal lymph nodes - capsular irregularity: yes\nMesorectal lymph nodes:  N2 ( >4)\n\nPelvic side wall nodes:  yes\nIf Yes to Pelvic side wall nodes (location): right\nIf Yes to Pelvic side wall nodes (type): malignant\n\nStaging Assessment: T4b\nExtramural spread (mm): > 10 mm\nCRM:   involved\nEMVI:  positive\nLocation: mid rectal tumor\nNodal:  N2\nMetastasis: M1\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and contains a large 4.9 cm partially calcified\nfibroid, which distorts the endometrium.  There is no fat plane between the\nuterus and the mass at the ___ o'clock positions.  Hyperenhancement in this\nregion is highly suggestive invasion into the uterine wall, similar to prior. \nTethering of the left posterolateral wall of the uterus to the adjacent tumor\n(09:27) likely reflects posttreatment changes.\n\nThe ovaries are not visualized.\n\nBLADDER AND DISTAL URETERS: Unremarkable\n\nVASCULATURE: New from prior, there is partial recanalization of the right\nexternal iliac veins extending to the common femoral, femoral, and saphenous\nveins which continue to demonstrate persistent large partially occlusive clot\nburden.  The internal iliac and its branches remain thrombosed as seen\npreviously.  There is interval development of multiple subcutaneous and\nintrapelvic varices.\nThe previously visualized expansile thrombus in the left gonadal vein, is no\nlonger visualized.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning focal hepatic or soft\ntissue lesions are noted.",
            "output": "1. Decreased circumferential thickening and mucinous component, decreased\nenhancement, and >50% fibrosis and visible intermediate signal intensity\nconstitute a moderate partial response to treatment.\n2. 7.0 cm annular rectal mass remains T4b, N2, M1 in staging.\n3. Partial recanalization of the external iliac, common femoral, femoral, and\ngreat saphenous veins with persistent partially occlusive thrombus.  Likely\ninterval resolution of left gonadal vein thrombosis.\n4. Stable mesorectal and pelvic lymphadenopathy with similar extent of\nextramural invasion."
        },
        {
            "input": "RECTOSIGMOID:\n\nThere is redemonstration of an annular tumor in mid to upper rectum.  The\ntumor extends approximately 3.5 cm.  The lower limit of the tumor is\napproximately 7 cm from the anal verge (3:20).\nThere is redemonstration of T2 hyperintense lesions extending beyond the\nserosal margins of the mass into the mesorectal fat (7:22) and again breaching\nthe CRM (series 16, image 70), reflecting mucinous components.  Since the\nprior MR examination from ___, there is a little change in the\noverall configuration and size of these mucinous components, with the largest\npocket along the right mesorectal fat measuring approximately 4.8 x 3.1 x 3.8\ncm (series 3, image 24, series 10, image 31).\n\nThere is focal narrowing of the lumen at the level of the mass, improved from\nprior (series 7, image 22).  In comparison to the ___ examination,\nthe tumor signal intensity has demonstrated a slight interval increase when\ncompared to the skeletal muscle (series 10, image 26), with less defined areas\nof fibrosis that was visualized previously (compare to series 7, image 18 from\nthe ___ MRI).  These areas demonstrate restricted diffusion\n(series 6, image 24) is slightly more prominent enhancement (series 16, image\n61).\n\nThere is mild sigmoid wall thickening, likely representing posttreatment\nchanges.\n\nLYMPHADENOPATHY:\n\nMesorectal nodes:\nThere is redemonstration of several mesorectal nodes measuring over 5 mm\ndemonstrating capsular irregularity, heterogeneity. (Series 16, 70, 69).\nThe largest of these nodes, the 0.9 cm left mesorectal lymph node (16:17)\nmeasured 1.3 cm on the prior study (16:17).  Adjacent posteriorly is an 8 mm\nnode which previously measured 10 mm (series 16, image 69).\n\nThe sigmoid mesocolon:\nMultiple confluent subcentimeter nodes in the sigmoid mesocolon appear\nimproved in comparison to the prior examination (series 18, image 18).\n\nPelvic lymph nodes:\nA prominent right external iliac lymph node now measures 0.9 cm (18:48)\ncompared with 1.1 cm from ___.  Other subcentimeter pelvic sidewall\nlymph nodes are stable in size when compared with the ___ study.  A\nslightly spiculated 9 mm left inguinal node is unchanged from prior (series\n18, image 60).\n\nUTERUS AND ADNEXA:\nThere is redemonstration of a 4.8 cm fibroid in the left-side of the\nmyometrium that is partly submucosal and partly intramural.  The posterior lip\nof the cervix and torus uterinus is appear tethered to the rectal mass with\nloss of the rectovaginal fat plane.\nThe ovaries are not identified.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nVASCULATURE: There is chronic occlusion of the right external iliac vein\nextending into the right common femoral vein and saphenous vein.  These\nvessels now appear diminutive when compared with the previous study (18:68). \nThe internal iliac and its branches remain thrombosed as seen previously.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning focal hepatic or soft\ntissue lesions are noted.",
            "output": "1. Interval increase in tumor components of a known mid upper rectal mass,\nwhen compared to the MRI from ___, with replacement of\npreviously-seen fibrotic components .  There is continued tethering against\nthe cervix and lower uterus.  Tumor regression grade 4.\n2. Extensive mucinous components extending from the mass into the mesorectal\nfat with invasion of the CRM.\n3. Interval decrease in size or stability of mesorectal and pelvic nodes. \nInterval decrease in perisigmoid adenopathy. No new lymphadenopathy.\n4. Chronic occlusion of the right external iliac, common femoral and greater\nsaphenous vein.\n5. Imaging stage T4aN2."
        },
        {
            "input": "There are multiple acute pelvic fractures which are likely insufficiency\nfractures this setting of osteoporosis.  No soft tissue component to suggest\npathologic fractures due to underlying neoplasm.\n\nSpecifically, these involved the right anterior acetabulum, there is marked\nmarrow edema with linear mildly displaced fracture line and likely\nnondisplaced fracture of the adjacent right superior pubic ramus (series 5,\nimage 30).  Fractures involving the left ilium extends intra-articularly into\nthe sacroiliac joint and right anterior sacrum are nondispalced (series 4,\nimage 11). There is extensive marrow edema in the left pubic ramus with linear\nminimally displaced left parasymphaseal fracture.\n\nMarked muscular edema in the left adductors, left gluteal, and left piriformis\nmuscles.  Trace left intrapelvic edema with rounded focus demonstrating\nhyperintense T2 and slightly hyperintense T1 signal suggests a small hematoma,\nalthough difficult to be definitive (series 3, image 17).\n\nSevere lumbar spine degenerative change and Tarlov cysts noted.",
            "output": "1. Multiple acute pelvic insufficiency fractures involving the right anterior\nacetabulum, right sacrum, left pubic ramus, and left iliac bone.  No femoral\nneck fracture.  No soft tissue component to suggest underlying neoplastic\npathologic fracture.\n2. Intramuscular edema and left pelvic edema with possible small left pelvic\nhematoma also likely reactive/posttraumatic in this setting.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 11:19 am, 5 minutes after\ndiscovery of the findings."
        },
        {
            "input": "Motion artifact significantly degrades the quality of the study.\n\nThere are multiple abnormal areas of T2 hyperintense signal which are\nhypointense on the T1 weighted images concerning for metastatic disease. For\ninstance, in the right lesser trochanter extending into the intertrochanteric\nregion, there is a lesion measuring approximately 40 x 39 mm.  Questionable\nlinear signal is noted on the STIR sequence (07:11). An underlying pathologic\nfracture cannot be excluded.\n\nIn the left hemisacrum and posterior left iliac bone, there is similar signal\nabnormality consistent with metastatic disease. The comminuted pathologic\nfracture of the iliac wing is better assessed on the previous CT scan.  There\nis surrounding intramuscular edema and fluid in this region.\n\nThere are multiple small foci identified in the L3-L5 vertebral bodies\nconcerning for metastatic disease.  The vertebral body heights are well\npreserved.\n\nFluid tracks along the iliacus muscles bilaterally and there is edema within\nthe left gluteal muscles.\n\nThere is a small amount of fluid within the pelvis.\n\nNo definite inguinal adenopathy by size criteria.",
            "output": "Limited study due to motion artifact.\n\n1. Multiple suspicious osseous lesions concerning for metastatic disease as\ndescribed above.\n2. Left iliac wing pathologic feature.\n3. Possible pathologic fracture in the right lesser trochanter. Follow-up CT\nscan of the right hip is recommended.\n\n\n\nRECOMMENDATION(S):  Follow-up CT scan of the right hip is recommended.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 4:48 ___, 5 minutes after discovery\nof the findings."
        },
        {
            "input": "Of note, study is limited without the use of IV contrast, which was given due\nto history of prior allergic reaction.\n\nRECTUM AND INTRAPELVIC BOWEL: Three setons are identified.  The first\noriginates at 12 o'clock, 4.6 cm above the anal verge and extends anteriorly\nand to the right of midline and descends inferiorly to exit at the medial\ngluteal fold medially below the anal verge.  There are 2 branch points\nextending from this tract: More proximally there is slight anterior extension\ninto a sinus tract that measures 1.2 x 0.9 x 0.8 cm (CC by TR by AP; 9:64,\n6:31).  More inferiorly, there is a branch point terminating in a sinus tract\nthat extends inferior to the ___ within the right ischioanal fossa measuring\nup to 3.7 x 1.0 x 2.0 cm (CC by TR by AP; 9:33, 6:30).  The ___ these\nsinus tracts is T2 hyperintense, either representing fluid collections or\nhyperdense granulation tissue, which cannot be delineated without the use of\nIV contrast.  A second ___ extends from 12 o'clock, 4.6 cm above the anal\nverge (arising from the same internal opening is the previously described\n___, and extends anteriorly and to the left of midline, descending and\nexiting approximately at the level of the anal verge.  There is no branching\nor associated sinus tract.  A third ___ enters through the skin of the\nmedial gluteal fold approximately 1.5 cm below the anal verge, extends\nsuperiorly within the intersphincteric space and posteriorly and then courses\ninferiorly, exiting the skin in the medial gluteal fold at the same level it\nentered.  There is no see stated sinus tract or fluid collection.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.\n\nLYMPH NODES: There is no suspicious lymphadenopathy.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesion.",
            "output": "Three setons in situ, detailed above.  The right-sided ___ is associated\nwith small branching sinus tracts that contain T2 hyperintense material, which\nmay represent small fluid collections or granulation tissue, with further\ncharacterization limited without the use of IV contrast.  No definite\ndrainable collections.\n\nRECOMMENDATION(S):  Subsequent follow-up studies should be performed with IV\ncontrast, either following premedication, or with the use of an alternate\ngadolinium based contrast agent as cross reactivity between gadolinium agents\nis very low. Patient appears to have tolerated Gadavist in the past, and this\ncould potentially be used for future studies."
        },
        {
            "input": "Lower thorax: No pleural effusion.  Bilateral breast prosthesis.\n\nLiver: The liver is not cirrhotic and there is no hepatic steatosis.  Again\nnoted is a 12 mm arterially enhancing lesion only seen on the arterial phase\nin segment VII (series 1201, image 76).  This likely represent a THID.  No new\nfocal concerning liver lesion meeting OPTN 5 criteria.  Tiny few scattered\ncysts/biliary hamartomas are noted.\n\nBiliary: No intra or extra biliary duct dilatation.  The gallbladder is\nunremarkable.\n\nPancreas: The pancreas is normal in signal and bulk.  No focal lesion.  No\nmain duct dilatation.  There is a 16 mm periampullary diverticulum.\n\nSpleen: The spleen is homogeneous and measures 10.5 cm.\n\nAdrenal Glands: unremarkable.  No focal lesion.\n\nKidneys: Status post right partial nephrectomy in the lower pole of the right\nkidney.  No signs of locoregional recurrence.  Again noted are tiny few\nscattered cyst the right kidney, the largest measuring 17 mm at the upper pole\nof the right kidney.  No hydronephrosis.  Tiny left hemorrhagic cyst.\n\nGastrointestinal Tract:  No bowel obstruction.  Uncomplicated colonic\ndiverticulosis.\n\nPelvis: The urinary bladder is unremarkable.  The uterus is in place.  There\nis a 3 cm fibroid in the anterior fundus.  No adnexal lesion.\n\nLymph Nodes: No abdominal or pelvic lymphadenopathy.  No ascites.\n\nVasculature: No abdominal aortic aneurysm.\n\nOsseous and Soft Tissue Structures: No focal concerning lesion.",
            "output": "Status post right partial nephrectomy with no signs of locoregional\nrecurrence."
        },
        {
            "input": "There is a left lower quadrant renal transplant with normal parenchymal signal\nintensity, enhancement, and excretion of intravenous contrast.  There is no\nevidence of hydronephrosis in the transplant. There are no enlarged pelvic\nlymph nodes or suspicious pelvic masses.\n\nThere are small fluid collections adjacent to the transplant as seen on prior\nCT without definite air, possibly representing postoperative hematoma. There\nis an unchanged T1 hyperintense collection in the midline lower abdominal\nsubcutaneous tissue consistent with hematoma as seen on prior CT.\n\nThe pancreas transplant in the right abdomen has normal signal intensity and\nenhancement characteristics without evidence of mass or ductal dilatation.\n\nThere is a small amount of free fluid in the pelvis. There is mild widening of\nthe cornual which may be seen setting of an arcuate uterus.",
            "output": "1. Left lower quadrant renal transplant with normal signal intensity,\nenhancement, and excretion of intravenous contrast.  No evidence of\nhydronephrosis.\n2. No evidence of pelvic mass or suspicious lymph node."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nBLADDER AND DISTAL URETERS: There is a focal nodular soft tissue mass at the\nright lateral wall of the bladder measuring 3.1 x 1.5 x 3.4 cm that is\nisointense to slightly hyperintense on the T2 weighted images relative to the\nbladder wall and isointense on the T1 weighted images with restriction on the\ndiffusion-weighted sequences and arterial enhancement on the postcontrast\nphases highly suspicious for a bladder tumor.  At the most inferior aspect of\nthe mass, there is evidence of perivesical soft tissue extension (Series 9,\nimage 20 and 21).\n\nThere is also flat area of the mucosal thickening along the posterior bladder\nwall extending to the left demonstrating early arterial enhancement and slight\nrestriction on the diffusion-weighted sequences (series series 400, image 38)\nwith a more focal nodular area adjacent to the left UVJ (series 9, image 17),\nalso suspicious for bladder tumor.  It however does not demonstrate evidence\nfor invasion of the deep muscle or extravesicle extension.\n\nA Foley's catheter is noted in situ.  The distal ureters are normal without\nfocal mass or wall thickening.\n\nPROSTATE AND SEMINAL VESICLES:  There is linear T2 hypointense signal within\nthe prostate gland, likely related to prior prostatitis.  There is\nasymmetrical atrophy of the right seminal vesicle as compared to the left.\n\nLYMPH NODES: No suspicious pelvic lymphadenopathy by size criteria.\n\nVASCULATURE: Visualized portions of the iliac vessels are unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Focal T2 hypointense lesion within the\nright ischial tuberosity (series 9, image 30) measuring 11 x 9 mm that\ndemonstrates drop of signal on the out of phase images, most likely a focal\nisland of red marrow.  Another lesion within the left iliac wing (series 3b,\nimage 18) that also demonstrates drop of signal on the out of phase images\nwith sclerotic borders on the CT, suggestive of benign etiology.  There is a\nsmall fat containing right inguinal hernia.",
            "output": "1.  Focal nodular soft tissue mass at the right lateral bladder wall that is\nhighly suggestive of bladder tumor.  The inferior aspect of the mass\ndemonstrates perivesical soft tissue extension, compatible with stage T3b\ndisease.\n\n2.  Mucosal thickening along the posterior bladder wall extending to the left\nwith a more focal nodular area, also highly suggestive of bladder tumor. \nThere is no evidence of invasion of the deep muscle or extravesical extension,\ncompatible with stage T2 disease.\n\n3.  No suspicious pelvic lymphadenopathy.  Focal hypointense bone lesion\nwithin the right ischial tuberosity that drops signal on the out of phase\nimaging, most likely a focal island of red marrow."
        },
        {
            "input": "There is a defect anteriorly at approximately 12 o'clock at the anorectal\njunction (6: 24) with an enhancing tract which extends anteriorly to the base\nof the penis and subsequently trifurcates. A ramification extends posteriorly\nalong the right ischiorectal fossa (10:75). An additional enhancing tract\nextends anteriorly along the right aspect of the corpus spongiosum and\ndistally coursing between the corpus spongiosum and right cavernosum. Each of\nthese two tracts appear to blindly terminate without associated fluid\ncollection.  A third ramification extends inferiorly along the posterior\naspect of the penis, anterior to the anal sphincter, exiting at the skin\nsurface of the right buttock (10:100 and ___.\n\nThree intrasphincteric enhancing perianal tracts are also present.  These are\nseen as internal sphincter defects anteriorly, right posterolaterally and left\nlaterally (1000:76), each coursing inferiorly towards the skin surface with\nsubcutaneous susceptibility artifact noted on the left.  No associated\ndrainable fluid collection is present.\n\nThickening of the rectum with wall edema and hyperemia is noted. There is\nsurrounding stranding within the mesorectal fat as well as numerous small\nlymph nodes (7:6) . The appearance is compatible with active proctitis.\n\nThe urinary bladder and prostate gland are unremarkable in appearance.\n\nExtensive susceptibility artifact is noted associated with the patient's right\nhip hardware. Mild degenerative changes are noted of the left hip. Muscular\nskeletal structures are otherwise unremarkable",
            "output": "1.  Perianal fistulous disease as detailed above, without associated drainable\nfluid collection.  The dominant transsphincteric tract arises anteriorly at\nthe anorectal junction, with trifurcation into two sinus tracts, including one\nextending anteriorly along the right aspect of corpus spongiosum, and a single\ninferiorly coursing cutaneous fistula.  There are three small intrasphincteric\ntracts as well.\n\n2.  Active proctitis."
        },
        {
            "input": "RECTUM: There is an intersphincteric fistula containing granulation tissue\narising between 6 to 7 o'clock position of the lower anal canal.  The fistula\nstarts from approximately 2.6 cm above the anal opening and forms a short loop\nsuperiorly in the intersphincteric space.  The fistula then travels inferiorly\nto to the right of the midline along the intersphincteric space to exit to the\nright gluteal area.  No supralevator extension. No fluid collection is\nidentified.  There is trace pelvic free fluid.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Limited evaluation of the prostate\nand seminal vesicles is unremarkable.\n\nLYMPH NODES: No lymphadenopathy.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions",
            "output": "Granulation tissue containing intersphincteric fistula arising at 6 to 7\no'clock position from approximately 2.6 cm above the anal opening  and exiting\nin  the right gluteal area.  No supralevator extension.  No fluid collection."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 59 x 28 x 40 mm.\nThe endometrium is normal in thickness for age and measures 2 mm.  Nabothian\ncysts are noted.\nThe junctional zone is not thickened.\n\nThe ovaries are not readily apparent.  Trace pelvic free fluid is within\nphysiologic limits.\n\nLYMPH NODES: There is no pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Unremarkable\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Redemonstration of diffuse bony\nmetastatic disease, with interval progression.  There is suggestion of a\npathological fracture (series 11, image 13) where we see a transverse T2\nhypointense line involving the superior and anterior aspect of the right\nsacral alae at the level of S1/S2, with no evidence of extension toward the\nneural foramina.  Additionally, the right nerve root of S3 abuts a bony\nmetastatic deposit at the level of the foramina with no definite compression. \nFocal enhancement in the left posterior paraspinal soft tissues at the level\nof L5-S1, series 10, image 8, with mild associated STIR hyperintensity may be\nposttraumatic, however a soft tissue lesion is not excluded..",
            "output": "1. Progression of pelvic bony metastatic disease since ___, with\nevidence of a pathological fracture involving the right superior sacral alae,\nand a metastatic deposit abutting the right S3 nerve root with no evidence of\ncompression at the level of the neural foramina.\n2. Focal enhancement in the left posterior paraspinal soft tissues at the\nlevel of L5-S1, series 10, image 8, with mild associated STIR hyperintensity\nmay be posttraumatic, however a soft tissue lesion is not excluded."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 15.9 x 9.3 x 15.7 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 9 mm however is distorted due to large\nadjacent fibroids.\nJunctional zone: 4 mm without focal thickening.\n\nFIBROIDS:\n\nFibroid burden: More than 15\nFibroid enhancement: None\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n1. none\n\nThe three dominant fibroids are:\n1. size 9.5 x 8.9 x 8.4 cm no enhancement, mostly intramural with less than\n50% submucosal component, anterior fundus, previously measuring 10.3.9.6 x 9.3\ncm (series 5, image 11).\n2. size 6.2 x 6.3 x 5.8 cm no enhancement, intramural with less than 50%\nsubmucosal component, right anterior fundus, previously 5.5 x 7.0 x 5.5\n(series 6, image 10).\n3. size 4.5 x 5.4 x 5.3 cm no enhancement, submucosal with less than 50%\nintramural component, right anterior fundus, previously 4.1 x 4.5 x 5.3\n(series 5, image 14).\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nThe left ovary is not visualized.  Re-demonstrated is a 1.2 cm right ovarian\nlesion demonstrating T1 hyperintensity and T2 hypointensity with no internal\nenhancement, consistent with an endometrioma.  (Series 9, image 55).\n\nThere is no intrapelvic free fluid.",
            "output": "1. Interval decrease in size of multiple fibroids since ___ as\ndescribed above.  Previously treated fibroids do not demonstrate evidence of\nenhancement.\n2. Unchanged 1.2 cm right ovarian endometrioma."
        },
        {
            "input": "Lower abdomen:  Imaged portion the liver, kidneys, spleen appears normal. \nNormal appendix.  No evidence of diverticulitis.\n\nLYMPH NODES: No adenopathy\n\nPelvis: No free fluid.  Small uterine fibroids.  Normal adnexa.  .\n\nBowel loops: No abnormalities\n\nVASCULATURE: Aorta in its major branches are patent.  IVC, iliac veins,\nvisualized proximal femoral veins are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No abnormalities",
            "output": "No evidence of DVT.  Patent venous system, including IVC."
        },
        {
            "input": "There is a large mass lesion centered at the left sciatic ___, measuring\n7.9 cm anterior to posterior, 14.1 cm transverse, 17.9 cm in craniocaudal\ndimension.  This lesion is isointense to fat on all sequences.  Minimal\ninternal septation and some traversing vessels are demonstrated.  Very slight\nhazy increased signal on STIR sequence and minimal enhancement post-contrast\nis demonstrated at the level of the sciatic notch (series 801, image 22). \nAlong its lateral aspect, the mass involves the left gluteus medius muscle and\nalso indents the deep aspect of the gluteus maximus muscle.  At its deep\naspect, the mass involves and displaces the piriformis muscle.  The left L5,\nS1, and S2 nerve roots are inseparable from the medial aspect of the mass\n(series 3, image 21).  The sciatic nerve is close to but appears separate from\nthe mass at the level of the ischial tuberosity (series 3, image 33).\n\nNo concerning focal bone lesion is identified.  Small low signal focus in the\nright iliac bone (Series 5, image 33), likely reflects a small bone island.\n\nNo pelvic sidewall lymphadenopathy is identified on this nondedicated study. \nNo free fluid in the pelvis.\n\nThere is some asymmetric edema along the deep surface of the left iliacus\nmuscle (series 4, image 19, and extending to involve the distal iliopsoas\nmyotendinous junction.  There is some fluid in the left iliopsoas bursa.\n\nThere are small bilateral fat containing inguinal hernias.",
            "output": "Large lipomatous mass involving the left greater sciatic notch, involving left\ngluteus medius, and piriformis muscles, with the left L5, S1 and S2 nerve\nroots inseparable from its medial aspect.  This lesion overall appears\nnonaggressive with no internal nodular enhancing component.  Minimal atypical\nappearance is demonstrated, with minimal hazy increased signal is demonstrated\nat the level of the sciatic notch which could reflect scar tissue or\ninflammatory change.\nEdema involving the left ileo psoas muscle may reflect strain injury.  There\nis also mild iliopsoas bursitis.\n\nRecommendation: If no intervention is planned for the lipomatous mass,\nconsider imaging follow-up."
        },
        {
            "input": "Again seen is a large mass centered in the left gluteus medius muscle and\nextending through the sciatic notch, measuring 7.9 x 12.4  X 17.5 cm,\npreviously 7.9 x 14.1 x 17.9 cm, with relatively homogeneous signal isointense\nto fat.  Traversing vessels and few thin internal septations are again seen. \nMild stranding of the fat passes to the sciatic notch is likely due to a\ndegree of compression (03:23).  There is a focal area of subtle enhancement\n3-4 mm is seen along the lateral aspect (08:31) of the mass adjacent to a\nvessel, which is unchanged from prior and may represent abnormal capillaries,\nhowever continued attention on followup is recommended.  The L5, S1 and S2\nnerve roots run through the medial aspect of the mass (03:24).  The sciatic\nnerve a runs adjacent to the mass, without abnormal signal intensity.\n\nThe partially imaged pelvic structures are notable for trabeculation of the\nurinary bladder wall with a small diverticulum along the right anterolateral\nwall, likely related to chronic bladder outlet obstruction.  Note is also made\nof an enlarged, heterogeneous prostate consistent with BPH.  Degenerative disc\ndisease is noted in the lower lumbar spine.  Bilateral fat containing inguinal\nhernias.",
            "output": "No significant change in large lipomatous mass centered in the left gluteus\nmedius and extending into the sciatic notch measuring up to 17.9 cm in\ngreatest dimension.  A small peripheral area of amorphous enhancement likely\nrepresents multiple small branching vessels, however cannot definitely exclude\nan atypical lipomatous component to the lesion and continued attention on\nfollowup is recommended."
        },
        {
            "input": "At 5 o'clock along the inferior third the anus there is a small inferior\nexcrescence, bright on T2-weighted images, measuring 9 mm that seems\ncontiguous with venous structures suggesting an external hemorrhoid.  Contrast\nenhanced images suggests that it is perhaps partly thrombosed or at least\nshows incomplete filling.  There is no evidence for abscess or active\ninflammatory disease along the anus.  There is a small amount of free fluid in\nthe pelvic cul de sac.  Although not well visualized, sagittal T2-weighted\nimages suggest abnormal ileal loops.  The rectal wall thickness is at the\nupper limits of normal.   The bladder, prostate and seminal vesicles appear\nnormal.  There is no lymphadenopathy.  There is relatively extensive red bone\nmarrow that is very likely normal for age.",
            "output": "1.  Small lower anal abnormality suggesting a hemorrhoid, perhaps partly\nthrombosed.\n\n2.  Small quantity of ascites in the cul de sac.  Limited visualization but\nsuggestion of abnormal ileal loops that are not assessed in detail with this\ntechnique."
        },
        {
            "input": "There is a small, enhancing defect at the posterior inferior margin of the\ninternal anal sphincter at 6 o'clock (series 801, image 35) with short\ninferior course to exit the left medial gluteal fold, compatible with\nsuperficial fistula, decreased in size and enhancement compared to MRI of the\npelvis from ___ status post interval fistulotomy.  There is no\nfluid within this tract.  There is no abscess.\n\nThere is also a 5 mm enhancing defect at the left lateral aspect of the\ninternal anal sphincter at 3 o'clock (series 801, image 40), without fistulous\ntract, similar to prior.\n\nThe visualized rectum is unremarkable with no evidence of bowel wall\nthickening or edema.\n\nThe prostate and seminal vesicles are unremarkable.  The bladder is normal.\n\nPerirectal lymph nodes measuring up to 4 mm are similar to prior.",
            "output": "1. Small, enhancing defect at the posterior inferior margin of the internal\nanal sphincter at 6 o'clock with short inferior course to exit the left medial\ngluteal fold, compatible with superficial fistula, decreased in size and\nenhancement compared to MRI of the pelvis from ___ status post\ninterval fistulotomy.  No fluid within this tract.  No abscess.\n2. No evidence new perianal fistula."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 10.0 x 3.7 x 5.0 cm.  A small\nindentation near the fundus of the uterus represents an arcuate or mild\nseptate configuration.\n\nThe endometrium is normal in thickness for age and measures 0.3 cm.\n\nThe junctional zone is heterogenous on T2-weighted images and post-contrast\nimages and measures up to 1.1 cm in maximum thickness.  There are scattered T2\nhyperintense foci within the junctional zone.  This constellation of findings\nis consistent with adenomyosis.  No definite fibroids are identified.\nHeterogenous hypoenhancement of the myometrium may be related to previous left\novarian vein embolization and adenomyosis.\n\nThe right ovary is visualized and appears within normal limits.There is a\nnormal appearing follicle in the right ovary.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No significant pelvic sidewall or inguinal lymphadenopathy by\nsize criteria.\n\nBLADDER AND DISTAL URETERS:  The bladder is unremarkable.  No mural or\nintramural masses\n\nRECTUM AND INTRAPELVIC BOWEL:  The visualized pelvic colon and rectum are\nwithin normal limits.\n\nVASCULATURE:  There is bilateral uterine artery supply.  No ovarian supply or\nearly draining veins.  The visualized aorta and iliac vessels are of normal\ncaliber throughout without any significant areas of narrowing or dilation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal\nsignal characteristics.  No concerning osseous lesions.",
            "output": "Uterine adenomyosis.  No discrete fibroids identified."
        },
        {
            "input": "There is a circumferential rectal mass with bulky craniocaudal extension of\napproximately 4.2 cm and another region of slight hyperintensity on T2W images\nand restricted diffusion over an additional 1 cm, having its distal margin\napproximately 4.1 cm above the anal verge.\n\nThere is loss of the normal T2 dark serosa along the right posterolateral\nmargin of the mass (series 5, image 22).  At the left posterolateral aspect of\nthe rectum at the same level, the mass replaces the mesorectal fat, extending\nto and abutting the mesorectal fascia and portions of the left levator ani\nover a circumferential extent of approximately 3 cm. There is edema and\nenhancement in the left levator muscles suggestive of local infiltration\n(series 11, image 65).  There are small adjacent mesorectal lymph nodes\n(series 9, image 62) measuring up to 5 mm. Overall, the mass is less bulky\nwhen compared to the prior study.\n\nThere is a trace amount of free fluid in the pelvis.\n\nThe partially distended bladder is grossly unremarkable. There is sigmoid\ndiverticulosis.\n\nThe osseous structures are unremarkable.",
            "output": "1. Circumferential rectal mass compatible with known rectal cancer which\nappears less bulky when compared to the prior study though still appearing\nlocally aggressive. Again seen is extension into the mesorectal fat along the\nright posterior and left posterior margins as described above. Along the left\nposterior margin, there is extension through the fat to the mesorectal fascial\nand likely with infiltration into the levator ani muscles.\n\n2. No evidence of distant metastatic disease within the limits of\nvisualization of this pelvic MRI."
        },
        {
            "input": "Postsurgical changes from prior APR. Endcolostomy is partially visualized in\nthe left lower quadrant.\n\nRoughly 41 x 39 mm heterogeneously enhancing solid presacral mass in axial\ndimension roughly 39 mm in craniocaudal extent (1502:55, 3:18) appearing to\narise inferiorly from the margin of the APR scar. Margins of this lesion or\nill-defined with obliteration of the presacral fat and fibrous bands attaching\nto the sacrum though there is no evidence of the rectus sacral involvement.\nThere is apparent invasion of the adjacent pelvic small bowel loops as well as\nthe residual vaginal vault with a areas of signal void within the vaginal\nvault corresponding to air seen on prior CT suggestive of fistulization. There\nis also a muscular invasion with involvement of bilateral levator and 9 with\ngreater invasion on the left with apparent invasion through the\nischiococcygeus muscle and into the piriformis. Another satellite rim\nenhancing mass is seen in the right hemipelvis measuring roughly 19 x 13 mm\n(1502:42). Several presacral pelvic lymph nodes are noted measuring 9 mm\n(1502:21) and 6 mm (1502:23).\n\nVisualized small bowel loops appear distended measuring up to roughly 4.5 cm\nin maximal diameter indicated continued obstruction. No free pelvic fluid.\nBladder appears grossly unremarkable.\n\nBone marrow signal is normal without a focal osseous lesion.",
            "output": "1. 41 x 39 x 39 mm heterogeneous mass with ill-defined margins in the\npresacral space compatible with local recurrent disease with invasion of\nadjacent small bowel loops, vaginal vault, and pelvic musculature as above.\nContinued secondary small bowel obstruction. Air within the vaginal vault is\nsuggestive of enteric fistulization.  Associated obliteration of the presacral\nfat with fibrous tethering though there is no evidence of direct involvement\nof the sacrum.\n2. Additional 19 x 13 mm enhancing satellite lesion in the right hemipelvis,\nas above.\n3. Several prominent presacral lymph nodes measuring up to 9 mm."
        },
        {
            "input": "The uterus is enlarged with multiple mural fibroids in both anterior and\nposterior walls.  The largest is seen in the mid-posterior body and measures\nup to 4.4 x 4.3 cm, demonstrating low signal intensity on T2 weighted\nsequences, with low level enhancement (series 9, image 71). The uterus\nmeasures 7.2 x 7.9 x 8.8 cm (trans x AP x CC.\n\nThe junctional zone is normal in thickness. The endometrial stripe is also\nnormal in thickness measuring 9 mm.\n\nThe cervix and vaginal canal are also normal in appearance with multiple\nincidental nabothian cysts.\n\nThe ovaries demonstrate bilateral T1-hyperintense lesions with T2 shading that\ndo not suppress with fat saturation.  The largest lesion is on the right\nmeasuring up to 3.2 cm (series 4, image 28 ), and largest on the left measures\nup to 1.8 cm (series 4, image 26 ). No internal enhancement is detected.\n\nWithin the right adnexa, is an area of ill-defined T2-hypointensity with\ntethering of the J-pouch which may reflect an adhesion against the adnexa and\nbroad ligament (series 4, image 31, series 9, image 66).  There is no bowel\nobstruction.\n\nThere is no significant free fluid in the pelvis. The partially distended\nbladder is grossly unremarkable.\n\nThe visualized bowel loops are within normal limits. There is no significant\npelvic or inguinal lymphadenopathy.\n\nThe osseous structures are unremarkable.",
            "output": "1.  Bilateral endometriomas measuring up to 3.2 cm on the right and 1.8 cm on\nthe left, with mild tethering of the J-pouch against the right adnexa and\nbroad ligament without bowel obstruction.\n\n2.  Fibroid uterus."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n\nTumor:  annular\nDistance from anal verge (AV) (mm): 77\nExtends cranio-caudally (CC) (mm):  49\nDistal edge lies:  30 mm above puborectalis sling\nUpper border lies: Approximately 8 mm above peritoneal reflection\n\nSTAGING\nInvading tumor edge: Near circumferential\nMuscularis propria:  The mass appears to have an abnormally large component of\nintramural extension relative to extramural extension of the primary mass,\nthough it does also extend through the muscularis propria.\nExtramural spread (mm): There is indistinct extramural extension through the\nmesorectal fat appearing to extend up to and through ___'s fascia and\ninto the presacral fat.  While there is fascia is significantly thickened and\nT2 hypointense with restricted diffusion from approximately 09:00 (series 6,\nimage 20).  There is also indistinct extension anteriorly into the right\napproximately ___ o'clock to the peritoneal reflection.\nExtramural venous invasion (EMVI):  Despite marked abnormalities, no definite\nEMVI seen\nPeritoneal reflection: involved.  There is indistinct spread of T2 hypointense\ntumor toward the peritoneal reflection.  The peritoneum is thickened and T2\nhypointense with restricted diffusion on the right (series 6, images ___\nAdjacent pelvic organs ___, prostate, vagina): Just inferior to the\nperitoneal reflection, there is indistinct T2 hypointense signal extending\ntoward the right seminal vesicles and vas deferens.\n\nMinimum tumor distance to MRF: MRF involved\n\nMesorectal lymph nodes- no abnormal nodes\n\nPelvic side wall nodes:  yes, measuring 1.1 cm (series 4, image 8).\nIf Yes to Pelvic side wall nodes (location): right\nIf Yes to Pelvic side wall nodes (type): malignant\n\nStaging Assessment: At least T4a, though the abnormally appearing right\nseminal vesicles could reflect T4b disease.\nExtramural spread:  The peritoneal reflection and Waldeyer's fascia are\ninvolved.\nCRM:   involved\nEMVI: Despite marked abnormalities, no definite EMVI seen\nLocation: upper rectal tumor\nNodal:  N1\nMetastasis: M0\n\nBLADDER AND DISTAL URETERS: The urinary bladder is unremarkable.  No distal\nhydroureter.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Low T2 signal extending into the\nright seminal vesicles concerning for malignant involvement of the rectal\nmalignancy.\n\nVASCULATURE: No pelvic deep vein thrombosis.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.",
            "output": "Invasive appearing rectal malignancy with extramural extension into the\nmesorectal fat, mesorectal fascia, peritoneal reflection, and probably right\nseminal vesicles.  In the absence of alternative etiologies for the extent of\nabnormal findings such as surgery or infection, there is at least T4a,\npossibly T4b disease involving the right seminal vesicles. An 11 mm right\npelvic sidewall lymph node represents N1 disease.  No definite EMVI."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\nPersistent mild circumferential mural thickening of the mid to upper rectum,\npredominantly T2 hypointense without restricted diffusion.  No areas of\nabnormal enhancement.  There is no definite residual tumor identified, but the\nwall remains thickened.\nThe T2 hypointensity along the right Waldeyer's fascia has decreased in size\nand shows no restricted diffusion or enhancement suggestive of post treatment\nfibrosis.  There is no restricted diffusion in the mesorectal fat.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM:\nThere is no evidence of right seminal gland involvement.  The left seminal\ngland and prostate are unremarkable.\n\nLYMPH NODES: 0.6 cm right pelvic side wall lymph node has decreased in size,\npreviously 1.1 cm, with no abnormal enhancement or restricted diffusion. There\nare no other suspicious lymph nodes.\n\nVASCULATURE: No pelvic deep vein thrombosis.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.  Patient\nis status post bilateral hip arthroplasties.",
            "output": "1. Residual thickening of the rectal wall, predominantly T2 hypointense with\nno abnormal enhancement or marked diffusion restriction, is consistent with\npost treatment fibrosis.  No definite residual tumor identified.\n2. Improved right mesorectal fascia thickening, T2 hypointense, in keeping\nwith fibrosis.\n3. Markedly decreased right pelvic wall lymph node, likely post treatment\nfibrosis.\n4. No evidence of right seminal gland involvement.\n5. Findings likely represent minimal residual disease less than 25%, in\nkeeping with tumor regression grade 2."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\nThere is diffuse T2 hypointense and progressively enhancing mural thickening\nin location of the previously identified rectal tumor consistent with scarring\nfrom treatment.  There is no definite residual tumor.\n\nPelvic side wall nodes:  No.  A right internal iliac lymph node which\ninitially measured 1.1 cm 7 months ago, then 0.6 cm 4 months ago now measures\n0.4 cm (series 10, image 17).\n\nStaging Assessment: T0\nExtramural spread (mm):  0\nCRM:   clear\nEMVI:  negative\nLocation: upper rectal tumor\nNodal:  N0\nMetastasis: M0\n\nREPRODUCTIVE: The prostate appears slightly enlarged.  There is nonfocal T2\nsignal hypointensity within the peripheral zone likely reflecting prostatitis.\nThere is a trace left hydrocele.  The seminal vesicles are unremarkable. \nContrary to the initial staging MRI, there is no evidence of tumor involvement\nof the right seminal vesicles.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is unremarkable.  No distal\nhydroureter.\n\nVASCULATURE: The imaged pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Status-post bilateral hip arthroplasties.",
            "output": "1. No definite evidence of residual tumor. There is dense mural fibrosis in\nlocation of the pre-existing tumor, tumor regression grade (TRG) 2.\n2. A previously enlarged right internal iliac lymph node has significantly\ndecreased in size, now 4 mm."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n\nThere is focal T2 hyperintensity with abnormal enhancement along the\nanterolateral aspect of the superior margin of the previously treated tumor,\nextending between approximately 12 o'clock and 3 o'clock 10-11 cm proximal to\nthe anal verge, near the level of the peritoneal reflection (series 9, images\n117-119; series 5, images ___. It extends at least up to and likely slightly\ninto the muscularis propria, concerning for T2 recurrence.  In retrospect,\nthere was a similar but larger area of abnormality in this location on the\ninitial staging MRI performed ___ and there may have been a smaller\nnodule with similar signal characteristics on the most recent prior MRI\nperformed ___.  There is substantial residual T2 hypointense mural\nthickening involving much of the remaining rectum consistent with scarring\nrelated to treatment.\n\nA previous 2 mm right common iliac lymph node has substantially increased in\nsize and now measures up to 10 mm with heterogeneous signal on T2 weighted\nimaging (series 4, image 12; series 3, image 22).  A smaller right common\niliac lymph node appears heterogeneous and spiculated and has also increased\nin size measuring 4 mm, previously barely visible (series 4, image 10).  A 4\nmm common iliac artery lymph node is unchanged.  A 2 mm indeterminate\nmesorectal lymph node is probably new (series 4, image 15).  Motion artifact\nfurther limits evaluation for small lymph nodes.  No extramural vascular\ninvasion.  There is trace free pelvic fluid.\n\nStaging Assessment: Suspect T2 recurrence\nExtramural spread (mm):  0\nCRM:   clear\nEMVI:  negative\nLocation: Mid-upper rectal tumor\nNodal:  N1\nMetastasis: M0\n\nBLADDER AND DISTAL URETERS: The urinary bladder is unremarkable.  No distal\nhydroureter.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate gland is mildly\nenlarged.  There is T2 signal hypointensity throughout much of peripheral zone\ncompatible with sequela of prostatitis.\n\nVASCULATURE: The imaged pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Status-post bilateral hip arthroplasties.\nNo concerning osseous or soft tissue lesions.",
            "output": "1. Concern for recurrent tumor 10-11 cm proximal to the anal verge.\n2. There is at least one newly involved right common iliac lymph node\nmeasuring up to 1 cm.  An additional right common iliac lymph node and a tiny\nmesorectal lymph node are new or increased in size and may also be involved. \nThis reflects N1 nodal disease."
        },
        {
            "input": "Incomplete examination.  Axial images do not extend inferiorly enough to cover\nthe extent of perianal fistulizing disease.\n\n\nANUS AND RECTUM:\n\nThere is complex perianal fistulizing disease.\n\nAn infrasphincteric and intersphincteric fistula arising from ___ o'clock\npartially communicates with ___ and courses superiorly toward the penile\nbulb (series 7, image 72). There is substantial heterogeneous enhancement\nalong the posterior, lateral, and inferior surfaces of the penile bulb.\nExtending from the lateral aspect of this inflammation, there is the fistula\ncoursing into the right gluteal subcutaneous fat containing a couple locules\nof gas.  The distal portion of the tract is not adequately imaged, excluded\nfrom the field of view on T1 weighted postcontrast images.  On coronal and\nsagittal images, the tract appears to terminate into an approximately 1.4 x\n1.0 cm abscess, though this is inadequately assessed in the absence of\nadequate postcontrast imaging, which could distinguish between abscess and\ngranulation tissue.\n\nThere is a 2.4 x 1.4 cm area of marked heterogeneous enhancement with small\nfoci of nonenhancing T2 signal hyperintensity at the base of the right\nscrotum, in continuity with the enhancing inflammation adjacent to the penile\nbulb (series 8, image 70).  There is a 1.8 x 1.1 area of marked heterogeneous\nenhancement and small foci of nonenhancing T2 signal hyperintensity adjacent\nto the left prostatic apex extending toward the left pubic bone, also in\ncontinuity with the enhancing inflammation adjacent to the penile bulb (series\n8, image 54).  The adjacent pubic bone is normal in signal intensity and\nenhancement.\n\nAn intersphincteric fistula arising from ___ o'clock approximately 2 cm from\nthe anal verge courses into the left gluteal subcutaneous fat (series 7,\nimages 64-80). The distal portion of the tract is not adequately imaged,\nexcluded from the field of view on T1 weighted postcontrast images and\nobscured by inadequate fat suppression on T2 weighted images.  This tract\nappears probably to exit the left gluteal fold (series 3, image 18).  This\ntract may communicate with the above-described infrasphincteric and\nintersphincteric tract (series 7, images 65 and 66).\n\n\nBLADDER AND DISTAL URETERS: The urinary bladder and distal ureters are\nunremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Nonfocal T2 hypointensity and\nenhancement in the peripheral zone of the prostate gland likely reflects\nprostatitis.  There is a small utricle cyst.  The seminal vesicles are\nunremarkable.\n\nLYMPH NODES: Inguinal lymph nodes measuring up to 1.1 cm are likely reactive.\n\nVASCULATURE: The imaged pelvic vasculature is unremarkable.\n\nOSSEOUS STRUCTURES: No concerning osseous lesion.",
            "output": "1. Incomplete examination.  Axial images do not extend inferiorly enough to\ncover the extent of perianal fistulas.  If indicated, repeat imaging could be\nperformed at no charge.\n2. Complex perianal fistulizing disease with substantial phlegmon adjacent to\nthe penile bulb with possible nondrainable developing microabscesses at the\nbase of the right scrotum and between the left prostatic apex and left pubic\nbone.  A fistula within the left gluteal subcutaneous fat probably exits the\nleft gluteal fold.  A fistula within the right gluteal subcutaneous fat\nprobably terminates in a 1.4 cm abscess. Correlate with physical examination.\n3. Prostatitis.\n\nNOTIFICATION:   The findings were discussed with ___, m.D. by ___\n___, M.D. on the telephone on ___ at 9:27 am, approximately 30\nminutes after discovery of the findings."
        },
        {
            "input": "The uterus is slightly anteverted with approximate ___ of 3.9 x 3.1 x\n5.1 cm. There is thinning of the anterior lower uterine segment with anterior\nbeaking of the endometrial cavity, findings consistent with prior cesarean\nsection. Zonal anatomy of the uterus is well preserved. There are several\nsmall uterine fibroids, each T2 hypointense, intermediate signal on T1\nweighted imaging and hyperenhancing relative to myometrium (1203:50). These\nare intramural and subserosal in location. There is a single exophytic\npedunculated fibroid seen posterior laterally extending towards the left\n(05:17). This structure has ___ of 2.5 x 1.6 x 2.0 cm with a 1 cm wide\nstalk connecting to the posterior wall. The mass is T2 hypointense, T1\nintermediate in signal and demonstrates no internal enhancement. The\nappearance is most consistent with the avascular degenerated pedunculated\nfibroid.\n\nEach ovary is normal in appearance without associated mass lesion.\n\nNote is made of a prominent T2 hypointense, T1 hyperintense and mildly\nenhancing structure with surrounding fat extending from the anterior midline\nbladder dome to the anterior abdominal wall.  This terminates about halfway\nbetween the umbilicus and pubic symphysis with linear surrounding scarring. \nAppearance is most suggestive of a post surgical configuration of the bladder\nand surrounding fat.\n\nThe cervix, vagina and urethra are unremarkable. There is a trace amount of\nfree pelvic fluid.  No lymphadenopathy is noted.  Visualized bowel loops and\nosseous structures are unremarkable as well.",
            "output": "2.5cm left adnexal mass corresponding to finding on recent ultrasound appears\nto represent an avascular pedunculated fibroid.  Several additional small\nintramural fibroids are also noted.  No ovarian mass identified.\n\nTethering of the bladder dome to the anterior abdominal wall, surrounded by\nfat, suggestive of a post surgical configuration."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n\nTumor: Interval decrease in size and bulk of a circumferential T2 hypointense\nmid rectal mass which extends beyond the muscularis propria into the\nmesorectal fat predominately along the left lateral aspect of the lesion.  The\ntotal extent of the tumor is 7.5 cm in the craniocaudal dimension, unchanged\nsince prior where it measures 7.7 cm when remeasured (03:16).  Again noted is\nmucosal hyper enhancement with overall hypoenhancement of the mass on\npost-contrast imaging. Significant fat stranding within left mesorectum is\nconsistent with posttreatment changes.\nDistance from anal verge (AV) (mm): 32mm\nExtends cranio-caudally (CC) (mm):  75mm\nDistal edge lies: Just superior to the internal anal sphincter\nUpper border lies: Just below the peritoneal reflection\n\nSTAGING\nInvading tumor edge: From 9 o'clock to 7 o'clock\nMuscularis propria:  Extends through\nExtramural spread (mm): 10 mm on the left\nExtramural venous invasion (EMVI):  yes anteriorly and left laterally\nPeritoneal reflection: Not involved\nAdjacent pelvic organs ___, prostate, vagina): Not involved\n\nCRM (Circumferential resection margin) - pick one\nPushing border of the tumor: There is extensive T3 tumor with the closest\ndistance to the CRM of 3 mm on the right anterolateral aspect of the rectum at\n11 o'clock (07:19).  Overall, the left lateral distance to the mesorectal\nfascia has increased to 16 mm from 2.4 mm in ___ (07:15).\nPushing border of an involved node: There are multiple mesorectal lymph nodes\nin close proximity to the mesorectal fascia.  Closest margins are 1 mm at: 11\no'clock anterolaterally (7: 14), and 1 mm at 6 o'clock posteriorly (7:5)\n(previously pushing border was 0 mm at this level).\n\nMinimum tumor distance to MRF: 1 mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: At and above the tumor, have mildly\ndecreased in size.  Representative presacral node measures 0.5 cm (previously\n0.8 cm).\nMesorectal lymph nodes - heterogeneous signal: yes\nMesorectal lymph nodes - capsular irregularity: no\nMesorectal lymph nodes:  N2 (>4)\n\nPelvic side wall nodes:  no\nIf Yes to Pelvic side wall nodes (location): No enlarged pelvic sidewall nodes\nbased on size criteria.\n\nStaging Assessment: T3\nExtramural spread (mm):  10 mm (previously 11 mm)\nCRM:   1 mm (previously 0 mm)\nEMVI:  positive\nLocation: Mid rectal tumor\nNodal:  N2\nMetastasis: No enlarged pelvic sidewall nodes based on size criteria.  No\nadditional findings worrisome for metastatic disease.\n\n\nBLADDER AND DISTAL URETERS: Bladder is diffusely thick-walled measuring up to\n0.8 cm, likely due to underdistention.  No adjacent fat stranding or mucosal\nhyper enhancement.  Distal ureters are unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Seminal vesicles are unremarkable. \nAgain seen is relatively low signal in the peripheral zone of the prostate on\nT2 weighted imaging, likely reflecting background prostatitis.  No pelvic free\nfluid.\n\nVASCULATURE: Patent vasculature.  No aneurysmal dilatation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.  Soft\ntissues are unremarkable.",
            "output": "1.  Decreased size and bulk of rectal mass centered in mid rectum which\nextends 7.5 cm in craniocaudal dimension (previously 7.7 cm).  Tumor is again\nnoted to extend into the mesorectal fat with minimum lymph node distance to\nmesorectal fascia of 1 mm (previously 0 mm).\n2. Numerous abnormal mesorectal lymph nodes have mildly decreased in size.\n3.  MRI stage T3N2\n4.  No enlarged pelvic sidewall nodes based on size criteria."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n\nTumor:  There is a near circumferential mid rectal mass with tumor extension\nthrough the muscularis propria into the mesorectal fat most pronounced in the\nleft aspect from approximately 3 to 5 o' clock position.  The total extent of\nthe tumor is approximately 7.0 cm in the craniocaudal extent (series 4, image\n21) (previously 7.1 cm, remeasured series 3, image 16)).  The mass is\nintermediate to mildly hypointense on the T2 weighted images with\nhypoenhancement on the postcontrast phase.\n\nDistance from anal verge (AV) (mm): 58mm\nExtends cranio-caudally (CC) (mm):  70mm\nDistal edge lies:  Superior to the internal anal sphincter\nUpper border lies: At the level of the peritoneal reflection\n\nSTAGING\nInvading tumor edge: From 10 o'clock to 8 o'clock\nMuscularis propria:  Extends through\nExtramural spread (mm): 11 mm on the left\nExtramural venous invasion (EMVI): (Yes) involving right and left superior\nrectal venous branches.\nPeritoneal reflection: Not involved\nAdjacent pelvic organs ___, prostate, vagina): Not involved\n\nCRM (Circumferential resection margin) -\n\nPushing border of the tumor: Extensive T3 tumor with the closest distance to\nthe CRM of 2 mm at right anterior aspect of the rectum at 11o'clock position. \nThe left lateral distance to the mesorectal fascia has decreased to 13 mm\n(series 12, image 7) from 16 mm previously\n\nPushing border of an involved node: Multiple mesorectal lymph nodes are seen\nin close proximity to the mesorectal fascia.  Closest margins are 1 mm\nanterolaterally at: 11 o'clock (S 12, Im 6) unchanged and 2 mm\nposterolaterally at 7 o' clock (S 12, Im 3), previously 1mm.\n\nMinimum tumor distance to MRF:  2 mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: At and above the tumor, no interval change\nin size since ___.\nMesorectal lymph nodes - heterogeneous signal: Yes\nMesorectal lymph nodes - capsular irregularity: Yes\nMesorectal lymph nodes: N2 (>4)\n\nPelvic side wall nodes: No enlarged pelvic sidewall nodes.\n\nStaging Assessment: T3\nExtramural spread (mm): 11 mm, unchanged from prior\nCRM: 2mm\nEMVI:  Yes\nLocation: Mid rectal tumor\nNodal:  N2\nMetastasis: None\n\nBLADDER AND DISTAL URETERS: Bladder again shows diffuse wall thickening up to\n7 mm, could be related to underdistention.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Stable low T2 signal in the\nperipheral zone of the prostate in keeping with prostatitis.  Seminal vesicles\nare unremarkable.  No free pelvic fluid.\n\nVASCULATURE: Patent vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No aggressive osseous lesions.",
            "output": "1. No interval change in the appearance and extent of the mid rectal mass as\ndescribed above.\n2. Numerous abnormal mesorectal lymph nodes are unchanged in size.\n3. MRI stage T3 N2.  No enlarged pelvic sidewall nodes."
        },
        {
            "input": "Tumor:  semi annular\nDistance from anal verge (AV) (mm): 61\nExtends cranio-caudally (CC) (mm):  61\nDistal edge lies:  at puborectalis sling\nUpper border lies: 28 mm below peritoneal reflection\nThere is increased mucinous degeneration of the tumor compared to ___.\n\nSTAGING\nInvading tumor edge: From 12 o'clock to 5 o'clock\nMuscularis propria:  extends through\nExtramural spread (mm):  11\nExtramural venous invasion (EMVI):  yes, involving left superior rectal venous\nbranches.\nPeritoneal reflection: not involved\nAdjacent pelvic organs (L. Ani, prostate): not involved\n\nCRM (Circumferential resection margin)\nPushing border of the tumor:  4 mm at: 12 o'clock (11:128)\n\nEncapsulated node abutting the fascia: None\n\nMinimum tumor distance to MRF:  greater than 1 mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: above tumor\nMesorectal lymph nodes - heterogeneous signal: no\nMesorectal lymph nodes - capsular irregularity: yes\nMesorectal lymph nodes:  N1 (< 4)\n2 enlarged posterior mesorectal lymph nodes are smaller compared to ___.  The largest lymph node measures 0.7 x 0.4 cm, decreased from 1.1 x 0.5\ncm previously (11:91).  0.5 cm lymph node is decreased from 0.6 cm (11:88).\n\nPelvic side wall nodes:  no\n\nStaging Assessment: T3\nExtramural spread (mm):  11\nCRM:   clear\nEMVI:  positive\nLocation: mid rectal tumor\nNodal:  N1\nMetastasis: M0\n\nBladder, prostate, and seminal vesicles are unremarkable.  No suspicious bone\nor soft tissue lesion is identified.",
            "output": "1. The tumor has undergone further mucinous degeneration compared to ___.\n2. Mesorectal lymph nodes are smaller than before.  2 mesorectal lymph nodes\nremain enlarged.\n3. MRI stage T3 N1."
        },
        {
            "input": "Tumor:  There is a circumferential mid rectal mass with tumor extension beyond\nthe muscularis propria with extension into the mesorectal fat most pronounced\nin the left aspect of the lesion.  Total extent of tumor measures 8.3 cm in\nthe craniocaudal dimension.  The mass demonstrates hypointense T2 weighted\nsignal with hypoenhancement on post-contrast images.\nDistance from anal verge (AV) (mm): 31 mm\nExtends cranio-caudally (CC) (mm):  83 mm\nDistal edge lies: Just superior to the anal internal sphincter.\nUpper border lies: Just below the peritoneal reflection.\n\nSTAGING\nInvading tumor edge: From 2 o'clock to 4 o'clock\nMuscularis propria:  extends through\nExtramural spread (mm):  11 mm\nExtramural venous invasion (EMVI):  yes on the left.\nPeritoneal reflection: not involved\nAdjacent pelvic organs ___, prostate, vagina): not involved\n\nCRM (Circumferential resection margin)\nPushing border of the tumor:  1 mm at: 3 o'clock\n\nEncapsulated node abutting the fascia: Yes, on the left (series 3, image 23. \nThere is 2 mm of fat between this lymph node and the mesorectal fascia\n\nMinimum tumor distance to MRF:  1 mm\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: At and above, including enlarged presacral\nlymph nodes, (series 3, image 12).\nMesorectal lymph nodes - heterogeneous signal: no\nMesorectal lymph nodes - capsular irregularity: Some mesorectal lymph nodes\nappear well encapsulated while others for example (series 5, image 18)\ndemonstrate capsular irregularity.\nMesorectal lymph nodes:  N2 (>4)\n\nPelvic side wall nodes:  yes\nIf Yes to Pelvic side wall nodes (location): Left internal iliac lymph node\ndemonstrating abnormal T2 hypointense signal measuring 5 mm is suspicious\n(series 5, image 14).  Additional left obturator lymph node measuring 4 mm\nwith loss of fatty hilum is also suspicious (series 5, image 24).\nIf Yes to Pelvic side wall nodes (type): malignant\n\nStaging Assessment: T3\nExtramural spread (mm):  11 mm\nCRM:   1\nEMVI:  positive\nLocation: mid rectal tumor\nNodal:  N2\nMetastasis: M1\n\nOTHER: There is no suspicious bony lesion.  Relatively low signal of the\nperipheral zone of the prostate on T2 weighted imaging, likely reflects\nbackground prostatitis.  There is no pelvic free fluid.  Pelvic vasculature is\npatent.",
            "output": "1. Extensive rectal mass centered in the mid rectum but extending 8.3 cm in\ncraniocaudal dimension.  Tumor extends into the mesorectal fat with 1 mm\nminimal tumor distance from the mesorectal fascia.  There are numerous\nabnormal mesorectal lymph nodes.  MRI stage T3N2.\n2. Suspicious pelvic sidewall lymph nodes, described above, are concerning for\nM1 disease."
        },
        {
            "input": "ANUS AND RECTUM:\n\nNumber of sinus tracts: 1\n\nFistula number 1:\n\nINTERNAL ANAL OPENING:\n\nLocation (quadrant and clock face) in supine position: Posterior, 6 o'clock,\nwhich now contains the transanal presacral catheter.\nDistance from anal verge: 1.9 cm\nRelation to the internal sphincter: Lower third of sphincter\n\nFISTULA TRACT:\n\nMaximum tract diameter:  Fistulous tract now contains the transanal presacral\ncatheter.\nFistula type (Parks classification):  Transphincteric\nSecondary branches: Single branch\nExit site: Presacral space.\nHyperintensity of the tract on T2: Unable to evaluate due to catheter.\nEnhancement of the tract: Unable to evaluate due to catheter.\n\nOTHER FINDINGS:\n\n\n\nAbscess: There is marked decrease in size of the perianal horseshoe shaped\nintersphincteric collection which is mostly decompressed with residual\nheterogeneous thickened wall with two small areas of fluid.  First collection\nin the anterolateral right aspect measures 0.4 x 0.2 cm (8:68) whereas the\nsecond superior component measures 0.8 x 0.2 cm.  The overall decompressed\nabscess measures 3.7 x 0.6 cm (05:29).\nRectal and sigmoid wall inflammation: No\nPresence of ___, drains or prior surgery: Yes, Interval placement of a\ndrainage catheter with tip terminating in the presacral space.\n\n\nUTERUS AND ADNEXA: Uterus is neutral in position measuring 5.6 x 1.9 x 2.8 cm.\nEndometrium is normal in thickness for age in measures 2 mm. The junctional\nzone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nSmall volume pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: Pelvic sidewall lymph nodes are nonenlarged.  Bilateral\nsubcentimeter inguinal lymph nodes are likely reactive.  Few subcentimeter\nperirectal lymph nodes are noted and are likely reactive measuring up to 0.5\ncm, unchanged since ___ CT.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nINTRAPELVIC BOWEL: Otherwise unremarkable.  No obstruction.\n\nVASCULATURE: Patent vasculature.  No aneurysmal dilatation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Diffuse anasarca predominantly anteriorly\nlocated.  No suspicious osseous lesions.",
            "output": "1.  Significant decrease in size of 3.7 x 0.6 cm horseshoe shaped\nintersphincteric perianal phlegmon with a residual 0.4 x 0.2 cm and 0.8 x 0.2\ncm fluid component.  No drainable collection.\n2.  Single trans sphincteric perianal fistula which now contains a transanal\npresacral catheter.\n2.  Diffuse anasarca."
        },
        {
            "input": "The drain has been removed.\n\nThere has been reaccumulation of a complex perianal fluid collection.  The\nlargest component measures 5.2 x 2.4 x 4.5 cm in greatest overall ___\nand is predominantly in the presacral space.  This appears to extend within\nthe external sphincter muscle across the level of the levator ani with a\nhorseshoe shaped collection measuring up to approximately 3.5 x 2.4 x 0.9 cm,\nlocated in the ischiorectal fossa and draped around the posterior anal canal\nbetween 3 and 9 o'clock.\n\nThe larger presacral component of the collection is communicating with a\nresidual sinus tract (previously containing the drain) measuring 3 mm in\ndiameter and containing fluid.  This arises within the anal canal at 6\no'clock, approximately 1.5 cm above the anal verge.  There is no definitive\ncommunication of a tract with the skin surface.\n\nThe entire collection demonstrates thick rim enhancement and there is\nextensive edema in the surrounding soft tissues.  There are mildly prominent\nreactive bilateral inguinal nodes measuring up to 11 mm in short axis.  There\nare subcentimeter reactive mesorectal/presacral nodes.  There is moderate\npresacral edema and minimal free fluid in the pelvis.  There are rectal\ninflammatory changes but there is no definite connection between the rectum\nand the collection.  The uterus and ovaries are unremarkable.\n\nThe vascular and osseous structures are unremarkable.",
            "output": "Recurrent complex perianal and presacral collection with a transsphincteric\nsinus tract."
        },
        {
            "input": "The visualized portion of the rectum and sigmoid colon demonstrates mild\nconcentric wall thickening and mucosal hyper enhancement suggestive of ongoing\nactive inflammation.\n\nThere are enlarged rounded homogeneously enhancing mesorectal fascia lymph\nnodes measuring up to 5 mm in short axis.\n\nThere are 2 sinus tracts with internal openings in the anal canal as follows:\n1: Location (quadrant and clock face) in supine position: Posterior at 6\no'clock position (05:20).\nDistance from anal verge: 1.6 cm\nRelation to the internal sphincter: Inferior to sphincter\n\n2: Location (quadrant and clock face) in supine position: Right-side at 9\no'clock position (05:17).\nDistance from anal verge: 2.7 cm\nRelation to the internal sphincter: Mid internal sphincter\n\nBoth sinus tracts do not demonstrate external openings.  The open into the\nhorseshoe shaped posteriorly located perianal abscess.  The tracts are lined\nby granulation tissue and do not encase fluid within them.\n\n\nAbscess: Yes.  A perianal abscess is again seen containing 2 components: #1: \nU shaped component in the intersphincteric plane measuring 4.3 x 2.3 x 3.5 cm\n(TV, AP, CC) (series 5 image 21, series 3 image 14).  This abscess does not\ncommunicate with the second more cranially located abscess.\n\n#2: The larger cranially located abscess is located above the levator ani\nmuscle  (series 5, image 15, series 3, image 17).  Both the above-described\nsinus tracts communicate with this larger cranially located abscess.\n\nAdditional discrete foci of inflammation are seen within the internal\nsphincter, anteriorly and to the left (801:63).  There is mild enhancement of\nthe pelvic floor musculature on the delayed postcontrast images, likely\nrelated to inflammation.\n\nThere is small parasacral fluid which has decreased in extent from to prior\nexam.  There is no extension of the absent to the skin.\n\nPresence of ___, drains or prior surgery: No",
            "output": "1. Persistent perianal abscesses.  There are 2 abscesses, a smaller horseshoe\nshaped posterior perianal abscess located in the intersphincteric plane and\nanother larger perianal abscess located above the levator ani complex.  The\nlatter, larger cranially located perianal abscess connects to the anal canal\nvia two sinus tracts described above.  These tract do not demonstrate external\nopenings, but instead open into the perianal abscess.  Overall the abscesses\nare smaller compared to ___.\n2. Mild active inflammation of the rectal wall and sigmoid colon with enlarged\nreactive mesorectal fascia lymph nodes and pelvic floor musculature\ninflammation noted."
        },
        {
            "input": "ANUS/RECTUM: There has been interval progression of perirectal and perianal\ndisease compared to the prior MRI performed in ___.\n\nThere is a large perirectal intersphincteric horseshoe abscess, which extends\nfrom 3 o'clock to 9 o'clock.  The largest component of the abscess at the\nposterior 6 o'clock position measures up to 3.2 x 2.3 cm, previously 2.5 x 1.7\ncm in ___ (06:20).  A communicating tract arising from the right\nanterior inferior aspect of the horseshoe abscess courses anteriorly through\nthe internal sphincter, resulting in an internal opening at 8 o'clock,\napproximately 4.8 cm from the anal verge (09:49).\n\nAt 9 o'clock, a linear component of this abscess courses inferiorly in the\nintersphincteric plane by approximately 1 cm, and communicates with another\nperianal horseshoe abscess, where the widest diameter measures up to 0.5 cm\n(11:59).  There is a secondary branch off of this tract that courses through\nthe internal sphincter at the 8 o'clock position, resulting in an internal\nopening at 9 o'clock approximately 4.8 cm from the anal verge (11:49).  This\nis fluid-filled and measures up to 0.3 cm in diameter.\n\nAlong the right posterolateral aspect of the perianal abscess described above\nat 8 o'clock, there is a secondary branch that courses posterolaterally\nthrough the external sphincter and ends blindly in the right ischioanal fat\nwhere there are extensive surrounding inflammatory changes (9:61).  Widest\npart of this fluid filled tract measures up to 0.6 cm in diameter, previously\nmeasuring approximately 0.1 cm (06:27).\n\nThere is another tract that extends from the anterior aspect of the perirectal\nabscess, coursing through the internal sphincter resulting in an internal\nopening at 5:30 o'clock position of the proximal anal canal approximately 3.2\ncm above the anal verge (09:57).  This is fluid-filled and measures up to 0.4\ncm in diameter, overall similar compared to the prior study.\n\nThere is involvement of the levator ani muscles.  There are extensive\ninflammatory changes involving the rectum, with associated mucosal\nhyperenhancement.  Multiple mesorectal lymph nodes are noted, measuring up to\n0.5 cm, which are likely reactive.\n\nBLADDER: There is no abnormal bladder wall thickening.\n\nREPRODUCTIVE ORGANS: The uterus and ovaries are unremarkable in appearance. \nNo adnexal masses are identified.\n\nVESSELS: Imaged iliac vessels are patent bilaterally.\n\nBONES: No focal osseous lesions are identified.",
            "output": "1. Large perirectal intersphincteric horseshoe abscess communicating with a\nmore inferiorly located horseshoe perianal abscess through a linear tract\ncoursing in the intersphincteric plane at 9 o'clock, significantly worse\ncompared to ___.\n2. Multiple secondary branches, including 8 o'clock position of the perianal\nabscess that ends blindly in the right ischioanal fat, arising from the right\nlateral aspect of the perirectal/perianal abscess with an internal opening at\n9 o'clock approximately 4.8 cm from the anal verge, and arising from the\nanterior aspect perianal abscess with an internal opening 5:30 o'clock 3.2 cm\nfrom the anal verge."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\nCompared to the prior MR from ___, there has been overall\nimprovement of complex perianal fistulous disease.\n\nAgain seen is a intersphincteric horseshoe fistula extending from 3 o'clock to\n9 o'clock (10:189), approximately 4.5 cm from the anal verge.  The mucosal\nopening is at the 8 o'clock position with a short tract which communicates\nwith the right limb anteriorly (10:193).  The previously seen large posterior\nintersphincteric abscess at the 6 o'clock position (10:186) has significantly\ndecreased in size status post placement of a ___, now measuring 9 x 11 mm,\npreviously 23 x 32 mm.  The ___ courses within a tract which extends\nanteriorly from the abscess, and inferiorly in the midline.  The limbs of the\nhorseshoe fistula measure up to 5 mm in thickness on the right, unchanged, and\n2 mm in thickness on the left, decreased and previously 7 mm, with enhancing\ngranulation tissue and no significant internal fluid component.\n\nThere is a complex branching pattern of the right limb.  There is a branch\ncoursing inferiorly by approximately 1 cm and forming a second\nintersphincteric horseshoe fistula, also extending from 3 o'clock to 9\no'clock, which has slightly decreased in caliber, measuring up to 7 mm in\nthickness, previously 9 mm.  This also demonstrates enhancing granulation\ntissue and no significant internal fluid component.  There is also a\ntranssphincteric branch coursing posterolaterally and terminating blindly in\nan area of phlegmonous change in the right ischioanal/medial gluteal fat.  The\nphlegmon appears more organized, measuring approximately 2.6 x 1.5 cm (4:32\nand 10:218), with decreased surrounding edema.\n\nUTERUS AND ADNEXA:\nFibroids are noted in the uterus.\nThe right and left ovary and appear within normal limits.\nThere is trace free fluid in the pelvis.\nProminent bilateral inguinal lymph nodes measure up to 1.3 cm on the right,\nsimilar to the prior study.\n\nBLADDER: Bladder is unremarkable.\n\nVASCULATURE: The visualized pelvic vasculature appears patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious osseous lesion.",
            "output": "1. Overall improvement of complex perianal fistulous disease.  Interval\nplacement of ___ with significant decrease in size of the previously seen\nposterior intersphincteric abscess.  Two communicating intersphincteric\nhorseshoe fistulae have decreased in caliber.  Transsphincteric branch\nterminates blindly an area of phlegmonous change in the right\nischioanal/medial gluteal fat, which appears more organized with decreased\nsurrounding edema."
        },
        {
            "input": "ANUS AND RECTUM:\n\nThe complex perianal fistula again contains a Mallinckrodt drain posteriorly\nin the intersphincteric space.  The drain has pulled back slightly from its\nprevious position but remains within the major component of the fistula. \nThere is an opening to the anal canal at 6 o'clock (902:68) leading to two\nposterior intersphincteric horseshoe components (902:56, 902:70).  The left\naspects of the horseshoe components show decreased thickness of granulation\ntissue.\n\nThere is also an opening to the anal canal at 8 o'clock (902:59) superior to\nthe 6 o'clock opening, communicating with a complex tract connecting the\nhorseshoe components and a transsphincteric tract (___) leading to an area\nof inflammation in the right ischioanal fossa and gluteal fold.  This area has\nincreased and now extends to the skin, where it may be communicating with the\nskin surface in the right medial gluteal fold (902:103).  There are 2 setons\ntransgressing the 6 oclock opening.\n\nThe multiple components of the fistula contain enhancing granulation tissue\nwith no residual fluid collection.  No new fistula tracts or abscesses are\ndemonstrated.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nUTERUS AND OVARIES: The uterus and both ovaries are unremarkable.  Small\nuterine fibroids seen previously are not well-defined on the study.\n\nLYMPH NODES: Mildly prominent bilateral inguinal nodes are again noted,\nmeasuring up to 12 mm on the right and 11 mm on the left, likely reactive.\n\nVASCULATURE: No significant findings.\n\nOSSEOUS STRUCTURES: Unremarkable.",
            "output": "1. Further extension of an inflammatory tract in the right ischioanal\nfossa/gluteal fold, which now appears to extend to the skin surface.\n2. Decreased thickness of granulation tissue in the left intersphincteric\ntract components.\n3. No evidence of abscess."
        },
        {
            "input": "There is a right gluteal mass measuring 11.4 x 8.4 x 11.8 cm (series 8, image\n34, series 9, image 33), containing hemorrhagic components, with a right\nlateral percutaneous drain terminating along the posterior aspect of the\nlargest cavity (series 5, image 36).  The lesion contains multiple areas of\nnodular enhancement with an irregular enhancing thickened wall (series 8,\nimage 24, 29).  There does not appear to be extension beyond the right gluteus\nmuscles.  The sciatic nerve appears clear from the mass.\n\nA right total hip arthroplasty is present.  There is no fracture.  No abnormal\nbone marrow signal is seen.\n\nThe rectum and intrapelvic bowel are within normal limits.\n\nThe bladder is normal.  The prostate is normal in size.\n\nThere is no inguinal or intrapelvic lymphadenopathy, and no pelvic ascites.",
            "output": "11.4 x 8.4 x 11.8 cm hemorrhagic right gluteal mass with multiple enhancing\nnodular components and an enhancing irregular wall, consistent with findings\nof a sarcoma on recent pathology.  The mass is confined to the right gluteus\nmusculature.  Percutaneous drain terminates within a hemorrhagic pocket."
        },
        {
            "input": "Evaluation is limited by susceptibility artifact related to a right hip\nprosthesis and associated inhomogeneous fat suppression in the surrounding\nbone and soft tissues.  Within this limitation,\n\nThere is a 15.5 x 9.1 x 19.0 cm heterogeneously T1 and T2 hyperintense mass,\nexpanding the subcutaneous tissues of the right gluteal region, inseparable\nfrom the gluteus maximus muscle and extending to the skin surface.  The mass\nis extensive hemorrhagic component limits evaluation for enhancement, however\non subtraction images there appears to be patchy enhancement within the\nlesion.  Along the superficial surface of the lesion there are curvilinear and\npunctate areas of signal void that extend to the skin surface unlikely\nrepresent foci of air related to prior drain placement and possible surface\nulceration as the mass extends to the skin surface.  The mass has increased in\nsize since the prior study of ___, previously measuring 11.4 x 8.4\nx 19.0 cm.  Extension to the skin surface appears new.  There is mild edema\nand enhancement along the deep margin of the mass abutting the hamstring\nmuscles mild for the T2 hyperintense signal with mild enhancement in right\nadductor compartment and the more superior portion of the gluteus maximus with\nno focal nodularity which may represent related to post radiation changes. \nThere is a small amount of fat surrounding the sciatic nerve which is in close\nproximity to the anterior margin of the lesion (series 3, image 18).  The\nhamstring muscles do not appear to be involved.\n\nBone marrow signal in the region of the right CT of the adequately assessed\ndue to extensive artifact region.  Bone marrow signal elsewhere does not\nreveal suspicious lesions.\n\nThe intrapelvic structures are grossly unremarkable.  There is no pelvic or\ninguinal lymphadenopathy.",
            "output": "Increased size of large heterogeneous hemorrhagic ulcerated right gluteal mass\nas described."
        },
        {
            "input": "OSSEOUS STRUCTURES AND SOFT TISSUES: There are curvilinear areas of T1\nhypointensity and corresponding T2 hyperintense signal in the anterior aspect\nof the subchondral portions of the bilateral femoral heads compatible with\nedema secondary to avascular necrosis (05:30).  There is negligible\nsurrounding marrow edema.  There is no evidence of fracture or collapse of the\nfemoral heads.  There is also mild subchondral edema in the bilateral\nsacroiliac joints and subchondral edema and subchondral cystic change in the\nbilateral acetabula compatible with degenerative changes.  At the edge of\nthese films, mild degenerative changes lower lumbar spine are suggested, not\nfully evaluated.\n\nINTRAPELVIC SOFT TISSUE STRUCTURES:  Limited assessment shows that the patient\nstatus post hysterectomy and removal of the left ovary.  There is a\nmultiloculated high T2 lesion in the left adnexa which measures 3.2 x 3.0 x\n1.8 cm (4:31, 6:20).  Enlarged iliac lymph nodes or intrapelvic fluid is\nidentified.",
            "output": "1. Curvilinear areas of subchondral edema in the anterosuperior of the right\nand (right slightly larger than left) femoral heads which are likely secondary\nto avascular necrosis.  No evidence of fracture.\n\n2.  Mild degenerative changes in the bilateral hips and bilateral sacroiliac\njoints.\n\n3.  Lobulated high T2 lesion in the left adnexa measuring up to a 3.2 cm. \nGiven the reported history of hysterectomy removal of the left ovary, this\ncould represent a lymphocele.  Recommend follow-up pelvic MRI in 6 months,\nwithout and with IV contrast, to confirm expected stability.\n\nRECOMMENDATION(S):  Follow up pelvic MRI in 6 months, without and with IV\ncontrast, to confirm expected stability of high T2 left adnexal lesion,\npresumed lymphocele."
        },
        {
            "input": "Aside from bone marrow signal abnormalities in the femoral heads detailed\nbelow, no worrisome bone marrow lesion is detected.  There is mild\ndegenerative change of the sacroiliac joints and pubic symphysis.  There are\npartially imaged degenerative changes in the lower lumbar spine worst at L4-L5\nwith mild disc space loss.\n\nRight hip:  There is a 2.1 x 1.7 cm geographic area with a peripheral rim of\nT1 hypointensity and surrounding T2 hyperintensity and preserved central fatty\nbone marrow signal in the anterior superior femoral head (4:29 and 2:33)\ncompatible with avascular necrosis, unchanged.  There is preserved rounded\nmorphology of the femoral head without evidence of subchondral collapse. \nThere is superimposed mild degenerative change with marginal spurring.\n\nLeft hip:  There is a similar lesion in the left anterior superior femoral\nhead measuring 1.8 x 2.1 cm (04:28 and 02:33).  Rounded morphology of the\nfemoral head is preserved without evidence of subchondral collapse.  There is\nsuperimposed mild degenerative change with marginal spurring.\n\nLimited assessment of the intrapelvic structures reveals normal caliber loops\nof small and large bowel.  There are a few scattered sigmoid diverticula.  No\ngross intrapelvic fluid or enlarged intrapelvic lymph nodes detected.  3.1 x\n2.6 cm lobulated T2 bright focus in left adnexa is well-circumscribed and\nunchanged since the prior study of ___, likely a benign entity\nsuch as lymphocele, peritoneal inclusion cyst or paraovarian cyst.  Patient is\nstatus post hysterectomy and oophorectomy.\n\nLimited assessment of the lower lumbar spine is grossly unremarkable.",
            "output": "1. Unchanged extent of avascular necrosis in both hips.  No evidence of\nsubchondral collapse.\n2. Lobulated T2 bright focus in the left adnexa is unchanged since ___ and is likely benign entity such as lymphocele, peritoneal inclusion cyst\nor paraovarian cyst."
        },
        {
            "input": "The patient is status post hysterectomy and salpingo-oophorectomy. The vaginal\ncanal is normal in appearance.  The right pelvic mass seen on multiple prior\nMRIs is not significantly changed in size currently measuring approximately\n2.7 x 2.9 cm on the T2 sequence and approximately 3.1 x 3.5 cm on the\npostcontrast imaging. The increased enhancement noted on the previous exam has\nresolved with only very faint enhancement noted on the current study.\n\nThere is no significant free fluid in the pelvis. The partially distended\nbladder is grossly unremarkable. The visualized bowel loops are within normal\nlimits. There is no significant pelvic or inguinal lymphadenopathy.  There is\nchronic thrombosis of the right external iliac vein. The remainder of the\npelvic vasculature appears patent. The osseous structures are unremarkable.",
            "output": "Stable right pelvic mass with interval decrease in the degree of enhancement\nnoted on the previous exam.\n\nChronic occlusion of the right external iliac vein with associated\ncollateralization."
        },
        {
            "input": "The patient is status post supracervical hysterectomy and bilateral salpingo\noophorectomy. Along the right lateral aspect of the remnant cervix, there\ncontinues to be abnormal soft tissue with  ___ of 2.7 x 2.6 x 2.1 cm,\nwithout significant change from prior.  This lesion is predominantly T2\nhypointense with internal serpiginous foci of T2 hyperintensity.  It is T1\nhypointense and demonstrates minimal homogeneous enhancement.  This extends to\nthe right pelvic wall with unchanged configuration from prior imaging (4:25).\n\nThere is no free pelvic fluid or lymphadenopathy.  Extensive diverticulosis\ncoli is noted of the visualized sigmoid colon, without evidence of\ndiverticulitis.\n\nThe bladder, urethra and vagina are normal in appearance.\n\nNote is made of chronic thrombosis of the right external iliac vein with\ncollateral superficial veins along the superficial right lateral aspect of the\npelvis (13:12).\n\nOsseous structures are notable for a benign Tarlov cyst within the sacral\nspinal canal at S2.  No concerning osseous lesion is appreciated.",
            "output": "Stable right pelvic mass without evidence of progression.\n\nChronic right external iliac vein occlusion with associated collateralization."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe patient is status post supracervical hysterectomy and bilateral\nsalpingo-oophorectomy.  Along the right lateral aspect of the remnant cervix\nthere is abnormal soft tissue with ___ of 2.2 x 2.8 x 3.5 cm (AP, TV,\nCC) which is unchanged from prior allowing for slightly different measuring\ntechnique.  The lesion remains predominantly T2 hypo intense.  There is\nminimal enhancement postcontrast.  The mass extends to the right pelvic wall\nin unchanged configuration from the prior exam.  Compared to ___ this has\ndecreased in size particularly solid components and lost most of the\nenhancement with only minimal residual enhancement.\n\nThere is no pelvic free fluid.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nKIDNEYS, BLADDER AND DISTAL URETERS: The right kidney is atrophic.  The\npreviously seen right hydronephrosis has resolved.  Multiple smaller T2\nhyperintensities are seen without the right kidney measuring up to 17 mm which\nare incompletely characterized but statistically likely represent cysts.  The\nbladder is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized loops of small and large bowel are\nnormal in caliber.  There is sigmoid diverticulosis without evidence of\ndiverticulitis.\n\nVASCULATURE: There is unchanged chronic thrombosis of the right external iliac\nvein with collateral superficial veins along the right pelvis.\n\nUPPER ABDOMEN:  Limited coronal T2 images through the upper abdomen were\nobtained to evaluate the kidneys.  Incidental note is made of multiple T2\nhyperintense lesions in the liver stone which were present as hypodensities on\nthe CT torso of ___.  They are incompletely characterized on this single\nsequence but statistically like represent cysts or biliary hamartomas.  The\npancreatic duct is top-normal in size measuring 3 mm which was not clearly\nseen on the CT torso ___ (the ___ study was not available for comparison).\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Multilevel degenerative changes of the\nlumbar spine with mild anterolisthesis of L4 on L5 are unchanged in appearance\nfrom prior.  Benign Tarlov cysts in the sacrum are also unchanged.",
            "output": "1. Stable right pelvic mass compared to a prior study of without evidence of\nprogression.  Please note, compared with in the MRI of ___ there has been\ndecrease in size particularly of the solid components and significant decrease\nin enhancement.\n2. Chronic right external iliac vein occlusion with associated\ncollateralization\n3. Atrophic right kidney without hydronephrosis.\n4. Top normal pancreatic duct caliber.\n\nRECOMMENDATION(S):  Recommend correlation with pancreatic enzymes and symptoms\nrelated to top normal pancreatic duct caliber.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 12:26 into the Department of Radiology\ncritical communications system for direct communication to the referring\nprovider."
        },
        {
            "input": "Status post hysterectomy and bilateral salpingo-oophorectomy.\n\nAgain noted along the right lateral aspect of the remnant cervix is abnormal\nT2 hypointense soft tissue, measuring 2.9 x 2.4 cm (series 5, image 18), which\naccounting for differences in imaging technique and measurement, is less\ndistinct when compared to the prior study, however is not increased in size It\ncontinues to demonstrate minimal enhancement postcontrast.  This lesion\ncontinues to extend a short distance anteriorly along the right pelvic\nsidewall.\n\nNo free fluid.\n\nNo pelvic sidewall or inguinal lymphadenopathy.\n\nAgain noted is chronic thrombosis of the right external iliac vein.  Remaining\nvascular structures are patent.\n\nColonic diverticulosis with no evidence of diverticulitis.  Marked motion\nartifact is generated from peristalsing bowel within the pelvis.\n\nImages through the upper abdomen demonstrate no evidence of hydronephrosis\ninvolving the left kidney.  The periureteric inflammatory stranding seen on\nrecent performed CT of the abdomen pelvis has resolved.  Atrophic right\nkidney.  Previously seen prominent main pancreatic duct has resolved.  The\npancreas demonstrates normal signal intensity and appearance.  A few small\nhepatic cysts/biliary hamartomas are noted.\n\nBladder is moderately distended grossly normal.\n\nNo acute or aggressive osseous lesions.  6 mm anterolisthesis of L4 on L5. \nDefect along the L2 vertebral body anterior endplate is unchanged.",
            "output": "2.9 x 2.4 cm right adnexal mass is grossly unchanged in size and signal\nintensities from the comparison study.  Slightly less conspicuity from before,\nbut may be associated with motion artifact related to bowel peristalsis.  No\nnew mass lesions.\n\nAtrophic right kidney.  Resolution of recently seen perinephric stranding\ninvolving the left kidney."
        },
        {
            "input": "UTERUS AND ADNEXA: The patient is status post supracervical hysterectomy and\nbilateral salpingo-oophorectomy.  There has been no significant interval\nchanges in a 2.6 x 2.5 cm predominantly T2 hypointense lesion showing\nprogressive enhancement demonstrating a heterogeneous serpiginous appearance\nlocated at the right side of the cervical remnant along the right pelvic\nsidewall(02:18).  No new masses are identiifed.\n\nNo pelvic free fluid is noted.\n\nLYMPH NODES: No enlarged pelvic lymph node is seen.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: No rectal mass is seen.\n\nVASCULATURE: Chronic thrombosis of the right external iliac vein is\nredemonstrated.  The left external iliac vein is patent.  The iliac arteries\nare patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Anterolisthesis grade 1 of L4 over L5 is\nagain seen.  There are unchanged bilateral sacral perineural cysts.",
            "output": "1.   No significant interval changes in a residual lesion along the right\npelvic sidewall adjacent to the cervical remnant.  No new lesion is seen in\nthe pelvis.\n2.  Chronic thrombosis of the right external iliac vein is redemonstrated."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe patient is status post supracervical hysterectomy and bilateral\nsalpingo-oophorectomy.\n\nAgain seen along the right side of the cervical remnant is an ill-defined area\nof heterogeneous hypointensity on T2 weighted images.  On the current exam\nthis measures 3.8 x 3.3 cm, stable from prior exams when measured in similar\nplanes.  Small differences in measurements are likely due to small differences\nin the imaging planes.\n\nLYMPH NODES: No pathologic pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Within normal limits.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Stable chronic thrombosis of the right external iliac vein.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Tarlov cysts are noted at the sacrum. \nThere is no suspicious osseous lesion.  The visualized subcutaneous soft\ntissues are unremarkable.",
            "output": "1. Essentially stable heterogeneous mass in the right side of the pelvis.\n2. Stable chronic thrombosis of the right external iliac vein."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nPatient is status post hysterectomy and bilateral salpingo-oophorectomy.\n\nThere has been marked interval increase incise in mixed solid and cystic soft\ntissue mass within the right hemipelvis at site of known recurrent tumor, now\nmeasuring 4.5 x 5.7 cm, previously 3.3 x 3.8 cm.\n\nThere is T2 intermediate signal soft tissue expanding the imaged portions of\nthe lower IVC and common iliac veins bilaterally with extension into the\nexternal and internal iliac veins which appear occluded with multiple venous\ncollaterals.  The degree of venous expansion has markedly increased in both\nsize and extent in comparison to the prior study, with contrast enhancement\npost gadolinium consistent with tumor thrombus.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder is unremarkable.  There is marked\nright-sided hydroureter measuring up to 13 mm. Partially imaged T2\nhyperintense structure within the right upper quadrant seen only on the wide\nfield-of-view coronal images likely represents marked right-sided\nhydronephrosis.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and visualized small bowel appear\ngrossly unremarkable with no bowel distention to suggest mechanical\nobstruction.  Anterior to the small bowel within the midline lower abdomen,\nthere is a 23 x 37 x 41 mm enhancing soft tissue mass with which appears\nseparate from the bowel loops and was not clearly present on prior\nexaminations.\n\nVASCULATURE: Preserved flow void within the aorta and iliac vessels\nbilaterally.  Expansile tumor thrombus within the IVC and iliac veins\nbilaterally as described above.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions are\nidentified. Stable Tarlov cysts.",
            "output": "1. Interval enlargement since ___ of a known mixed solid and\ncystic mass within the right hemipelvis at site of known recurrent tumor.\n2. Interval increase in tumor thrombus within the IVC and iliac veins\nbilaterally, with multiple collateral vessels.\n3. New peritoneal metastasis anterior to the small bowel at the level of the\nlower abdomen.\n4. New severe right hydroureteronephrosis.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr. ___\n___ on ___ at 18:46 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "There is a large multilobulated pelvic soft tissue mass measuring 10 x 12 in\nthe axial plane.  The craniocaudal extent is difficult to accurately measure\nbut it is at least 16 cm.  There is extensive invasion of the venous system,\nincluding the left internal iliac, common iliac veins, the right common,\nexternal and internal iliac veins, and tracking superiorly into the distal\nIVC.\nThe more proximal IVC is not evaluated on this exam.  Extension into smaller\nvenous branches extending at the right sciatic notch is also demonstrated\n(series 1002, image 60).  The mass is heterogeneous in signal intensity, with\nseveral areas of intrinsic T1 hyperintensity likely representing blood\nproducts, and heterogeneous enhancement with some central areas of\nhypoenhancement likely reflecting areas of necrosis.  The lesion contacts and\nhas mass effect on several right sacral nerves, in particular the right first\nsecond and third sacral nerves.  There is some asymmetric expansion and\nheterogeneous enhancement of the right sciatic nerve which may be reactive or\nrepresent direct infiltration (series 1001, image 35).\n\nThere is a urinary catheter in-situ.  The bladder is decompressed.\n\nThere is a small left hip joint effusion.  There is some asymmetric dilation\nof left gluteal venous structures likely due to upstream occlusion.  Patchy\nbilateral gluteal muscle edema is also seen.  No definite focal bone lesion is\nseen.\n\nLocalizer images demonstrate severe right hydronephrosis.",
            "output": "-Extensive pelvic soft tissue mass, with associated contact and mass effect on\nright sacral nerves, in addition to expansion and heterogeneous enhancement of\nthe right-sided nerve itself which may be reactive or represent additional\nlocal tumor infiltration.\n-Extensive venous involvement by the pelvic tumor is again demonstrated."
        },
        {
            "input": "UTERUS AND ADNEXA:\nPatient is status post supracervical hysterectomy.  Multiple metastatic solid\nand cystic implants are again seen, unchanged from prior CT, largest cystic\nlesion measuring 4.1 x 8.3 cm, previously 6.2 x 7.4 cm and largest solid\nlesion in the right posterior pelvis measuring 4.6 x 6.3 cm (series 7, image\n70), previously 4.6 x 6.5 cm.\n\nLYMPH NODES: There is no lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable\n\nVASCULATURE: IVC filter is in place with thrombosis noted upstream to IVC\nfilter.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Right S1 nerve root exits and courses\nthrough the adjacent infiltrative metastatic mass, not well separated and may\nbe involved.  The left S1 and the remaining of the nerve root are normal.\nThere is marked signal abnormality of the sacrum characterized by increased T2\nsignal and low T1 signal potentially due to prior radiation therapy if this\nwas the region of treatment.\nMultiple small Tarlov cysts are seen in the canal",
            "output": "1. Right S1 nerve root exits and courses through the adjacent infiltrative\nmetastatic right posterior pelvic mass, and may be involved by the neoplastic\nprocess.\n2. Marked signal abnormality of the sacrum characterized by increased T2 and\nlow T1 signal likely due to prior radiation therapy (correlation with\ntreatment zone).\n3. Stable solid and cystic omental implants and thrombosis upstream to the IVC\nfilter."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: There are 4 thin fistula tracts within the\ndistal anus traveling in the intersphincteric plane without associated\ncollection or abscess.\n\nFISTULA #1\nFistula type: Intersphincteric\nInternal opening:  17 mm above anal orifice, 9 o'clock (axial series 9, image\n60)\nExternal opening:  Right natal cleft (axial series 9, image 70)\nCourse of the fistula tract: Inferiorly, intersphincteric\nAbscess: None.\nSetons: None.\n\nFISTULA #2\nFistula type: Intersphincteric\nInternal opening:  18 mm above the anal orifice, 12 o'clock (axial series 9,\nimage 57)\nExternal opening:  None definitively visualized.\nCourse of the fistula tract: Inferiorly, intersphincteric\nAbscess: None.\nSetons: None.\n\nFISTULA #3\nFistula type: Subsphincteric\nInternal opening:  At the level of the anal orifice, 3 o'clock (axial series\n9, image 67)\nExternal opening:  Left natal cleft (axial series 9, image 69)\nCourse of the fistula tract: Inferiorly, subspincteric\nAbscess: None.\nSetons: None.\n\nFISTULA #4\nFistula type: Intersphincteric\nInternal opening:  28 mm above the or phase, 6 o'clock (axial series 9, image\n52)\nExternal opening:  None definitively visualized.\nCourse of the fistula tract: Extending inferiorly and towards the left in the\nintersphincteric plane\nAbscess: None.\nSetons: None.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Unremarkable.",
            "output": "3 short intersphincteric and 1 subsphincteric fistula tracts as described\nabove.  No undrained abscess or fluid collection."
        },
        {
            "input": "Tumor:  semi annular\nDistance from anal verge (AV) (cm): 1.6 cm\nExtends cranio-caudally (CC) (cm): 5.5 cm (04:16)\nDistal edge lies:  at puborectalis sling\nUpper border lies: at peritoneal reflection\n\nSTAGING\nInvading tumor edge: From 4 o'clock to 12 o'clock.\nMuscularis propria:  extends through\nExtramural spread (mm): Greater than 24 mm (Se 8, Im 1).\nExtramural venous invasion (EMVI):  yes. At the 9 o'clock position of the\nrectal mass, there is tumor in a tubular configuration that extends superiorly\ninvading the right pelvic sidewall, and terminating in a 1.3 x 1.1 cm\noval-shaped lesion with central hypoenhancement (14:33).  This likely\nrepresents extramural venous invasion, extending towards a necrotic pelvic\nsidewall node.\nPeritoneal reflection: not involved\nAdjacent pelvic organs ___, prostate, vagina): There is soft tissue\nthickening around the distal ureter at several sites as it courses through the\npelvis, and is compatible with tumor involvement (series 14, images 31, 42,\n43). There is also mild stranding about the left distal ureter just proximal\nto the UVJ, also suspicious for tumor involvement (14:47).\n\nThe rectal mass directly contacts the posterior vaginal wall with resulting\nmass effect, although no definite evidence of tumor invasion (14:60).\n\nFOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN\nIntersphincteric plane:  invaded\nExternal anal sphincter:  There is tumor invasion at the junction of the right\npuborectalis-external anal sphincter (series 10, images 57-58).\nIschiorectal fossa:  invaded\n\nCRM (Circumferential resection margin) - pick one\nPushing border of the tumor:  0 mm at 9 o'clock\n\nEncapsulated node abutting the fascia:\n\nMinimum tumor distance to MRF:  greater than 1 mm\n\nMesorectal lymph nodes - Size (mm): <5mm.  There is a suspicious 4 mm\nmesorectal lymph node just above the tumor (13:29).  A second 3 mm slightly\nmore superior node is non-specific, and could be reactive (14:144).\nMesorectal lymph nodes - location: above tumor\nMesorectal lymph nodes - heterogeneous signal: yes\nMesorectal lymph nodes - capsular irregularity: no\nMesorectal lymph nodes:  N1 (< 4)\n\nPelvic side wall nodes:  yes (see description above, under \"extramural venous\ninvasion\")\nIf Yes to Pelvic side wall nodes (location): right\nIf Yes to Pelvic side wall nodes (type): malignant\n\nStaging Assessment: T4b\nExtramural spread (mm):  >24mm\nCRM:   involved\nEMVI:  positive\nLocation: Mid/low rectal tumor\nNodal:  N1\nMetastasis: Mx\n\nSeveral subcentimeter enhancing osseous lesions are noted in the posterior\nacetabulum, femoral head neck junction, and proximal femur on the right\n(series 13, images 52, 61, 81).  Additional millimetric patient is seen in the\nproximal right femoral shaft (07:16).  The acetabular and femoral shaft\nlesions do not have correlates on the recent CT from ___.",
            "output": "1. 5.5 cm mid/low rectal tumor, radiologic stage T4bN1Mx.\n2. Extramural tumor extends superiorly and rightwards, with extramural venous\ninvasion and extension beyond the right mesorectal fascia into the right\npelvic sidewall, contacting a necrotic node.  There is adjacent soft tissue\ninfiltration along the adjacent right pelvic sidewall.\n3. There is tumor infiltrating both distal ureters, more pronounced on the\nright.  Tumor abuts the posterior vaginal wall with mild mass effect without\ndefinite invasion.\n4. Invasion of the mass into the superior aspect of the anal sphincter\ncomplex.\n5. Several indeterminate subcentimeter enhancing osseous lesions within the\nright acetabulum and femur do not have definite correlates on recent CT. \nThese could represent metastases.  PET-CT is recommended for further\nevaluation.\n\nRECOMMENDATION(S):  PET-CT."
        },
        {
            "input": "LOWER ABDOMEN:\nOvoid shaped heterogeneity near the appendix with adjacent fat stranding, T1\nand T2 mixed intensities and heterogeneous post gadolinium enhancement,\nmeasures 3.5 x 4.9 x 6.3 cm (previously 5.5 x 6.7 x 8.5 cm).  Subcentimeter\nfluid and gas locules without drainable fluid collection.  Findings are\nsuggestive of a phlegmon with or without a coexistent underlying neoplastic\nlesion.\n\nThe inflammatory process extends near an adjacent sigmoid loop with loss of\nfat planes and sigmoid wall thickening thickening concerning for sigmoid\nmicroperforation/fistula (4:14,15 ;  1603:33).\n\nVisualized proximal appendix with distorted distal aspect consistent with\nknown perforation.  Prominent adjacent right lower quadrant adenopathy.\n\nColonic diverticulosis.\n\nAnterior abdominal soft tissue nodules consistent with metastases (04:21). \nPeritoneal reflections soft tissue nodules consistent with drop metastases.\n\nPELVIS:\nUnremarkable rectum, prostate, and seminal vesicles.  Slightly trabeculated\nbladder wall without discrete lesions.\n\nLYMPH NODES: Prominent right lower quadrant mesenteric lymph nodes.\n\nVASCULATURE: Patent visualized vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: T2 hyperintense lesion an right L4 with\npost gadolinium enhancement concerning for metastasis.",
            "output": "1.  Improvement of inflammatory changes near the perforated appendix without a\ndrainable collection.  Inflammation of adjacent sigmoid loop with loss of fat\nplanes concerning for microperforation/fistula.\n\n2.  Peritoneal/omental and osseous metastases."
        },
        {
            "input": "The uterus measures 7.7 x 4.6 x 6.2 cm. Subserosal T2 hypointense (4:22)\navidly-enhancing rounded well-defined lesion, measuring 1 cm in diameter is\npresent, consistent with a subserosal uterine fibroid. The endometrial stripe\nis normal in thickness measuring 9 mm. The junctional zone measures up to 10\nmm in thickness and there are scattered foci of T2 hyperintensity within it\n(04:18), consistent with adenomyosis.\n\nAlong the posterior serosal surface of the uterus T2 hypointense strands\n(4:22) and intrinsically T1 hyperintense foci (9:39, 45) are demonstrated,\nconsistent with endometriosis.\n\nThe cervix and vaginal canal are normal in appearance.\n\nBoth ovaries are well visualized and are normal in size and appearance without\nevidence of mass. There is no significant free fluid in the pelvis. The\npartially distended bladder is grossly unremarkable.\n\nThe right-sided external iliac lymph node that demonstrated increased FDG\nuptake on the prior PET-CT is stable in size measuring 1.7 x 0.5 mm (5:10). \nThe node is morphologically normal, elongated, with preserved fatty hilum and\nis benign appearing. There are no pelvic or inguinal lymphadenopathy.\nThe osseous structures are unremarkable.",
            "output": "1. Normal-appearing pelvic lymph nodes without suspicion for malignancy.\n2. Deep pelvic endometriosis.\n3. Mild uterine adenomyosis."
        },
        {
            "input": "Centered within the lower pelvis, there is a heterogeneous mass measuring 10.4\nx 22.6 x 15.6 cm (AP x SI x TRV).  Comparing to the outside hospital MRI from\n___, the lesion is slightly grown, previously measuring 9.8 x 19.8 x\n11.7 cm.  The lesion is hypointense to muscle on T1 weighted images, contains\nT2 hyperintense cystic areas, as well as prominent vessels.  There is\ncontinued mass effect upon the bladder (10:15), displaced anterolaterally to\nthe left, as well as on the rectum, displaced posterolaterally to the left\n(10:40).  Walled lesion closely abuts the sigmoid colon, there is no evidence\nof a claw sign to suggest a sigmoid origin of the lesion.  The iliac vessels\nare splayed laterally and there is a well-defined capsule around the lesion.\nMass effect upon the distal ureters results in bilateral hydroureteronephrosis\n(10:9), better demonstrated within the kidneys on the concurrent lumbar spine\nMRI.\nThe base of the lesion appears to arise within the expected region of the\nprostate, which is itself not well visualized.  The posterior margin of the\nlesion closely abuts the sacrum however there appears to be separation from\nthe bony sacrum by fat.\n\nNo suspicious osseous lesions are appreciated.  The inferior abdominal aorta,\nIVC, and iliac vessels are patent.",
            "output": "1. Mild interval growth of the large pelvic mass compared to ___, with\npersistent mass effect upon the bladder and rectum as before.  Resultant\nhydroureteronephrosis is moderate to severe.\n2. Given the lesion's proximity with the expected location of the prostate, a\nsarcomatous lesion arising from the stromal tissue of the prostate is a\npossibility.  Other considerations include a neurogenic tumor or a\nmammary-type myofibroblastoma."
        },
        {
            "input": "As on the prior imaging, there is a large mass which is positioned posterior\nand superior to the prostate and anteromedial to the rectum and sigmoid colon,\nhaving mass effect on the sigmoid colon against in the bony pelvic wall.  This\nalso displaces the bladder and prostate anteriorly, but perhaps to a slightly\nlesser compressive extent than on the prior imaging.\n\nThis mass is slightly smaller than on the prior imaging.  It currently\nmeasures 18.6 cm SI x 9.0 cm AP x 12.8 cm TV, previously 22.6 x 10.4 by 15.6\ncm when measured in a similar manner.\n\nAs on prior imaging, this is hyperintense to muscle on T2 weighted images with\nheterogeneous appearance in region centrally of high signal on T2 weighted\nimaging probably representing areas of focal necrosis.  As on the prior\nimaging, there are regions which is drop signal on later echo gradient echo\nimages, suggesting susceptibility which may be related to hemorrhage or\ninfarct.  This is somewhat more extensive than on the prior examination.  The\nmass continues to have significant intra lesional enhancement and large\nvessels, similar to the prior examination.  This mass appears fairly similar\nto the prior study. However, the number of smaller vessels within the mass\nappear decreased compared to the prior.\n\nWhile causing clear anterior displacement of the bladder and prostate, this\nmass is not convincingly arising from either.  It also appears to be\ndisplacing but not arising from large bowel loops.  As on prior imaging, there\nis some suggestion that this may be arising from seminal vesicles, as on\nsagittal T2 weighted images (series 3, image 19) there is suggestion this of a\nneck of communication to the superior aspect of the seminal vesicles. \nSimilarly, on sagittal reformations of contrast-enhanced imaging there is a\nhyperenhancing tongue of tissue (series 1250, image 15) which extends\nposteriorly from prostate into this mass arising from the general region of\nthe seminal vesicles.\n\nThe vascular supply of this mass appears to be dominantly from multiple\nbranches from the bilateral hypogastric/internal iliac arteries.\n\nThere is no worrisome osseous lesion.  There is no pelvic lymphadenopathy or\nfree fluid present.",
            "output": "1.  Interval decrease in the size of the large prostatic mass between the\nprostate/bladder and rectosigmoid colon, presumably secondary to treatment\nresponse from radiation.\n2.  Vascular supply appears to be predominantly from branches of the\nhypogastric arteries.  Although the exact origin of the mass is difficult to\ndetermine with certainty, there is some suggestion that these may be arising\nfrom the seminal vesicles or mesenchymal/stromal aspects of the prostate.\n3.  No visualized metastasis or pelvic free fluid."
        },
        {
            "input": "There is a central defect within the prostate gland which measures\napproximately 2 x 2 cm. Within the remaining prostate gland there are numerous\nbrachytherapy seeds.\n\nThere is a fistula between the rectum and the central defect within the\nprostate.  The fistula extends anteriorly from 1 o'clock position from the\nrectum (04:14).  There is layering fluid and air within the central defect\nwithin the prostate which communicates with the prostatic urethra.\n\nNo pelvic free fluid.\n\nLYMPH NODES: No enlarged inguinal nor pelvic lymph node\n\nBLADDER AND DISTAL URETERS: Distal ureters are normal.  Bladder wall is\ndiffusely thickened and demonstrates bullous edema.  There is some free air\nwithin the bladder due to the fistula between the prostatic urethra and the\nrectum.\n\nURETHRA:  As described above there is a fistula from the rectum to the\nprostatic urethra.  There is abnormal enhancement of the membranous portion of\nthe urethra, consistent with inflammatory changes\n\nVASCULATURE: No aneurysm.  Normal caliber.  No stenosis\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Changes within the bone marrow signal\nfrom radiation therapy.  No soft tissue mass.",
            "output": "There is a fistula between the rectum and the central defect within the\nprostate which includes the prostatic urethra.  Comparison to CT from ___ is not possible due to differences in technique."
        },
        {
            "input": "Patient is post hysterectomy, cystectomy and reportedly a partial vaginectomy.\nNo urethra is identified.  There is a prolapsing 11 cm lobulated, partly\nnecrotic mass seen anterior to the distal aspect of the vagina extending\nexternally through the introitus, splaying the labia minora and extending\nexternally between the thighs.\n\nAlong with the herniating mass, there is fat and vasculature and the mass\nappears to contain multiple engorged vessels within it.  The mass and vessels\ncontained within the herniating fat appear to be originating from the left\ngastroepiploic, as seen on prior CT, and extend from the left upper quadrant\nall the way to the pelvis including portions of the omentum, pulling portions\nof the transverse colon into the pelvis, however no bowel is demonstrated\nwithin the herniation.  This is a malignant mass until proven otherwise and is\nhighly concerning for recurrent tumor possibly originating from the omentum\nand prolapses externally through a hernia defect anterior to the anterior\nvagina.\n\nAgain seen is a small amount of pelvic free fluid.  The right lower quadrant\nurostomy is partially seen on the coronal T2.  Trace fluid extends within a\nsmall left obturator hernia.\n\nNo worrisome osseous lesions.",
            "output": "Prolapsing malignant-appearing mass that appears to herniate thru a defect\nanterior to the vagina, into the introitus ending externally between the\nthighs.  Portions of this mass contain omental fat and pull the transverse\ncolon into the lower pelvis.  No bowel is demonstrated within the herniation.\n\nNOTIFICATION:  Discussed with the gynecology-oncology team at the moment of\ndictation."
        },
        {
            "input": "A known mass within the upper pole of a right lower quadrant renal transplant\nnow measures 2.9 x 2.6 x 2.7 cm, compared to 2.4 x 2.4 x 2.2 cm in ___. The mass demonstrates T2 hyperintense signal with T2 hypointense wall\nnodularity (4:9). The signal on T1WI is homogeneously hypointense, without\nevidence of internal fat or hemorrhage.  No hydronephrosis is present.\n\nA 1.3 cm T2-hyperintense left adnexal cystic lesion is unchanged (4:24).\n\nTwo T2-hypointense fibroids along the left broad ligament are unchanged, the\nlarger measuring 1.5 cm (04:29, 30). The cervix is unremarkable.\n\nThe urinary bladder is unremarkable.\n\nThe visualized lower poles of the spleen and the liver demonstrate low signal\non T2WI consistent with known hemosiderosis (3:28). The visualized portions of\nthe native kidneys demonstrate atrophic parenchyma without focal masses.\n\nThe visualized bowel is unremarkable.\n\nThere is no free fluid in the pelvis.\n\nThere is no concerning pelvic or inguinal lymphadenopathy.\n\nThe bone marrow signal is normal.",
            "output": "Interval enlargement of a complex cystic mass in the upper pole of the renal\ntransplant, now measuring 2.9 cm.  RCC remains on the differential."
        },
        {
            "input": "ANUS, RECTUM AND INTRAPELVIC BOWEL:\nThere is a 9 x 4 mm focus of progressive enhancement along the internal\nsphincter at 6 o'clock (supine position), just above the anal verge (series\n901 and 902, image 62), presumably representing postprocedural sequelae from\nprior incision and drainage.  There is no focal fluid collection.  There is no\nevidence of mucosal opening or fistulous tract.\n\nVisualized intrapelvic bowel loops are unremarkable.\n\nREPRODUCTIVE STRUCTURES:\nThe prostate is enlarged with BPH changes of the central gland.  Striated\nareas of T2 hypointensity in the peripheral zone with early enhancement is\ncompatible with background prostatitis.  There is a 0.9 x 0.6 cm focal T2\nhypointense lesion in the posterior right peripheral zone in the mid gland\n(series 6, image 15), which demonstrates early enhancement and washout;\ndifferential considerations include carcinoma or focal prostatitis.\n\nThe seminal vesicles are normal in signal intensity.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are within normal\nlimits.\n\nVASCULATURE: Visualized pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious osseous lesion. \nThere are small fat containing bilateral inguinal hernias, left larger than\nright.",
            "output": "1. 9 x 4 mm focus of progressive enhancement along the internal sphincter at 6\no'clock (supine position), just above the anal verge, presumably representing\npostprocedural sequelae from prior incision and drainage.  No focal fluid\ncollection.  No evidence of perianal fistula.\n2. 0.9 x 0.6 cm focal, enhancing lesion in the posterior right peripheral zone\nin the mid gland of the prostate, for which differential considerations\ninclude carcinoma or focal prostatitis.  Correlation with digital rectal exam,\nPSA, biopsies and/or dedicated MRI of the prostate is recommended.\n\nRECOMMENDATION(S):  Digital rectal exam, PSA, biopsies and/or dedicated MRI of\nthe prostate.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 16:21 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "UTERUS:\nThe uterus is mid-positioned, measuring 6.2 x 2.5 x 3.6 cm.\n(note: measurement includes the cervix).\n\nEndometrium: Homogeneous, measuring 2 mm\nJunctional zone: 6 mm without focal thickening.\n\nFIBROIDS:\nFibroid burden: 1\nFibroid enhancement: Homogeneous\n\nSubmucosal fibroids: None\n\nThere is a 2.9 x 2.9 x 3.4 cm T2 hypointense, lobulated mass arising from the\nfundus, which demonstrates mild enhancement, compatible with an exophytic\nfibroid.\n\nOVARIES:\nThe ovaries are normal in size.  The right ovary is normal in appearance.\n\nThere is a 1.7 x 1.4 cm simple, unilocular cyst in the left ovary, present on\nprior pelvic ultrasounds from ___ and ___.  No solid\ncomponent is seen.  The peripheral calcification described on ultrasound is\nnot visualized by MRI.\n\nThere is no intrapelvic free fluid.\n\nThere is discogenic disease and endplate degenerative changes at L5-S1.",
            "output": "1) 2.9 x 2.9 x 3.4 cm mildly enhancing, exophytic fibroid arising from the\nfundus.\n\n2) 1.7 x 1.4 cm simple, unilocular cyst in the left ovary, present on prior\npelvic ultrasounds from ___ and ___.  ___ year ultrasound\nfollow-up is recommended.\n\nRECOMMENDATION(S):  ___ year ultrasound follow-up for a simple left ovarian\ncyst."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Unremarkable.  The previously seen peritoneal\nnodules are better appreciated by CT.\n\nBLADDER AND DISTAL URETERS: The distal ureters are unremarkable.  There is a 3\nmm nodule within the bladder lumen arising from the right anterolateral\nbladder wall (12:4, 1701: 21, 22).  This appears to correspond to a hyperdense\nfocus seen on prior CTs.  Layering T1 hyperintense material within the bladder\nlumen may represent blood products or delayed renal excretion of previously\nadministered gadolinium based contrast.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.\n\nLYMPH NODES: No suspicious lymphadenopathy.\n\nVASCULATURE: Unremarkable.\n\nSOFT TISSUES: There is extensive retroperitoneal, pelvic, and presacral edema\nwith disorganized free fluid in the dependent portions of the pelvis. A 5 mm\nperipherally enhancing nodule contacts the lateral aspect of the right sciatic\nnerve without definite compression at the level of the right femoral greater\ntrochanter (1702:23).  Multiple additional small enhancing subcutaneous\nnodules are present throughout the visualized soft tissues, as seen on\nconcurrent CT.\n\nOSSEOUS STRUCTURES: Multiple osseous metastases are present throughout the\npelvis.  The majority of these are well-circumscribed and subtly\nhyperenhancing, hyperintense on T2 weighted imaging and hypointense on T1\nweighted imaging.  The largest such lesion is in the mid body of the sacrum\nmeasuring up to 1.1 cm (1702:81), previously seen to be mildly sclerotic on\nthe recent prior CT.  Multiple additional lesions are present throughout the\nsacrum and iliac bones (1702: 1, 3, 21, 23, 67, 73, 75, 81, 85, 104).  Within\nthe right acetabulum, there are 2 irregular foci of intrinsic T1\nhyperintensity that demonstrate little to no postcontrast enhancement\nmeasuring up to 1.3 cm posteriorly and 1 cm anteriorly (16:37).  These are\nassociated with extensive marrow edema and heterogeneous marrow enhancement\nand likely represent hemorrhagic metastases.  There is no definite associated\npathologic fracture.  There is a small right hip effusion (12:10).",
            "output": "1. Numerous enhancing osseous metastases as detailed above, including 2 likely\nhemorrhagic metastases within the right acetabulum with extensive reactive\nedema and enhancement likely contributing to the right lower extremity pain. \nNo definite pathologic fracture.\n2. 5 mm enhancing nodule in the subcutaneous fat contacting the lateral aspect\nof the right sciatic nerve the level of the greater trochanter without\ncompression while the hip is extended.\n3. 3 mm bladder wall nodule corresponding to an area of calcification on prior\nstudies, which remains suspicious for a partially calcified soft tissue\nnodule.  This lesion was not present on ___ and appeared on the\nCT of ___.  Continued attention on follow-up imaging is\nrecommended.  Cystoscopy could be considered for further evaluation.\n4. Small right hip effusion.\n5. Extensive presacral edema and small volume pelvic free fluid."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 4.8 x 7.3 x 5.6 cm.\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is diffusely thickened and ill-defined with multiple foci\nof hyperintensity on T2 weighted images consistent with sub endometrial cysts.\n\nThere are subtle foci of T2 hyperintensity within the inferior aspect of the\nendocervical canal with seen on series 3, image 15 and 16 as well as series 6,\nimage 12.  There is suggestion of enhancement in this region seen on series\n1101, image 46 and series 12, image 51.  No clear diffusion abnormality is\nseen however this area may be too small for accurate diffusion\ncharacterization.  There is no evidence of parametrial extension.\n\nThe right ovary is visualized and appears within normal limits with multiple\nfollicles.\nThe left ovary is visualized and appears within normal limits with multiple\nfollicles.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No lymphadenopathy is appreciated.\n\nBLADDER AND DISTAL URETERS: Within normal limits.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Within normal limits.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.",
            "output": "1.  Subtle areas of T2 hyperintensity and enhancement within the endocervical\ncanal could represent residual cervical cancer following LEEP.  No evidence of\nlocal invasion or metastatic disease.\n2.  Diffuse uterine adenomyosis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 9.5 x 7.6 x 6.9 cm.  There uterine\nfibroids noted.  The dominant fibroid with heterogeneous T2 hypointense signal\nin the posterior fundus with hypoenhancement with a less than 50% submucosal\ncomponent measures 5.8 x 5.5 x 6.2 cm.  Endometrial canal is distorted by the\nfibroids and is top-normal in size for a postmenopausal patient measuring up\nto 6 mm.  Susceptibility within these fibroids corresponds to calcifications\nseen on prior CT.\nThe junctional zone is not thickened.\n\nThe right ovary is notable for a T2 slightly heterogeneous intermediately\nhyperintense 1.2 x 1.1 cm cystic lesion with a single thin enhancing septation\nseen inferiorly (series 11, image 43)..\nThe left ovary is atrophic and demonstrates T2 hypointense signal\n\nThere is trace pelvic free fluid.\n\nLYMPH NODES: There are no pelvic sidewall or inguinal lymph nodes.\n\nBLADDER AND DISTAL URETERS: The bladder is decompressed.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum is unremarkable.  There is\ndiverticulosis of the sigmoid colon.\n\nVASCULATURE: Pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome bony lesions are seen.",
            "output": "1. 1.2 cm cystic lesion in the right ovary with a single thin enhancing\nseptation, recommend MR ___ in ___ year to ensure stability.\n2. Top-normal endometrial cavity for a postmenopausal patient, if there is a\nhistory of bleeding recommend correlation with curettage and histopathology.\n3. Fibroid uterus.\n\nRECOMMENDATION(S):\n1. One year ___ pelvic MRI\n2. Top-normal endometrial cavity for a postmenopausal patient, if there is a\nhistory of bleeding recommend correlation with curettage and histopathology."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.5 x 6.8 x 9.4 cm.  There is a large\narea of T1 and T2 hypointensity along the anterior myometrium, with loss of\njunctional zone.  These findings are suggestive of focal adenomyosis versus a\nlarge fibroid with slightly submucosal component.  No discrete fibroid is able\nto be measured.\nThe endometrium is mildly obscured, but appears normal in thickness for age\nand measures 3 mm.\nThe junctional zone is difficult to visualize anteriorly and within normal\nlimits in the posterior uterus.\n\nOn T2 weighted images, there are multiple areas hypointensity spanning from\nthe posterior uterine wall to the rectum, with distortion the cul-de-sac,\nlikely sequela of chronic endometriosis.\n\nThe right ovary is not definitely visualized.  At the right adnexa, there is a\nT1 hyperintense tubular structure, with intermediate signal intensity on T2\nweighted images, and incomplete septations, most compatible with\nhematosalpinx.  There also adjacent subcentimeter foci of high signal\nintensity on T1 weighted precontrast images demonstrating intermediate signal\nintensity on T2 weighted sequences (series 10 image 17).  A simple-appearing\n2.0 x 1.5 cm posterior right adnexal cyst is present.\n\nThe left ovary shows two T1-hyperintense rounded lesions, measuring up to 1.2\ncm in size.  These regions show intermediate T2 signal and are suggestive of\nendometriomas.\n\nNo concerning lesion is noted in either adnexa.  There is no free fluid in the\npelvis.\n\nLYMPH NODES: Previously seen left external iliac node is not visualized on\ntoday's exam due to field of view.  No additional pelvic lymphadenopathy is\nidentified.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters appear within normal\nlimits.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized rectum and large bowel are\nunremarkable.\n\nVASCULATURE: Iliac vasculature is within normal limits.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Visualized osseous structures are\nunremarkable.  There is signal the midline, in the medial aspect of the right\nrectus abdominus, likely due to prior surgery.",
            "output": "1. Bilateral endometriomas with right hematosalpinx and evidence of chronic\ndeep endometriosis at the cul-de-sac.\n2. Indistinct junctional zone along the anterior uterus, suggestive of focal\nadenomyosis versus a predominately intramural anterior fibroid with submucosal\ncomponent.\n3. Previously seen, enlarged left iliac lymph node was not included in the\nfield of view.  CT is the recommended modality for reassessment.\n\nRECOMMENDATION(S):  CT of the pelvis (including the aortic bifurcation)."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is partially visualized and contains several nonenhancing fibroids\nwith the dominant fibroid in the fundus measuring 3.8 x 3.5 x 2.8 cm.\n\nThe endometrium is asymmetrically thickened measuring up to 14 mm and contains\ndebris with the suggestion of abnormal enhancement (1603:30).\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nNo free fluid in the pelvis.  There are nabothian cysts.\n\nLYMPH NODES: No lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Colonic diverticulosis without evidence of acute\ndiverticulitis.  No bowel obstruction.\n\nVASCULATURE: No aneurysmal dilatation of the visualized pelvic vessels.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Small fat containing umbilical hernia. \nIn the soft tissues of the lower anterior superficial abdominal fat there is a\nfocus of T2 hypointense and T1 hypointense signal which is nonenhancing with\nmild surrounding fat stranding and enhancement which is suspected to represent\na granuloma related to subcutaneous injection.\n\nThe site of palpable abnormality was marked.  There are no abnormalities to\ncorrespond this area.  There is normal subcutaneous fat.",
            "output": "There are no abnormality seen to correlate to the patient's site of palpable\nabnormality which was marked using a skin marker.  There is normal\nsubcutaneous fat subjacent to the marker.  No lymphadenopathy.  No drainable\nfluid collections.  No masses.  The ovaries are normal in appearance.\n\nThe endometrium is asymmetrically thickened measuring up to 14 mm and contains\ndebris with the suggestion of abnormal enhancement.  Further evaluation with\npelvic ultrasound and/or biopsy is recommended.  Differential considerations\ninclude endometrial hyperplasia or endometrial cancer, less likely endometrial\npolyp.\n\nThe uterus is partially visualized and contain several nonenhancing fibroids,\nlikely calcified, with the dominant fibroid in the fundus measuring 3.8 x 3.5\nx 2.8 cm.\n\nColonic diverticulosis without evidence of acute diverticulitis.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 16:01 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "There are bilateral hip prostheses. Associated susceptibility artifact\nobscures the surrounding bone and soft tissue to some degree. Allowing for\nthis, bone marrow signal is within normal limits without evidence for\nfracture, avascular necrosis or osteomyelitis.  No gross hip joint effusion is\nseen, though small joint effusions may not be apparent due to artifact. No\nfluid is seen in the greater trochanteric bursa a.\n\nThere is dependent edema within the iliacus and paraspinal muscles\nbilaterally. Muscle bulk and signal is otherwise normal.\n\nThe visualized tendons are normal in appearance including the hamstring\norigins and gluteal tendons.  No abnormal signal is seen at the rectus\nabdominus/adductor tendon aponeurosis.\n\nThe sacroiliac joint spaces are maintained.  Aside from mild degenerative\nchanges, the pubic symphysis. Is within normal limits.\n\nLimited assessment of the lower lumbar spine is grossly unremarkable in\nappearance allowing for some disc degeneration.\n\nLimited evaluation of the pelvic viscera demonstrates a suprapubic catheter\nwith the distal tip noted within the distal right ureter just proximal to the\nright ureterovesicular junction with proximal right ureteral dilatation\n(series 4 images ___. There has been prior removal of a previously\ndemonstrated penile prosthesis. There is nonspecific edema involving the\ncorpora cavernosa and corpus spongiosum. Scrotal edema is seen. There is a\nsmall left-sided hydrocele. No discrete fluid collection is seen. There is no\nfree fluid within the pelvis. There are prominent bilateral inguinal station\nlymph nodes measuring up to 1.3 cm on the right (series 4, image 30).\n\nThere is a right sacral decubitus ulcer with loss of the normal subcutaneous\nfat signal and linear edema extending within the posterior subcutaneous soft\ntissues abutting the right posterior iliac bone and sacrum without associated\nmarrow signal changes or a discrete fluid collection within this region\n(series 3, image 14 and series 4, image 14).",
            "output": "1. Status post removal of penile prosthesis with nonspecific edema noted\nwithin the corpora cavernosa, corpus spongiosum and scrotum. No discrete fluid\ncollection is seen. No marrow signal changes are noted within this region\nabout the pubic symphysis to suggest osteomyelitis. Small left-sided\nhydrocele.\n\n2. Right-sided sacral decubitus ulcer with a linear tract of edema and loss of\nthe normal subcutaneous fat signal extending to the right posterior iliac bone\nand sacrum. No convincing adjacent marrow signal changes to suggest\nosteomyelitis.\n\n3. Status post placement of a suprapubic catheter with the distal tip noted in\nthe region of the distal right ureter just proximal to the ureteral vesicular\njunction and with mild proximal ureteral dilatation.  Repositioning and sub\nsome imaging re-evaluation should be considered.\n\n4. Bilateral inguinal lymphadenopathy, likely reactive.\n\n\nNOTIFICATION:   The findings were discussed by Dr. ___ with Dr. ___\nUrology on the telephone on ___ at 11:59 AM, 5 minutes after discovery of\nthe findings."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n\nTumor:  not seen\n\nMesorectal lymph nodes - Size (mm): <5mm\nMesorectal lymph nodes:  None\n\nPelvic side wall nodes:  no\n\nStaging Assessment:\nCRM: Clear\nEMVI:  negative\nLocation: Tumor not seen.\nNodal:  N0\nMetastasis: M0\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 3.8 x 7.9 x 5.5 cm.  There is an\nintramural 1.0 x 1.6 x 1.8 cm T2 hypointense fibroid in the right fundus\n(7;21).  There is also a 1.2 x 1.0 cm intramural anterior wall fibroid (6;\n12).\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is borderline in thickness measuring 11 mm, which may be\nseen in adenomyosis..\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There is no inguinal or pelvic sidewall lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable\n\nVASCULATURE: Visualized pelvic vessels appear patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are bilateral fat containing\ninguinal hernias.",
            "output": "1. No focal rectal mass is visualized on imaging.  There is no pelvic or\ninguinal lymphadenopathy.  There is no evidence of metastasis in the pelvis.\n2. Borderline thickened junctional zone can be seen with adenomyosis.\n3. Fibroid uterus."
        },
        {
            "input": "A nonenhancing 1 cm lesion in the right iliac bone is unchanged.  A\nperipherally enhancing 1 cm lesion previously demonstrating dotatate avidity\nin left iliac bone, adjacent to the left sacroiliac joint.  This is unchanged\nsince ___.  A separate enhancing 9 mm lesion previously demonstrating\ndotatate avidity in left iliac bone is unchanged since ___.  Both left\niliac bone lesions are new since ___.  No additional osseous lesions\nidentified.\n\nThe marrow signal throughout the rest of the pelvis is within normal limits\nwith patchy red marrow.  There is normal marrow signal within the proximal\nfemurs bilaterally.  There is no evidence of avascular necrosis, fracture,\nstress fracture.  There are mild bilateral sacroiliac joint degenerative\nchanges.\n\nLimited assessment of intrapelvic structures reveals diverticulosis and trace\nfree fluid.\n\nThe lumbar spine is better assessed on concurrent lumbar spine MRI.",
            "output": "Bilateral iliac bone lesions are unchanged since ___, though both left\niliac bone lesions are new since ___ and previously demonstrated dotatate\navidity consistent with carcinoid metastases.  No new lesions identified."
        },
        {
            "input": "Lower thorax: Innumerable metastatic lung nodules are noted.  Please refer to\nseparate chest CT done the same day for thoracic findings.\n\nLiver: The liver is not cirrhotic and there is no hepatic steatosis.\n\nInterval worsening with progression of the multiple metastases in the liver.\n\n-The largest at the junction of segment II/IV measures 7.7 x 9.2 cm,\npreviously measuring 7.2 x 8.1 cm.\n-Another lesion in segment V measures 3.2 x 2.1 cm, previously measuring 2.8 x\n2 cm (series 6, image 28).\n-A lesion at the junction of segment VII/VIII measures 3.3 x 4.1 cm,\npreviously measuring 2.5 x 3 cm (series 6, image 10).\n-Progression of a lesion in segment VIII measuring 6 x 3.5 cm, previously\nmeasuring 3 x 4.3 cm (series 6, image 13).\n-Additional few subcentimeter lesions appears new in the right liver lobe.\nBiliary: Status post cholecystectomy.  No intra or extra biliary duct\ndilatation.\n\nPancreas: The pancreas is homogeneous and normal in signal.  No main duct\ndilatation.\n\nSpleen: The spleen measures 12.8 cm.  Unchanged 15 mm hyper T2 lesion at the\nupper pole of the spleen likely representing hemangioma.\n\nAdrenal Glands: Unremarkable.\n\nKidneys: The kidneys are unremarkable.  No hydronephrosis.\n\nGastrointestinal Tract:  No bowel obstruction.  Again noted is a 3.3 cm lesion\nin the lower rectum.  There is a fistulous track extending anteriorly through\nthe posterior wall of the vagina (series 17, image 19).  Clinical correlation\nis recommended.\n\nPelvis: The urinary bladder is unremarkable.  The uterus is unremarkable. \nThere is a 2 cm solid enhancing left adnexal lesion (series 16, image 28).\n\nInterval increase in the amount of ascites in the pelvis and the abdomen, now\nmoderate.\n\nLymph Nodes: Multiple retroperitoneal and pelvic lymphadenopathy are noted as\ndescribed below on series 1201:\n\n-Stable left para-aortic implant encasing the left renal vein measuring 15 x\n25 mm, previously measuring 25 x 13 mm (image 82).\n-Left para-aortic lymph node below the left renal vein measures 14 mm (image\n111), previously measuring 1 cm.\n-Right retro vena cava adenopathy is stable measuring 1 cm (image 125).\n-Right common iliac lymph node is stable measuring 12 mm (series 22, image\n54).\n-Right internal iliac lymph node measuring 16 mm is stable (series 22, image\n62).\nMultiple peritoneal implants are again noted.  The largest is in the right\nflank measuring 4.3 cm, previously measuring 2.9 cm (series 22, image 26).\nAdditional peritoneal nodules in the right upper quadrant also appears larger.\nFor example, a nodule now measures 3.2 x 1 cm, previously measuring 1.5 x 0.6\ncm (Series ___, image 95).\nExtensive presacral implants are also noted.\n\nVasculature: No abdominal aortic aneurysm.\n\nOsseous and Soft Tissue Structures: Focal area of enhancement in the posterior\naspect of L2 vertebral body that could represent a focal metastasis. There is\na new 4.3 cm soft tissue enhancing mass involving the left obturator internus\nmuscle and adjacent adductor muscle (series 13, image 50).",
            "output": "1. Interval worsening with progression of the liver metastases and peritoneal\ndisease.\n2. Extensive presacral disease with pelvic and retroperitoneal lymph node\ninvolvement.\n3. Moderate ascites.\n4. Malignant rectovaginal fistula.\n5. Left medial groin muscular involvement.\n6. Innumerable lung metastases.  Please refer to separate chest CT."
        },
        {
            "input": "The examination is limited due to motion as the patient was in pain.\n\nThere is re-demonstration of a left presacral mass measuring 5 x 3.7 x 4.4 cm.\nThis demonstrates mild T2 hyperintense signal and hypoenhancement on\npostcontrast images.  This appears to infiltrate through the left S1, S2 and\nprobably S3 neural foramina and the exiting nerve roots.  There is abnormal\nbone marrow signal in the left S2 and S3 and probable the inferior aspect of\nS1 suggesting osseous involvement as well.\n\nThis mass has not significantly changed in size.\n\nThe remaining osseous structures show no fractures.  The sacroiliac joints are\nunremarkable in appearance.  There is no femoral acetabular joint effusion.\n\nThe tendons and muscles around the hip appear unremarkable and symmetric.  No\ntrochanteric bursitis is appreciated.\n\nBladder and uterus appear unremarkable.  No appreciable pelvic sidewall\nadenopathy.",
            "output": "Re-demonstrated left presacral mass not significantly changed as detailed\nabove.  This invades through the left S1, S2 and probably S3 neural foramina\nand involves the S2 and S3 vertebral bodies."
        },
        {
            "input": "No perianal fistula is identified.  Note is made of multiple hemorrhoids,\nprobably some that are external.  A few demonstrate intrinsic T1 hyperintense\nsignal suggesting they may thrombosed.  Some do not completely fill on post\ncontrast images and may be slow filling versus thrombosed.  There is wall\nthickening of the rectum and visualized sigmoid colon with some areas of\nheterogenous enhancement.\n\nThe uterus measures 7.3 x 3.3 x 4.5 cm.  Junctional zone and endometrial canal\nare not thickened.  Susceptibility in the region of the uterus is likely\nrelated to prior C-section.\n\nThere is no pelvic sidewall or inguinal adenopathy, although there is\nfibrofatty proliferation.\n\nThe bladder is unremarkable.  Distal ureters are without dilation.\n\nThere is no superficial soft tissue abnormality.  There is no bony lesion.",
            "output": "1.  No evidence of perianal fistula.\n2.  Thickening of the rectum and sigmoid with heterogenous enhancement, likely\nsecondary to chronic UC.\n3.  Internal and apparent external hemorrhoids, which are slow filling or may\nbe thrombosed, correlate with clinical exam."
        },
        {
            "input": "Bones: Diffuse low T1 signal of the bone marrow without prominent increased T2\nsignal.  No focal osseous lesion is identified.  Degenerative changes of the\nlumbar spine.  Degenerative changes of bilateral SI joints with anterior\nhypertrophic spurring.\n\nNo joint effusions of the bilateral hips.  There is likely cartilage space\nnarrowing of the superior femoroacetabular joints bilaterally, however full\ncharacterization of hip degenerative change is difficult on large\nfield-of-view imaging.\n\nAlignment appears preserved.  No fractures.\n\n\nSoft tissues: A transplant kidney is seen of the right hemipelvis.  Mild edema\nand focal areas of susceptibility artifact along the right lateral ventral\nabdominal wall is most consistent with postsurgical changes.  Small bowel\nloops appear to underlie the post surgical scar.\n\nMuscle bulk and signal surrounding the pelvis appears relatively well\npreserved.  The bilateral iliopsoas tendons, rectus femoris tendons, and\ngluteus minimus, medius, and maximus tendons appear intact.  Bilateral\nhamstring tendons appear intact.  Adductor aponeurosis appear intact.\n\nSmall amount of nonspecific edema underlies the iliac muscles bilaterally,\nright slightly greater than left.",
            "output": "Degenerative changes of the lumbar spine are incompletely characterized on\nthis exam.  Mild degenerative change of the bilateral SI joints.  Likely mild\ndegenerative changes of the bilateral hips.  No fracture.\n\nStatus post right transplant kidney.\n\nDiffuse bone marrow signal abnormality may represent prominent red marrow\nchanges versus changes due to chronic renal failure.  A hematologic neoplastic\nprocess is considered much less likely.  Clinical correlation recommended."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\n2.5 x 1.6 x 2.2 cm abscess is identified in the left ischioanal fossa. \nInfraspinatus teres CT sinus tract is identified connecting from the anterior\ninferior aspect of the sphincter complex at 2:00 position connecting to the\nabscess.  No definite luminal opening is identified, however focal enhancement\nat the 2 o'clock internal sphincter (901:62) is suspicious for luminal\nconnection.  Rectosigmoid colon appears otherwise unremarkable.\n\nBLADDER AND DISTAL URETERS: Bladder is unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Diffuse enhancement of the prostate\nperipheral zone is identified, consistent with prostatitis.\n\nLYMPH NODES: Prominent bilateral inguinal lymph nodes are likely reactive.\n\nVASCULATURE: Iliac and femoral vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning bone lesion is identified.",
            "output": "1. 2.5 x 1.6 x 2.2 cm left ischioanal fossa abscess is identified with an\ninfraspinteric sinus tract with possible luminal connection at 2 o'clock."
        },
        {
            "input": "There is a T1 hypointense and STIR hyperintense lobulated lesion within the\nleft gluteal medius muscle measuring approximately 1.3 x 1.3 x 1.7 cm.  There\nis increased surrounding fat around the lesion and a curvilinear T1\nhypointense structure exiting at the distal aspect of the structure, which may\nrepresent a nerve.  Enhancement on post-contrast imaging is difficult to\nassess given lack fat saturation, however, there probable low level\nenhancement.  The lesion is not significantly changed from prior CT when\nallowing for differences in technique.\n\nMetallic susceptibility artifact is noted from on the plate and screw hardware\nalong the left acetabular and iliac bone.\n\nThere is on a deformity of the right inferior pubic ramus compatible with\nprior fracture.  More recent left inferior pubic ramus fracture is difficult\nto visualize due to hardware related artifact but is likely healing.  There is\nbone marrow edema pattern within the right pubic bone, at its junction with\nthe right superior and inferior pubic rami, compatible with subacute fracture,\nas suspect from previous radiograph.\n\nThere is mild bilateral greater trochanteric bursitis.\n\nThere is mild tendinosis of the hamstring tendons left worse than right.\n\nRemaining visualized tendons are intact.\n\nThere is severe atrophy of the bilateral gluteus minimus muscles.  Remaining\nmuscles are grossly normal in signal and bulk.\n\nThere is an IUD in place.\n\nThere are perineural cysts bilaterally at the level of the S2 exiting nerve\nroots.  Limited evaluation of pelvic soft tissues is grossly unremarkable.",
            "output": "1.  STIR hyperintense lesion in the left gluteus medius muscle with\nsurrounding fat and suggestion of minimal enhancement.  The lesion may\nrepresent a myxoid lesion versus peripheral nerve sheath tumor and\npercutaneous biopsy or follow up MRI can be obtained to definitely\ncharacterize the lesion or ensure stability.  Findings are less likely to be\npost traumatic in etiology.\n\n2. There is bone marrow edema pattern within the right pubic bone, which may\nbe related to prior trauma and possible non displaced fracture.\n\n3.  Post surgical changes from prior fixation of the left acetabulum fracture.\n\n4.  Mild bilateral greater trochanteric bursitis.\n\n5.  Mild bilateral hamstring tendinosis, left worse than right."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 10.4 x 5.2 x 5.8 cm.\nThe endometrium is normal in thickness for age.\nThere is loss of the junctional zonal anatomy with heterogeneous enhancement\nof the uterus on the postcontrast images suggestive of adenomyosis.\n\nFocal bulging of the anterior myometrium on the sagittal sequence (series 2,\nimage 19) that normalizes on the other sequences compatible with a myometrial\ncontraction.\n\nThere are no uterine fibroids..\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No suspicious pelvic or inguinal lymphadenopathy by size\ncriteria.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are normal without\nfocal mass or wall thickening.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Visualized portions iliac vessels are normal in caliber and\npatent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: 11 mm T2 hyperintense benign-appearing\nlesion within the right femoral neck most likely an enchondroma.\n5 mm enhancing subdermal nodule in the pubic region on the right just superior\nto the right labia majora (series 17, image 92) of unknown etiology, to be\ncorrelated with physical exam.",
            "output": "1.  No uterine fibroids.\n\n2.  Loss of the normal junctional zonal anatomy with heterogeneous enhancement\nof the uterus on the postcontrast images suggestive of adenomyosis.\n\n3. 5 mm enhancing subdermal nodule in the pubic region on the right just\nsuperior to the right labia majora of unknown etiology, to be correlated with\nphysical exam."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.7 x 4.7 x 6.3 cm, previously 10.4 x\n5.2 x 5.7 cm.\nThe endometrium is normal in thickness for age and measures 7 mm.\nThe junctional zone is not significantly thickened measuring 8 mm in\nthickness.  Heterogeneous T2 signal and enhancement of the myometrium is\nnoted.  C-section scar noted.\nNote is again made of multiple small nabothian cysts in the cervix.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary contains a 17 mm peripherally enhancing lesion which is likely\nan involuting corpus luteal cyst.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No enlarged pelvic or inguinal lymph nodes by size criteria.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: The visualized portions of the vessels are normal in caliber and\npatent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: 11 mm nonaggressive-appearing lesion\nwithin the right femoral neck is unchanged and most likely an enchondroma.\nThe previously seen 5 mm enhancing subdermal nodule in the pubic region is not\nvisualized on today's study.",
            "output": "No evidence of junctional zone thickening on the current exam.  No fibroid or\nfocal adenomyosis.\nPost cesarean section changes in the anterior uterine wall."
        },
        {
            "input": "ANUS, RECTUM AND INTRAPELVIC BOWEL: There is an intersphincteric perianal\nfistula arising just above the anal verge at approximately ___ o'clock which\nhas a blind ending horseshoe tract extending superiorly from approximately\n10:00 to 4:00 (802:89-91).  Additionally, there is a tract extending\ninferiorly into the left posterior perineum where there is a abscess measuring\napproximately 2.8 x 2.4 cm (97).\n\nNumber of fistulas: 1.\n\nINTERNAL ANAL OPENING:\nLocation (quadrant and clock face) in supine position: Anterior at 12 to 1\no'clock\nDistance from anal verge:  0.5 cm\nRelation to the internal sphincter: Lower third of sphincter\n\nFISTULA TRACT:\nMaximum tract diameter:  5 mm\nFistula type (Parks classification):  Intersphincteric\nSecondary branches: There is a blind ending horseshoe tract extending\nsuperiorly from approximately ___ o'clock, as well as a tract extending\ninferiorly into the posterior left perineum where there is an abscess.\nExit site: Posterior left perineum\nHyperintensity of the tract on T2: Mild\nEnhancement of the tract: No central enhancement compatible with a\nfluid-filled tract\n\nOTHER FINDINGS:\n\n\n\nAbscess: Yes, there is a 2.9 x 2.4 cm rim enhancing collection which has\ninternal T2 heterogeneous material and some internal T1 hyperintensity as well\nas foci of blooming compatible with air in the posterior left perineum.\nRectal and sigmoid wall inflammation: No\nPresence of ___, drains or prior surgery: No\n\nAnteriorly to the region of the clitoris, there is a curvilinear focus of\nfluid signal spanning approximately 1.3 cm, of uncertain etiology, possibly\nfluid trapped between folds (5:28; 802: 73).\n\nUTERUS AND ADNEXA: The enlarged fibroid uterus is only partially included in\nthe field of view, however measures approximately 16 x 17 x 12 cm on the\nlocalizer images.  There are numerous T2 hypointense uterine fibroids, the\nincluding a peripherally calcified fibroid measuring up to approximately 8.3 x\n7.2 x 6.9 cm.  A more superior pedunculated fibroid on the left is only seen\non the localizer images, measuring up to approximately 8.9 x 7.8 cm.  The\nendometrium is distorted by fibroids, however measures approximately 3 mm\nwhere it is seen.  The ovaries are not identified, however no adnexal\nabnormality is seen.  There is trace free fluid in the pelvis.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Normal.\n\nVASCULATURE: Patent pelvic vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is diffuse low T1 signal in the\nbone marrow compatible with history of leukemia.  No focal concerning osseous\nlesions.  There is diffuse edema in the pelvic musculature as well as diffuse\nsubcutaneous edema.\n\nABDOMEN: A 3.6 cm right renal cyst is partially visualized on the localizer\nimages.",
            "output": "Intersphincteric perianal fistula arising at approximately ___ o'clock\napproximately 0.5 cm above the anal orifice with a blind-ending\nintersphincteric horseshoe tract extending superiorly from approximately 10\no'clock to 4 o'clock, as well as a tract extending inferiorly below the\nsphincter into the posterior left perineum where there is a 2.9 cm abscess."
        },
        {
            "input": "Again seen is the destructive mass centered in the left sacrum measuring\napproximately 11.4 x 5.7 x 7.8 cm with extension across the left sacroiliac\njoint into the posterior aspect of the left iliac bone, soft tissue extension\ninto the posterior aspect of the pelvis predominantly on the left, and\nextension into the left sciatic notch with displacing/invading the left\npiriformis muscle.  Compared to most recent CT on ___, the\nextent of the lesion is grossly unchanged, however compared to the MRI on ___, there is increase in extension across the left SI joint and into the\nleft iliac bone.  The T2 signal is more heterogeneous on today's study\ncompared to ___, and there is now mostly peripheral enhancement with\nnon-enhancement of the more central portions.  The remaining blood marrow\nsignal is otherwise within normal limits and the surrounding musculature is\nwithin normal limits.\n\nLimited evaluation of the intrapelvic structures is notable for a fibroid\nuterus which is unchanged compared to ___ and sigmoid diverticulosis\nbut no evidence of diverticulitis.  Otherwise the intrapelvic structures are\nunremarkable.",
            "output": "Compared to most recent CT on ___, the size and extent of the\nlesion is grossly unchanged, however compared to the MRI on ___, there\nis increase in extension across the left SI joint and into the left iliac\nbone.\n\nFindings consistent with necrosis within the lesion with decrease in central\nenhancement and T2 signal.\n\nNo new areas of concern."
        },
        {
            "input": "Again seen is the destructive mass centered in the left sacrum, which measures\napproximately 9.1 x 4.8 x 7.0 cm, not significantly changed compared to ___ given slight differences in technique.  The mass extends across\nthe left sacroiliac joint and into the posterior left iliac bone, with soft\ntissue extension into the posterior aspect of the pelvis and the left sciatic\nnotch, displacing/invading the left piriformis muscle.  There is also mild\nenhancement of left paraspinal muscles which may be tumor extension or\nradiation changes, unchanged.  There is peripheral enhancement without central\nenhancement, similar to prior study and consistent with necrosis.  There are\nno new areas of enhancement or abnormal bone marrow signal.  There is a right\nsided sacral insufficiency fracture, likely radiation induced, unchanged.\n\nLimited evaluation of the intrapelvic structures again demonstrates multiple\nfibroids in the uterus, unchanged.  Otherwise the intrapelvic structures are\nwithin normal limits.",
            "output": "No significant change in known sacral plasmacytoma compared to ___, described in detail above.  No new areas of disease.\n\nRight sided sacral insufficiency fracture, likely radiation induced,\nunchanged."
        },
        {
            "input": "There is again seen a marrow replacing mass in most of the sacrum with some\nsparing of the right sacral ala.  There is extension of the mass across the\nleft sacroiliac joint into the left iliac bone as well as soft tissue\nextension to the posterior aspect the pelvis and adjacent to the left sciatic\nnotch.  The mass measures 9.4 x 5.3 x 5.3 cm, 9.5 x 5.5 x 5.2 cm previously. \nFollowing the administration of intravenous contrast, there is mostly\nperipheral enhancement throughout much this lesion suggestive of necrosis,\nunchanged.  This lesion is unchanged in size and signal characteristics from\nthe prior study.\n\nThere is again seen a fracture line in the right sacral ala superiorly with\nsurrounding marrow edema, unchanged and compatible with an insufficiency\nfracture.  There are no new areas of abnormal marrow edema.\n\nThe proximal femurs are unremarkable without focal lesions or signs for\navascular necrosis.  There is no hip joint effusion on either side.  There are\ndegenerative changes the lower lumbar spine, stable.  There is a fibroid\nuterus.",
            "output": "1.  Unchanged lesion replacing much of the sacrum extending into the left\niliac bone across the SI joint compatible with known plasmacytoma.  The lesion\nhas peripheral enhancement suggestive of necrosis, unchanged.\n2.  Right sacral ala insufficiency fracture, stable.\n3.  Degenerative changes of the lumbar spine.\n4.  Fibroid uterus."
        },
        {
            "input": "As before there is extensive, geometrically complex lesion involving the\nsacrum and left ilium crossing the sacroiliac joint.  In total the lesion\nmeasures approximately 9.9x5.2x5.3 cm TRV x AP x CC, previously 9.9x5.3x5.3 cm\nTRV x AP x CC, unchanged since the prior study allowing for differences in\nslice selection and measurement technique.  Imaging characteristics are\nsimilar- centrally T2 bright and cystic with peripheral hyperenhancement. \nThere is also a 2 x 1 cm T2 hyperintense enhancing focus along the superior\nendplate of the S1 vertebral body (701: 14), unchanged.\n\nThere is mild edema in the left piriformis muscle similar prior (03:25).\nBilateral sciatic nerves appear normal in size and signal.\n\nThere is a fracture of the right sacral ala with mild residual bone marrow\nedema, probably slightly improved compared with prior (09:27).  There is mild\ndegenerative change in both hips with marginal acetabular spurring.  There is\nmild gluteal tendinosis bilaterally, right greater than left.  There is mild\ntendinosis at the proximal origin of the left hamstring tendon (701:42). \nMuscle signal and bulk about the pelvis is normal with exception of mild fatty\natrophy of gluteus major and tensor fascia ___ bilaterally (02:42).\n\nThis study is not optimized for evaluation of the intrapelvic structures,\nhowever as before multiple T2 dark uterine fibroids are re-demonstrated. \nThere is trace pelvic free fluid, likely within physiologic limits.  There is\nno frank pelvic wall or inguinal lymphadenopathy.\n\nThere is partially imaged degenerative change in the lower lumbar spine worst\nat L3-L4 and L4-L5 with disc height loss.  There is mild leftward convex\ncurvature of the lumbar spine.",
            "output": "1. No appreciable change in large lesion involving the sacrum and left iliac\nbone crossing the SI joint with central necrosis and peripheral enhancement. \nAlso, unchanged apparent 2 x 1 cm enhancing component along the superior\nendplate of the S1 vertebral body.\n2. Possible slight improvement in right sacral ala insufficiency fracture.\n3. Mild bilateral gluteal tendinosis.  Mild left proximal hamstring\ntendinosis.\n4. Degenerative changes in the lumbar spine.\n5. Fibroid uterus."
        },
        {
            "input": "Again, there is a complex mass involving the sacrum and extending into the\nleft iliac bone crossing the left sacroiliac joint.  This mass is relatively\nunchanged in size from the prior study from ___.  It currently\nmeasures 9.8 x 4.8 x 5.4 cm.  It previously measured 9.8 x 4.6 x 5.3 cm in\nsimilar ___.  There are unchanged imaging characteristics with central\nSTIR signal hyperintensity with heterogeneous peripheral enhancement.  Again,\nthere is a separate but adjacent 2 x 1 cm STIR hyperintense enhancing focus\nalong the superior endplate of the S1 vertebral body, unchanged (3:44).\n\nThere is new mild marrow edema of the pubic bones adjacent the pubic\nsymphysis, left greater than right.  Additionally, there is mild adjacent\nedema of the left adductor magnus muscle (___).  Otherwise, the muscles\nare symmetric in bulk.  Minimal residual marrow edema is noted adjacent a\nfracture of the right sacral ala, improved from the prior studies (05:24).\n\nMild degenerative changes noted of both hips as well as the visualized lower\nlumbar spine.  Mild tendinosis at the origin of the hamstrings bilaterally. \nMild gluteal tendinosis bilaterally, right greater than left.\n\nIncidental note is made of an ovoid well-circumscribed focus within the left\ngluteus maximus muscle measuring approximately 25 x 5 by 30 mm (2:13, 4:29)\nwithout internal septations or nodular component, that is low signal on the\nSTIR images and loses signal on the fat saturated T1 weighted images (06:14),\nlikely reflecting an intramuscular lipoma.  There is no corresponding internal\nenhancement.  The surrounding left gluteus maximus muscle is within normal\nlimits.  The appearance is unchanged compared with ___.\n\nLimited evaluation of the pelvis demonstrates uterus to be multilobulated with\nfibroids.  Trace pelvic free fluid is noted.  No pelvic lymphadenopathy is\nseen.",
            "output": "1. No definite interval change in the large peripherally enhancing lesion\ninvolving the sacrum and crossing the left sacroiliac joint into the left\niliac bone.\n2. Continued healing of right sacral ala insufficiency fracture.\n3. New mild marrow edema in the parasymphyseal pubic bones,\nleft-greater-than-right, with adjacent edema of the adductor magnus muscle on\nthe left.  Clinical correlation is requested, as this could represent a stress\nresponse in the parasymphyseal pubic bones.  No fracture line is identified at\nthis time.\n4. No other significant interval change.\n5. Small simple lipoma within the left gluteus maximus muscle again noted,\nunchanged."
        },
        {
            "input": "Bones:\n\nA again seen is a T2 hyperintense marrow replacing process of the sacrum\ninvolving the S1 and S2 vertebral bodies, likely the S3 vertebral body, as\nwell as nearly the entire left sacral ala and a portion of the right sacral\nala.  There is similar signal abnormality of the posterior left iliac bone. \nOverall the axial measurement measures approximately 9.2 x 3.8 cm and\napproximately 4.6 cm in the greater chondral dimension, relatively unchanged\nfrom the ___.  These areas of marrow abnormality demonstrate\npredominately peripheral enhancement, relatively similar.\n\nModerate bone marrow edema and enhancement across the pubic symphysis the\nprogressed from prior exam.  Small ovoid focus of T1 and T2 hypointensity at\nthe right pubic body, represents a bone island.\n\nEnhancement along the right L4-L5 facet joint is likely degenerative.  Mild\nedema and enhancement of the right L5 transverse process appears similar to\nmildly progressed from prior exam (image 3:5, 5:15, and 9:15).\n\nSoft tissues:\nAgain seen is mild enhancement of bilateral gluteus medius tendon and proximal\nhamstrings at their attachments, nonspecific.  Mild paraspinous muscle edema.\n\nMulti fibroid uterus appears similar.",
            "output": "No definite interval change and large peripherally enhancing lesion involving\nthe sacrum and posterior left iliac bone.\n\nEnhancement along the right L4-L5 facet joint is likely degenerative. Mild\nedema and enhancement of the right L5 transverse process appears similar to\nmildly progressed from prior exam and may be reactive due to degenerative\nchanges at the right L4-L5 facet joint though tumor involvement cannot be\ncompletely excluded. This could be followed on subsequent exams.\n\nModerate edema across the pubic symphysis bilaterally appears progressed from\nprior exam and may be seen in osteitis pubis.  Tumor involvement is thought to\nbe less likely given the symmetry of the finding.  Clinical correlation\nrecommended.  Consider radiographic correlation to evaluate for sclerosis."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 6.7 x 3.3 x 3.8 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 2 mm\nJunctional zone: 4 mm without focal thickening.\n\nFIBROIDS:\n\nFibroid burden: 4\nFibroid enhancement: Heterogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n1.      none\n\nThe three dominant fibroids are:\n1.      size 1.7 x 1.6 x 1.7 cm enhancement, 100 % intramural, posterior\nfundus\n2.      size 1.4 x 1.3 x 1 cm enhancement, 100% intramural, anterior right\nlateral\n\nNo cornual or cervical fibroids are detected.\n\nOVARIES:\nThe left ovary is normal.\n\nAgain noted is a 3.2 x 3.1 x 4 cm right adnexal lesion showing minimal\nenhancement and dark T2 signal.  This lesion is unchanged in sizes since ___.  A 2.9 x 1.9 cm anterior cystic lesion is also noted, previously\nmeasuring 2.2 x 2.1 cm.\n\nTrace of free-fluid in the pelvis.  No pelvic lymphadenopathy.  The urinary\nbladder is unremarkable.  No concerning bone lesions.  No bowel obstruction.",
            "output": "1. Solid right adnexal lesion with features suggestive of either fibroma,\nfibrothecoma or less likely, ___ tumor.\n2. Fibroid uterus."
        },
        {
            "input": "Vertically-oriented linear T1 hypointense signal is identified along the left\nfemur greater trochanter and superior to inferior orientation, spanning\napproximately 50% of the length between the greater and lesser trochanters.\n\nReticular area of T1 hypointensity with marked surrounding bone marrow edema\nin bilateral paraacetabular regions, right greater than left, are suspicious\nfor insufficiency fractures.  The fracture on the right side involves superior\nand anterior para acetabular regions, extending to the lateral aspect of the\nright superior pubic ramus.  The fracture on the left side is mostly limited\nto the superior paraacetabular region.\n\nDegenerative changes are mild in bilateral sacroiliac joints.  T1 hypo and T2\nisointense focus in the left iliac bone may reflect red marrow.\n\nThere is no significant hip joint effusion.  Edema is noted in lateral gluteal\nregions bilaterally, left greater than right, as well as about the proximal\nleft quadriceps musculature, including possible intramuscular hematoma. \nNonspecific mild edema about the lateral aspect of the greater trochanters\nnoted bilaterally.  T2 hyperintense lesion in the proximal right femoral\ndiaphysis may reflect an enchondroma\n\nLimited assessment of intra-pelvic soft tissue structures is grossly\nunremarkable.\n\nLimited assessment of the lower lumbar spine demonstrates degenerative\nchanges.",
            "output": "1. Incomplete nondisplaced fracture of the left femur greater trochanter,\nspanning approximately 50% of the intertrochanteric length.\n2.  Age-indeterminate bilateral paraacetabular nondisplaced fractures, right\ngreater than left, possible subacute, concerning for insufficiency fractures.\n3. Grade 2 strain and contusion of the proximal left quadriceps musculature\nand grade 1 strain of the  gluteus minimus.  Possible strain of the right\ngluteal muscles."
        },
        {
            "input": "Gravid uterus with intrauterine pregnancy of 2 fetuses is demonstrated. There\nare 2 placentas present: An anterior placenta is located high in the uterine\nbody. A posterior placenta is located at the fundus and the body of the\nuterus. There is no evidence of placental invasion into the myometrium.\nPrior C-section scar is seen in the subcutaneous tissues (10:27).\nThe visualized portions of the liver, spleen, pancreas are normal. The\ngallbladder is normal. There is no dilatation of the biliary ducts. The\nkidneys are normal, without hydronephrosis. There is no free fluid the abdomen\nand pelvis. There is no lymphadenopathy.\nThe bone marrow signal is normal.\nThis examination is not intended to assess for fetal anomalies.",
            "output": "Gravid uterus with twin pregnancy. There are 2 placentas, anterior and\nposterior. No evidence of placenta accreta or percreta."
        },
        {
            "input": "Again demonstrated is ___ ring penetrating through the caudal aspect of\nthe anus at the 6 o'clock position, approximately 1.7 cm above the anal verge.\nThis again travels in the intersphincteric plane to exit the right gluteal\ncrease (11, 15 and 10, 30). A small amount of T2 hyperintense signal is noted\nadjacent to the ___ within the posterior ischioanal fat, which may reflect\ngranulation tissue. No IV contrast administered due to patient's pregnancy. No\ndiscrete perirectal abscess is noted.No new perianal fistulous tracts are\nnoted.\n\nNo free pelvic fluid. Small bilateral pelvic nodes. Mildly distended bladder\nwithout focal wall thickening.\n\nThere is a partially visualized gravid uterus with single intrauterine\npregnancy, breech position, with placenta noted within the posterior and\nfundal aspect of the uterus.  There is T1 hyperintense signal along the\nposterior and right lateral aspect of the uterus between the uterine wall and\ngestational sac, inferior to the placenta, suggestive of a small amount of\nsubchorionic hemorrhage.\n\nNo suspicious osseous lesions.",
            "output": "-No discrete perirectal abscess identified. Similar appearance ___ ring\ntraversing the anus in the 6 o'clock position with small amount of adjacent T2\nhyperintensity, possibly reflecting granulation or inflammatory tissue.\n-No new perianal fistulous tracts.\n-T1 hyperintense material in the posterior and right lateral aspect of the\nuterus, as described above, inferior to the placenta, suggestive of a small\nsubchorionic hemorrhage. Recommend followup fetal ultrasound and OB\nconsultation.\n\nNOTIFICATION:   The impression above was entered by Dr. ___ on\n___ at 09:20 into the Department of Radiology critical communications\nsystem for direct communication to the referring provider."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: At approximately 1.5 cm above the anal verge\nfrom ___ o'clock position, corresponding to the location of prior sinus tract\nseen on MR from ___, there is a thin intersphincteric T2 signal\nhyperintensity (series 6, image 31) which demonstrates progressive enhancement\non postcontrast images, consistent with granulation tissue.  No definite\nmucosal opening identified.\n\nThere is extensive inflammatory changes including edema and enhancement of the\nright ischial anal fossa at similar level that extends along the right\ninferior pubic ramus to the root of the penile shaft, where there is a 2.5 x\n1.3 cm fluid collection (series 1002, image 72), consistent with abscess.  The\ncollection demonstrates mass effect on adjacent right corpus cavernosum and\nthe corpus spongiosum without direct involvement.  The mass also abuts the\nurethra (series 5, image 6).  No open connection between the abscess and the\nanal canal.  The connection is likely collapsed.\n\nThe patient is status post total colectomy.  The rectal stump appears within\nnormal limits.\n\nBLADDER AND DISTAL URETERS: The urinary bladder and distal ureters are within\nnormal limits.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The study is not tailored for\nevaluation of the prostate.  Given the limitation, striated hypointense signal\nintensity on T2 weighted images in the peripheral zone of the prostate most\nlikely represent sequela of prior prostatitis.  The seminal vesicles are\nwithin normal limits.  The visualized rectum is within normal limits.\n\nLYMPH NODES: There are scattered round nonspecific mesorectal lymph nodes\nmeasuring up to 5 mm.  Scattered external iliac and inguinal lymph nodes are\nnot enlarged by size criteria.\n\nVASCULATURE: The pelvic vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue\nlesions.  There are moderate right and small left fat containing inguinal\nhernias.",
            "output": "1. 2.5 x 1.3 cm right perineal abscess abutting the right aspect of the\nurethra, right corpus cavernosum, and corpus spongiosum.  There are extensive\nsurrounding inflammatory changes extending from the right ischial anal fossa\nto the base of the penis.  No communication between the abscess and the anal\ncanal, urethra, or vasculature.\n2. Intersphincteric granulation tissue at approximately 1.5 cm above the anal\nverge from ___ o'clock position, corresponding to the location of prior sinus\ntract.  No patent perianal fistula."
        },
        {
            "input": "ANUS AND RECTUM:\nArising from the 11 o'clock position approximately 1.7 cm above the anal\nverge, there is a complex perianal fistula which branches into 2 tracts. \nFirstly, there is an intersphincteric sinus tract extending from the 11\no'clock to 1 o'clock position, with a thin T2 hyperintense tract that\ndemonstrates progressive enhancement on post-contrast images, consistent with\ngranulation tissue.  Secondly, also arising at the 11 o'clock position, there\nis a fistulous tract extends inferiorly for a short distance in the\nintersphincteric plane, then traversing the external sphincter at the 11\no'clock position, and entering the ischioanal fat at 09:00 o'clock, with 2.0 x\n0.8 cm focus of granulation tissue with a small central 1 mm focus of fluid,\nnew compared to MR from ___.\n\nA known right perineal abscess collection, abutting the right inferior pubic\nramus, at the root of the penile shaft, now measures 0.4 x 1.4 cm, previously\n1.3 x 2.5 cm, demonstrating significant interval decrease in the size.  There\nis associated inflammatory changes at the base of the penile shaft and penile\nurethra.  There is no definite connection noted with the anal canal, likely\nsuggest collapse of the fistulous tract.\n\nPrior total colectomy.  The rectal stump appears within normal limits.\n\nLYMPH NODES: There are no suspicious pelvic or inguinal lymph nodes.  Tiny\nmesorectal lymph nodes are noted.\n\nBLADDER AND DISTAL URETERS: The urinary bladder and distal ureters are within\nnormal limits.\n\nVASCULATURE: The pelvic vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.  Bilateral\nsmall fat containing inguinal hernias.",
            "output": "1. Known complex perianal fistula which branches into 2 tracks.  The\nintersphincteric portion is unchanged in configuration.  There is a new\ninferior transsphincteric tract which extends into the right perineum,\ncomprised primarily of granulation tissue with a 1 mm focus of fluid.\n2. A known right perineal abscess has decreased in size, currently 0.4 x 1.4\ncm, with persistent inflammatory change at base of the penile shaft and right\nischioanal fossa.  There is no communication demonstrated between the abscess\nand anal canal or urethra."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.9 x 2.9 x 4.6 cm.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.  A hemorrhagic\ncyst is noted within the left ovary.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: Numerous retroperitoneal, mesenteric, and iliac chain lymph nodes\nare prominent but not pathologically enlarged, likely reactive.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The sigmoid colon and rectum are closely\nunremarkable on this nondedicated study.  A right lower quadrant ileostomy is\nunremarkable.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesion.\n\nWithin the presacral soft tissues, there is persistent extensive edema and\nenhancing tissue.  A right transgluteal drainage catheter terminates in the\npresacral space in the region of previous abscess with minimal residual fluid\ncomponent (04:24, 21:2).  A left transgluteal catheter terminating in the left\npiriformis muscle also appears well positioned with minimal residual fluid\ncomponent (04:16, 07:28).  There is extensive enhancing tissue throughout the\npresacral space and extending into the piriformis muscles bilaterally with\nnumerous subcentimeter foci of hypoenhancement consistent with microabscesses\nin the setting of a large area of phlegmonous change (1302:57).  There is no\nresidual drainable fluid collection.\n\nThere are multiple complex fistulae and sinus tracts throughout the pelvis. \nThere is extension from the presacral collection through a sinus tract into\nthe right S1 neural foramina with associated edema and enhancement within the\nright sacrum (4:27, 21:1, 07:21).  Multiple fistulae extend into the mid upper\npelvis with associated tethering adjacent bowel loops (07:22, 1303:48).  There\nappears to be a patent sinus tract extending from the distal sigmoid colon to\nthe presacral collection (07:25).",
            "output": "1. Large area of phlegmonous change within the presacral space with multiple\nsmall microabscesses. Bilateral transgluteal catheters are well positioned\nwith minimal residual fluid.  There is no residual drainable fluid collection.\n2. Extensive complex fistulae and sinus tracts throughout the pelvis,\nincluding a sinus tract between the distal sigmoid colon and the presacral\ncollections, and a sinus tract extending into the right S1 neural foramen.\n3. Enhancement and edema within the sacrum in the region of the S1 neural\nforamen may be reactive or reflect early osteomyelitis."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe uterus is anteverted and measures 10.2 x 15.4 x 11.2 cm.\n\nThere is abnormal thickening and distortion of the junctional zone with foci\nof increased signal intensity on T2 weighted images consistent with\nadenomyosis.  Spanning along the anterior wall of the uterus body and fundus\nthere is an ill-defined but rounded mass measuring 6.2 x 9.0 x 7.5 cm.  This\nmass is heterogenous on the T2 weighted sequences with small non-enhancing\nhigh T2 regions consistent with cystic change.  On the T2 weighted images, the\nfindings are classic for an adenomyoma; however, there is no central\nenhancement which may reflect infarction or inflammation.  In addition, there\nis an enhancing heterogenous component spanning the entire myometrium into the\nleft cornua and pushing almost into the left broad ligament.  On the T2\nweighed images, these findings are suggestive of a focal adenmyoma along with\nadenomyosis; however, the heterogeneous enhancement is atypical and may\nreflect infarction.  A component of infection is possible in light of the\nrecent endometritis but the appearance is not classic for superinfection.  \nMalignant degeneration can not be fully excluded.\n\nArising from the fundus on the right, there is an enhancing subserosal fibroid\nmeasuring 15 x 15 mm.\n\nThe endometrium is normal in thickness for age and measures 13 mm and has\nnormal enhancement.  Nabothian cysts are seen in the cervix.\n\nIn the left adnexa, there is a large hydrosalpinx with thin walls.  A\nwell-circumscribed lesion, homogenously hyperintense on the T1 weighted images\nand hypointense on the T2 weighted images, in keeping with an endometrioma. \nThere is scattered high signal on the T2 weighted images with enhancement\ntracking along the left broad ligament and fallopian tube likely reactive. \nThe right adnexa has normal follicles and what appears to be a small amount of\nhydrosalpinx with thin walls.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES:  No pelvic sidewall or inguinal adenopathy by size criteria.\n\nTRANSPLANT KIDNEY, BLADDER AND DISTAL URETERS:  The transplant kidney is\nwithin normal limits.  No hydronephrosis or hydroureter.  The bladder is\nwithin normal limits.\n\nRECTUM AND INTRAPELVIC BOWEL:  The sigmoid colon appears tethered to the\nanterior aspect of the left fallopian tube with linear enhancement likely from\nendometriosis or prior salpingitis.  The rectum is normal.  Visualized small\nbowel is normal.\n\nVASCULATURE:  The pelvic vessels are of normal caliber throughout without any\nsignificant areas of narrowing\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal\nsignal characteristics.  No concerning osseous lesions.",
            "output": "1.  Background uterine adenomyosis with a larger mass along the anterior\naspect of the uterus suggestive of an adenomyoma.  The central non-enhancing\nregion is atypical of a classic adenomyoma and may reflect infarction.  A\ncomponent of infection is possible in light of the recent endometritis but the\nappearance is not classic for superinfection.   Malignant degeneration can not\nbe fully excluded but the lesion spans the entire myometrium on the left and\npushes through the cornua up to the broad ligament.\n2.  Left endometrioma with likely small endometrial deposits along the\nfallopian tube with tethering of the sigmoid colon.\n3.  Small left hydrosalpinx.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 6:06 ___, 10 minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.9 x 13.4 x 9.9 cm.\n\nThe previously seen dominant mass in the anterior fundus, attributed to\nadenomyosis, has undergone significant degeneration and shrinkage compared to\nprior examination.  Central hyperintesnsity on T1-weighted images likely\nreflects hemorrhagic degeneration or blood products in the endometrial cavity.\nResidual heterogeneity with thickening of the junctional zone around the mass\nis again seen.\n\nThe left fallopian tube is distended with blood products.  Two left\nendometriomas are again visualized measuring up to 6.2 cm.  Tiny endometrial\ndeposit anterior to the uterus on series 10, image 49 is also present.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nThere is moderate free fluid in the pelvis.\n\nLYMPH NODES: Prominent right pelvic sidewall lymph node on series 4, image 23\nmeasuring 11 mm in short axis diameter likely reactive.\n\nBLADDER AND DISTAL URETERS: Within normal limits.\n\nRECTUM AND INTRAPELVIC BOWEL: The sigmoid colon appears to be displaced\nanteriorly though not tethered on today's examination.\n\nVASCULATURE: Within normal limits.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.  Right\niliac fossa renal transplant is again visualized.",
            "output": "1.  Marked interval involution of focal adenomyosis along the anterior uterine\nfundus with hemorrhagic degeneration, reflecting treatment response.  There\nremains background diffuse adenomyosis.\n2.  Two left endometriomas and left hematosalpinx.  Additional focal\nendometriosis along the anterior pelvis."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe uterus is in mid position and measures 4.8 x 12.4 x 6 cm.  Note is made of\na septate uterus.  A 2.6 x 2.1 x 3.4 cm T2 intermediate, T1 dark lesion in the\ncervix demonstrates an irregular enhancing wall without internal enhancement. \nNo definite hemorrhagic contents are seen within this lesion. Multiple\nwell-circumscribed cystic lesions are seen within the cervix, compatible\nnabothian cysts.  At least one of these nabothian cysts demonstrates intrinsic\nT1 hyperintensity, compatible with hemorrhage contents.\nThe endometrium is normal in thickness for age and measures up to 9 mm.\nThe junctional zone is not thickened.\n\nA 5.2 x 3.6 x 4.4 cm simple cyst is seen in the right adnexa.  Two additional\nsmaller T2 hyperintense nonenhancing are seen in the right adnexa, which may\nbe ovarian or paraovarian cysts.  The right ovary is not seen separate from\nthese cysts.\n\nThe left ovary is visualized and appears within normal limits.\n\nThere is a small amount of simple fluid in the pelvis.\n\nLYMPH NODES: A left external iliac lymph node measures 1.6 x 0.8 cm.  A right\nexternal iliac lymph node measures 1.4 x 1 cm.  No enlarged inguinal\nlymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and terminal ureters are within normal\nlimits.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum is within normal limits.  Imaged\nloops of small and large bowel are normal in course and caliber.\n\nVASCULATURE: Pelvic vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous lesions are\nidentified.  There are bilateral fat containing inguinal hernias.",
            "output": "A 3.4 cm cervical lesion with an irregular enhancing wall likely represents an\ninflamed or infected nabothian cyst.  No evidence of internal hemorrhagic\ncontents.  Lack of endometrial obstruction by this lesion makes malignancy\nunlikely.\nSeptate uterus.\nBilateral prominent pelvic sidewall lymph nodes are likely reactive.\nSimple right ovarian cyst measures up to 5.2 cm."
        },
        {
            "input": "PROSTATE, SEMINAL VESICLES, AND SCROTUM: There is been interval department of\nthe right groin and scrotal sac.  There is inflammatory fat stranding and\nedema within the superficial subcutaneous tissues of the right anterior pelvic\nwall and right scrotal sac.  There is gauze surrounding the right spermatic\ncord and scrotum.  Heterogeneous appearance of the remaining tissue within the\nright scrotal sac.\n\nBilateral testicles exhibit normal signal.  Bilateral epididymis are grossly\nunremarkable.  On the right side, there is an equivocal short-segment\nthrombosed peripheral vein in the right scrotum (9:61-70).\n\nA small simple epididymal cyst is seen on the left.\n\nThe prostate and seminal vesicles are normal in size and signal\ncharacteristics.\n\nThere is small volume free fluid within the rectovesical pouch.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic bowel appears\nunremarkable.  In particular, no perirectal or perianal fistula is identified.\n\nBLADDER AND DISTAL URETERS: Foley catheter in situ, with air in the bladder.\n\nLYMPH NODES: Multiple bilateral inguinal lymph nodes within the upper limits\nof normal in size.  There are also bilateral external iliac lymph nodes within\nthe upper limits of normal in size, likely reactive.\n\nVASCULATURE: Bilateral external iliac and common femoral arteries and veins\nare patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Fatty bone marrow within the pelvis,\nparticularly the pubic ramus and ischium.",
            "output": "1. Post-debridement changes along the right scrotal sac and right anterior\npelvic wall, with residual inflammatory fat stranding.  No fistula detected. \nNormal anus and rectum.\n2. Equivocal short-segment thrombosed superficial vein along the right\nscrotum, lateral to the penis.\n3. Normal MRI appearance of the testes.  Small left epididymal cyst."
        },
        {
            "input": "There is diffuse high T2 signal involving right gluteus muscles and adductor\ncompartment.  Increased T2 signal is also noted at the obturator externus and\nquadratus femoris muscles. Curvilinear lobe T1 signal is identified involving\nposterior right iliac bone and right sacral ala.  Centrally to these\ncurvilinear signal, fat signal is preserved, which is suggestive of\nosteonecrosis. This appearance is not typical for osteomyelitis, and there is\nno localized signal abnormality in the subcutaneous tissue that connects to\nthe abnormal signal in the bones.  Small areas of high T2 signal in the left\niliac bone are nonspecific.\n\nSacroiliac joint erosion is identified which may be a sequela of\nhyperparathyroidism in the setting of renal failure.\n\nA 1.5 cm round well-circumscribed structure with low T1 and high T2 signal in\nthe right buttock subcutaneous tissue is new since ___.  Subcutaneous\nedema is noted in the right buttock.\n\nRight lower quadrant transplant kidney identified.  A 1.7 cm round lesion in\nthe anterior pole with increased T1 and T2 signal likely represents a\nproteinaceous or hemorrhagic cyst.  Two round lesions measuring 2.3 cm and 0.8\ncm respectively in the posterior pole of the kidney demonstrates low T1 and\nhigh T2 signal consistent with simple renal cysts.  Rectal tube is in place.\nThe hematomas involving right iliacus and gluteus minimus appear similar to CT\nfrom ___.  Large right retroperitoneal hematoma is partially imaged,\nalso similar to prior CT.  Peritoneal dialysis catheter present in the pelvis.\n\nSmall amount of free fluid in the pelvis.",
            "output": "1.  Signal abnormality in the posterior iliac bone and right sacral ala are\nmost compatible with bone infarcts / osteonecrosis.  The appearance is not\ntypical for osteomyelitis.\n2.  Diffusely increased T2 signal in the right gluteus muscles, adductor\nmuscles and left obturator externus may reflect edema / inflammatory changes.\n3.  A 1.5 cm cystic structure in the right buttock subcutaneous tissue is new\nsince ___ and a small superficial abscess is possible.\n4.  Large right retroperitoneal hematomas are partially imaged and appear\nsimilar to prior CT from ___.\n5.  Sacroiliac joint erosions may be sequela of hyperparathyroidism in the\nsetting of renal failure."
        },
        {
            "input": "The study is degraded by motion artifact limiting evaluation.\n\nThere is asymmetric atrophy of musculature in the proximal right thigh\nrelative to the left (06:51). Gluteal and hamstring tendons appear grossly\nnormal.  Heterogeneous soft tissue edema in the right gluteus maximus is\nimproved since ___.  More homogeneous muscle increased signal on\nfluid sensitive images in the proximal right quadriceps is increased (07:52). \nMuscle edema on the left adductors is nearly resolved.\n\nThere is a right gluteal soft tissue defect status post prior debridement. \n11.9 x 4 cm area of abnormal T1 dark signal extends from the base of the soft\ntissue defect to the right sacroiliac joint.  The posterior right iliac bone\nat this level shows faint associated bone marrow signal increase on fluid\nsensitive images and mild low T1 signal (06:14) centrally which is\nsignificantly improved since the study of ___.  As before there\nare bilateral anterior SI joint erosions (06:16).\n\nT1 bright, fat suppressed T2 dark focus deep to the right gluteal muscles\nabutting the right iliac wing (07:15) measuring 3.4 x 1.2 cm is unchanged and\nis fat density on CT compatible with a lipoma.  Previous intrapelvic fluid\ncollection along the right iliac wing and iliopsoas collection are resolved. \nThe retroperitoneal component of this in the abdomen is not completely\nincluded in the current study would is likely resolved or significantly\nimproved.\n\nThere is a transplanted kidney in the pelvis with a transverse lie containing\n2 adjacent T2 bright foci in the lateral pole compatible with simple cysts. \n1.9 cm T1 bright T2 dark focus in the left pole with dependent low signal is\nunchanged and likely reflects a proteinaceous or hemorrhagic cyst.",
            "output": "1. Right posterior gluteal soft tissue defect with T1 dark heterogeneous\nsignal extending to the posterior right iliac bone.  This abnormal tissue\ncould reflect granulation tissue, necrosis or inflammation, however its\nvascularity cannot be assessed on this noncontrast enhanced study.\n2. The posterior right iliac bone again shows mild bone marrow signal\nabnormality, however this is improved since the study ___. \nFindings could reflect resolving sequela of prior bone infarction.   While\nosteomyelitis cannot be completely excluded given the interval improvement and\nthe configuration of the signal abnormality this is thought less likely.\n3. Heterogeneous edema in the right gluteal musculature is improved since\n___ and may be inflammatory, particularly given its proximity to the\narea of previous tissue debridement.\n4. More homogeneous increased signal on fluid sensitive images in the right\nquadriceps has worsened and may related to denervation or myositis.\n5. Previous muscle edema in the left adductors is essentially resolved."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nNo large adnexal mass.  Status post hysterectomy. Vaginal cuff is\nunremarkable.\n\nLYMPH NODES: Subcentimeter inguinal lymph nodes are morphologically normal\nwith central fatty hila and do not meet criteria for enlargement.  Borderline\nenlarged bilateral external iliac lymph nodes measure 0.8 cm in short axis\n(1102:60, 62).\n\nBLADDER AND DISTAL URETERS: The bladder is mildly decompressed, otherwise\nunremarkable.  Distal ureters are unremarkable.  Trace presacral free fluid\nnoted.\n\nVASCULATURE: Patent vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Multiple sacral Tarlov cysts noted. \nOtherwise unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: There is irregular rectal wall thickening\nmeasuring up to 1.5 cm with shouldering at the superior aspect of the rectum\nwith adjacent fat stranding, heterogeneous enhancement, and minimal wall\nedema, highly worrisome for rectal carcinoma (05:24).  This lesion appears\npartially ulcerating.  The the lesion involves the posterior and lateral\nrectal wall bilaterally. The anterior aspect of the rectal wall is clear\nsuperiorly, however more inferiorly there is circumferential involvement of\nthe rectum.  Small pockets of rim enhancing ___ fluid are\ndemonstrated at the left posterior-lateral aspect (series 6, image 31), and\nright lateral aspect (series 6, image 33).  Of the right lateral aspect, this\nprocess is inseparable from the right levator muscle.\n\nThe borders of the rectum and surrounding fat are irregular particularly\nposteriorly where heterogeneous signal extends to the mesorectal fascia\n(series 4, image 22).\n\nAlong the right medial aspect and posteriorly at the level of the previously\ndescribed ulcerations there is extension to the mesorectal fascia, making it\ndifficult to exclude right levator muscle involvement on this nondedicated\nrectal mass study.  (1102:94)\n\nNo drainable collection. Colonic diverticula noted.\n\nOf note, evaluation is limited for staging of rectal neoplasm since the\nprotocol was not performed to address this based on clinical information. \nApproximately however:\nDistance from anal verge (AV) (mm): 8 mm\nExtends cranio-caudally (CC) (mm): 93 mm\nDistal edge lies:  Below the puborectalis sling.\nUpper border lies: Approximately 14 mm above peritoneal reflection\n\nSTAGING\nInvading tumor edge: Limited evaluation.\nMuscularis propria:  extends through\nExtramural spread (mm):  Yes, most notable along the right posteromedial\naspect of the mid rectum measuring 0.8 cm (1101:88).\nExtramural venous invasion (EMVI):  No gross invasion.\nPeritoneal reflection: Limited evaluation\nAdjacent pelvic organs: Limited evaluation, however no gross invasion of\nadjacent organs.  Possible involvement of the levator ani on the right.\n\nFOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN\nIntersphincteric plane:  Not well assessed.\nExternal anal sphincter:  Limited evaluation.\nIschiorectal fossa: Limited evaluation\n\nCRM (Circumferential resection margin) -\nPushing border of an involved node: There is a 0.7 cm (short axis) right\nmesorectal fascial lymph node at 8 o'clock which appears to be in contact with\nthe right posterolateral aspect of the mesorectal fascia with apparent\nthickening of the mesorectal fascia (1102:69).  Second additional\nsubcentimeter lymph node is seen within the mesorectal fat at 6 o'clock\n(1102:67).\n\nMinimum tumor distance to MRF:  less than or equal to 1mm, as above.  Further\ncharacterization of mesorectal lymph nodes is limited due to nondedicated\nrectal mass study.\n\nPelvic side wall nodes:  yes\nIf Yes to Pelvic side wall nodes (location): Bilateral external iliac, 0.8 cm\nin short axis bilaterally are borderline enlarged (6:20, 21).\n\nStaging Assessment: Not optimally performed by this exam.",
            "output": "1.  Findings worrisome for rectal carcinoma spanning 9.3 cm with possible\ninflammatory component given the irregular rectal wall thickening with\nshouldering/ulceration and possible right levator ani involvement,\ncorresponding to the abnormality noted on noncontrast CT from ___.\n2.  Study was not tailored to assess for rectal mass, however given this\nlimitation findings are worrisome for T3 if not T4 disease due to potential\nright levator ani involvement.\n\nRECOMMENDATION(S):  Recommend proctoscopy with biopsy, and dedicated rectal\nmass MR if clinically indicated.\n\nNOTIFICATION:   The impression and recommendation above was entered by Dr.\n___ on ___ at 16:58 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "Tumor:  Partly mucinous with diffusion restriction and multiple mucinous\nlakes.  A satellite mucinous lesion extends to the mesorectal fascia (___) on\nthe right side at 9 o'clock.  This extends to the fascia immediately overlying\nthe right levator muscle, with less than 1 mm distance between the right\nlevator and this component of the lesion (series 7, image 27).\nDistance from anal verge (AV) (mm): 11\nExtends cranio-caudally (CC) (mm):  82\nDistal edge lies:  20 mm below puborectalis sling\nUpper border lies: 9 mm above peritoneal reflection\n\nSTAGING\nInvading tumor edge: Nearly circumferential with anterior sparing from\napproximately 11 o'clock to 1 o'clock\nMuscularis propria:  extends through without normal appearance of the\nmuscularis (___)\nExtramural spread (mm):  5\nExtramural venous invasion (EMVI):  no\nPeritoneal reflection: not involved\nAdjacent pelvic organs ___, prostate, vagina): involved, left puborectalis\n(___).\n\nFOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN\nIntersphincteric plane:  invaded\nExternal anal sphincter:  Invasion of both the external and internal anal\nsphincter in their posterior aspects (___).\nIschiorectal fossa:  not invaded\n\nCRM (Circumferential resection margin):\nPushing border of an involved node: 0 mm at: 8 o'clock\n\nEncapsulated node abutting the fascia: Yes.\n\nMinimum tumor distance to MRF:  less than or equal to 1mm, on the right\n(series 6, image 5).\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: at tumor\nMesorectal lymph nodes - heterogeneous signal: yes\nMesorectal lymph nodes - capsular irregularity: yes\nMesorectal lymph nodes:  N2 (>4)\n\nPelvic side wall nodes:  yes, bilateral external iliac lymph nodes, borderline\nenlarged, measuring up to 0.8 cm in short axis (___)\nIf Yes to Pelvic side wall nodes (location): Bilateral\nIf Yes to Pelvic side wall nodes (type): Borderline enlarged, metastasis is\nnot excluded.\n\nStaging Assessment: T4\nExtramural spread (mm):  5\nCRM:   involved\nEMVI:  negative\nLocation: Extensive, extending from the upper to the lower rectum\nNodal:  N2\nMetastasis: Mx\n\nUTERUS AND ADNEXA: The uterus is surgically absent.  The ovaries are atrophic\nor surgically absent. No pelvic free fluid.\n\nVAGINA: There is a 1.0 cm focus of asymmetric enhancement in the left vaginal\ncuff (___) without restricted diffusion and possibly postsurgical in nature.\n\nBLADDER AND DISTAL URETERS: Mild thickening of the bladder is likely related\nto underdistention.\n\n INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Visualized iliac vessels are unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions.  Normal\nbone marrow signal.  As seen on prior CT, the right sciatic nerve is\nasymmetrically bulky without associated mass, of indeterminate clinical\nsignificance.",
            "output": "1. There is a large nearly circumferential partially mucinous rectal tumor\nextending to the anal canal.  Left external sphincter and pubic rec talus\nprobable involvement compatible with T4 disease.  Direct tumor contact with\nmesorectal fascia overlying the right levator muscle also noted, with less\nthan 1 mm between this tumor extension and the right levator muscle.\n2. Multiple heterogeneous abnormal mesorectal lymph nodes, N2 disease.\n3. Bilateral external iliac lymph nodes are borderline enlarged in short axis,\nmeasuring up to 0.8 cm.  Pelvic sidewall metastasis is not excluded."
        },
        {
            "input": "MR PELVIS: The bladder is unremarkable.  The urethra is normal and smooth\nwithout evidence of a urethral diverticulum or enhancing mass.  The uterus and\novaries are normal. The right ovary has a 3.1 cm dominant physiologic\nfollicle. The left ovary is normal with a dominant 1.8 cm follicle.  The\nfinding on the prior pelvic ultrasound was likely two adjacent follicles.\nVisualized portions of the rectum are normal.  Small free fluid is in the\nphysiologic range. No pelvic or inguinal lymphadenopathy.\n\nNo bone marrow signal abnormality is identified.",
            "output": "1.  Normal pelvic MRI. Specifically, normal appearance of the urethra.\n\n2.  Normal ovaries with physiologic cysts."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and tilted to the left measuring 4.8 x 4.3 x 3.7 cm.\nThere are multiple T2 hypointense masses consistent with fibroids.\nThe endometrium is difficult to visualize.\nBoth ovaries are not clearly visualized.  There are no adnexal masses.\n\nThere has been interval resolution of the free-fluid within the pelvis.\n\nLYMPH NODES: There is no adenopathy.\n\nBLADDER AND DISTAL URETERS: Urinary bladder is under distended, otherwise\nunremarkable.  Urethra is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized small bowel loops and rectum are\nunremarkable.\n\nVASCULATURE: Vascular structures are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Osseous structures are intact.  There are\nno groin hernias.",
            "output": "1. Interval resolution of free fluid within the pelvis.\n2. Fibroid uterus, retroverted and tilted to the left."
        },
        {
            "input": "ANUS, RECTUM AND INTRAPELVIC BOWEL: Compared with ___, a right-sided\nanal mass appears increased in size, currently spanning approximately 5.8 x\n2.4 cm, previously 4.2 x 1.5 cm.  The bulky is portion of the mass has central\nhypoenhancement with restricted diffusion (14:335; 10:140-143).  There is\ninvolvement of the right external sphincter complex with extension completely\nthrough the external sphincter and likely just beyond it into the right\nischial anal fossa fat (10:140-143, 14:333-338, 17:49-54).  There is signal\nabnormality along the superior aspect of the tumor involving the right\npuborectalis with soft tissue thickening which is favored to represent post\nradiation fibrosis and edema rather than tumor extension.  The inferior aspect\nof the mass extends to the medial right gluteal cleft (14:333-336, ___. \nThe tumor does not extend to the level of the coccyx, with preserved fat\nbetween the posterior and superior aspect of the mass and the distal tip of\nthe coccyx.  The distance to the right ischial tuberosity from the mass is\napproximately 2.7 cm (14:321).  There is no invasion of the prostate or other\nintrapelvic organs.\n\nThere are colonic diverticula without evidence of acute diverticulitis.\n\nLYMPH NODES: A 13 mm right inguinal lymph node correlates with the FDG avid\nnode seen on recent PET scan.  There is a small cystic foci non-enhancing\nfocus within this lymph node consistent with necrosis.  There are additional\nbilateral inguinal lymph nodes which are not pathologically enlarged and did\nnot have radiotracer uptake on recent PET-CT.  No pelvic sidewall\nlymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder is normal in appearance.\n\nPROSTATE AND SEMINAL VESICLES: The prostate measures 3.9 x 5.8 x 4.7 cm with a\ncalculated volume of 56 cc.  The central gland has a appearance suggestive of\nbenign prostatic hypertrophy.  Seminal vesicles are unremarkable.\n\nVASCULATURE: Pelvic vasculature is patent and without concerning finding.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is disc space narrowing at L4-L5. \nNo concerning osseous lesions.",
            "output": "1. Interval increase in size of a 5.8 cm anal mass predominantly on the right\nwith full-thickness involvement of the right external sphincter complex and\nlikely a small area of extension into the right ischial anal fat.  Signal\nabnormality along the superior aspect of mass involving the right puborectalis\nmuscle is favored to represent post radiation fibrosis and edema rather than\ntumor.\n2. 13 mm right inguinal lymph node with a small focus of internal necrosis\ncorrelates with the FDG avid lymph node seen on recent PET scan.\n3. No pelvic sidewall lymphadenopathy or involvement of the intrapelvic\norgans."
        },
        {
            "input": "Bony metastases involving the sacrum and the bilateral iliac bones is\ndemonstrated, denoted by T1 hypointense and enhancing masses (2:29).  There is\ntumor infiltration anteriorly in the presacral space at the level of S1 -S2\n(101:44). There is a metastatic mass involving the left acetabular roof\n(02:13).\nT2 dark serpiginous lines in the femoral heads are consistent with bilateral\navascular necrosis, without cortical collapse (02:10, 03:10).\n\nThe sacral plexus is involved at the levels S1 and S2 on the left and S2 on\nthe right. The intraforaminal portion of the left S1 nerve root is thickened\nand edematous (02:24, 05:26) and there is hyper enhancing tissue along the\nnerve root (101:44).\nThe intraforaminal portion of the left S2 nerve root is not thickened, but is\nsurrounded by edema and hyper enhancement (02:27, 05:30, 101:51).\nThe intraforaminal portion of the right S1 nerve root is edematous and\nsurrounded by hyper enhancement (5:24, 101:41).\n\nThe prostate gland is enlarged. There is mild diffuse wall thickening of the\nurinary bladder.\nThere is no significant free fluid in the pelvis. The partially distended\nbladder is grossly unremarkable. The visualized bowel loops are within normal\nlimits. There is no significant pelvic or inguinal lymphadenopathy.",
            "output": "1. Malignant involvement of left S1 and S2 and right S1 nerve roots.\n2. Extensive bony metastatic disease involving the sacrum and the iliac bones,\nincluding the left acetabular roof and posterior wall.\n3. Bilateral femoral head AVNs, without cortical collapse."
        },
        {
            "input": "Arising at 6:00 to 6:30 o'clock in the low anus within 1 cm of the anal verge,\nthere is a mucosal opening which extends into a short 2-3 cm focus of linear\nenhancement.  This enhancement extends intersphincterically, then dives below\nthe sphincter and through the subcutaneous fat to the skin surface of the\nright gluteal cleft.  Given this appearance, it most likely represents an\nearly or healing sinus tract or fistula.  There is no significant fluid within\nthe tract.  Less likely, this could be an inflamed hemorrhoid, though if\npresent that should be apparent on physical exam.\n\nThe remainder of the anal sphincter complex is normal.  There is no evidence\nof a fistula or abscess.\n\nThe rectum and intrapelvic bowel loops are normal without focal inflammatory\nchanges.  The bladder is normal without evidence of a mass or focal\nthickening.  The prostate gland is normal in size.  This exam is not tailored\nto evaluate for tumor.  Within the limitations of the examination, the signal\nwithin the prostate gland is normal.  The seminal vesicles are within normal\nlimits.\n\nThe pelvic arterial vasculature is normal.  The pelvic veins are patent. \nThere is no pelvic or inguinal lymphadenopathy.  No free fluid is identified\nin the pelvis.\n\nThere are no concerning osseous lesions.  Heterogeneity of the bone marrow\nlikely is due to red marrow.  The soft tissues are unremarkable.",
            "output": "1.  Short linear focus of enhancement extending from the low anus to the right\ngluteal cleft, as described above.  This most likely represents an early or\nhealing intersphincteric sinus or fistulous tract.  There is no significant\nfluid within this possible tract.\n\nGiven the location, this could alternatively represent an inflamed hemorrhoid,\nthough this is less likely.  If that is the case, it would be expected to be\nappreciable on physical exam.\n\n2.  No perianal abscess.\n\nNOTIFICATION:  Results were emailed to the ED QA nurses on ___ 9:30 AM\nby Dr. ___.."
        },
        {
            "input": "Extremely limited evaluation of the pelvis.  Only 1 series was obtained.\nEvaluation of potential colovesical or colouterine fistulas is indeterminate. \nThe bladder appears intact.  There is fluid within vagina.  Suggestion of\nfluid within uterus.  Dilatation of the distal right ureter is similar\ncompared with CT ___.  Moderate volume stool in the colon has\ndecreased since prior.  No osseous abnormalities.\nSuggestion of small volume ascites.",
            "output": "Suboptimal exam, only 1 series was obtained, see above.\n\nRECOMMENDATION(S):  Repeat MRI of the pelvis."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe uterus is anteverted and measures 7.3 x 4.4 x 5.0 cm.\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is thickened at 14 mm (06:21).\n\nThe right ovary is normal in size with a dominant follicle as well as an\nisolated T1 hyperintense focus (12:79) measuring 11 mm.\n\nWithin the left adnexa, there is a cystic T2 hyperintense mass with\nseptations, but no internal enhancement or debris, measuring approximately 6.4\nx 5.8 cm (06:15), larger than on the prior study from ___ where it\nmeasured 5.4 x 5.1 cm.  This compatible with a hydrosalpinx.\n\nAdjacent to the hydrosalpinx, there was previously a heterogeneous enhancing\nmass which measured 6.2 x 6.3 cm.  In the same location, there is now a\npredominantly cystic mass with a small intrinsically T1 hyperintense component\n(12:63) which measures 3.8 x 3.6 cm.\nA trace amount of free fluid is noted within the dependent portion the pelvis,\non the right.\n\nRECTUM AND INTRAPELVIC BOWEL:  There is a large ventral abdominal wall hernia\ncontaining loops of small and large bowel.  There is extensive diverticulosis\nof the sigmoid colon, with a focal outpouching measuring 4.9 x 1.9 cm,\ninferiorly from the sigmoid colon (08:16), closely abutting the roof of the\nbladder, with associated bladder wall thickening (08:17).  This either\nrepresents a large diverticulum or a sinus tract, however was present in a\nsimilar configuration in ___.  Around this area of diverticulosis,\nthere is enhancing soft tissue in the pelvic mesentery, with associated\nstranding, likely reflective of chronic postinflammatory changes.\n\nBLADDER AND DISTAL URETERS: The bladder is relatively underdistended. There is\nthickening at the dome of bladder, with traction anteriorly towards loops of\nsigmoid colon, possibly reflecting postinflammatory changes from diverticular\ndisease. No focus of susceptibility within the bladder to suggest a patent\ncolovesical fistula.\n\nLYMPH NODES: There is a stable 13 x 8 mm mesenteric lymph node (13:52). \nInguinal lymph nodes are prominent but not pathologically enlarged.\n\nVASCULATURE: The iliac vasculature is normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Bone marrow signal intensity is normal. \nThere is a T1 hyperintense focus in the left iliac wing (11:19) likely an\nintraosseous hemangioma.  Best appreciated on T2 weighted imaging, there is a\nsubcutaneous cystic mass along the left gluteal cleft measuring 17 x 8 mm\n(06:40), possibly a sebaceous cyst.",
            "output": "1. At site of a previously enhancing, complex adnexal lesion, there is a\nsmaller - 3.8 x 3.6 cm (previously 6.2 x 6.3 cm) -  predominantly cystic\nlesion with a small hemorrhagic component.  This lilkely represents an\nendometrioma. Additional small right ovarian hemorrhagic focus is consistent\nwith endometriosis.\n2. Interval enlargement of the left hydrosalpinx.\n3. Extensive diverticulosis of the sigmoid colon with a stable focal\noutpouching, either a diverticulum or a sinus tract, abutting the dome of the\nbladder, with associated bladder wall thickening, possibly sequela of prior\ndiverticular disease. No current evidence of a colovesical fistula.\n4. Enhancing soft tissue surrounding the protruding loops of bowel in the\nanterior abdominal wall may be sequela of prior peritonitis."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:  The heterogeneously enhancing anorectal mass,\nwhich is mildly hyperintense on the T2 weighted images and demonstrates\nrestricted diffusion, representing known neuroendocrine carcinoma, is re-\ndemonstrated.  The mass measures approximately 5 cm in the CC direction which\nis unchanged compared to the prior exam.  However, compared to the prior MR\nthere is interval enlargement of areas of extramural extension.  The component\nof the mass on the left posterolaterally at the anal verge, centered at 5\no'clock measuring 18 x 20 mm which extends posteriorly through the muscularis\npropria to the left, is increased in size, having previously measured 1.3 x\n1.2 cm compared to the prior MRI though similar to the recent CT.  The\nintersphincteric plane is invaded which is unchanged compared to the prior\nexams.\nAt least 4 additional areas of extension through the muscularis propria/EMVI\nare seen, including left lateral, ___ o'clock (9 a: 46), left anterolateral,\n___ o'clock (9 a: 52), left posterior lateral, 4 o'clock (9a: 57), left\nlateral, 3 o'clock (98:64), and left superolateral, 1 o'clock (9a:65).  The\nmajority of these areas are either progressed or new since the prior MRI and\ndifficult to compare accurately with CT, grossly stable to possibly slightly\nprogressed.\n\n\nThe peritoneal reflection and adjacent pelvic organs are not involved. \nHowever, due to progression of extramural vascular invasion of tumor, there is\nlinear extension of metastatic disease along the presacral fascia and within\nthe mesorectal fat, extending superiorly for a distance of approximately 6.5\ncm (03:19), with tumor showing spiculated margins and tethering of the\npresacral fascia (4:8 as representative image).  There is also mild presacral\nedema.  There is no evidence of an perirectal abscess.\n\nLYMPH NODES:\n\nThere are multiple suspicious, heterogeneously enhancing pelvic lymph nodes. \nFor instance, there is an adjacent right mesorectal lymph node which measures\n6 mm (previously 3 mm, 9a:80).  An irregular hypoenhancing left obturator\nlymph node measuring 11 mm (9:84) is unchanged compared to the recent CT scan\nbut slightly larger compared to the prior MRI.  This lymph node comes in close\nproximity to the sciatic nerve and shows spiculated margins.   A superior\nrectal lymph node measures 8 x 17 mm which is larger compared to the prior MRI\nbut similar to the recent CT (9 x 14 mm on the previous MRI, 3:19).\n\nBLADDER AND DISTAL URETERS: There is a small bladder diverticulum on the\nright.\n\nProstate:  In the peripheral zone, there are scattered linear areas of\nhypointense signal on the T2 weighted images with mild heterogeneous\nenhancement.  This finding can be seen in the setting of prostatitis.\n\nVASCULATURE:  The pelvic vessels are of normal caliber throughout with any\nsignificant areas of narrowing or dilation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is new trace non-specific free\nfluid in the pre-sacral space.  This finding could reflect lymphatic\nobstruction.  No rim-enhancing collections.   The bone marrow demonstrates\nnormal signal characteristics.  No concerning osseous lesions.",
            "output": "1.  Heterogeneously enhancing anorectal mass representing known neuroendocrine\ncarcinoma shows increased size and increased perirectal tumor involvement\ncompared to the prior MRI, though without significant change compared to the\nrecent CT.\n2.   Multiple metastatic pelvic lymph nodes are grossly stable compared to the\nrecent CT scan.  A left obturator lymph node or tumor deposit/EMVI is in close\nproximity to the sciatic nerve with some spiculation and tethering of adjacent\nstructures.\n3.  No perirectal abscess or other acute abnormality identified to suggest the\ncause of rectal pain."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 3.7 x 8.5 x 6.4 cm.  Nabothian cysts\nnoted.\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is at the upper limits of normal, measuring 10 mm.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No enlarged or morphologically abnormal lymph nodes.\n\nBLADDER AND DISTAL URETERS: No evidence for hydronephrosis or bladder mass.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized bowel is within normal limits.  No\nevidence for fistula.\n\nVASCULATURE: Major flow voids are maintained in the pelvic vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous lesions.  There is\na small focus of T2 hyperintensity along the gluteal cleft, seen on image 13\nof series 5, with mild surrounding edema, potentially corresponding to the\nreported draining pilonidal cyst.  This measures 3 mm AP x 6 mm transverse. \nNo drainable perianal abscess or fistula.  An additional, small, likely\nsebaceous cyst is seen more inferiorly in the cleft (series 5, image 24).",
            "output": "Tiny focus of fluid along the upper gluteal cleft with adjacent edema, likely\ncorresponding to the reported draining pilonidal cyst.  No drainable\ncollections.  No fistula or sinus tract."
        },
        {
            "input": "Tumor: There is a semi annular mass involving the posterior wall of the\nprimarily mid rectum.\nDistance from anal verge (AV) (mm): 48\nExtends cranio-caudally (CC) (mm):  48\nDistal edge lies:  at puborectalis sling\nUpper border lies: 9 mm below peritoneal reflection\n\nSTAGING\nInvading tumor edge: From 8 o'clock to 4 o'clock\nMuscularis propria: There is irregular enhancement of the inferoposterior\naspect of the muscularis propria layer, consistent with tumor involvement\n(series 13, image 33).  Tumor does however remains confined to and does not\nextend beyond the muscularis propria.\nExtramural spread (mm):  None\nExtramural venous invasion (EMVI):  no\nPeritoneal reflection: not involved\nAdjacent pelvic organs ___, prostate, vagina): not involved\n\nFOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN\nIntersphincteric plane:  Free\nExternal anal sphincter:  not invaded\nIschiorectal fossa:  not invaded\nThe internal anal sphincter is located approximately 5-10 mm below the distal\nedge of the tumor.\n\nCRM (Circumferential resection margin) - pick one\nPushing border of an involved node: 4 mm at: 6 o'clock (series 13, image 8).\n\nMinimum tumor distance to MRF:  greater than 1 mm\n\nThere are three scattered mesorectal lymph nodes which measure between 4 and 5\nmm and appearing encapsulated and without suspicious features (series 4, image\n19, 20, 19).  There is a 7 mm superior mesorectal lymph nodes which maintains\na normal morphologic shape (series 4, image 11).\n\nThere is a somewhat suspicious 4 mm left mesorectal lymph node at the level of\nthe lesion which demonstrates more hypointense T2 weighted signal than\nadjacent lymph nodes, but remains encapsulated.  Superior to the tumor there\nis a suspicious lymph node measuring 6 mm with irregular borders (series 12,\nimage 9).\n\nMesorectal lymph nodes - Size (mm):\nMesorectal lymph nodes - location: At and above tumor\nMesorectal lymph nodes - heterogeneous signal: no\nMesorectal lymph nodes - capsular irregularity: yes\nMesorectal lymph nodes:  N1 (< 4)\n\nPelvic side wall nodes:  no\n\nStaging Assessment: T2\nExtramural spread (mm):  None.\nCRM:   clear\nEMVI:  negative\nLocation: mid rectal tumor\nNodal:  N1\nMetastasis: M0\n\nViews of the intrapelvic bowel loops are otherwise unremarkable.  There is no\npelvic free fluid.  Prostate demonstrates low signal in the peripheral zone\ndiffusely, likely secondary to prostatitis.  There is no suspicious bony\nlesion.",
            "output": "Semiannular mass spanning 4.8 cm involving the posterior primarily mid rectum\nconfined to the muscularis propria, consistent with MR stage T2 disease.  At\nleast one suspicious lymph node in the superior mesorectal fascia posteriorly,\nhighly concerning for N1 disease."
        },
        {
            "input": "Bone: There is diffuse marrow signal abnormality throughout the visualized\nosseous structures of the pelvis and lumbar spine with diffuse stippled and\nserpiginous T1 marrow signal abnormality which is Iso to hypointense on T1 and\nSTIR hyperintense with mild enhancement.  No definite fractures are\nidentified.  There are mild degenerative changes of the bilateral hips. \nDegenerative changes of the visualized lower lumbar spine.\n\nThe stippled and serpiginous marrow signal abnormalities as described above\nare seen throughout the bilateral femurs.  In addition, there is an area of\nmore confluent T1 isointense and STIR hyperintense signal filling the majority\nof the medullary cavity of the mid to distal femoral diaphysis, measuring\napproximately 7.6 cm in cranial to caudal with less discrete superior and\ninferior margins.  This area demonstrates intramedullary enhancement as well\nas enhancing circumferential periosteal edema and surrounding moderate\nenhancing muscle edema of the vastus intermedius muscle and slightly of the\ndistal posterior lateral aspect of the vastus medialis muscle.  No definite\nendosteal scalloping is seen.\n\nSoft tissues:\n\nThere is mild asymmetric fatty atrophy of the proximal left psoas muscle\n(image 3:2).  There is slightly asymmetric mild fatty atrophy of the right\ntensor fascia ___.  There is mild-to-moderate fatty atrophy of the long head\nof the right biceps femoris and mild fatty atrophy of the proximal portion of\nthe right semitendinosis muscle.\n\nWithin the pelvis there is a 2.2 x 1.9 cm T2 hyperintense, T1 hypointense,\nnonenhancing ovoid lesion superior to the uterus and anterior to the sacrum\nmost consistent with an adnexal cyst (image 7: 16).  A more tubular T2\nhyperintense, T1 isointense focus along the right pelvic sidewall adjacent to\nthe iliopsoas muscle without definite solid enhancement may represent slightly\nengorged gonadal veins with or without and adnexal cystic appearing lesion\n(image 4: ___.  The more cystic appearing portion on the right measures 2.0\nx 1.3 cm (image 4:16).\n\nSmall cyst along the anterior inferior aspect of the left acetabulum measuring\n8 mm and may represent a small ganglion (image 04:30).",
            "output": "Aggressive appearing marrow replacing process of the mid to distal right\nfemoral diaphysis with surrounding periosteal reaction and muscle edema and\nenhancement is concerning for an aggressive neoplastic process or infection. \nNeoplastic considerations include an aggressive hematologic process given\npatient's known myelodysplastic disorder, however the process of the right\nfemoral diaphysis appears different than the background appearance of the\npatient's underlying disease.  Metastatic disease or primary osseous neoplasm\nwould be considered less likely.\n\nDiffuse stippled and serpiginous marrow signal abnormality of the visualized\npelvis, lumbar spine, and bilateral legs is most likely due to patient's\nunderlying myelodysplastic syndrome.\n\nLikely bilateral adnexal cysts are incompletely characterized.  Ultrasound\nwould be required for complete evaluation if clinically warranted.\n\nRECOMMENDATIONS:\nTissue sampling of the right femur could be considered for diagnosis purposes\nif clinically warranted.  This should be followed with subsequent MR imaging.\n\nNOTIFICATION:   The findings were discussed with ___ M.D. by ___\n___, M.D. on the telephone on ___ at 5:09 pm, 20 minutes after\ndiscovery of the findings."
        },
        {
            "input": "Bone: There is diffuse marrow signal abnormality throughout the visualized\nosseous structures of the pelvis and lumbar spine with diffuse stippled and\nserpiginous T1 marrow signal abnormality which is Iso to hypointense on T1 and\nSTIR hyperintense with mild enhancement.  No definite fractures are\nidentified.  There are mild degenerative changes of the bilateral hips. \nDegenerative changes of the visualized lower lumbar spine.\n\nThe stippled and serpiginous marrow signal abnormalities as described above\nare seen throughout the bilateral femurs.  In addition, there is an area of\nmore confluent T1 isointense and STIR hyperintense signal filling the majority\nof the medullary cavity of the mid to distal femoral diaphysis, measuring\napproximately 7.6 cm in cranial to caudal with less discrete superior and\ninferior margins.  This area demonstrates intramedullary enhancement as well\nas enhancing circumferential periosteal edema and surrounding moderate\nenhancing muscle edema of the vastus intermedius muscle and slightly of the\ndistal posterior lateral aspect of the vastus medialis muscle.  No definite\nendosteal scalloping is seen.\n\nSoft tissues:\n\nThere is mild asymmetric fatty atrophy of the proximal left psoas muscle\n(image 3:2).  There is slightly asymmetric mild fatty atrophy of the right\ntensor fascia ___.  There is mild-to-moderate fatty atrophy of the long head\nof the right biceps femoris and mild fatty atrophy of the proximal portion of\nthe right semitendinosis muscle.\n\nWithin the pelvis there is a 2.2 x 1.9 cm T2 hyperintense, T1 hypointense,\nnonenhancing ovoid lesion superior to the uterus and anterior to the sacrum\nmost consistent with an adnexal cyst (image 7: 16).  A more tubular T2\nhyperintense, T1 isointense focus along the right pelvic sidewall adjacent to\nthe iliopsoas muscle without definite solid enhancement may represent slightly\nengorged gonadal veins with or without and adnexal cystic appearing lesion\n(image 4: ___.  The more cystic appearing portion on the right measures 2.0\nx 1.3 cm (image 4:16).\n\nSmall cyst along the anterior inferior aspect of the left acetabulum measuring\n8 mm and may represent a small ganglion (image 04:30).",
            "output": "Aggressive appearing marrow replacing process of the mid to distal right\nfemoral diaphysis with surrounding periosteal reaction and muscle edema and\nenhancement is concerning for an aggressive neoplastic process or infection. \nNeoplastic considerations include an aggressive hematologic process given\npatient's known myelodysplastic disorder, however the process of the right\nfemoral diaphysis appears different than the background appearance of the\npatient's underlying disease.  Metastatic disease or primary osseous neoplasm\nwould be considered less likely.\n\nDiffuse stippled and serpiginous marrow signal abnormality of the visualized\npelvis, lumbar spine, and bilateral legs is most likely due to patient's\nunderlying myelodysplastic syndrome.\n\nLikely bilateral adnexal cysts are incompletely characterized.  Ultrasound\nwould be required for complete evaluation if clinically warranted.\n\nRECOMMENDATIONS:\nTissue sampling of the right femur could be considered for diagnosis purposes\nif clinically warranted.  This should be followed with subsequent MR imaging.\n\nNOTIFICATION:   The findings were discussed with ___ M.D. by ___\n___, M.D. on the telephone on ___ at 5:09 pm, 20 minutes after\ndiscovery of the findings."
        },
        {
            "input": "Please note the study is mildly degraded by motion.\n\nThere is diffuse T1 hypointensity in the bone marrow with relative sparing of\nthe greater trochanters, with intramedullary contrast-enhancement, much more\nextensive than the low T1 signal seen on the MRI from ___.  A few\nscattered areas of bone marrow which drop in signal on out of phase images are\ncompatible with red marrow conversion, but most of the abnormal T1 hypointense\nbone marrow does not drop in signal, concerning for leukemic infiltration.\n\nSurrounding the imaged portion of the left femur, extending to the imaged\nextent of the distal third of the femur, there is a thin rim of soft tissue\nedema and enhancement, immediately about the periphery of the cortex, which\nwas not seen on ___.  No fluid collection or soft tissue\nenhancement further from the bone.  This abnormality extends beyond the\ninferior edge of these images in appears slightly more pronounced than on the\nprior study..\n\nMild asymmetric fatty atrophy of the proximal left psoas muscle is again seen.\nMild bilateral acetabular spurring is again seen.  9 mm cyst along the\nanterior left acetabulum (05:29) is unchanged since prior when measured\nsimilarly.\n\nApproximately 1.9 cm left adnexal cystic lesion (06:21) is unchanged since ___ when measured similarly.  Tubular T2 hyperintense structure\nalong the right pelvic sidewall with an associated cystic structure measuring\n1.4 cm is also stable since prior.  Limited assessment of intra-pelvic soft\ntissue structures is otherwise grossly unremarkable. No gross intrapelvic\nfluid or enlarged intrapelvic lymph nodes detected.",
            "output": "1. Interval progression of diffuse marrow infiltration (low T1 marrow signal\nand marrow enhancement) in the imaged pelvis and proximal femurs is concerning\nfor worsening involvement of AML.  Marked progression of red marrow\nreconversion is considered less likely given findings on the out-of-phase\nimages.\n2. Thin rim of soft tissue edema and enhancement surrounding the imaged left\nfemur (extending beyond the inferior edge of these images) is slightly more\npronounced than in ___.  This is non-specific, of uncertain etiology\nor significance..  The differential includes changes secondary to neoplastic\ninvolvement.  Inflammatory and infectious areas might also account for this\nappearance but are considered less likely.  Early bone infarct could also have\na similar appearance.  (Soft tissue changes in the left thigh are seen only\nimmediately abutting the femur, without findings to suggest more extensive\nsoft tissue involvement.)\n3. Right femoral marrow edema and surrounding muscle edema have improved\ncompared to ___.\n4. Please note that the vasculature is not effectively evaluated on this non\nangiographic study."
        },
        {
            "input": "There is patchy hyperintense STIR signal involving the majority of the muscles\nabout the pelvis.  There is enlargement of the right obturator internus\nmuscle, which contains a discrete nonenhancing area with peripheral rim\nenhancement measuring 6.3 x 1.3 x 0.9 cm and 2.6 x 1.0 x 3.9 cm.  In addition,\nthere is edema in the right gluteus maximus muscle with a nonenhancing area\nwith peripheral rim enhancement measuring 4.7 x 2.0 x 3.4 cm (9, 28).  There\nis fluid in the left greater trochanteric bursa with peripheral rim\nenhancement measuring 3.5 x 1.9 x 4.3 cm.\n\nThere is a large ulcer within the subcutaneous tissues extending to the\ninferior sacrum and coccyx measuring approximately 5.3 x 5.0 cm.  The\nunderlying bone marrow signal in the sacrum is normal without evidence of\nedema or enhancement.  Evaluation of the coccyx is limited due to the lack of\nsagittal images and osteomyelitis cannot ruled out in the coccyx.  There is no\nfracture or stress fracture.  There is no suspicious osseous lesion.\n\nThere is mild levoscoliosis of the visualized lower lumbar spine and moderate\ndegenerative changes. There are minimal degenerative changes in the hips\nbilaterally. The proximal hamstring tendon origins are intact.\n\nThe prostate is enlarged measuring 5.6 x 4.5 x 5.6 cm.  A Foley catheter is in\nthe bladder.  The rectum is distended with stool.  Otherwise the visualized\nintrapelvic structures are within normal limits.",
            "output": "Large ulcer within the subcutaneous tissues extending to the sacrum and\ncoccyx.  No evidence of osteomyelitis in the sacrum.  Evaluation of the coccyx\nis limited due to the lack of sagittal images and osteomyelitis cannot ruled\nout in the coccyx.\n\nAreas of nonenhancing muscle with peripheral rim enhancement in the right\nobturator internus and right gluteus maximus laterally may represent diabetic\nmyonecrosis or pyomyositis.  Patchy areas of edema in the majority of the\nremaining musculature of the pelvis.\n\nSmall amount of fluid with peripheral rim enhancement of the left trochanteric\nbursa.\n\nEnlarged prostate.\n\nNOTIFICATION:   The findings were discussed by Dr. ___ with Dr.\n___ on the ___ ___ at 10:57 AM, 5 minutes after\ndiscovery of the findings."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: The rectum and portion of the bowel visualized\nare unremarkable\n\nBLADDER AND DISTAL URETERS: In the interval, there is a right ureteral stent\nthat was placed on the right side.  We visualized again a soft tissue lesion\nsurrounding the distal lead right ureter that is stable incise measuring 16 x\n22 mm.  This lesion is hypointense T2 and slightly enhancing.  We also note\nsome inflammatory changes surrounding the more proximal right ureter.  The\nright kidney is not visualized.\n\nThere is also a presacral mass at the level of S1-S2 measuring 3.6 x 1.7 cm\nwhich is ill-defined hypointense T2 and demonstrating avid enhancement post\ngadolinium.  This lesion does not seem to originate from the bone.  On the\ncoronal view we could appreciate an asymmetrical thickening of the fascia that\ncommunicates this lesion to the soft tissue mass next to the right ureter.\nThere is also 7 mm enhancing lesion situated 1 cm more medial to the left\nureterovesical junction.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate measures 4.9 x 4.2 by a\n5.6 cm.  The left the physical seminal demonstrate T1 hyperintense signal\ncompatible with some proteinaceous or hemorrhagic content.\n\nLYMPH NODES: There is highly suspicious right common iliac adenopathy\nmeasuring 14 x 7 mm and also small lymph nodes next to the right external\niliac which is still subcentimeter.  No ascites.\n\nVASCULATURE: Unremarkable\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No new bone lesion.",
            "output": "1.  Soft tissue mass surrounding the right ureter highly concerning for a\nprimary ureter neoplasm.\n2. There is also a new or enlarged presacral soft tissue mass highly\nconcerning for metastatic disease as well as small lesion next to the left\nureterovesical junction as described.\n3. Right common iliac adenopathy concerning for metastatic disease. \nSubcentimeter right external iliac lymph nodes, nonspecific."
        },
        {
            "input": "There are innumerable diffuse punctate foci of increased marrow STIR signal,\ndecreased T1 signal and enhancement throughout the pelvis, proximal femurs and\nvisualized portions of the lower lumbar spine.\n\nThere is no fracture. There is avascular necrosis at the femoral heads\nbilaterally involving greater than 50% of the articular surfaces without\nsignificant associated articular surface collapse.\n\nThere is fatty atrophy of the gluteal muscles bilaterally. The remainder the\nmuscles are normal in signal and bulk.\n\nThe femoral acetabular and sacroiliac joint spaces appear well maintained.\nThere is no significant joint effusion. There is no bursitis. No paralabral\ncyst is seen.\n\nThere are mild degenerative changes within visualized portions of the lower\nlumbar spine.\n\nThe visualized tendons are intact and normal in signal.\n\nVisualized portions of the pelvis demonstrate no gross abnormality on this non\ntailored exam. There is no free fluid within the pelvis. There is no\nsignificant pelvic or inguinal lymphadenopathy.\n\nThere is generalized subcutaneous soft tissue edema.",
            "output": "1. Innumerable punctate foci of increased marrow STIR signal, decreased T1\nsignal enhancement throughout the pelvis, proximal femurs in visualized\nportions of the lower lumbar spine. These findings are nonspecific and are\nsimilar in appearance to the marrow changes visualized on the recent MRI of\nthe right shoulder.\n\n2. Bilateral avascular necrosis at the femoral heads involving greater than\n50% of the articular surfaces without associated articular collapse."
        },
        {
            "input": "UTERUS AND ADNEXA:\nEvidence of a prior hysterectomy is noted.\n\nThe ovaries are atrophic in keeping with a normal postmenopausal state.\n\nNo pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No pelvic sidewall or inguinal adenopathy by size criteria.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Diverticulosis without any evidence of\ndiverticulitis.\n\nVASCULATURE: Within the limitations of a noncontrast study, the pelvic vessels\nare normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal\nsignal characteristics.  No concerning osseous lesions.",
            "output": "Diverticulosis in the sigmoid colon without any evidence of diverticulitis."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: There is an intersphincteric anal fistula with\norigin at 10 o'clock which tracks along the right side into the right perianal\nfold measuring approximately 3.5 cm in length consistent with Clinical History\nprovided.  Remaining visualized rectum and intrapelvic bowel is unremarkable. \nNo significant free fluid or abscess.\n\nBLADDER AND DISTAL URETERS: Normal as visualized\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Normal as visualized.\n\nLYMPH NODES: No suspicious lymphadenopathy.\n\nVASCULATURE: No acute or significant findings.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Normal marrow signal without fracture or\nsuspicious osseous lesion.",
            "output": "3.5 cm perianal fistula as detailed above."
        },
        {
            "input": "There is a T2 hyperintense, rim-enhancing, horseshoe shaped fluid collection\ncentered in the intersphincteric plane of the anus just distal to the J-pouch\nanastomosis, from the 4 to 8 o'clock position, which splays the internal and\nexternal sphincters, measuring 2.1 x 1.3 cm in greatest axial dimension and\n3.5 cm craniocaudal, compatible with an abscess.  There is a short\ntranssphincteric sinus tract which traverses the external sphincter at 7\no'clock (series 8, image 57) and terminates in a 1.1 x 0.9 cm abscess within\nthe midline to right ischioanal fat. There is abnormal enhancement of the\nanastomosis at the left posterolateral aspect (series 10, image 38),\ncompatible with phlegmonous change.\nScattered tiny perirectal lymph nodes are likely reactive.\n\nThere is a small amount of free fluid in the presacral space.\n\nThe prostate demonstrates an enlarged and heterogeneously enhancing central\ngland.  The seminal vesicles are symmetric.\n\nThe bladder is within normal limits.\n\nThere is artifact related to fixation hardware in the right acetabulum.  No\nsuspicious osseous lesion is identified.",
            "output": "2.1 x 1.3 x 3.5 cm horseshoe shaped abscess centered in the intersphincteric\nplane of the anus just distal to the J-pouch anastomosis, from the 4 to 8\no'clock position, which splays the internal and external sphincters.\nShort transsphincteric sinus tract which traverses the external sphincter at 7\no'clock and terminates in a 1.1 x 0.9 cm abscess within the midline to right\nischioanal fat.  Phlegmonous change of the anastomosis at the left\nposterolateral aspect."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.2 x 8.8 x 12.0 cm. The junctional zone\nis not thickened.  The endometrium measures 1.9 cm and demonstrates internal\ndebris which is slightly hypointense relative to the myometrium on the T2\nweighted images and hyperintense on the T1 weighted images in keeping with\nblood products.  The endometrium is distorted to the left secondary to the\nlargest fibroid and the cervix is on the right.\n\nThere are multiple heterogeneously enhancing fibroids noted throughout the\nentire myometrium.  There is a 1.1 cm intramural non-enhancing fibroid along\nthe mid anterior wall (___).\n\nThe largest fibroid is along the anterior wall of the uterus on the right is\nnear the fundus and measures approximately 5.5 x 5.9 x 5.6 cm.  The fibroid is\nheterogeneously enhancing with central non-enhancing cystic areas.  This\nfibroid is in keeping with a FIGO leiomyoma subclassification 3 lesion (5:11,\n3:17, 1601:36).\n\nThe second largest fibroid is along the base of the anterior wall and is\nheterogeneously enhancing.  It measures 33 x 37 x 34 mm (3:11, 1601:58, 4:24).\nThe fibroid is slightly exophytic and is in keeping with a FIGO leiomyoma\nsubclassification 5 lesion.\n\nAlong the base of the posterior wall on the left, the third largest fibroid\nmeasures 22 x 22 x 24 mm and is mildly heterogeneously enhancing (3:8,\n1601:48, 04:20).  This fibroid is predominantly intramural and is in keeping\nwith a FIGO leiomyoma subclassification 4 lesion.\n\nThere is a partially subserosal, minimally enhancing, fibroid along the\nmid-anterior wall measuring approximately 18 x 12 mm mm consistent with a FIGO\nleiomyoma subclassification 6 lesion (3:14, 1601:49).\n\nA predominantly intramural, slightly submucosal, enhancing fibroid measuring\n11 x 11 mm on the right near the base is noted and consistent with a FIGO\nleiomyoma subclassification 2 lesion (1601:40).\n\nOn the right, there is dual blood supply from the ovarian and uterine arteries\nwith significant collateral formation. The dominant blood supply to the\nlargest fibroid is from the right ovarian artery.  Blood supply on the left is\nexclusively from the uterine artery.\n\nSusceptibility artifact along the uterus and anterior pelvic wall is most in\nkeeping with a previous myomectomy.\n\nThe right ovary is visualized and appears within normal limits.  There is a 32\nx 31 mm cyst in the right ovary. The left ovary is visualized and appears\nwithin normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No significant pelvic sidewall or inguinal adenopathy by size\ncriteria.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: The pelvic vessels are of normal caliber throughout without any\nsignificant areas of narrowing or dilation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The bone marrow demonstrates normal\nsignal characteristics.  No concerning osseous lesions.",
            "output": "1. Multiple heterogeneously enhancing submucosal, intramural, and subserosal\nfibroids as described above.  The largest fibroid is supplied by the right\novarian and uterine arteries.\n2.  32 mm right ovarian cyst."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7.3 x 9.1 x 8.6 cm (2:22, 5:14).\nThe endometrium is is somewhat distorted secondary to multiple uterine\nfibroids, the largest of which is in the uterine fundus.  Elsewhere, the\nendometrium does not appear thickened.  The junctional zone is not thickened. \nPlicae palmatae are noted in the cervix, a normal variant (5:16, 102:38).\n\nNumerous previously described uterine fibroids are again noted throughout the\nentire myometrium.  The largest fibroid along the anterior wall of the right\nuterine fundus (FIGO class 3) is approximately 5.6 x 5.3 x 5.3 cm, previously\n5.5 x 5.9 x 5.6 cm (3:19, 6:22).  There is no residual enhancement on\npostcontrast images.  No residual enhancement is identified in any of the\nother numerous uterine fibroids including the second largest slightly\nexophytic fibroid which is now 2.6 x 3.1 x 2.5 cm, previously 3.3 x 3.7 x 3.4\ncm (3:27, 6:24) along the anterior lower uterine segment fibroid (FIGO class\n5).  Other intramural, submucosal, and partially sub serosal uterine fibroids\nare similarly nonenhancing, many of which are slightly smaller compared to the\nprior examination.\n\nSusceptibility artifact along the uterus and anterior pelvic wall is in\nkeeping with previous myomectomy.\n\nThe right ovary contains a 32 mm ovarian cyst (06:16), with a small amount of\nsurrounding free fluid (3:11, 12).\n\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There is no pelvic sidewall or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic bowel loops are\nnormal in appearance.\n\nVASCULATURE: The pelvic vasculature remain patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous lesion worrisome for\nmalignancy or infection is identified.",
            "output": "1. No evidence of residual enhancement in any of the numerous uterine fibroids\nfollowing uterine arterial embolization.\n2. Interval decrease in size of several uterine fibroids including the 2\nlargest fibroids in the anterior right fundus and anterior lower uterine\nsegment.\n3. 32 mm right ovarian cyst with small volume adjacent free fluid, unchanged."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 4.5 x 3.8 x 8.7 cm.\n\nThere is an intramural fundal fibroid measuring approximately 1 x 2 x 1.8 cm\n(04:14).  The fibroid does not demonstrate any significant enhancement on\npostcontrast sequences.\n\nNo additional uterine fibroids are demonstrated.\n\nThe endometrium is not well visualized but appears normal where visualized. \nMeasurement of the endometrium is difficult due to poor visualization.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nNo pelvic free fluid.\n\nLYMPH NODES: No lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: There are multiple asymmetric prominent left-sided periuterine\nveins with mild asymmetric prominence of the left gonadal vein measuring up to\n9 mm in diameter (1602:18, 1502:40) (1602:39).\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Unremarkable.",
            "output": "1. Single fundal intramural uterine fibroid without significant post-contrast\nenhancement.\n2. Multiple prominent left-sided periuterine veins with mild prominence of the\nleft gonadal vein."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7.6 x 3.2 x 4.0 cm.\nThe endometrium is not thickened.\nThe junctional zone is not thickened.\n\nJust superior to the uterine fundus, there is a 8.3 x 5.8 x 8.0 cm mixed soft\ntissue and cystic mass most likely arising from the left ovary.  The central\naspect of the mass demonstrates hypointense signal on the T2 weighted images\nand hypointense signal on the T1 weighted images with homogeneous enhancement\non the postcontrast images.  The periphery of the mass demonstrates multiple\ncystic components with thin internal enhancing septations.\n\nThe right ovary is normal in size, however there is a focal 1.6 cm T2\nhypointense nodule (series 6, image 15) with equivocal hypoenhancement on the\npostcontrast images (series ___, image 38) for which an early small fibrous\nlesion is not excluded.\n\nThere is a 1.3 x 1.0 cm cystic lesion within the right labia demonstrating\nhomogeneously hyperintense signal on the T2 and T1 weighted images compatible\nwith internal hemorrhagic products most compatible with a small hemorrhagic\nBartholin's cyst.\n\nNo free fluid in the pelvis.\n\nLYMPH NODES: No suspicious pelvic or inguinal lymphadenopathy by size\ncriteria.\n\nBLADDER AND DISTAL URETERS: Bladder is decompressed, however appears grossly\nunremarkable without focal mass or wall thickening.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Visualized portions of the iliac vessels are normal in caliber\nand patent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue mass\nlesions.",
            "output": "1.  8.3 x 8.0 cm adnexal mass separate from the uterus most likely arising\nfrom the left ovary with central T2 hypointense enhancing component and\nperipheral cystic component suspicious for a stromal ovarian tumor. \nDifferential includes fibrothecma, cystadenofibroma and sclerosing stromal\ntumor.\n\n2.  1.6 cm T2 hypointense nodule within the right ovary with equivocal\nhypoenhancement on the postcontrast images for which an early small fibrous\nlesion is not excluded.  This can be followed up with ultrasound.\n\n3.  1.3 cm small hemorrhagic Bartholin's cyst in the right labia.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 17:34 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "Imaging of the area of concern in the right flank, as indicated by the\npatient, does not show any abnormality.  Specifically, no hernia, mass or\nabnormal signal is demonstrated in this region.\n\nDiastasis of the rectus abdominus muscles at the level of the umbilicus is\npresent, without frank ventral or umbilical hernia. Susceptibility artifacts\nare present in the right groin after inguinal hernia repair. Left-sided\ninguinal hernia containing a loop of small bowel is again demonstrated,\nwithout bowel wall thickening or edema.\n\nThe patient is status post hysterectomy and left oophorectomy. The right ovary\nis well visualized and is normal in size and appearance without evidence of\nmass.\n\nSimple cortical renal cysts are re-demonstrated in the left kidney.\nDiverticulosis throughout the colon is present, without evidence of\ndiverticulitis. The partially distended bladder is grossly unremarkable. There\nis small amount of free fluid in the pelvis.\nThere is no significant pelvic or inguinal lymphadenopathy.\nDegenerative changes present in the imaged lumbar spine.",
            "output": "1. No abnormality in the area of concern in the right flank, as indicated by\nthe patient, nor in the right lower quadrant.\n2. Left-sided small bowel containing inguinal hernia, without complications.\n3. Diverticulosis.\n4. Left renal simple cysts."
        },
        {
            "input": "UTERUS AND ADNEXA: Uterus is absent.  No adnexal masses are identified.\n\nThere is trace free fluid in the pelvis (2:4).\n\nLYMPH NODES: There are scattered external iliac and inguinal lymph nodes that\nare not enlarged by size criteria.\n\nBLADDER: Bladder is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No focal osseous lesions seen. \nEvaluation of the soft tissues is notable for susceptibility artifact around\nthe left inguinal canal, compatible with prior hernia repair.  No evidence of\nrecurrent hernia, mass or fluid collection.",
            "output": "Postsurgical changes after prior left inguinal hernia repair, without evidence\nof recurrent hernia, mass or fluid collection.  Trace pelvic free fluid."
        },
        {
            "input": "Note is made of subtle subchondral edema along bilateral pubic bodies, along\nthe inferior aspect of the pubic symphysis, left greater than right (series 4,\nimage 18), consistent with osteitis pubis.  There is no rectus\nabdominis-adductor aponeurosis injury identified.\n\nThere is subchondral edema along the inferior aspects of bilateral sacroiliac\njoints, left greater than right.  No sacroiliac joint effusions are seen.  The\nmarrow signal throughout the rest of the pelvis is within normal limits. \nThere is normal marrow signal within the proximal femurs bilaterally. There is\nno evidence of avascular necrosis, fracture, stress fracture.\n\nFocused imaging of the hips demonstrate no significant joint effusions. The\narticular cartilage is grossly preserved bilaterally. The hamstring insertions\nonto the ischial tuberosities are normal bilaterally.\n\nLimited assessment of intra-pelvic soft tissue structures is grossly\nunremarkable.\nNo gross intrapelvic fluid or enlarged intrapelvic lymph nodes detected.\n\nLimited assessment of the lower lumbar spine is grossly unremarkable.",
            "output": "1. Mild, left greater than right osteitis pubis.  No evidence of rectus\nabdominis-adductor aponeurosis injury.\n2. Mild nonspecific bilateral sacroiliac joint subchondral edema likely\ndegenerative."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: A perianal fistula arises from the middle\nportion of the internal anal sphincter from the 6:30 - 6 o'clock position\n(series 5, image 18) and does not traverse the external anal sphincter,\ncompatible with an intersphincteric perianal fistula.  The fistula\ndemonstrates simple linear morphology, without evidence of abscess.  Avid\nenhancement of the tissues surrounding the fistulous tract following contrast\nadministration is compatible with an active fistula (series 902, image 60 and\nseries ___, image 58). Findings are compatible with ___\nclassification Grade I simple intersphincteric fistula.\n\nOtherwise, the imaged rectosigmoid colon is unremarkable without evidence of\nadditional sites of fistulization, obstruction, wall-thickening or mural or\nmucosal hyper-enhancement.\n\nBLADDER AND DISTAL URETERS: The bladder and terminal ureters are unremarkable.\n\nPROSTATE AND SEMINAL VESICLES: Abnormal enhancement of the prostate is\nconsistent with prostatitis.  The seminal vesicles are unremarkable.\n\nLYMPH NODES: There is no pelvic lymphadenopathy.\n\nVASCULATURE: The imaged iliac and proximal femoral vasculature is patent\nwithout evidence of aneurysm or dilation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious focal marrow signal\nabnormalities are seen.",
            "output": "1. Simple linear intersphincteric perianal fistula arising from the middle of\nthe internal anal sphincter from the 6:30 - 6 o'clock position.  No abscess.\n2. Prostatitis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.0 x 4.4 x 4.5 cm.\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is not well visualized, however no focal left adnexal\nabnormality is identified.\n\nThere is no free pelvic fluid.\n\nLYMPH NODES: There are multiple prominent closely clustered ___ lymph\nnodes measuring up to 8 mm in short axis (07:13 and 16).  Elsewhere, no\nadditional enlarged pelvic or inguinal lymph nodes.\n\nBLADDER AND DISTAL URETERS: The bladder and terminal ureters are within normal\nlimits.\n\nRECTUM/INTRAPELVIC BOWEL: The patient is status post proctocolectomy with\nJ-pouch anal anastomosis.  The pouch is well distended, with an internal\nair-fluid level, however is otherwise normal in appearance without evidence of\nwall thickening or inflammation.  Distally, there are slightly prominent\nmucosal folds at the anorectal junction in the region of the anastomosis,\nnon-specific (09:54).  There is no evidence of perirectal/perianal fistula. \nThere is no evidence of focal fluid collection to suggest abscess.\n\nVASCULATURE: The imaged iliac and femoral vasculature is normal in caliber and\npatent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious foci of abnormal marrow\nsignal are seen.",
            "output": "1. Expected appearance status post proctocolectomy and J-pouch.  Normal MRI\nappearance of the pouch, which is well-distended with an air-fluid level but\nwithout wall thickening or other signs of inflammation.  No evidence of\nperirectal/perianal fistula or abscess.\n2. Prominent ___ lymph nodes are likely reactive in nature."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.2 x 9.3 x 6.9 cm.  There are\npostsurgical changes noted along the anterior uterus likely from prior\nmyomectomies.  There are numerous (more than 10) small intramural uterine\nfibroids demonstrate heterogeneous enhancement on the postcontrast images, the\nlargest measuring approximately 19 mm.  No submucosal or subserosal uterine\nfibroids..\nThe endometrium is normal in thickness for age and measures 14 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized containing a well-defined 3.5 x 1.9 cm T2\nhypointense and slightly T1 hyperintense lesion without significant\nenhancement on the postcontrast images most compatible with a hemorrhagic\ncyst.  Although endometrioma is on the differential, given that it was not\nseen on the prior ultrasound, this is thought to be less likely.\n\nThe left ovary is visualized and appears within normal limits.\n\nThere are multiple focal areas of thickening along the peritoneal lining\nwithin the pelvis.  A focal nodular area of thickening posterior to the\nvaginal fornix on the left measuring 14 x 10 mm (series 5, image 30) with\nslight hyperintense signal on the T1 weighted images most compatible with a\ndeep endometrial plaque.  There is also diffuse thickening along the posterior\nperitoneal lining within the cul-de-sac also most compatible with deep\nendometrial plaques (series 3, image 17, 19 and 27).  A focal area of\nthickening within the peritoneal lining anteriorly (series 5, image 21)\nextending up to the deep surface of the right rectus abdominus muscle (series\n5, image 15) could represent postoperative scarring, however these could also\nrepresent deep endometrial plaques.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No suspicious pelvic or inguinal lymphadenopathy by size\ncriteria.\n\nBLADDER AND DISTAL URETERS: Bladder is decompressed, however appears grossly\nunremarkable without focal mass or wall thickening.\n\nRECTUM AND INTRAPELVIC BOWEL: Grossly within normal limits.  No evidence of\nobstruction.\n\nVASCULATURE: Visualized portions of the iliac vessels are normal in caliber\nand patent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue mass\nlesions.  A well-defined tubular lesion within the periumbilical subcutaneous\nsoft tissues measuring 2.2 x 1.1 cm with hyperintense signal on the T1\nweighted images (series 14, image 1) most likely representing endometrial\nplaque.",
            "output": "1.  Anterior ureters containing numerous intramural fibroids.\n\n2.  3.5 cm T1 hyperintense and T2 hypointense cyst within the right ovary most\ncompatible with a hemorrhagic cyst.  Given that it was not seen on the prior\nultrasound from ___, an endometrioma is thought to be less likely.\n\n3.  Multiple areas of thickening of the peritoneal lining within the pelvis is\ndescribed in detail above most likely representing deep endometrial plaques.\n\n4.  No bowel obstruction."
        },
        {
            "input": "Normal appearance of the anus and rectum, without apparent inflammatory tract\nor granulation tissue. Stool within the rectum and visualized sigmoid colon.\n\nMinimally distended bladder. Prostate and seminal vesicles are grossly\nunremarkable. No free pelvic fluid. No pelvic adenopathy.\n\nNormal appearance of osseous structures.",
            "output": "Normal appearance of the anus and rectum.  No apparent inflammatory tract or\ngranulation tissue to represent active or healed fistula."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 3.9 x 8.2 x 5.9 cm.  There is a 1.0 x\n1.0 cm submucosal (<50%) anterior uterine wall fibroid (5; 6).  A nonspecific\npunctate T2 hyperintense, T1 hypointense nonenhancing focus within the\nendometrium appears to be within or adjacent to this submucosal fibroid (6;\n16).\nThe endometrium is normal in thickness for age and measures 6 mm.\nThe junctional zone is not thickened.\n\nThe right and left ovaries were not visualized.\nIn the right adnexa, there is a nonenhancing 2.9 x 3.2 x 1.6 cm T2\nhyperintense, T1 hypointense cyst (6; 13) which may represent a right ovarian\ncyst but no definite ovarian tissue is visualized.\n\nIn bilateral adnexa, there are bilateral tubular appearing structures with\nincomplete septa with non enhancing T1 hyperintense material with T2 shading\nand layering dependent T2 dark foci consistent with bilateral hematosalpinges\n(6; 11).\n\nThere is T2 dark plaque in the torus uterinus measuring 4 mm in thickness\nconsistent with deep infiltrating endometriosis.\n\nThere is a significant amount of tethering of the sigmoid colon and rectum (4;\n12, 9) with the uterus and fallopian tubes consistent with sequelae of deep\ninfiltrating endometriosis.\n\nSmall amount of pelvic free fluid is seen.\n\nLYMPH NODES: There is no pelvic sidewall or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder is decompressed but appears unremarkable. \nDistal ureters appear unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The visualized small and large bowel appear\nunremarkable without evidence of obstruction.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesion is\nidentified.",
            "output": "1. Findings compatible with endometriosis including bilateral hematosalpinges\nand evidence of deep infiltrating endometriosis with significant tethering of\nthe sigmoid colon, rectum, uterus and adenxa.\n2. A 3.2 cm right adnexal cyst may be within the right ovary, however no\ndefinite ovarian parenchyma is identified bilaterally.\n3. 1.0 cm submucosal anterior uterine fibroid."
        },
        {
            "input": "Uterus:\nThe uterus measures 9.9 x 9.9 x 13.0 cm. There are multiple T2 hypointense\nuterine fibroids which appear mainly in a mural location. The largest is\nwithin the fundus on the right and measures 4.0 x 4.8 x 4.4 cm (03:16), which\nis likely mural but extends to the endometrial surface therefore could be\nsubmucosal.  There is a small subserosal fibroid posteriorly measuring 1.6 x\n1.7 cm ( 03:16 ).  The majority of the fibroids demonstrate enhancement post\ncontrast administration, however, the dominant fibroid demonstrates mild\ndegeneration but is still predominantly enhancing. The is no evidence of\novarian artery parasitization/supply bilaterally to any of the fibroids.\n\nThe junctional zone is normal in thickness and appearance.\n\nEndometrium: The endometrial stripe is distorted by the multiple intrauterine\nfibroids but appears thin.\n\nCervix and Vagina: There are multiple incidental nabothian cysts in the cervix\nwith no suspicious cervical or vaginal lesion identified.\n\nOvaries: Both ovaries are well visualized, with no evidence of focal mass.\n\nLymph Nodes: There are no size-significant or suspicious pelvic or inguinal\nlymph nodes.\n\nUrinary bladder: The bladder is partially distended and normal in appearance\nwith no filling defect or wall thickening.\n\nThere is mild colonic diverticulosis.  There is increased enhancement around\nthe origin of the hamstrings likely related to tendinopathy.\n\nOsseus structures: There is no suspicious bone lesion.",
            "output": "Multiple uterine fibroids, some submucosal and some subserosal, with a\ndominant fibroid in the fundus, in a likely intramural location, measuring 4.8\ncm.  No evidence of ovarian artery supply to the fibroids."
        },
        {
            "input": "Limited and essentially nondiagnostic exam.  The bowel wall of the ___\npouch does not appear thickened or edematous.\n\nBladder is decompressed around a Foley catheter.\n\nThere is a trace amount of free pelvic fluid.\n\nDiffuse muscular atrophy.",
            "output": "Exam is very limited and was terminated early.  Only motion degraded T2\nweighted images were obtained.  Of note the bowel wall of the ___ pouch\nis not appear to be grossly thickened or edematous"
        },
        {
            "input": "The areas of low T1 marrow signal seen about much of the pelvis on the ___ MRI lose signal on the out of phase images, consistent with red\nmarrow (rather than a marrow infiltrating process). This could either\nrepresent normal variation or, in the appropriate clinical setting, red marrow\nexpansion due to anemia.\n\nThe previously identified rounded lesion in the S2 vertebral body posteriorly\nnear the midline (6b:53) demonstrates no loss of signal on out of phase\nimaging, indicating a lack of microscopic fat within this lesion. The lesion\nis isointense to muscle on T1 weighted images, excluding a fatty lesion.",
            "output": "1. Areas of low T1 marrow signal seen about much of the pelvis on the ___ MRI lose signal on the out of phase images, consistent with red marrow\n(rather than a marrow infiltrating process). This could either represent\nnormal variation or, in the appropriate clinical setting, red marrow expansion\ndue to anemia.\n\n2.  No fat identified within the previously identified lytic lesion in the S2\nvertebral body near the midline. No loss of signal seen within this lesion on\nthe out of phase images. This remains is suspicious lytic lesion, for which\nfurther evaluation is recommended. The possibility of an atypical hemangioma\nremains in the differential, but is considered quite unlikely."
        },
        {
            "input": "The visualized bone marrow is normal in signal intensity.  There is minimal\nloss of the normal high T2 signal in the L3-L4 and L4-L5 intervertebral disc\nspaces consistent with disc desiccation.  There is no posterior disc bulges or\nother degenerative changes visualized lower lumbar spine and sacrum.  There\nare no masses or fat stranding in the presacral space.  Visualized loops of\nsmall and large bowel appear normal.  No free fluid in the pelvis.  No pelvic\nlymphadenopathy seen.  The muscle signal intensity and bulk appears normal. \nThere are no subcutaneous lesions.",
            "output": "Unremarkable MRI of the sacrum and coccyx."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Just superior to the anal orifice centered in\nthe labia majora abutting/adjacent to the right posterolateral wall of the\nlower third of the vagina, there is a lobulated approximately 3.4 x 2.5 x 1.8\ncm (CC by AP by TV) (4:11 and 7:10) T2 hyperintense, nonenhancing (___)\ncollection with multiple internal incomplete septa.  The T2 hyperintense\ncontents demonstrate intrinsic T1 hyperintensity (see series 8 image 46).\n\nThere is a similar but smaller left-sided collection measuring up to 2.3 x 1.6\nx 1.0 cm (CC by AP by TV) (4:10 and 5:22), also with incomplete internal\nsepta, and also with intrinsically T1 hyperintense internal components and\nwithout enhancement (08:50 and ___.\n\nThere is no significant soft tissue edema or inflammatory change surrounding\nthe collections.  There is no evidence of perianal fistula or sinus tract. \nThe imaged proximal rectum and visible loops of intrapelvic small and large\nbowel are grossly unremarkable, without evidence of inflammation.\n\nThere are T2 hypointense nodular foci seen in the mesorectal space outlined by\nlayering ascites, larger on the left (4.0 x 2.1 cm) than the right (2.1 x 1.1\ncm), demonstrating delayed enhancement, concerning for peritoneal\nimplants/deposits (see series 4, image 24, 5:4, 5:1, as well ___: 92 and\n112). These appear smaller compared to the prior CT of ___.\n\nUTERUS AND ADNEXA:\n\nThe patient is status post hysterectomy and bilateral salpingo-oophorectomy. \nNo left or right adnexal abnormality identified.\n\nA small amount of ascites layers dependently in the pelvis.\n\nLYMPH NODES: No pathologically enlarged pelvic or inguinal lymph nodes.\n\nBLADDER AND DISTAL URETERS: The bladder and terminal ureters are within normal\nlimits.\n\nVASCULATURE: Imaged pelvic vasculature is normal in caliber and patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: The marrow signal in all the visualized\npelvic bones is homogenously hypointense on the T1 and T2-weighted sequences\ncompatible with red marrow.",
            "output": "1. Lobulated non-enhancing labia majora cysts centered at the right and left\nposterolateral margins of the lower third of the vagina, measuring 3.4- and\n2.3 cm, respectively, without inflammation of the surrounding tissues, most\nconsistent with Bartholin's gland cysts containing proteinaceous secretions.\n2. Bilateral, left-larger than right peritoneal implants/deposits in the\nmesorectal space outlined by trace layering pelvic ascites, smaller since\nprior CT of ___."
        },
        {
            "input": "UTERUS:\nThe uterus is retroverted, measuring 9.8 x 6.5 x 7.5 cm.\n\n\nEndometrium: The endometrium is distorted by the fibroids but otherwise\nhomogeneous, measuring 5 mm\nJunctional zone:\nThe myometrium is thickened to 23 mm with loss the junctional anatomy and\npresence of endometrial tissue in the myometrium, consistent with adenomyosis.\n\nIn the posterior uterine fundus, there is a 4.4 x 4.4 x 3.7 cm\nwell-circumscribed lesion with similar enhancement to the myometrium.  This\ncould represent a well-circumscribed adenomyoma or a fibroid.  However, the\npunctate T2 hyperintensity, likely representing endometrial glandular tissue,\nfavors adenomyoma.\n\nFIBROIDS:\n\nSee above.\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nNormal size with normal follicular activity bilaterally.\n\nThere is a physiologic amount of intrapelvic free fluid.",
            "output": "1.  4.4 x 4.4 x 3.7 cm well-circumscribed adenomyoma versus fibroid in the\nposterior uterine fundus in the setting background adenomyosis. Punctate T2\nhyperintensities within the well-circumscribed lesion, likely representing\nendometrial glandular tissue, favors adenomyoma.\n2.  Normal ovaries."
        },
        {
            "input": "Bones: Schmorl node and degenerative disc changes are seen at L2-L3 level. \nMild multilevel facet hypertrophy of the lower lumbar spine.\n\nAlignment of the right hip appears preserved.  Likely diffuse mild cartilage\nthinning.  Small subchondral cystic change of the a bilateral acetabulum knee\npain.  No evidence of fracture.  Labrum is not well evaluated on large\nfield-of-view images.\n\nAlignment of the left hip appears preserved.  Moderate diffuse cartilage\nthinning with possible areas of full-thickness cartilage loss of the superior\nfemoroacetabular joint and.  Labrum is not well evaluated on large\nfield-of-view images.\n\nThere is a rounded heterogeneously T2 hyperintense, T1 slightly hyperintense\nlesion in the left intratrochanteric region measuring 2.8 x 1.9 x 0.9 cm.  The\nlesion appears to have a sclerotic rim with out prominent surrounding bone\nmarrow edema.  There does not appear to be any cortical breakthrough or\nprominent endosteal scalloping.\n\nSoft tissues:\nMild edema at the myo-tendinous junction of the right adductor aponeurosis\nnear its insertion on the right pubic bone likely represents moderate strain.\n\nSmall amount of Fluid at the insertion of the bilateral hamstrings likely\nrepresents chronic partial tears.  Trace effusions of the bilateral hips.\n\nFluid deep to the left iliacus muscle may represent nonspecific edema.  Small\namount of fluid is seen tracking distally into the iliopsoas muscle toward the\ntendon and may represent extension the nonspecific edema versus small\nmyotendinous tear.\n\nBilateral gluteus tendons appear intact.  Bilateral iliopsoas tendons appear\nintact.\n\nThere are small bilateral hydroceles.\n\nAt the left apex of the peripheral zone of the prostate there is a small area\nof triangular shaped T2 hypointensity measuring 1.2 x 0.7 cm in axial\ndimension (image 5:41).",
            "output": "Nonaggressive appearing lesion of the left intertrochanteric femur with likely\nsclerotic rim is incompletely characterized on this noncontrast enhanced exam.\nPossibilities include fibrous dysplasia, liposclerosing myxofibrous tumor, or\na complicated bone cyst.  A more aggressive neoplastic process is thought to\nbe less likely.  Correlation with radiographs is recommended.  If this lesion\nis an incidental finding and the patient does not have pain in this area and\nthe lesion is identifiable on radiographs, it could be followed with\nsubsequent radiographs.\n\nNo fracture of the right hip.\n\nMild edema at the myo-tendinous junction of the right adductor aponeurosis\nnear its insertion on the right pubic bone likely represents moderate strain.\n\nMild degenerative change of the right hip.  Mild-to-moderate degenerative\nchange of the left hip.\n\nLikely chronic partial tears of the bilateral hamstrings.\n\nSmall bilateral hydroceles.\n\nSmall area of T2 hypointensity within the left apex of the peripheral zone of\nthe prostate is nonspecific on this nondedicated exam.  A small focus of\nprostate cancer could have this appearance.  Consider correlation with\nphysical exam and PSA.  A dedicated prostate MRI could be considered for\nfurther evaluation if clinically warranted.\n\nRECOMMENDATION(S):  In regards to incidental finding in the left femur\nintratrochanteric region, correlation with radiographs is recommended. If this\nlesion is an incidental finding and the patient does not have pain in this\narea and the lesion is identifiable on radiographs, it could be followed with\nsubsequent radiographs.\n\nIn regard to prostate lesion, consider correlation with physical exam and PSA.\nA dedicated prostate MRI could be considered for further evaluation if\nclinically warranted."
        },
        {
            "input": "There is normal marrow signal within the proximal femurs bilaterally.  There\nis no evidence of avascular necrosis, fracture, stress fracture. Scattered\narea of T1 intermediate signal in the bone marrow are consistent with red\nmarrow.  There are several areas of more discrete T1 intermediate signal\nwithin the bone marrow, the largest seen in the right iliac bone, measuring\n1.8 cm (02:10).  There is no evidence of sacroiliitis.  1.1 cm Tarlov cyst is\nnoted at S2-3 level.  Small lobulated T2 hyperintense lesions in midline S3,\nS4, and S5 are nonspecific and without of aggressive features.\n\nThere is no hip joint effusion.  There is no greater trochanteric bursitis.\nThe hamstring insertion onto the ischial tuberosity is normal.\n\nLimited assessment of intra-pelvic soft tissue structures is grossly\nunremarkable.\n\nLimited assessment of the lower lumbar spine is grossly unremarkable.",
            "output": "1. No acute fracture is identified.\n2. Small lobulated lesions in S3, S4, and S5 are indeterminate however without\nconcerning features.\n3. 1.1 cm Tarlov cyst is identified at S2-3.\n4. Heterogeneous appearance of the bone marrow is \\ consistent with red\nmarrow.  More focal areas of bone marrow signal change is still favored to be\nred marrow, however a discrete bone lesion is a possibility.  If clinically\nindicated, further evaluation with contrast enhanced MRI and additional in and\nout of phase sequences may be helpful.\n\nRECOMMENDATION(S):  If clinically indicated, the bone marrow can be further\nevaluated with contrast enhanced MRI with additional in and out of phase\nsequences."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 11.4 x 5.9 x 5.2 cm.\nAn IUD is seen within the endometrium, in satisfactory position.  The\nendometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.  Previously\nidentified cystic structure in the left pelvis is no longer seen, presumably\nrepresenting a physiologic cyst which has resolved in the interim.\n\nThere is a nabothian cyst.  There is no pelvic free fluid.\n\nLYMPH NODES: There are no pathologically enlarged lymph nodes.\n\nBLADDER AND DISTAL URETERS: The urinary bladder and distal ureters are within\nnormal limits.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized loops of small and large bowel are\ngrossly unremarkable.\n\nVASCULATURE: Visualized portions of the internal and external iliac arteries\nare patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES:  No concerning osseous lesions\nidentified.  Soft tissues are within normal limits.",
            "output": "1. Previously identified cystic structure in the left pelvis is no longer\nseen, presumably representing a physiologic cyst which has resolved.\n\n2.  IUD in satisfactory position.\n\n3.  Otherwise, normal pelvic MR examination."
        },
        {
            "input": "An enhancing soft tissue defect is seen posteriorly along the right gluteal\nregion which appears to connect to the rectum (11; 36).  There is enhancement\nof the perirectal fat which extends superiorly.  Inferior to the coccyx, T1\nhypointense phlegmonous debris is seen involving the right-sided perirectal\nfat, extending into a 7.2 x 3 x 6.4 cm rim enhancing collection which contains\ninternal foci of signal void suggestive of locules of air.  Phlegmonous\nchanges are also seen extends anteriorly to the right of the bladder edema and\nposteriorly into the presacral space.\n\nThe bone marrow signal is unremarkable without fracture or avascular necrosis\nof the femoral heads.  There is no evidence of osteomyelitis.  The sacroiliac\njoints are unremarkable in appearance.  Degenerative changes are seen in the\nlower lumbar spine at L5-S1.\n\nThere is trace fluid in the left acetabular joint.  There is no right\nacetabular joint effusion.\n\nThe tendons about the hips are unremarkable. The gluteal and proximal\nhamstring tendons are normal in appearance.\n\nNo trochanteric bursitis is appreciated.\n\nThe muscles demonstrate fatty atrophy bilaterally.",
            "output": "7.2 cm right gluteal abscess with visible skin track contains internal foci of\nair and appears to communicate with the rectum.  No evidence of osteomyelitis."
        },
        {
            "input": "Limited scout images and a severely motion degraded sagittal T2 sequence were\nobtained.  The examination could not be completed due to patient discomfort\nand motion.  Limited images reveal Foley catheter within the bladder and\nmild-to-moderate posterior and middle compartment pelvic floor descent at\nrest.  The known abscess is not visualized.",
            "output": "Study is nondiagnostic as it was terminated prematurely due to patient\ndiscomfort and patient motion."
        },
        {
            "input": "Bone marrow signal intensity is normal.  There is no evidence of fracture or\nbone marrow edema at the sacrum or coccyx.  No presacral edema is\ndemonstrated.\n\nNo pelvic sidewall lymphadenopathy.  No pelvic soft tissue mass is identified.\nThe uterus and adnexa appear unremarkable within limits of non dedicated\nstudy.\n\nThere is some high signal intensity at the origin of the hamstring tendons\nbilaterally compatible with mild tendinosis.\nI note low signal intensity focus at the left iliac bone adjacent sacroiliac\njoint likely reflects a small bone island (series 4, image 8).  Very minimal\nsubchondral edema adjacent to the left sacroiliac joint is likely degenerative\nin nature (series 7, image 16).",
            "output": "No sacral or coccygeal fracture is evident.\nThere is mild hamstring tendinosis bilaterally."
        },
        {
            "input": "",
            "output": "Heterogeneous area within the right ovary concerning for a solid mass lesion\nwith a large amount of free fluid. Further evaluation with pelvic MRI is\nrecommended.  // Unspecified ovarian cyst, right side\n\nTECHNIQUE:  T1- and T2-weighted multiplanar images of the pelvis were acquired\nin a 1.5 T magnet.\nIntravenous contrast: 6 mL Gadavist.\n\nCOMPARISON:  No prior MRI available for comparison.  Study was correlated to\nprior ultrasound dated ___.\n\nFINDINGS: \n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7.4 x 2.8 x 4.8 cm.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nWithin the right adnexa, there is a large complex solid and cystic mass lesion\ninvolving the right ovary (series 4, image 24) measuring 6.8 x 4.6 x 4.9 cm\nthat appears heterogeneously isointense to slightly hyperintense on the T2\nweighted images and isointense on the T1 weighted images with avid enhancement\nof the solid components on the postcontrast images, highly suspicious for\nprimary ovarian neoplasm.\n\nThere is dilatation of the right fallopian tube measuring up to 6 x 2 cm\n(series 5, image 20) with internal solid enhancing components suggestive of\ntumoral extension.\n\nThere is significant thickening of the right round ligament with enhancing\nsoft tissue extending into the right inguinal ligament (series 4, image 28, 30\nand 33).\n\nThere is a moderate amount of free fluid in the pelvis with multiple enhancing\nperitoneal nodules within the cul-de-sac (series 4, image 30 and series 5,\nimage 28 and 16).  There is also large soft tissue nodules measuring\napproximately 3.4 x 1.6 and 3.8 x 1.5 cm anterior to the lower uterine segment\nabutting the bladder dome (series 5, image 26 and series 4, image 32).\n\nMultiple large omental masses extending into the left paracolic gutter, the\nlargest of these nodules measures 4.6 x 2.5 cm (series 4, image 9).  There\nalso multiple enhancing peritoneal nodules in the right paracolic gutter\n(series 4, image 7 abutting the appendix.  The appendix is otherwise not\ndilated.\n\nThe left ovary is visualized and appears within normal limits.\n\nLYMPH NODES: There is an enlarged right internal iliac lymph node measuring\n1.6 x 1.0 cm (series 4, image 20).  There is also an enlarged partially\nvisualized retroperitoneal lymph node at the aortic bifurcation measuring 3.9\nx 2.3 cm\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are normal without\nfocal mass or wall thickening.  There is enhancing soft tissue nodularity\nanterior to the lower uterine segment as described above overlying the bladder\ndome, however no invasion.  There is a clear fat plane between soft tissue\nnodules and the bladder wall.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Visualized portions of the iliac vasculature are normal in\ncaliber and patent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: 1.2 x 0.8 cm focus within the left\nacetabulum that appears hypointense on the T1 weighted images with ___ ink\nartifact on the out of phase images.  This lesion appears slightly\nhyperintense on the T2 weighted images with minimal enhancement on the\npostcontrast images.  Findings are nonspecific and could represent an\nintraosseous venous Lake, however metastases cannot be ruled out.\n\nIMPRESSION: \n\n1.  Large 6.8 cm complex solid and cystic mass involving the right ovary with\navid enhancement of the solid components on the postcontrast images extending\ninto the right fallopian tube with associated hydrosalpinx as well as\nextension into the round ligament extending up to the right inguinal canal,\nhighly suspicious for primary ovarian neoplasm, most likely a serous\ncystadenocarcinoma.\n\n2.  Moderate amount of free fluid in the cul-de-sac with multiple enhancing\nsoft tissue peritoneal nodules within the cul-de-sac as well as the paracolic\ngutters, retroperitoneal lymphadenopathy and large omental nodules, highly\nsuggestive of peritoneal carcinomatosis and omental caking.\n\n3.  1.2 cm left acetabular bone lesion with nonspecific imaging finding as\ndescribed above.  It could represent an intraosseous venous Lake, however\nmetastasis cannot be ruled out.  PET-CT can be obtained for further\nevaluation.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 1:20 ___, 60 Minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 4.1 x 5.8 x 3.0 cm.   Multiple T1\nhyperintensities demonstrating enhancement are consistent with intramural\nfibroids.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No evidence of pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are normal\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized bowel is normal in caliber.\n\nVASCULATURE: Major pelvic vasculature is patent.  No evidence of aneurysm.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No evidence abnormal enhancement or\nrecurrent mass along the surgical bed in the left pelvis.  Mild-to-moderate\ndegenerative changes of the right hip.  No evidence of concerning osseous\nlesion.",
            "output": "Post resection of a left pelvic mass, without evidence of recurrence, pelvic\nadenopathy, or pelvic metastasis."
        },
        {
            "input": "The uterus measures 7.2 x 3.5 x 4 cm. Several T2 hypointense this and T1\nisointense, intramural and subserosal masses are demonstrated in the uterine\nwall measuring up to 1.4 cm (5:15, 21), consistent with fibroids. The\nendometrial stripe is normal in thickness measuring 5.5 mm. The junctional\nzone indistinct in a postmenopausal woman. The cervix and vaginal normal\nappearance.\n\nBoth ovaries are well visualized and normal in appearance and size (5:20).\n\nA left pelvic mass adjacent posteriorly to the external iliac vessels is\ndemonstrated, measuring 2.6 x 1.9 x 3.2 cm (6:18, 5:16). The mass is\nlobulated, well defined, mostly hyperintense on T2 relative to striated muscle\n(05:16), demonstrates restricted diffusion (09:28) and shows heterogeneous low\nlevel of enhancement on the venous phase (1202:45). On CT from ___ the\nmass measured 2.4 x 2 x 2.5 cm and was located anteriorly to the external\niliac vessels.  On CT from ___ there was a 0.9 x 1.3 cm soft tissue\nmedial to the external iliac vessels. On CT from ___ no obvious\nmass was seen.  On the current study the mass appears to be intimately\nassociated with the gonadal vessels (1202:51, 6:19).  Differential diagnoses\ninclude ectopic ovarian tumor or a tumor of mesenchymal origin.\n\nThere is no pelvic or inguinal lymphadenopathy.\nThere is no free fluid in the pelvis.\nBone marrow signal is normal.",
            "output": "1.  Enhancing left pelvic 2.6 x 1.9 x 3.2 cm mass located posterior to the\nexternal iliac vessels, demonstrating gradual enlargement since ___ and\nintimate association with gonadal vessels.  Differential diagnoses\nconsiderations include ectopic ovarian tumor or a tumor of mesenchymal origin.\nGiven the variation of the location of this lesion in comparison to the ___\nCT, lymphadenopathy is felt to be less likely. Surgical consultation is\nadvised.\n2.  Fibroid uterus.\n\nNOTIFICATION:  The impression was placed on the critical findings dashboard by\nDr. ___ on ___."
        },
        {
            "input": "The uterus is anteverted with approximate total ___ of 7.7 x 4.1 x 3.6\ncm.\n\nThere are numerous small lesions scattered throughout the uterus, measuring up\nto 1.2 cm in size. Each is hypointense relative to myometrium on T2 weighted\nimaging, isointense on T1 weighted imaging and avidly enhancing. Most are\nintramural in location with a single subserosal exophytic mass extending\nanteriorly from the periuterine segment (13:13). The appearance is compatible\nwith multiple fibroids. In the absence of large, aggressive appearing masses\nand no associated hypermetabolism on PET-CT, these are most consistent with\nmultifocal fibroid without evidence of leiomyosarcoma.\n\nA tiny T2 hyperintense focus is noted within the fundal junctional zone\n(12:13).  This may represent a tiny focus of ectopic endometrial tissue\n(adenomyosis) or a tiny cyst, but is of doubtful clinical significance.\n\nThe right ovary is normal in appearance.  The left adnexa is surgically\nabsent.\n\nThe bladder is decompressed, limiting its evaluation. The urethra, cervix and\nvagina are normal in appearance. There is no lymphadenopathy or ascites.\nDegenerative changes are noted at the lumbosacral junction.",
            "output": "Multiple small uterine fibroids without features concerning features."
        },
        {
            "input": "SOFT TISSUES: No worrisome lesion is identified.  There is no evidence of\nrecurrence at the resection bed along the left pelvic sidewall and posterior\nto the left external iliac vessels.\n\nLYMPH NODES:  No lymphadenopathy.\n\nUTERUS AND ADNEXA:\nThe uterus is anteverted and measures 6.8 x 3.7  X 3.1 cm.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.  A 7 mm T2 hypointense lesion in the\nleft uterine wall and 8 mm exophytic lesion in the anterior uterine wall are\nconsistent with fibroids.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary has been surgically removed.\n\nTrace pelvic free fluid is within physiologic limits.\n\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Bilateral external iliac arteries are normal size.\n\nBONES:  Bilateral femoroacetabular joint degenerative changes are noted, right\nmore than left.  There is cartilage loss and osteophyte formation at the\nbilateral femoral heads.  There is new irregularity focally of the condylar\nsurface of the right femoral head and new subchondral cysts in the right\nfemoral head and acetabulum.",
            "output": "1.  No evidence of recurrence or metastasis in the pelvis.\n\n2.  Fibroid uterus.\n\n3.  Progression of degenerative changes of the bilateral femoral acetabular\njoints, right more than left.  Chondral injury is noted in the right femoral\nhead."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.6 x 2.3 x 4.7 cm.  Multiple fibroids\nare demonstrated that appear to be subserosal, intramural, and submucosal. \nMultiple, round circumscribed lesions with that are hypointense on T1 and T2\nweighted images are consistent with fibroids, largest measuring up to 6 mm\nanteriorly.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is surgically absent.\n\nThere is a small amount of free fluid in the pelvis, new since ___.\n\nLYMPH NODES: No pathologically enlarged inguinal or pelvic sidewall lymph\nnodes.\n\nBLADDER AND DISTAL URETERS: The partially distended bladder and distal ureters\nare unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and visualized loops of bowel the\npelvis are within normal limits without dilatation or wall thickening.\n\nVASCULATURE: The visualized lower abdominal aorta are widely patent.  The\ncommon iliac and bilateral external and internal iliac arteries are widely\npatent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous signal abnormality suspicious\nfor malignancy or infection.  Degenerative changes in the hips are again seen.",
            "output": "1.  No MR evidence of disease recurrence in the pelvis.\n\n2.  Fibroid uterus.\n\n3.  Non-specific small amount of simple free fluid in the pelvis that is new\nsince ___."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.9 x 2.9 x 4.2 cm.  Multiple fibroids\nare demonstrated that appear to be sub serosal, intramural and submucosal,\nsimilar to the prior study.  The largest fibroid is located in the fundus and\nmeasures 9 mm (series 5, image 25).\nThe endometrium is normal in thickness for age and measures 1 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is surgically absent.\n\nThe previously seen trace free fluid in the pelvis has resolved.\n\nLYMPH NODES: No pathologically enlarged lymph nodes.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters appear normal.\n\nRECTUM AND INTRAPELVIC BOWEL: There is colonic diverticulosis.\n\nVASCULATURE: The pelvic arteries and veins are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are degenerative changes in the\nlower lumbar spine including grade 1 anterolisthesis of L4 on L5.",
            "output": "1. No recurrent pelvic mass.  No new lymphadenopathy.\n2. Fibroid uterus."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 3.9 x 4.5 x 5.6 cm.  The uterus contains\nmultiple T2 hypointense enhancing nodules compatible with fibroids.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is not visualized, compatible with the history of prior left\noophorectomy.\n\nThere is no free pelvic fluid.\n\nLYMPH NODES: No lymphadenopathy seen.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic bowel are of normal\ncaliber and thickness.\n\nVASCULATURE: The pelvic vasculature is patent and of normal caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are partially visualized\ndegenerative changes of the lower lumbar spine, better evaluated on the\ndedicated MR ___ from ___.  No suspicious osseous lesions are\nseen.",
            "output": "1. Post left oophorectomy. No recurrent pelvic mass or lymphadenopathy.\n2. Fibroid uterus."
        },
        {
            "input": "UTERUS AND ADNEXA: The uterus is anteverted and measures 6.6 x 3.0 x 4.3 cm. \nMultiple fibroids are stable. The endometrium is within normal thickness for\nage and measures 2 mm.  The junctional zone is not thickened.  The right ovary\nis unremarkable for age. A small right hydrosalpinx or paratubal cyst is\nunchanged.  Status-post left oophorectomy.\n\nLYMPH NODES: No pelvic or inguinal lymphadenopathy.\n\nOTHER: No bowel obstruction.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No evidence of recurrent pelvic mass.  A\nnonspecific 1.0 x 0.6 cm well-circumscribed cystic lesion along the left\npelvic sidewall is unchanged since the ___ CT abdomen/pelvis, new since\nbefore then (series 7, image 5) - probably benign, attention on routine\nfollow-up for primary malignancy.",
            "output": "1. Fibroid uterus. No evidence of pelvic recurrence or metastasis.\n2. Additional findings as above."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.6 x 3.3 x 3.8 cm.  Small fibroids are\nagain noted, not appreciably changed.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary surgically absent.\n\nNo free pelvic fluid.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Mild diffuse bladder wall thickening likely\nrelates to underdistention.  The bladder is otherwise unremarkable.  No\nterminal ureteral abnormality.\n\nRECTUM AND INTRAPELVIC BOWEL: Imaged portions of the rectum and intrapelvic\nsmall bowel are within normal limits.\n\nVASCULATURE: The imaged iliac and femoral arterial and venous vasculature is\nnormal in caliber and patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: A previous identified 10 x 6 mm T2\nhyperintense cystic focus along the left posterior lower abdominal/pelvic\nretroperitoneum is not imaged on the current study.  Imaged musculature of the\npelvic wall proximal thighs is normal in bulk and signal intensity.  At least\nmoderate bilateral hip degenerative changes are noted.  There is probable bone\nisland in the right hemipelvis just superior to the acetabulum.  No suspicious\nfoci of abnormal marrow signal are seen.",
            "output": "1. No MR evidence of recurrent disease or metastasis within the pelvis.\n2. Status post left salpingo-oophorectomy.\n3. Fibroid uterus.  Other incidental findings, as above.\n4. Note, previously imaged left retroperitoneal/pelvic cystic focus seen on\nscan of ___ is not seen on the current study, and may have possibly have\nbeen bowel-related, of doubtful clinical significance given appearance\npreviously; attention to this on followup studies."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.2 x 3.0 x 3.7 cm.  There are several\nintramural fibroids measuring 0.7 cm in the right fundus and 0.4 cm in the\nleft fundus (series 5, image 26).\n\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is not visualized compatible with prior surgical resection.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No abnormally enlarged pelvic lymph nodes are present.  Scattered\nnon-pathologically enlarged nodes appear stable.  No visualized\nretroperitoneal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: No concerning abnormalities.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Patent pelvis vasculature.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Moderate to severe degenerative changes\ninvolving the right hip are redemonstrated.  No concerning osseous lesions.",
            "output": "1. No evidence of recurrence or lymphadenopathy.\n2. Fibroid uterus.\n3. Moderate to severe right hip degenerative change."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 24 x 59 x 44 mm (AP by SI by TV). \nMultiple intramural fibroids are again noted.  Some of the fibroids are\nintrinsic T1 hyperintense, as well as demonstrating enhancement.  The\nenhancement appear similar compared to prior imaging.\nThe endometrium is normal in thickness for age, measuring 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is not visualized in keeping with prior resection\n\nLYMPH NODES: Multiple subcentimeter pelvic lymph nodes are unchanged compared\nto prior.  No new or enlarging lymph nodes.\n\nBLADDER AND DISTAL URETERS: Unremarkable\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable\n\nVASCULATURE: Major vasculature are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Marked degenerative changes of the right\nhip joint is again noted.  No suspicious bony lesions.",
            "output": "1. No evidence of disease recurrence or new or enlarging lymph nodes.\n2. Multifibroid uterus.\n3. Marked right hip degenerative changes with associated joint effusion are\nagain noted."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 7.6 x 10.7 x 10.2 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 3 mm\nJunctional zone: 8 mm without focal thickening.\n\nA tampon is noted in the vaginal canal.\n\nFIBROIDS:\n\nFibroid burden: 5\nFibroid enhancement: Heterogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n1.      none\n\n\nThe three dominant fibroids are:\n1.      size 7.0 x 6.3 x 6.7 cm heterogeneous enhancement, likely hyaline\ndegeneration, 100 % intramural, right fundal (8; 15).\n2.      size 3.0 x 4.5 x 4.5 cm heterogeneous, exophytic subserosal, left\nfundal (8; 14).\n3.      size 1.1 x 1.2 x 1.5 cm homogeneous, exophytic subserosal, left\nposterior wall.\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nRight ovary is normal size with normal follicular activity bilaterally.  The\nleft ovary contains a 1.8 x 4.3 x 3.1 cm simple cyst (4; 27), likely\nphysiologic.\n\nThere is mild pelvic ascites.",
            "output": "1. Multiple uterine fibroids, the largest is 7.0 cm right fundal intramural\nfibroid with heterogeneous enhancement, likely hilar degeneration.\n2. 4.3 cm simple left ovarian cyst, likely physiologic."
        },
        {
            "input": "Artifact from brachytherapy seeds mildly limits evaluation in the pelvis.\n\nThere has been interval enlargement of a T2 heterogeneous rim enhancing\nnecrotic mass centered along the posterior prostate with both low rectal and\nleft obturator internus muscle invasion.  Mass rectal component measures 3.9 x\n4.6 cm, previously 2.3 x 3.5 cm (Series 11, image 38).  Left obturator\ninternus component measures 3.2 x 8.2 cm, previously 2.8 x 6.9 cm (series 11,\nimage 43).  There is new tumor extension into the obturator externus muscle\n(series 11, image 54).  Necrotic mass extends to the posterior bladder wall\nwith bladder wall thickening and hyperenhancement, also concerning for tumor\nextension (series 11, image 38).\n\n Markedly enlarged necrotic pelvic sidewall and mesorectal lymphadenopathy has\nincreased in size.  Largest lymph node conglomerate now measure 2.8 and 2.1 cm\ninvolving the right and left pelvic sidewall, previously 1.8 and previously\nnot seen on the prior examination, respectively (series 11, image 20, 17).\n\nThere is a an apparent tract extending from the lower portion of the necrotic\nmass at the anorectal junction at the 4 o'clock position which connects to a\n1.3 x 3.5 cm T2 hyperintense rim enhancing collection in the left gluteal\ncleft, which is new from ___ (series 11, image 56).  There is marked\nedema and abnormal enhancement involving the left greater than right gluteal\nclefts.\n\nPelvic vasculature is patent.  There is small volume ascites.\n\nNo suspicious osseous lesions are seen.  No evidence of osteomyelitis.",
            "output": "1. Necrotic mass centered along the posterior prostate with rectal and left\nobturator externus/internus involvement and also concern for posterior bladder\nwall invasion, significantly increased in size compared to ___. The \nfindings are consistent with progression of locally-invasive disease.\nSuperinfection of the mass is a possibility but cannot be confirmed with\nimaging alone.  Please note that MRI is limited for evaluation of gas.\n2. Fistula extending from the lower aspect of the necrotic mass at the 4:00\nposition of the anorectal junction, connecting to a 1.3 x 3.5 cm left gluteal\nrim enhancing fluid collection, new since ___,  concerning for\nabscess given the patient's infectious symptoms. Underlying neoplastic\ninvolvement cannot be excluded.\n3. Worsening pelvic sidewall and mesorectal lymphadenopathy.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 4:01 pm, 5 minutes after\ndiscovery of the findings."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\nArising approximately 4.5 cm from the anal verge is an irregular, enhancing\nintraluminal mass within the rectal cuff appearing to arise inferior to the\nJ-pouch (series 6, image 10 and series 12, image 58).  The mass extends to\napproximately 9.4 cm past the anal verge.  The inferior extent of the mass\nappears to be contacting involving the internal sphincter (series 9, image\n19).  There is haziness and low T2 signal along the left lateral aspect of the\ninvolved rectal wall, with low signal extending into the adjacent mesorectal\nfat just medial to the left levator ani, concerning for extramural extension,\nrepresenting T3 disease (series 8 image 16). At least two (2) posterior\nperirectal nodes measure up to 6 mm and are abnormal in morphology, appearing\nrounded, and demonstrate enhancement following contrast administration (series\n12, image 57 and image 47, as well as series 5, images 20 and 26).  The more\nposterior node is approximately 3 mm from the closest aspect of the mesorectal\nfascia as measured from its closest margin (series 8, image 10).  These\nfindings are concerning for T3, N1 disease.\n\nDistance from anal verge (AV) (mm): 45\nExtends cranio-caudally (CC) (mm):  94\n\nSTAGING\nInvading tumor edge: From 3 o'clock to 6 o'clock\nMuscularis propria:  extends through\nExtramural spread (mm):  3\nExtramural venous invasion (EMVI):  no\nAdjacent pelvic organs ___, prostate, vagina): Not involved.  Specifically,\nleft posterolateral mesorectal fat haziness and T2 hypointense signal extends\nto the left aspect of the CRM (series 8 image 16), and abuts the medial edge\nof the left levator ani without invasion.\n\nFOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN\nIntersphincteric plane:  invaded\n\nClosest CRM (Circumferential resection margin) at: 3 o'clock by tumor.\n\nMinimum tumor distance to MRF:  less than or equal to 1 mm.\n\nMesorectal lymph nodes - Size (mm): >5mm\nMesorectal lymph nodes - location: above tumor (series 9, image 24).\nMesorectal lymph nodes - heterogeneous signal: no\nMesorectal lymph nodes - capsular irregularity: no\nMesorectal lymph nodes:  N1 (< 4)\n\nStaging Assessment: T3\nCRM:   involved\nEMVI:  negative\nLocation: low rectal tumor\nNodal:  N1\n\nBLADDER AND DISTAL URETERS: The bladder internal ureters are unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate is normal.\n\nLYMPH NODES: There is no iliac chain or inguinal lymphadenopathy.  Prominent\nmesorectal/perirectal nodes measuring up to 6 mm demonstrate abnormal, rounded\nmorphology, as detailed above.\n\nVASCULATURE: The imaged iliac and proximal femoral vasculature is patent and\nunremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious foci of abnormal marrow\nsignal are seen.",
            "output": "Irregular, enhancing intraluminal mass arising from the left posterolateral\nrectal cuff, extending from a 4.5 - 9.4 cm from the anal verge, consistent\nwith biopsy-proven adenocarcinoma.  The mass involves the internal anal\nsphincter and demonstrates left extramural extension to within 1 mm of the\nCRM.  Multiple nodes measuring up to 6 mm are abnormally rounded in\nmorphology, and are seen within 3 mm of the adjacent mesorectal fascia. \nOverall, findings consistent with T3 N1 disease."
        },
        {
            "input": "LYMPH NODES: No enlarged inguinal lymph node. No enlarged pelvic lymph node.\n\nBLADDER: Bladder is moderately distended. Bladder wall is of normal thickness.\n\nRECTUM AND INTRAPELVIC BOWEL:  Postsurgical changes noted at the rectum with a\n1.9 x 1.3 cm seroma at the surgical site. This seroma contains air-fluid level\nand tracks inferiorly through the right gluteal fold subcutaneous fat and\nlikely has a thin connection with the skin surface.\n\nSuperior to this in the presacral space there is a 1.8 x 1.4 cm stellate T2\ndark mass with tethering of the adjacent small bowel which appears to be post\nsurgical in nature.  There is no nodular component highly concerning for\nrecurrent disease.  Exam is limited due to lack of postcontrast images.\n\nVASCULATURE: Aortoiliac vessels are patent and of normal caliber.\n\nOSSEOUS STRUCTURES: No concerning osseous lesion.",
            "output": "1. Incomplete exam due to lack of post contrast images. Radiology technologist\nrecorded that  8 mL of Gadavist was administered through an existing port\nhowever there are no post contrast images. Patient will be contacted and\ninstructed to return to the department for contrast-enhanced imaging at no\ncost.\n\n2.  Postsurgical changes noted at the rectum with a 1.9 x 1.3 cm seroma at the\nsurgical site. Superior to this in the presacral space there is a 1.8 x 1.4 cm\nstellate T2 dark mass with tethering of the adjacent small bowel which appears\nto be post surgical in nature.  There is no nodular component highly\nconcerning for recurrent disease.  Exam is limited due to lack of postcontrast\nimages.\n\n3. No lymphadenopathy and no concerning bone lesion."
        },
        {
            "input": "1.9 x 1.3 cm seroma at the surgical site shows rim enhancement without central\nenhancement.\n\n1.8 x 1.4 cm stellate low T2 signal soft tissue in the presacral space shows\nminimal linear ill-defined enhancement on the arterial phase with some\nprogressive enhancement consistent with surgical changes and scar.  No nodular\nenhancement is noted.  These findings likely represent postsurgical fibrosis\nhowever the presence of small amounts of residual tumor is not entirely\nexcluded.  Recommend continued follow up.\n\nBone marrow signal of pelvis is somewhat heterogenous. There is a 4 mm rounded\nfocus of enhancement in the right femoral intertrochanteric region which is\nindeterminate and not evaluated on the prior MRI from ___ due to\ndifferences in the field of view.  There is no correlate on the CT performed\non ___ to account for this finding.\n\nThere is a 9 mm focus of enhancement within the left sacral ala which is\nunchanged when compared to ___.  There is no correlate on\nprecontrast T1 weighted or T2 weighted images.\n\nThere is a 2 cm geographic area of enhancement in the left supra-acetabular\nbone marrow which is new when compared to ___ which also does\nnot have a CT correlate and is indeterminate.",
            "output": "1.   Today's exam is regarding contrast enhancement characteristics only as\ncontrast was not administered on ___. Refer to noncontrast MRI from\n___ for complete evaluation.\n\n2.  The 1.8 x 1.4 cm stellate low T2 signal soft tissue in the presacral space\nshows minimal linear ill-defined enhancement on the arterial phase with some\nprogressive enhancement consistent with surgical changes and scarring.  No\nnodular enhancement is noted. These findings likely represent postsurgical\nfibrosis however the presence of small amounts of residual tumor is not\nentirely excluded.  Recommend continued follow up.  PET-CT may be helpful in\ndistinguishing fibrosis from residual tumor if clinically indicated.\n\n3.  There are 3 osseous lesions as described above including a 4 mm enhancing\nfocus in the right femoral intertrochanteric region (this is of indeterminate\nchronicity as the prior MRI from ___ did not include this area\nin the field of view), a 9 mm focus of enhancement in the left sacral ala\nwhich is unchanged compared to ___, and a 2 cm geographic area\nof enhancement in the left supra-acetabular region which is new from prior. \nThese lesions are indeterminate but could represent metastatic foci. \nAttention on followup imaging is recommended.  Dedicated MSK-MRI of the pelvis\nor PET-CT could be performed for further evaluation if clinically indicated."
        },
        {
            "input": "2.7 x 2.4 cm seroma at the inferior aspect of the surgical site shows rim\nenhancement without central enhancement containing internal gas.  This seroma\nextends inferiorly to abut the skin surface.\n\nStellate low T2 signal soft tissue in the presacral space shows minimal linear\nill-defined enhancement on the arterial phase with some progressive\nenhancement without nodular enhancement.  This presacral soft tissue is not\nchanged in size or morphology when compared to prior.  Exact measurements are\ndifficult due to irregular morphology. This soft tissue contacts the right vas\ndeferens, the seminal vesicles, and a loop of small bowel with some tethering\nof the structures.  There is U-shaped soft tissue at the superior aspect of\nthis presacral space soft tissue which is unchanged in size or morphology from\nprior.  It demonstrates intermediate low signal on T2 weighted images, low\nsignal on T1 weighted images, and high signal on the diffusion-weighted images\n(3:21, 4:18, 09:18, 9:64), the high signal on diffusion-weighted images is new\nfrom prior.  This may be artifactual due to susceptibility artifact as there\nis a loop of bowel tethered to the U-shaped soft tissue however recurrent\ndisease is a possibility.  PET-CT could be performed for further evaluation.\n\nBone marrow signal of pelvis is somewhat heterogenous.  Again seen is a 4 mm\nrounded focus of enhancement in the right femoral intertrochanteric region\nwhich is unchanged from prior.\n\nThere are 2 lesions within the left sacral ala (4:13, 16), the more superior\nlesion was well seen on the prior exam.  These demonstrate high signal on T2\nweighted images and internal punctate foci of high signal on T1 weighted\nimages and are consistent with hemangiomas.  These are not increased in size\nwhen compared to prior.  These measure 9 mm (04:13) and 8 mm (04:16).\n\nPreviously seen 2 cm geographic area of abnormal signal on diffusion-weighted\nimaging and to a lesser degree postcontrast images in the left\nsupra-acetabular bone marrow is essentially resolved on today's exam, this was\nwas likely reactive bone marrow due to degenerative changes.\n\nBladder mucosa enhances prominently, likely post radiation change/cystitis.",
            "output": "1. Stellate low T2 signal soft tissue in the presacral space is not changed in\nsize or morphology when compared to prior. There is U-shaped soft tissue at\nthe superior most aspect of this presacral space soft tissue which\ndemonstrates new high signal on the diffusion-weighted images which may be\nartifactual due to susceptibility artifact as there is a loop of bowel\ntethered to the U-shaped soft tissue however residual/recurrent disease is not\nexcluded. PET-CT could be performed for further evaluation.\n\n2. Previously seen 2 cm geographic area of abnormal signal on\ndiffusion-weighted imaging and to a lesser degree postcontrast images in the\nleft supra-acetabular bone marrow is essentially resolved on today's exam,\nthis was was likely reactive bone marrow due to degenerative changes.\n\n3. Unchanged 4 mm enhancing focus in the right femoral intertrochanteric\nregion. Attention on followup imaging is recommended.\n\n4.  There are 2 lesions within the left sacral ala with signal characteristics\nconsistent with hemangiomas.  The more superior lesion measures 9 mm and is\nunchanged in size from prior.  The more inferior lesion measures 8 mm and was\nnot as well seen on the previous exam.\n\nRECOMMENDATION(S):  PET-CT to further evaluate the U shaped soft tissue at the\nsuperior aspect of the presacral space stellate soft tissue area which is\noverall unchanged in size and morphology but demonstrates new high signal on\ndiffusion-weighted imaging.\n\nNOTIFICATION:   The impression and recommendation above was entered by Dr.\n___ on ___ at 10:18 into the Department of Radiology\ncritical communications system for direct communication to the referring\nprovider."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and enlarged measuring 15.3 x 6.9 x 10.2 cm. \nInnumerable uterine fibroids are seen in the intramural, subserosal locations,\nshowing heterogenous T2 signal.  There is no evidence of internal hemorrhage. \nOn the postcontrast phase these fibroids demonstrate heterogeneous enhancement\nwith central nonenhancing areas which may represent cystic degeneration. \nIndex ones as described below:\n\n-Intramural fibroid in the posterior uterine body on the left measuring 4.4 x\n4.2 cm (series 6 image 22).\n-Intramural fibroid in the lateral aspect on the left measuring 3.6 x 3.2 cm\n(series 6 image 18).\n-Anterior subserosal location measuring 2.6 x 2.3 cm.\n\nThe fibroids are causing the formation of the endometrial canal which measures\napproximately 5 mm in maximum ___.  The junctional zone is not\nthickened.\n\nThe right ovary is visualized and shows a simple nonenhancing cyst measuring\nup to 3.2 x 2.3 cm, stable.  The left ovary is visualized and shows normal\nfollicular activity.  Both ovaries show normal appearance and position with no\nevidence to suggest ovarian torsion.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No pathologically enlarged pelvic lymph nodes seen.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is within normal limits.  No\nhydroureter.\n\nRECTUM AND INTRAPELVIC BOWEL: The visualized bowel loops are normal in\ncaliber.\n\nVASCULATURE: The iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No abnormal marrow signal seen.",
            "output": "1. Normal appearance of both ovaries, no evidence to suggest ovarian torsion.\n2. Bulky uterus with innumerable fibroids as described above."
        },
        {
            "input": "Please note that comparison to the prior study is slightly difficult due to\ndifferences in protocol.\n\nUTERUS:\nThe uterus is anteverted, measuring 11.9 x 6.2 x 7.3 cm, previously measuring\n15.3 x 6.9 x 10.1 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Endometrium is distorted by fibroids, but not thickened and\nmeasures 4 mm.\nJunctional zone: The junctional zone is partially distorted by fibroids, but\nnot thickened.\n\nFIBROIDS:\n\nFibroid burden: ___\nFibroid enhancement: Heterogeneous\n\nThe three dominant fibroids are:\n1.      size 3.1 x 3.0 x 2.7 cm mild heterogeneous enhancement, predominantly\nintramural, with less than 50% submucosal component, posterior lower uterine\nsegment (03:14).  This has decreased in size compared to the prior MRI in\n___, where it measured 4.2 x 3.9 x 2.8 cm.\n2.      size 2.5 x 2.4 x 2.4 cm no internal enhancement, 100 % intramural,\nleft posterior lower uterine segment (03:14).  This has also decreased in size\ncompared to the prior study.\n3.      size 2.0 x 1.5 x 2.0 cm mild heterogeneous, 100 % intramural, right\nposterior mid uterus (03:12).\n\nNo cornual or cervical fibroids are detected.\n\nThere are gonadal vessels supplying the uterus (13:8).\n\nThere is trace free fluid in the pelvis.",
            "output": "Overall decreased size of fibroid uterus, with some fibroids showing decreased\nor lack of enhancement.  However, there remain several fibroids that\ndemonstrate persistent heterogeneous enhancement.  There is suggestion of\nvascular supply by the gonadal vessels."
        },
        {
            "input": "There is no acute fracture or dislocation seen.  There is a trace left hip\njoint effusion.  There is no evidence for osteomyelitis.  Study is not\noptimized for evaluation of the acetabular labrum.There is extensive muscular\nedema involving the left gluteal musculature, most pronounced in the gluteus\nminimus and medius and to lesser extent the mid to inferior aspect of the\ngluteus maximus, piriformis and obturator internus.  There is associated rim\nenhancement, including a 3.9 x 6.4 x 8.9 cm geographic area centered within\nthe gluteus minimus and medius with relative internal ___, and\nmore inferiorly in the lateral gluteus maximus a 2.3 x 3.7 by 3.5 cm rim\nenhancing geographic region with relative internal ___, which are\nconcerning for areas of myonecrosis.  There is no drainable fluid collection\nor abscess seen.There is mild intermuscular fascial edema tracking along the\nproximal thigh distally, without significant hyperenhancement.  The visualized\nintrapelvic contents are unremarkable.",
            "output": "1. Extensive intramuscular edema centered in the gluteal musculature\nconcerning for myositis, inflammatory/infectious versus traumatic, with\nassociated large geographic area of rim enhancement and internal\n___ centered in the gluteus medius and minimus, and smaller area\nwithin the lateral gluteus maximus which are concerning for areas of\nmyonecrosis.  No drainable fluid collection or rim enhancing abscess seen.\n2. Trace left hip joint effusion.  No evidence for osteomyelitis."
        },
        {
            "input": "UTERUS:\nThe enlarged uterus is anteverted, measuring 13.8 x 18.1 x 12.3 cm.  The\nenlarged anteverted uterus exerts mass effect on the urinary bladder with\ncompression of the dome of the bladder (03:11).\n\nEndometrium: Homogeneous, measuring 4 mm\nJunctional zone: 4 mm without focal thickening.\n\nFIBROIDS:\nFibroid burden: 1\nFibroid enhancement: None\n Occupying and expanding the posterior uterine wall extending from the fundus\nto the lower uterine segment is a large circumscribed 13.0 x 10.4 x 11.9 cm\nheterogeneous T2 hyperintense intramural mass with heterogeneous central T2\nhypointense areas.  This mass demonstrates an intrinsic T1 hyperintense rim\n(4:16, 3:13, 10:44), and findings are compatible with red/carneous\ndegeneration of the fibroid, with no internal enhancement on postcontrast\nimages.  This fibroid demonstrates no restricted diffusion.\n\nNo cornual or cervical fibroids are detected.\n\nOVARIES:\nNormal size with normal follicular activity bilaterally.  Corpus luteum is\nnoted within the left ovary.\n\nThere is a physiologic amount of intrapelvic free fluid.",
            "output": "1. Markedly enlarged uterus containing a single large circumscribed 11.9 cm\nposterior intramural non-enhancing fibroid with red/carneous degeneration.\n2. Normal homogeneous 4 mm endometrium.\n3. No evidence of adenomyosis.\n4. Normal right and left ovaries.\n5. Trace physiologic free fluid in pelvis."
        },
        {
            "input": "ANUS:  There is a shallow tract that courses anteriorly from 12 o'clock\nposition (series 802, image 88) at the level of the external anal opening\ncoursing along the gluteal cleft, with enhancement and no evidence of a patent\ntrack, that likely represents either a low fissure or a blind ending tract.\n\nRevisualization of an anovaginal fistula arising 2 cm proximal to the anal\nverge at the right anterior anus at approximately 11 o'clock position (series\n802, image 69) with a transsphincteric course to the posterior vagina.  There\nis mild granulation tissue within the fistulous tract with T2 hyperintense\nsignal and linear enhancement, however no abscess collection.\n\nThere is inflammatory enhancement in the intersphincteric space in a horseshoe\ndistribution as seen on the prior study approximately 4 cm proximal to the\nanal verge.  The prior study demonstrated a mucosal opening at approximately 3\no'clock position which is less well depicted on today's examination.  There is\nalso mild enhancement within the fistulous tract which may represent\ngranulation tissue.  No abscess collection identified.\n\nThere is no air in the bladder or secondary signs of an anovesicular fistula.\n\nNote ischianal or ischiorectal abscess collections.  No supralevator disease.\n\nRECTUM AND INTRAPELVIC BOWEL: Normal caliber with no signs of active\ninflammatory disease.\n\nBLADDER AND DISTAL URETERS: No air in the bladder or signs of bladder wall\nthickening.  The distal ureters are normal.\n\nUTERUS AND OVARIES:  The uterus is in neutral position.  The junctional zone\nis indistinct and thickened consistent with adenomyosis.  It measures 6.4 x\n2.8 x 4.8 cm.  No adnexal masses.\n\nLYMPH NODES: No size significant intrapelvic lymphadenopathy.\n\nVASCULATURE: Within normal limits.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue\nlesions.",
            "output": "1.  Persistent anovaginal simple transsphincteric fistula tract as described\nabove with granulation tissue.  No abscess collections.\n\n2.  Intersphincteric inflammatory enhancement in a horseshoe distribution as\ndescribed above with no abscess collections.  Low blind-ending track or\nfissure at the external anal opening anteriorly.\n\n3.  No signs of anovesicular fistula."
        },
        {
            "input": "This is a limited study due to the specifics of contrast administration\n\nRECTUM AND INTRAPELVIC BOWEL:\nThe previously visualized anovaginal fistula is again noted (6:32).  It begins\n2 cm proximal to the anal verge with a transsphincteric course from the\nanterior anus to the posterior vagina. No abscess collection.\n\nThere is a complicated branching intersphincteric perianal fistula. It begins\nas an skin level opening at the 6 o'clock position (with the patient in supine\nposition) relative to the anal canal (902:109). It then ascends cranially\nuntil it bifurcates (902:93).  The left branch then bifurcates again (902:87)\nand forms a phlegmon (902:83).  A fistula tract then descends from this fluid\ncollection back towards the anal verge, forming a skin opening at the 3\no'clock position (902:109). This fistula system appears to be in the\nintersphincteric space and involving the internal sphincter. There is no\nsupralevator involvement.\n\nThe visualized small bowel, colon demonstrate remarkable caliber and wall\nthickness.  No bowel obstruction.\n\nBLADDER AND DISTAL URETERS:\nThe bladder is distended with no air within to suggest presence of a\ncommunicating fistula. The distal ureters are unremarkable.\n\nUTERUS AND OVARIES:\nThe uterus is anteverted and measures 4.9 x 2.9 x 6.8 cm, which is grossly\nunchanged from prior. The junctional zone margin is poorly visualized but\nappears thickened, compatible with known adenomyosis.  There are multiple\nsubcentimeter T2 hyperintense lesions within the uterus, most compatible with\nheterotrophic endometrial glands.\n\nLYMPH NODES:\nNo significant mesorectal lymphadenopathy.\n\nVASCULATURE:\nConventional iliac vasculature branching that are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES:\nNo osseous or soft tissue focal lesions with suspicious features.",
            "output": "Branching intersphincteric perianal fistula also involving the internal\nsphincter as described above without definitive abscess formation visualized. \nThere is no supralevator involvement.  Compared to the prior study from ___,\nthere is slightly increased inferior extent, surfacing to the gluteal skin\nsurface, but the morphology of the fistula complex is otherwise largely\nsimilar."
        },
        {
            "input": "MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:\n\nThere is extensive circumferential submucosal rectal and sigmoid wall\nthickening and fat deposition, demonstrating high signal intensity on T1 and\nT2 weighted precontrast images (series 2, image 11), compatible with known\nchronic ulcerative colitis.\n\nArising from the left aspect of the rectum, approximately 5 cm above the anal\nverge, is a 7 mm wide and 4 mm thick mucosal mass demonstrating contrast\nenhancement (series 9, image 46), with mild subjacent signal intensity\nirregularity contained within the submucosa, possibly relating to a vascular\npedicle (series 3, image 22). The muscularis propria is intact.\n\nA tiny perianal fistula extends just above the anal verge, arising from the 2\no'clock aspect (lithotomy orientation) and abutting the inferiormost aspect of\nthe internal sphincter, extending anteriorly and appearing to exit the left\nperineum (series 11, image 69). The track demonstrates mild adjacent soft\ntissue enhancement and contains minimal internal fluid denoted by a high\nsignal intensity on T2 weighted sequences (series 3, image 36).\n\nNumerous prominent posterior mesorectal lymph nodes at the level of the lesion\n(series 3, image 19, 18) measure up to 5 mm along the short axis, not possible\nto differentiate between IBD-reactive versus neoplastic process.\n\nIncluded views of the intrapelvic small bowel are normal. There is no\nintrapelvic free fluid.\n\nThe uterus is normal. No adnexal masses are detected. The bladder wall is\nthin.\n\nThere are no bony lesions concerning for malignancy or infection.",
            "output": "1. 7 mm wide, 4 mm thick, mucosal mass at the left aspect of the lower rectum,\n5 cm above the anal verge, with equivocal submucosal component, no greater\nthan T1 disease.\n2. Small, simple intersphincteric perianal fistula, arising from the 2 o'clock\naspect just above the anal verge, approaching but may not exit just anterior\nto left anal orifice. No fluid collection.\n3. Numerous posterior mesorectal lymph nodes are likely related to ulcerative\ncolitis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and retroflexed.  The uterus is enlarged with\nmultiple enhancing fibroids, measuring 12 x 4.7 x 6.9 cm.\n\nThe dominant fibroid is intramural, measuring 2.5 x 1.9 cm in the left fundus\nanteriorly and has moderate enhancement (series 4, image 13).  There is a 1.9\ncm exophytic fibroid arising from the right posterior wall (series 4, image 7;\nseries 3, image 17).  There is a 2.5 cm intramural fibroid in the lower\nuterine segment posteriorly (series 3, image 25; series 4, image 15).  There\nis an 1.4-cm intramural fibroid with less than 50% submucosal component in the\nleft posterior uterus (series 3, image 24; series 1201, image 91).\n\nThe endometrium measures up to 7 mm (series 3, image 22).\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and has a simple-appearing, thin-walled,\nnonenhancing cystic structure measuring 1.4 cm, overall similar in size to the\nprior CT (series 5, image 17) and may have been under measured on the prior\nultrasound.\nThe left ovary is visualized and appears within normal limits.\n\nThere is no free fluid in the pelvis.Tiny hemorrhagic or proteinaceous\nnabothian cyst is incidentally noted.\n\nLYMPH NODES: No pelvic or inguinal lymphadenopathy by CT size criteria.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is partially distended within\nnormal limits.  The distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Colonic diverticulosis is moderate.  The rectum\nand remaining imaged large bowel are relatively decompressed and unremarkable.\n\nVASCULATURE: The imaged iliac vessels are patent and normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous lesions suspicious for\nmalignancy.  Multilevel degenerative changes in the imaged lower lumbar and\nsacral spine are moderate.  Right fat containing inguinal hernia and umbilical\nhernia are small (series 18, image 9).",
            "output": "1.  Enlarged uterus with multiple enhancing fibroids, measuring up to 2.5 cm\nas above, including an 1.4-cm intramural fibroid with less than 50% submucosal\ncomponent.\n\n2.  1.4 cm right ovarian cyst, unchanged from ___.  Given\npostmenopausal status in size greater than 1 cm, follow-up pelvic ultrasound\nin ___ year is recommended.\n\nRECOMMENDATION(S):  Pelvic ultrasound in ___ year for right adnexal cyst.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 15:22 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "The postpartum uterus is enlarged measuring 14.0 x 6.7 x 7.8 cm.  The\nendometrial cavity is distended with mildly complex fluid which is slightly\nheterogeneously hyperintense on T1 weighted sequences and hypointense on T2\nweighted sequences compatible blood and contains enhancing material adherent\nto the posterior wall, measuring 5.0 x 1.7 cm (13:47, 1203:29). There is no\nearly venous filling to suggest arterial venous fistula.\nIn the right fundus there is 4.5 x 3.1 cm intramural/subserosal mass, which\nfollows the signal of the myometrium on all sequences. There are bridging\nvessels between the myometrium and the mass, findings consistent with a\nfibroid.\nThere are several nabothian cysts in the cervix.\n\nBoth ovaries are well visualized and are normal in size and appearance without\nevidence of mass. What is seen of the ovarian arteries and veins bilaterally\nare patent. There is minimal free fluid in the pelvis. The partially distended\nbladder is grossly unremarkable. The visualized bowel loops are within normal\nlimits. There is no significant pelvic or inguinal lymphadenopathy. The\nosseous structures are unremarkable.",
            "output": "1. Enhancing endometrial material, consistent with retained products of\nconception, measuring up to 5.0 x 1.7 cm. No evidence of arteriovenous\nfistula.\n2. Uterine fibroid on the right.\n3. Patent distal ovarian vessels bilaterally.\n4. Small amount of free fluid in the pelvis without a focal collection."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 3.8 x 3.2 x 7.5 cm.  There is a punctate\nnonenhancing T1 hyperintense, T2 hypointense focus within the endometrium\n(10:66, ___ which may represent a small blood clot in the setting of a\npremenopausal patient.  No evidence of adenomyosis.\nThe endometrium is normal in thickness for age and measures 6 mm.\nThe junctional zone is not thickened.\n\nThe right ovary contains a 4.1 x 5.0 x 4.6 cm multiloculated nonenhancing,\ncystic lesion arising from the right ovary with thin nonenhancing septations\nalong the smaller loculations (05:12).  This lesion is relatively stable in\nsize compared to CT from ___.  There is no evidence of concerning\nfeatures such as thickened irregular enhancing septations, nodular\nenhancement, or internal signal heterogeneity.  There is no evidence of\nintrinsic T1 hyperintensity within the cystic lesions to suggest endometrioma.\n\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No inguinal or pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: No evidence of obstruction of the partially\nimaged bowel loops.  There is diverticulosis of the sigmoid colon.  No\nevidence of diverticulitis.\n\nVASCULATURE: Imaged vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous lesions.  Soft\ntissues are unremarkable.",
            "output": "1. Stable in size since ___, is a 4.6 x 5.0 cm multiloculated\nnonenhancing cystic lesion arising from the right ovary without concerning\nenhancing features, likely representing a benign epithelial neoplasm such as a\nserous cystadenoma.\n2. Punctate T1 hyperintense focus in the endometrium likely represents a tiny\nblood clot.\n3. No evidence of deep pelvic endometriosis or adenomyosis.\n4. Normal left ovary.  Trace physiologic free fluid.\n5. No pelvic lymphadenopathy.\n6. Colonic diverticulosis."
        },
        {
            "input": "There is diffuse patchy heterogeneity of the bone marrow, without a discrete\nfocal mass.  There is no pathologic fractures.\n\nPartially visualized levoscoliosis of the lumbar spine.  Stable compression\nfracture of L4.  Stable grade II anterolisthesis of L5 in respect to S1 with\nsevere loss of intravertebral disc space, better evaluated on prior MRI lumbar\nspine.\n\nLimited evaluation of the hip and sacroiliac joints are unremarkable.  Fluid\nat the right greater the left hamstring origins could either lie within the\nbursa or, on the right, could reflect a nonacute partial tendon tear. \n(03:33).\n\nLimited assessment of intrapelvic soft tissue structures is grossly\nunremarkable.",
            "output": "1.  Diffuse patchy heterogeneity of the bone marrow without discrete focal\nmass.  No acute fracture.\n\n2.  Stable compression fracture of L4 and grade 2 anterolisthesis of L5\nrespect S1.  This finding is noted on the sagittal localizer images and is\nbetter seen on prior MRI lumbar spine.\n\ns"
        },
        {
            "input": "There is a background of heterogeneous red marrow throughout the lower lumbar\nspine, pelvis and proximal femurs.  On top of this there are innumerable\nsmall, subcentimeter T1 dark, T2 bright foci, scattered throughout the pelvis,\nand bilateral proximal femurs, the largest 7 mm in the left femoral neck\n(04:15).\n\nThere is no evidence of avascular necrosis, fracture, stress fracture.  There\nis mild edema on opposing margins of the right sacroiliac joint, likely\ndegenerative.  (7:7) There is mild edema about the right greater trochanter at\nthe insertion of the hamstring tendons (09:12).  There is mild edema at the\norigin of the hamstring tendons, trace on the right and mild on the left\n(03:24).\n\nLimited assessment of intra-pelvic soft tissue structures reveals moderate\nfecal loading with notable amount of retained stool in the cecum and ascending\ncolon.  There is a small calcified uterine fibroid (07:12).\n\nCollapse of the L4 vertebral body is grossly unchanged since the skeletal\nsurvey ___.  There is grade 2 anterolisthesis of L5 on S1.  Posterior\ndisc osteophyte complex at L4-L5 causes mild central canal narrowing.  These\nfindings are better assessed on previous MRI of the spine.",
            "output": "1. Innumerable subcentimeter T1 dark, T2 bright scattered foci throughout the\npelvis and proximal femurs the largest 7 mm, on a background of heterogeneous\nred marrow worrisome for multiple myelomatous lesions.  This is substantially\nprogressed since ___.\n2. Collapse of L4 vertebral body and grade 2 anterolisthesis of L5 on S1 is\nunchanged, better assessed on previous MRI of the spine\n3. Mild hamstring tendinosis, left greater than right.  Mild right greater\ntrochanteric bursitis.  Mild edema around the right SI joint is likely\ndegenerative."
        },
        {
            "input": "The study is degraded by motion artifact limiting the evaluation.\n\nThere is extensive T1 hypointense signal involving the right and left aspects\nof the sacrum, and associated STIR hyperintensity.  On STIR coronal images\nthere are vertical curvilinear lines on the right and left aspects of the\nsacrum compatible with non-displaced fractures (07:26).  Signal abnormality\nextends across the midline.  There is stable degenerative signal change along\nthe right iliac side of the sacroiliac joint.\n\nThere is also a new T1 hypointense, STIR hyperintense signal in the right\npubic bone (04:27) with vertically oriented fracture line (05:26) paralleling\nthe pubic symphysis compatible with nondisplaced fracture.\n\nAs on the prior study of ___ there is a background of multiple T1\ndark rounded lesions throughout the pelvis and upper femurs, for example, 8 mm\nlesion in the left femoral neck, unchanged (06:18).\n\nThere are unchanged mild to moderate degenerative changes in both hips.  There\nis no evidence of greater trochanteric bursitis.  There is a small partial\ntear at the right hamstring origin. There is re- demonstration of fatty\natrophy of the bilateral erector spinae muscles.\n\nAs before there is moderate to severe collapse of the superior endplate of L4\nand anterolisthesis of L5 on S1.  Degenerative discogenic change was better\nassessed on previous spine MRI ___.\n\nThere are calcified uterine fibroids as before.  No frank free fluid in the\npelvis.",
            "output": "1. Stress fractures of bilateral sacral ala and midline sacrum, as\ndemonstrated on prior CT.\n2. New stress fracture of the right pubic bone.\n3. Background of small rounded bone marrow lesions compatible with history of\nmultiple myeloma similar to the prior MRI of ___.\n4. Partial tear at the origin of the right hamstring."
        },
        {
            "input": "ANUS AND RECTUM: At the mid third of the sphincter, 2.3 cm above the anal\nverge, a fistulous opening is noted at the 6 o'clock position forming a small\nhorseshoe shaped (802:36) sliver of fluid within the deeper aspect of the\ninternal sphincter/intersphincteric space and coursing inferiorly in the\nintersphincteric plane until exiting through the midline between both gluteal\nfolds.\n\nNumber of fistulas: 1\n\nINTERNAL ANAL OPENING:\n\nLocation (quadrant and clock face) in supine position: Posterior at 6 o'clock\nDistance from anal verge: 2.3 cm\nRelation to the internal sphincter: Involving middle third of sphincter\n\nFISTULA TRACT:\n\nMaximum tract diameter:  2 mm\nFistula type (Parks classification):  Intersphincteric\nSecondary branches: At the internal opening the fistula takes a horseshoe\nshaped configuration which contains a sliver of nonenhancing fluid (1 mm in\ndiameter) being present within the deeper aspect of the internal\nsphincter/intersphincteric space.\nExit site: Midline, at the confluence of the gluteal folds\nHyperintensity of the tract on T2: Mild\nEnhancement of the tract: Central enhancement with high signal intensity on T2\ncompatible with granulation tissue along the intersphincteric tract\n\nOTHER FINDINGS:\n\n\n\nAbscess: Sliver of nonenhancing fluid at the internal opening as described\nabove\nRectal and sigmoid wall inflammation: No\nPresence of ___, drains or prior surgery: No\n\n\nUTERUS AND ADNEXA:\n\nPatient is status post partial hysterectomy.  The cervix remains, with\nnabothian cysts noted.  The ovaries are not in the field of view.\n\nLYMPH NODES: No inguinal or pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Urinary bladder is well distended and\nunremarkable. Distal ureters are not distended.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized rectum and large bowel loops are\nunremarkable.  The anus is within normal limits.  No perianal fistulas are\nidentified.\n\nVASCULATURE: Major vessels in the pelvis are normal in caliber and patent\nthroughout.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions or acute\nfractures.",
            "output": "Single intersphincteric perianal fistula, as described above."
        },
        {
            "input": "There is normal bony marrow signal.  There is no evidence of avascular\nnecrosis, fracture, stress fracture.  There is normal signal at the sacroiliac\njoints, without evidence of sacroiliitis.\n\nThere is no greater trochanteric bursitis.  There is right hamstring origin\ntendinosis and thinning of the origin of the left hamstring tendon, without\ndiscrete tear.  Though ischial bursitis identified.\n\nThere is discogenic degenerative change at the presumptive L4-5 intervertebral\nlevel, with endplate marrow edema marginal osteophytes and disc space\nnarrowing (series 4, image ___.\n\nA fibroid uterus is noted.  Otherwise, limited assessment of intra-pelvic soft\ntissue structures is grossly unremarkable.  No gross intrapelvic fluid or\nenlarged intrapelvic lymph nodes detected.",
            "output": "1.  No evidence of sacroiliitis, bursitis or gross degenerative change at the\nsacroiliac joints.  No evidence of sacral fracture.\n2.  Mild tendinosis of the right and mild attenuation of the left hamstring\ntendon origin, without discrete tendon tear or ischial bursitis.\n3.  Degenerative disc disease at L4-L5, within plate marrow edema, marginal\nspurring, and narrowing and desiccation of the intervertebral disc, not fully\nevaluated on this exam.\n4.  Fibroid uterus noted."
        },
        {
            "input": "Mild mural thickening of the left posteroinferior bladder wall with prominent\ntrabeculations, without discernible mass lesion (9, 17). This region\ndemonstrates mild increased postcontrast enhancement in comparison to the\nremainder of the bladder wall (14, 48).\n\nNo pelvic mass the is appreciated posterior to the bladder to explain findings\nof papillary edema.  There is atrophy of the left seminal vesicle, without\nclear of mass lesion.\n\nLarge field-of-view images of the prostate demonstrate scattered low T2\nhypointense foci within the peripheral zone, without obvious mass lesion.  BPH\nof the central gland is noted. Visualized rectum is grossly unremarkable.\n\nNo free pelvic fluid. No adenopathy within the visualized pelvis. Fat\ncontaining direct left inguinal hernia. No suspicious osseous lesions.",
            "output": "1.  Mild thickening, enhancement and prominent trabeculation of the left\nposteroinferior bladder wall is noted, nonspecific finding, possibly\nrepresenting inflammatory changes. No evident bladder mass or mass posterior\nto the bladder.\n\n2.  Mild atrophy of the left seminal vesicle.\n\n3.  No pelvic adenopathy."
        },
        {
            "input": "As seen previously, there is a midline sacral decubitus ulcer with abnormal\nreplacement of the subcutaneous fat (05:19) but no definite replacement of the\nunderlying bone marrow.  There is edema of the adjacent gluteal muscles\n(04:20), bilaterally, with associated hyper enhancement likely reflecting soft\ntissue infection (cellulitis and myositis).  There is a small fluid collection\nin the left gluteus maximus muscle measuring up to 1 cm, this appears to be\ncontiguous with the surface of the ulcer (10:22).\n\nThe visualized bone marrow is normal in signal intensity throughout.  There\nare mild degenerative changes in the bilateral hip joints.\n\nThere is edema in the right gluteal muscles, with what appears to be a tear of\nthe gluteus medius tendon distally (04:28).  There is diffuse fatty atrophy of\nvisualized musculature.  There is nonspecific edema within the adductor\nmuscles on the left without hyper enhancement, this may reflect denervation. \nSimilar but less are changes in the right adductor musculature.\n\nA Foley catheter is in-situ.  There is irregular thickening of the bladder\nwall, which may be due to a neurogenic bladder but cystitis cannot be\nexcluded.  There are fat containing inguinal hernias bilaterally, larger on\nthe left.  No free fluid in the pelvis.",
            "output": "1. Decubitus ulcer overlying the sacrum without definite evidence of\nosteomyelitis.  Adjacent soft tissue changes suggest cellulitis/myositis.\n2. Partial tear the gluteus medius tendon on the right.\n3. Diffuse fatty atrophy of the visualized musculature, diffuse nonspecific\nedema, likely reflecting denervation.\n4. Irregular bladder wall thickening may be related to a neurogenic bladder\nhowever cystitis cannot be excluded.\n5. Bilateral fat containing inguinal hernias."
        },
        {
            "input": "The study is somewhat limited by motion artifact, nonethelss, diagnostic\nimages were obtained.\n\nThere is abnormal signal intensity in the subcutaneous tissues and muscles\noverlying the right greater trochanter with   an area of nonenhancement \nmeasuring approximate 2.4 x 3.8 cm.  There is no fluid signal in the region of\nhypoenhancement, therefore this likely represents devitalized tissues and may\nbe at risk for development of an ulcer  (09:28).  There is no bone marrow\nsignal abnormality in the adjacent greater trochanter to suggest osteomyelitis\nin this region.  Additionally, there is an ulcer along the midline at the\nlevel of the distal sacrum/coccyx with a shallow defect and mild surrounding\nedema/hyperemia.  There is normal T1 signal in the distal sacrum/coccyx and \nno abnormal enhancement, making osteomyelitis unlikely.  There is no  fluid\ncollection.\n\nThe proximal femurs demonstrate normal shape and signal intensity without\nevidence of fracture, stress reaction, or avascular necrosis.  There is no\nsignificant hip joint effusion on either side.  The hamstring, gluteal, and\niliopsoas tendons are intact.  There is mild-to-moderate bilateral hamstring\ntendinosis.  There is bilateral symmetric feathery edema in the piriformis,\nadductor and gluteal musculature.  Moderate diffuse fatty atrophy of the\ngluteal musculature is also noted.\n\nIrregular thickening of the bladder wall may be related to under distention\nhowever cystitis cannot be excluded and should be clinically correlated. \nThere is no pelvic or inguinal lymphadenopathy.  There is no pelvic free\nfluid.",
            "output": "1. Midline skin ulceration at the level of the distal sacrum/coccyx with a\nshallow defect and mild surrounding edema/hyperemia.  No evidence of fluid\ncollection or osteomyelitis.\n2.  Devitalized tissue/scarring measuring approximately 2.4 x 3.8 cm overlying\nthe right greater trochanter may be at risk for development of an ulcer. \nThere is no drainable fluid collection or evidence of osteomyelitis in this\nregion.\n3. Mild-to-moderate bilateral hamstring tendinosis.\n4. Mild diffuse nonspecific edema in bilateral piriformis, adductor and\ngluteal musculature and moderate diffuse fatty atrophy of the gluteal\nmusculature.\n5. Irregular thickening of the bladder wall may be related to underdistention\nhowever cystitis cannot be excluded and should be clinically correlated."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 2.9 x 6.5 x 4.7 cm.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone measures 9 mm, in the upper limits of normal.\n\nIn the posterior cul-de-sac, abutting the rectum, sigmoid colon, and uterus,\nthere is extensive deep infiltrating endometriosis including kissing ovaries,\nextensive fibrosis and tethering of bowel increased compared to prior, and\nmultiple T1 bright lesions with T2 shading consistent with endometriomas, the\nlargest measuring 2.1 x 2.9 cm (4; 13), overall decreased in size compared to\n___.  There is extensive plaque formation and layering fluid in the region of\nthe left adnexa which may represent a hematosalpinx.\n\nNo suspicious lesions are seen arising from the endometriomas.\n\nMinimal pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: Prominent right pelvic sidewall lymph node measures to 0.6 cm in\nshort axis (1203; 25).  There is no inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters appear\nunremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: There is tethering the rectum and sigmoid colon\nin the posterior cul-de-sac.  No evidence bowel obstruction.\n\nVASCULATURE: No vascular abnormalities are identified.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is heterogeneous T1 and T2\nappearance of the right iliac bone measuring 2.0 x 2.7 cm is similar compared\nto prior, may represent post treatment change.\n\nPost kyphoplasty appearance of the L3 vertebral body is partially visualized.\n\nThere is a small fat containing umbilical hernia.",
            "output": "1. Extensive deep infiltrating endometriosis with overall increased fibrosis\nand obliteration of the posterior cul-de-sac and tethering of the bowel\ncompared to ___ but decreased sizes of the endometriomas, now measuring up to\n2.9 cm.  There may be left hematosalpinx.  No suspicious lesions are seen\narising from the endometriomas.\n2. Heterogeneous appearance of the right iliac bone is similar to prior."
        },
        {
            "input": "ANTERIOR COMPARTMENT: The prevesicular space, bladder, and distal ureters are\nunremarkable.\n\nUTERUS AND ADNEXA: The uterus is distorted and displaced anteriorly and to the\nright. The uterus is anteverted and measures 8.5 x 8 x 6.6 cm (series 2, image\n21; series 4, image 9).  There are two T2 hypointense submucosal fibroids\n(series 3, image 29).  There are multiple nabothian cysts seen within the\ncervix.  There is redemonstration of a left-sided Bartholin's gland cyst,\nwhich is increased in size compared to prior exam, now measuring up to 1.5 cm\n(series 8, image 47). Endometrium is normal in thickness for the patient's age\nand measures up to 8 mm (series 2, image 21). The junctional zone is top\nnormal, measuring up to 11 mm (series 2, image 22), suggestive of adenomyosis.\n\nIn the torus uterinus, there is an abnormally thickened T2 hypointense plaque\ncontaining punctate T2 hyperintense foci.  This plaque is causing tethering of\nthe large complex multi-loculated cystic structure.  Compared to prior exam,\nthere is increased cystic components in the right anterior pelvis, suggestive\nof progression of deep infiltrating endometriosis.\n\nAdditionally, again seen is and 11.1 x 8.0 x 8.8 cm (series 4, image 25;\nseries 3, image 24) (previously 11.7 x 0.1 x 9.6 cm) T2 hyperintense T1\nhypointense left adnexal mass, compatible with a left hydrosalpinx, not\nsignificantly changed compared to prior exam.  There is more prominent\nfrond-like enhancement noted along the anterior wall of this lesion,\nconcerning for malignant involvement.\n\nThere is thickening and abnormal signal within the right round ligament\n(series 3, image 28), suggestive of involvement.\n\nPOSTERIOR COMPARTMENT: There is thickening and abnormal signal within the\nright rectouterine ligament (series 3, image 30), suggestive of involvement. \nSecondary to the large multiloculated cystic structure, there is mass-effect\non the sigmoid colon.  The appendix is seen abutting the right cystic lesion\n(series 3, image 12; series 4, image 11).\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There are prominent pelvic lymph nodes noted bilaterally, none of\nwhich are enlarged by sized criteria.  For example, there is a 4 mm right\npelvic node (series ___, image 13) and a 5 mm left pelvic lymph node (series\n___, image 15).\n\nVASCULATURE: No vascular abnormalities noted.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Redemonstration of a 2.2 x 2.7 cm\nheterogeneous area in the posterior right iliac bone, unchanged compared to\nprior exam and likely post treatment change.",
            "output": "1. Extensive deep infiltrating endometriosis with redemonstration of bilateral\novarian endometriomas and a large complex blood containing cystic lesion\ntethered to a plaque seen at the torus uterinus.  Compared to prior exam,\nthere is enlargement of the cystic component likely due to repeat hemorrhage. \nThe uterus is distorted and deviated to the right side.  Likely submucosal\nfibroid.\n2. Redemonstration of an 11.1 cm cystic lesion in the left adnexa, likely a\nhematosalpinx.  Compared to prior exam, there is more prominent frondlike\nenhancement seen along the anterior wall, malignancy cannot be excluded.\n3. Nodular thickening of the right round ligament and right uterosacral\nligament also noted.\n4. Left Bartholin's gland cyst is larger compared to most recent MRI dated ___.\n5. Prominent pelvic lymph nodes are again seen; however, none are enlarged by\nsize criteria."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.3 x 4.2 x 6.4 cm.  A left sided\nBartholin's gland cyst appears slightly increased compared with the prior\nstudy (08:47).\nThe endometrium is normal in thickness for age and measures 1 cm.\nThe junctional zone is not thickened.\n\nNeither ovary is identified.  Complex changes of deep infiltrating\nendometriosis have progressed compared with prior study.  There is increased\ndistortion and tethering of the posterior cul-de-sac with similar appearance\nof pre-existing endometriomas with multiple new intrinsically T1 hyperintense\ncollections consistent with additional endometriomas and hematosalpinx.  There\nis a new large lobulated nonenhancing T2 hyperintense, T1 hypointense\nstructure in the left adnexa most consistent with a large left hydrosalpinx\nmeasuring up to 11.7 x 8.1 x 9.6 cm (8:24, 5:19).  Mass effect causes\nsubstantial new anterior and rightward displacement of the uterus.  There is\nno suspicious lesion or abnormal enhancement.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: Mildly prominent mesenteric lymph nodes are partially imaged. \nThere is no suspicious pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The visualized loops of large and small bowel\nare unremarkable.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is a fat containing umbilical\nhernia.  There is no suspicious osseous lesion.  Changes of L2 and L3\nkyphoplasty are similar to prior studies.",
            "output": "Interval progression of deep infiltrating endometriosis with increasing\nendometriomas, hematosalpinx, and new large left hydrosalpinx measuring up to\n11.7 cm and exerting mass effect on the pelvic structures.  No suspicious\nenhancing lesion and no suspicious adenopathy."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroflexed and measures 6.9 cm in length, and 4.9 cm x 4.5 cm\nin transverse and craniocaudal ___.\n\nA small focus of increased signal is seen within the cervix, which could\nrepresent a small amount of hemorrhage or proteinaceous material.  At least 2\ntiny intramural fibroids measuring up to 9 mm are seen.\n\nThe endometrium is normal in thickness for age and measures 10 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No significant lymph nodes.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: At the upper aspect of the intergluteal\nfold, there is increased T2 signal, compatible with edema within the\nsubcutaneous soft tissues, with trace amount of fluid.  Post gadolinium\nadministration, there is no rim enhancement to suggest abscess.  The area of\nedema measures approximately 4.4 cm x 2.3 cm.  No evidence of fistula.  No\nabnormal bone marrow edema is seen of the subjacent coccyx.  There are no\nosseous lesions concerning for malignancy.",
            "output": "1. At the upper aspect of the intergluteal fold is subcutaneous edema and\ninflammation spanning approximately 4.4 cm x 2.3 cm, with only trace amount of\nfluid.  The subjacent coccyx appears normal without MRI evidence of\nosteomyelitis.\n2.  Two subcentimeter intramural uterine fibroids."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 11.1 x 7.7 cm this includes the presence\nof a single homogeneous fibroid which measures 6.8 x 6.5 cm.  This fibroid\nenhances homogeneously.\nThe endometrium is normal in thickness for age and measures 1 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and contains a 4.3 x 2.4 cm hemorrhagic cyst.\nThe left ovary is visualized and contains 2 hemorrhagic cyst measuring 2.4 x\n2.7 and 3.1 x 2.  9 cm respectively.  The fact that there are bilateral\nadnexal hemorrhagic cyst with different ages of blood products the\nconstellation of findings is highly suggestive for endometriosis.  In addition\nthere is a tubular structure draped around the left ovary which is most\nconsistent with the hydrosalpinx.  Finally there is fluid in the cul de sac\nwith minimal enhancement of the peritoneal lining and several internal\nseptations.  The fluid seems to incomplete as the right ovary and therefore is\nsuggestive for peritoneal inclusion cyst.\n\nLYMPH NODES: The nor enlarged pelvic lymph nodes.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is only mildly distended but\ndoes not show any gross abnormalities.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and sigmoid colon are unremarkable.\n\nVASCULATURE: The vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious bony lesions.",
            "output": "Bilateral hemorrhagic adnexal cyst most likely suggestive of adnexal\nendometriomas.  The tubular structure draping around the left ovary is most\nlikely representing a left hydrosalpinx.  The fluid in the cul de sac with\nminimal enhancement of the peritoneal lining and several septations and\ncompressing the right ovary suggestive for peritoneal inclusion cyst.\n\nLarge homogeneous solitary fibroid within the myometrium."
        },
        {
            "input": "There is moderate sclerosis of the sacroiliac joints bilaterally most\nprominent along the iliac sides.  This is seen as low signal on all pulse\nsequences.  There is no fluid in the sacroiliac joints, erosions, or\nsignificant edema to indicate active sacroiliitis.  The patient could not\ncomplete the intravenous contrast portion of the exam thus evaluation for\nsynovial enhancement cannot be performed; however, given the lack of edema,\nsynovial proliferation in the SI joints is unlikely.  There is slightly more\nsclerosis of the SI joint since the ___ study.  Overall findings are\nsuggestive of degenerative changes as opposed to an acute inflammatory\netiology.\n\nThere are areas of red marrow seen throughout the pelvis and proximal femurs. \nThis is similar to the ___ study.  Physiologic amount of fluid is seen within\nbilateral hip joints.  There are moderate degenerative changes with acetabular\nspurring and some medial hip joint space narrowing bilaterally.\n\nThe visualized intrapelvic contents are within normal limits.  There are\ndegenerative changes at the sacrococcygeal junction with spurring.",
            "output": "1.  No MRI signs for active sacroiliitis.  However evaluation for synovial\nenhancement is limited given that the patient could not complete the contrast\nportion of the examination.  There is sclerosis of the SI joints more\nprominent on the iliac side bilaterally suggestive of degenerative changes\nwhich have progressed since the ___ study.\n2.  Mild-to-moderate degenerative changes of bilateral hips with spurring."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: There is rectal wall thickening with intramural\nfat deposition.  No surrounding inflammatory changes seen.  Anus is notable\nfor a few scattered internal hemorrhoids.  No evidence of fistulous tract.  No\nperianal/rectal fluid collection is seen.\n\nBLADDER AND DISTAL URETERS: The bladder is partially distended and\nunremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Although not optimized for\nevaluation, views of the prostate are unremarkable.\n\nLYMPH NODES: There is no pelvic sidewall or inguinal adenopathy.\n\nVASCULATURE: Pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious bony lesions. \nNote is made of a right hip prosthesis.",
            "output": "1. No evidence of perianal fistula.\n2. Rectal wall thickening with intramural fat, suggest chronic inflammation.\n3. Internal hemorrhoids noted."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.4 x 5.3 x 5.4.  A few small intramural\nfibroids are seen, for example left lower intramural measuring 1.1 cm.\nThe endometrium is not thickened for age.  The junctional zone is within\nnormal limits.\n\nThere is a 7 cm right ovarian endometrioma with regions of higher T2 signal\nwithin its inferior aspect.  No solid enhancing components are seen within it.\nThere is a multiseptated cystic lesion in the periphery of the right ovary\nthat is most likely a hydrosalpinx with a small amount of blood products\nwithin its anterior aspect suggestive of hematosalpinx.\n\nThe left ovary demonstrates a 3.2 cm endometrioma, however within its\nposterior aspect, it demonstrates two nodules measuring up to 7 mm,both\ndemonstrating enhancement on the subtracted images.\n\nThere is no pelvic free fluid.  There is deep invasive endometriosis along the\nposterior wall of the corpus, as well as thick adhesions between the ovaries,\nposterior corpus, rectum and adjacent sigmoid colon.\n\nLYMPH NODES: No enlarged pelvic lymph nodes.\n\nRECTUM AND INTRAPELVIC BOWEL: No bowel obstruction visualized.  Possible\nendometriosis involving the tip of the appendix.  Additional small adhesions\nare also seen between the right adnexa and adjacent small bowel.\n\nVASCULATURE: No deep venous thrombosis seen.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No aggressive osseous lesions visualized.",
            "output": "Deep invasive endometriosis and bilateral ovarian endometriomas.  The right\novarian endometrioma demonstrates likely dilution of the hemorrhagic contents\nand the left ovarian endometrioma demonstrates two enhancing nodules in its\nposterior aspect.  These findings are ominous for malignant degeneration.\n\nLower abdominal and pelvic adhesions as described.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 08:46 into the Department of\nRadiology critical communications system for direct communication to the\nreferring provider."
        },
        {
            "input": "Again seen is T1 hypointense, STIR hyperintense signal and enhancement within\nthe left sacral ala and left iliac bone surrounding the sacroiliac joint. \nThere is mild asymmetric widening of the left sacroiliac joint with small\namount of enhancing fluid seen within the joint space.  There are erosive\nchanges of the bone along the joint, more prominent on the sacrum. There is\nenhancement and edema within the surrounding soft tissues predominantly along\nthe inferior aspect of the joint.  There is edema and enhancement within the\nleft iliacus and piriformis muscles, without definite fluid collection or\nabscess, not significantly changed from prior study.\n\nNo new areas of bone marrow edema.  No occult fracture.\n\nVisualized pelvic soft tissues are unremarkable.",
            "output": "1.  Findings are most consistent with infectious sacroilitis/osteomyelitis and\nseptic joint, not significantly changed from prior study.\n\n2.  Persistent edema and enhancement in the left iliacus and piriformis\nmuscles."
        },
        {
            "input": "1.5 cm from the anal verge at the 6:30 position there is a sinus tract\nextending into the intersphincteric space with a horseshoe shaped morphology. \nThere is no extension through the external anal sphincter.  There is no\ncollection associated with this.\n\nNo pelvic free fluid.\n\nLYMPH NODES: No enlarged inguinal or pelvic lymph node\n\nBLADDER AND DISTAL URETERS: Bladder is moderately distended.  Bladder wall is\nnormal.  Distal ureters are normal.\n\nVASCULATURE: Normal caliber.  No aneurysm.  No stenosis\n\nREPRODUCTIVE ORGANS:  Uterus and ovaries are grossly normal.  Prostate and\nseminal vesicles are grossly normal.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Incompletely seen at the left inguinal\nregion and extending slightly towards the left spermatic cord there is\nabnormal soft tissue which shows low signal on T1 weighted images intermediate\nsignal on T2 weighted images and some enhancement as well as a few foci of\nsusceptibility artifact.  This may be related to prior hernia repair. \nCorrelate with surgical history and clinical symptoms.  Normal bone marrow\nsignal.",
            "output": "1.5 cm from the anal verge at the 6:30 position there is a sinus tract\nextending into the intersphincteric space with a horseshoe shaped morphology. \nThere is no extension through the external anal sphincter.  There is no\ncollection associated with this.\n\nIncompletely seen at the left inguinal region and extending slightly towards\nthe left spermatic cord there is abnormal soft tissue which shows low signal\non T1 weighted images intermediate signal on T2 weighted images and some\nenhancement as well as a few foci of susceptibility artifact.  This may be\nrelated to prior hernia repair.  Correlate with surgical history and clinical\nsymptoms."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: The rectum as well as the anus are normal in\nappearance with the exception of a tiny hemorrhoid at the posterior aspect of\nthe anus near 6 o'clock (8:27).  No perianal fistula or fluid collection is\nidentified.  At the left perineum is a 2.8 x 1.1 cm (AP x TRV) area involving\nthe dermis and subcutaneous fat which demonstrates stranding and\nhyper-enhancement (1001:37, 6:9) compatible with inflammation or infection,\nwithout fistula or focal fluid collection.  The anal sphincter complex is\nnormal.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate and the seminal vesicles\nare normal in appearance.\n\nLYMPH NODES: There is no pelvic sidewall or inguinal lymphadenopathy.\n\nVASCULATURE: The bilateral common femoral and superficial as well as deep\nfemoral vessels are patent.  The visualized internal iliac vessels are also\npatent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Background marrow signal is within normal\nlimits.  Soft tissues are otherwise unremarkable.",
            "output": "1. No perianal fistula.\n2. 2.8 x 1.1 cm area of dermal and subdermal inflammation or infection along\nthe left perineum without associated sinus tract or fluid collection."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 7.3 x 2.1 x 5.0 cm.  The endometrium is\nnormal in thickness for age and measures 0.6 cm.  The junctional zone is not\nthickened.  There are two heterogeneously enhancing predominantly intramural\nfibroids along the anterior wall of the uterus near the fundus measuring 16 x\n17 mm and 18 x 19 mm.\n\nThere is a 4.1 x 3.0 x 4.7 cm well defined cyst arising from the right adnexa.\nThere is no nodularity or internal enhancement.   The left ovary is not well\nvisualized but no adnexal masses are seen.\n\nNo free fluid.\n\nLYMPH NODES:  Multiple enlarged bilateral pelvic sidewall lymph nodes are\nnoted.  The largest lymph nodes are along the left external iliac chain and\nmeasure up to 17 mm in short axis diameter.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: The pelvic vessels are of normal caliber throughout without any\nsignificant areas of narrowing or dilation.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Centered in the right adductor brevis\nmuscle is a well-defined rim-enhancing lesion measuring 21 x 21 mm The lesion\nis ill-defined and difficult to assess on the T2 weighed images but there is\nabnormal high signal in the right adductor brevis muscle.  There is\nsurrounding hyperenhancement in the right adductor brevis muscle on the\npost-contrast images.  There is subtle non-specific hyperenhancement\nsurrounding the inferior pubic ramus and ischial tuberosity.  The adjacent\nfemoral diaphysis and and ischial tuberosity appear normal in signal\ncharacteristics.",
            "output": "1.  Centered in the right adductor brevis muscle is a well-defined rim\nenhancing lesion with surrounding inflammatory change.  This finding is\nnon-specific and may be related to prior trauma, infection, inflammation or\nmetastatic disease.  This lesion most likely accounts for the patient's right\ngroin pain.\n2.  Simple appearing right adnexal cyst measuring up to 4 cm is almost\ncertainly benign.  Yearly follow-up, at least initially, with US is\nrecommended.  One may opt to continue follow-up annually or to decrease the\nfrequency of follow-up once stability or decrease in size has been confirmed.\n3. Multiple enlarged pelvic sidewall lymph nodes measuring up to 17 mm in\nshort axis diameter may be related to the patient's known history of lymphoma.\n\nRECOMMENDATION(S):  A follow-up non-contrast CT lower pelvis/upper thigh scan\nis recommended for further evaluation of right adductor brevis muscle lesion."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and redemonstrates a few fibroids, decreased in\nsize, for example the largest measures 1.4 cm, previously 2.6 cm.  There has\nbeen marked interval improvement of disease.  For instance, the cervical mass\nnow measures 2.2 x 2.7 x 1.7 cm, previously 5.5 x 4.6 x 5.3 cm.  Portions of\nthe cervical stroma are now visualized anteriorly and posterior to the mass. \nPost treatment changes in the parametrium are again seen.\n\nThe ovaries are unremarkable. Trace pelvic free fluid is improved.\n\nLYMPH NODES: There has been resolution of pelvic adenopathy, for example a\nprevious 2.3 cm left external iliac lymph node is now 0.9 cm and cystic in\nappearance compatible with diffuse necrosis.  Additional enlarged cervical\nlymph nodes are no longer seen and the largest external lymph node measures\n0.6 cm.  The previous perirectal adenopathy is no longer visualized.\n\nBLADDER AND DISTAL URETERS: No hydronephrosis.\n\nRECTUM AND INTRAPELVIC BOWEL: No bowel obstruction.\n\nVASCULATURE: The iliac vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions.",
            "output": "Good treatment response evidenced by marked decrease of the cervical\nmalignancy with restoration of some of the cervical stroma surrounding it as\nwell as resolution of pelvic adenopathy."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThere is re-demonstration of a primary cervical mass measuring 6.3 x 5.4 x 4.6\ncm.  This involves the upper third of the vagina.  It extends into the uterus.\nThere are multiple foci of parametrial invasion however, without extension\ninto the pelvic sidewall, adjacent structures or distal third of the vagina.\n\nThe uterus is anteverted and measures 11.5 x 5.5 x 7.2 cm.  Uterine fibroids\nare present mainly at the fundus.\n\nUpper endometrial cavity appears unremarkable with a thin endometrial stripe\nmeasuring 3 mm.  The junctional zone in the upper the uterine segment is\npreserved as well.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary not clearly identified.\n\nThere is a Skene gland on the left.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There are extensive bilateral pelvic centrally necrotic\nadenopathy measuring up to 3.1 cm.  This involves bilateral external iliac,\ninternal iliac, obturator, pre sacral wall, and the retroperitoneal groups at\nthe aortic bifurcation.  There is also mesorectal lymph nodes.  The extent of\nadenopathy is much better evaluated on the recent PET-CT.  There are no\ninguinal adenopathy.\n\nBLADDER AND DISTAL URETERS: Urinary bladder is under distended.  The tumor\ndoes not involve the ureters.\n\nRECTUM AND INTRAPELVIC BOWEL: Fat planes between the rectum and the cervix\nappear intact with no evidence rectal wall invasion.\n\nVASCULATURE: Vascular structures are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious osseous lesions.",
            "output": "FIGO stage IIB cervical carcinoma.  Extensive metastatic adenopathy."
        },
        {
            "input": "There is no acute fracture or dislocation.  A T1 and T2 dark lesion in the\nleft femoral neck is consistent with a bone island (series 3, image 21). \nThere are no significant degenerative changes.  There is no abnormal synovial\nenhancement, bony erosion, or cartilage loss.  There is no MR evidence\n___ impingement.  Muscle bulk is normal.  Tendon insertions are\nunremarkable.  Absence of an oblique axial image limits assessment of the\nfemoral head alpha angle.  However, no similar herniation pit is identified to\nsuggest impingement.\n\nLimited assessment of the right hip shows no effusion, gross degenerative\nchange, or greater trochanteric bursitis.  Visualized portion of the right\ngluteus maximus in the overlying subcutaneous fat is within normal limits. \nHamstring tendon origins are within normal limits bilaterally.\n\nLimited views of the pelvic soft tissues are grossly unremarkable.  Trace free\nfluid is within physiologic limits.  Possible right-sided physiologic corpus\nluteum cyst.  Apparent asymmetry of the piriformis muscles likely account for,\nby slight asymmetric positioning.",
            "output": "Left hip MRI within normal limits.  Specifically, no joint effusion, gross\ndegenerative change, evidence of synovitis, or bony erosion.  No evidence for\nleft greater trochanteric bursitis.\n\nLimited views of the right buttock are also normal."
        },
        {
            "input": "Kidney transplant: Renal transplant a right lower quadrant.  Prominent calyces\nare noted without frank hydronephrosis.  Homogeneous renal parenchymal\nenhancement.  Susceptibility artifact around the kidney related to the\npostsurgical material.  There is no hydroureter.\n\nKidney transplant angiogram: Single transplanted main renal artery anastomosis\nto right internal iliac artery.  There is at least moderate at least greater\nthan 50% short-segment stenosis at the anastomosis site, however this could be\naccentuated given the susceptibility artifact from surgical changes.  Renal\nvenous vasculature is patent.\n\nGastrointestinal Tract:  No bowel obstruction.\n\nLymph Nodes: No pelvic adenopathy.\n\nOsseous and Soft Tissue Structures: No aggressive osseous lesions.\n\nVisualized upper abdomen: Iron deposition within the visualized liver and\nspleen evidence by diffuse hypointense signal on T2.",
            "output": "1. Mild to moderate stenosis at the anastomosis of the main renal artery to\nthe internal iliac artery as described.\n2. Iron deposition within the visualized portions of the liver and spleen."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures approximately 7.3 x 10.9 x 7.1 cm .\nThe endometrium is normal in thickness for age and measures 4.\nAn intramural anterior uterine body fibroid measures 2.1 x 1.4 cm (03:25). \nObscuration of the junctional zone and heterogeneous signal intensity on T2\nweighted images is likely related to other small fibroids.\n\n\nThe right ovary is visualized and appears within normal limits, with a 3.5 cm\nphysiologic simple cyst (1:4).\nThe left ovary is visualized and appears within normal limits, with a 3.0 cm\nphysiologic simple cyst (1:4).\n\nThere is trace physiologic pelvic free fluid.\n\nLYMPH NODES: No pelvic lymphadenopathy is identified.\n\nBLADDER, URETHRA AND DISTAL URETERS: The distal ureters are unremarkable. \nAlthough incompletely distended, the bladder wall is unremarkable.  Below the\nlevel of the pubic symphysis and along the right aspect of the distal urethra,\nthere is an ovoid 1.3 x 0.7 x 0.8 cm homogeneously T2 hyperintense\nnonenhancing cyst (6:23, 4:19), with a subtle small projection directed toward\nthe urethra (801:56).\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic loops of large bowel\nare unremarkable.\n\nVASCULATURE: Pelvic vasculature remains patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous lesion worrisome for\nmalignancy or infection is identified.  There is a subchondral cyst in the\nleft superior acetabulum.",
            "output": "1.3 cm right urethral diverticulum.  No suspicious mass or pelvic\nlymphadenopathy.\n\nFibroid uterus."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 11 x 7 x 5 cm..\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nTubular Fluid collections seen in both adnexa indistinct from the ovaries,\nmeasuring altogether to the left 7.0 x 4.5 x 4.1 cm and to the right 8.1 x 7.7\nx 5.8 cm.  There is mild fat stranding to the right, and dominant bulbous part\nof the hydrosalpinx immediately deep to the abdominal wall shows markedly\nrestricted diffusion.  Adjacent abdominal wall is involved with inflammatory\nchange.\n\nLYMPH NODES: No distinct retroperitoneal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder wall is of regular width there too small\ntibiotalar chole in the left inferior wall (06:31).\n\nRECTUM AND INTRAPELVIC BOWEL: Imaged segments are unremarkable.\n\nVASCULATURE: No obvious aneurysms.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning bone lesions.",
            "output": "Evidence of bilateral hydrosalpinx with significant areas in each adnexa\nsuggesting fluid content.  There is edema surrounding the right side and mild\nrestriction to diffusion suggesting probable infection on the right. \nPyosalpinx is not excluded on the left."
        },
        {
            "input": "Limited examination due to the patient's body habitus.\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.6 cm x 5.0 cm x 11.0 cm.\nThe endometrium is normal in thickness for age and measures 6 mm.\nThe junctional zone is not thickened.\n\nThere is no free fluid.\n\nUnchanged position of the right lower quadrant drain with the distal tip\noutside the abdominal cavity, cavity, in the deep subcutaneous fat of the\nright anterolateral abdominal wall.\n\nThere is redemonstration of the bilateral tubular tubo-ovarian abscesses.\n\nOn the right, the whole complex measures 5.5 cm x 6.5 cm x 4.9 cm and there\nare ___ small pockets of fluid, the largest measuring 3.5 cm x 1.2 cm, seen on\nseries 6, image 29, although this one seems to lack evidence for active\ninflammation or fibrosis.  The second largest fluid collection is seen\nadjacent to it and slightly lateral, measuring 2.3 cm x 1.8 cm.  This is\nsurrounded by robust progressive enhancement; scar tissue is suspected.  This\nhas slightly cranially, two very small round fluid collections are seen\nmeasuring 1.7 cm and 1.4 cm in diameter respectively with mild wall\nthickening.  Post gadolinium injection, there is peripheral enhancement of the\nright fluid collections. There is inflammatory extension to the posterior\naspect of the right anterolateral abdominal wall.\n\nOn the left, the tubo-ovarian complex measures 5.2 cm x 4.1 cm x 5.6 cm. A\ntubular fluid-filled structure is seen, likely corresponding to left\nhydrosalpinx, measuring up to 15 mm in width.  No other cystic structure\nfound.\n\nThese tubo-ovarian complexes are not significantly changed compared to the CT\nperformed 1 day prior, allowing for difference in technique.\n\nT2 hyperintense lesions are seen within the partially visualized kidneys,\nlikely representing cortical cysts.\n\nLYMPH NODES: No sized significant lymph nodes are seen.\n\nBLADDER AND DISTAL URETERS: The bladder is not well-distended but appears\nwithin normal limits.  Distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The partially visualized bowel is unremarkable. \nNo dilatation or obstruction.\n\nVASCULATURE: The abdominal aorta appears unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Mild-to-moderate degenerative disc\ndisease, worse at L3-L4 and L4-L5.",
            "output": "1.  Few tiny residual right adnexal collections and decompressed thick wall\nhydrosalpina.\n\n2. No discrete fluid collection is seen in the left adnexa.  Unchanged small\nto medium sized hydrosalpinx.  Active inflammation/infection is not excluded.\n\n3. Unchanged position of the right lower quadrant drain with the distal tip\noutside the abdominal cavity, cavity, in the deep subcutaneous fat of the\nright anterolateral abdominal wall."
        },
        {
            "input": "The uterus is anteverted with approximate ___ of 13.3 x 5.7 x 6.5 cm. \nThere is evidence of prior cesarean section. The zonal anatomy is well\npreserved and no focal uterine lesion is appreciated. The cervix and vagina\nare also unremarkable. Urinary bladder is notable for a diverticulum along the\nposterior lateral left aspect (05:26). The bladder is minimally thickened for\nthe degree of distension. No filling defect is noted within the lumen. The\nurethra is unremarkable in appearance.\n\nThere are bilateral hydrosalpinges.  On the left, the minimal layering T1\nhyperintense material is noted, without associated inflammatory change.  This\nhas total axial ___ of 4.8 x 3.1 cm, and appears improved in size and\ncomplexity as compared to ___.   The ovary noted at the inferior\naspect of the adnexa low with multiple small follicles.\n\nThe right hydrosalpinx is distended to greater extent with more complex\ncontent and layering T2 hypointense material.  This has total ___ of\napproximately 9.1 x 7.1 x 6 cm. The surrounded by extensive edema and\nhyperenhancing tissue. Foci of nonenhancing fluid extend toward the right\nlower quadrant abdominal wall (12:21), involving the parietal peritoneum.  The\nconfiguration of this component extends beyond the serpiginous tubular\nstructure and may be on the basis of a contained perforation or fimbrial\nabscess.   Minimal edema tracks along the fascial planes of the wall. Fluid\nalso seen tracking inferiorly along the round ligament to the inguinal canal.\n(04:30).  The ovary is noted along the medial aspect of this presumed\ntubo-ovarian abscess, abutting the uterine fundus (14:18).\n\nA tiny fat containing hernia is noted within the right lower quadrant, with\nnarrow neck but no associated inflammation.\n\nThe appendix is identified just anterior to the right lower quadrant\ninflammatory process, normal in appearance, without evidence of secondary\ninflammation.\n\nThere are numerous right pelvic wall nodes, presumably reactive in etiology.\n\nA very large anterior abdominal wall hernia contains multiple bowel loops and\nextends out of the field of view on the left.\n\nOsseous structures are only notable for bilateral hip joint effusions, without\nassociated synovial hyperemia.",
            "output": "Bilateral hydrosalpinges.  While chronic bilaterally, and appearing better\nthan previously on the left, the right adnexa is markedly distended with\ncomplex contents and inflamed, consistent with a pyosalpinx and likely\ntuboovarian abscess.  Extensive surrounding inflammation extends to the\nanterior parietal peritoneum with mild secondary edema within the abdominal\nwall musculature.\n\nSlightly thickening urinary bladder, with small left posterolateral\ndiverticula likely from chronic bladder outlet obstruction.\n\nNOTIFICATION:  Findings were discussed by Dr ___ with Dr ___ at\napproximately 4 pm on ___."
        },
        {
            "input": "Limited examination secondary to patient body habitus.\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 14.1 x 5.3 x 6.3 cm.  Surgical changes\nfrom prior cesarean section noted.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is mildly enlarged measuring 4.1 x 4.6 x 4.2 cm, overall\ndecreased in size compared to examination on admission from ___.  There is\nenhancing tract extending from the right ovary to the superficial soft\ntissues, likely chronic inflammatory change.  Small amount of inflammatory\nchange also noted along the pigtail catheter tract (series 21, image 27). \nThere is a tiny right hydrosalpinx without surrounding inflammatory change\n(series 8, image ___.\n\nRe-demonstrated is a left adnexal complex multiseptated cystic lesion\nmeasuring 10.6 x 8.7 x 10.5 cm with associated surrounding fat stranding,\nhyperenhancement, and restricted diffusion, consistent with a tuboovarian\nabscess (series 21, image 27).  Overall size has not significantly changed\ncompared to ___.\n\nThere are enlarged left pelvic sidewall and left common iliac lymphadenopathy\nmeasuring up to 19 mm, likely reactive (series 21, image 11).\n\nThe sigmoid colon is adjacent to the left adnexal lesion with associated\nsecondary inflammatory change and engorgement of the Vasa recta (series 21,\nimage 24).\n\nThere is a small amount of pelvic free fluid.\n\nThe bladder is decompressed.  Apparent bladder wall thickening, is likely\nsecondary to underdistention.\n\nAgain seen, is a bowel containing large ventral abdominal wall hernia.  No\nevidence of obstruction.\n\nVASCULATURE: Pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious bony lesions are seen. \nIncidental note made of fatty atrophy of the bilateral quadratus femoris\nmuscles, likely secondary to impingement.",
            "output": "1. 10.6 x 8.7 x 10.5 cm left tuboovarian abscess, unchanged in size compared\nto the most recent prior CT from ___.  Associated surrounding inflammatory\nchange including secondary thickening of the sigmoid colon.\n2. Overall size and appearance right ovary has significantly improved since\nadmission CT on ___.  There is mild chronic inflammatory change and a small\nhydrosalpinx, but no drainable collection is identified on the right.\n3. Enlarged reactive left pelvic sidewall and common iliac lymph nodes."
        },
        {
            "input": "OSSEOUS STRUCTURES AND SOFT TISSUES: No T2 stir edema present in the greater\ntrochanter of the right femur to suggest a fracture.  There is edema within\nthe adductor muscles on the right consistent with strain.\n\nMarked degenerative changes of the right hip joint with a small associated\nright hip joint effusion.\n\nLeft total hip arthroplasty prosthesis in situ resulting in susceptibility\nartifact.\n\nRECTUM AND INTRAPELVIC BOWEL: Large fecal load in the rectum.  No surrounding\nedema in the mesorectal fat to suggest stercoral colitis.\n\nBLADDER AND DISTAL URETERS: No abnormality\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: No abnormality\n\nLYMPH NODES: No lymphadenopathy.\n\nVASCULATURE: No filling defects.",
            "output": "No right greater trochanteric fracture.\nAdductor muscle strain."
        },
        {
            "input": "The pelvic venous structures an inferior vena cava are widely patent, contrast\nopacified and without filling defect.  Mild narrowing of the distal-most left\ncommon iliac vein secondary to compression by the crossing right common iliac\nartery is noted.\n\nArterial vascular anatomy is conventional, without aneurysmal change or\nsignificant atherosclerotic disease.\n\nThe visualized portions of the liver and biliary tree, spleen, adrenal glands,\nkidneys and pancreas are unremarkable. There is no lymphadenopathy.\n\nA trace amount of free pelvic fluid is noted with cul-de-sac (05:54).\n\nVisualized bowel loops are unremarkable.\n\nThere is superficial edema and susceptibility artifact associated with the are\nleft hip which has been recently replaced. The hip prosthetic results and of\nsusceptibility artifact. Edema and hyperemia is noted within the adjacent\nperiarticular muscles.",
            "output": "No deep venous thrombosis identified within the inferior vena cava or pelvic\nveins."
        },
        {
            "input": "There is an abdominal aortic dissection arising immediately distal to the\norigin of the left renal artery. The dissection extends inferiorly into the\nright common iliac artery. The extent of dissection is unchanged compared to\nprior outside facility MR ___ with slight reduction in size of the\nfalse lumen.\n\nThe celiac, superior mesenteric, right renal, and left renal artery originate\nsuperior to the origin of the dissection flap. The inferior mesenteric artery\narises from the true lumen.\n\nOn prior examination, there was a thin crescentic focus, 3 mm in thickness,\nwithin the right aspect of the aorta at the aortic hiatus spanning\napproximately 3 cm in craniocaudal dimension. This finding is not present on\nthe current examination and may represent resolution of a focus of\nnon-propagating dissection.\n\nVisualized abdominal and pelvic organs are grossly unremarkable. There are\nbilateral renal cysts. There is symmetric renal enhancement and excretion of\nintravenous contrast.",
            "output": "1.  Redemonstration of abdominal aortic dissection arising immediately\ninferior to the origin of the left renal artery with extension into the right\ncommon iliac artery. The extent of the dissection is unchanged and the false\nlumen is mildly decreased in size. The inferior mesenteric artery originates\nfrom the true lumen.\n\n2.  Previously seen thin crescentic focus along the right aspect of the aorta\nas it crosses through the diaphragmatic hiatus spanning 3 cm is no longer\nvisualized and likely indicates resolution of another locale of focal\ndissection."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: Arising 1 cm above the anal verge at 12 o'clock,\nthere is a trans sphincteric perianal fistula extends anteriorly and slightly\nto the right of midline and then inferiorly, terminating at the medial gluteal\nfold.  The tract is composed of enhancing granulation tissue without central\nfluid component.  There is no drainable fluid collection.  No other fistula is\nidentified.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.\n\nLYMPH NODES: No suspicious adenopathy.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious osseous lesion. \nThere is a fat containing left inguinal hernia.",
            "output": "Transsphincteric perianal fistula arising at 12 o'clock, 1 cm above the anal\nverge and terminating in the right gluteal fold, composed of enhancing\ngranulation tissue.  No central fluid component or drainable fluid collection."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 9.2 x 5.3 cm.  There are multiple\nuterine fibroids the largest in the anterior uterine wall measuring up to 2.3\ncm.  Note is also made of an exophytic fibroid arising from the right\nanterolateral lower segment measuring 1.5 cm.\nThe endometrium is slightly distorted by fibroids.  The endometrium is normal\nin thickness for age and measures 10 mm.\nThe junctional zone is not thickened.\nNabothian cysts are noted in the cervix.\n\nThe right ovary is not clearly visualized.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There are no enlarged pelvic lymph nodes.  Prominent external\niliac nodes measure up to 7 mm in short axis (series 1101, image 58).  Note is\nmade of few prominent mesorectal nodes measuring up to 5 mm (series 1101,\nimage 31).\n\nBLADDER AND DISTAL URETERS: The urinary bladder is unremarkable.  Distal\nureters are normal in caliber.\n\nRECTUM AND INTRAPELVIC BOWEL: Susceptibility artifact is noted in the anterior\nmid rectum from prior tumor resection.  There is no evidence local tumor\nrecurrence.  No new suspicious enhancing foci identified.\n\nVASCULATURE: Normal caliber of the iliac arteries.  There is no evidence of\ndeep venous thrombosis in the pelvis.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue\nlesion seen.",
            "output": "1. No evidence disease recurrence in the rectum.\n2. No evidence of metastatic disease in the pelvis.\n3. Fibroid uterus."
        },
        {
            "input": "UTERUS:\nThe uterus is retroverted and retroflexed and measures 4.6 x 4.6 x 7.1 cm.\n(Note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: The endometrium is distorted by the multi fibroid uterus but\nappears thin throughout measuring up to 3 mm in thickness.\nJunctional zone: Measures up to 0.7 cm in the inferior segment.  The remainder\nof the junctional zone is distorted and not well seen.\n\nFIBROIDS:\n\nFibroid burden: 3 fibroids are noted.\n\nIntramural fibroids:\n1.  3.4 x 3.4 x 3.3 cm heterogenously enhancing fibroid located in the right\nuterine body/fundus, with a 25% submucosal component, with the remainder\nintramural in location.  The thinnest portion of overlying myometrium\nextending from the fibroid to the serosa measures 0.6 cm.  Allowing for\ndifferences in modality, this fibroid is unchanged in size since ___, and is also grossly unchanged compared to pelvic ultrasound from\n___.  The apparent increase in size on recent ultrasound from ___ is favored related to differences in measurement technique rather than\ntrue growth.\n2.  0.5 x 0.5 cm intramural fibroid, with a 25% subserosal component,\ninvolving the uterine fundus on the right, demonstrating homogeneous\nenhancement.\n3.  0.7 x 0.8 cm intramural fibroid involving the left body of the uterus,\nwith mildly heterogenous enhancement.\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nThe ovaries are not well visualized.\n\nThere is trace free fluid in the pelvis.\n\nLYMPH NODES: No pathologic lymphadenopathy.\n\nBLADDER: The bladder is normal.\n\nRECTUM AND INTRAPELVIC BOWEL: Sigmoid diverticulosis.  The remainder of the\nvisualized small large bowel are unremarkable.\n\nSOFT TISSUES AND BONES: Soft tissues are unremarkable.  There are no\ndestructive osseous lesions.",
            "output": "1.  Multi fibroid uterus with the largest fibroid measuring up to 3.4 cm, with\na 25% submucosal component and a 75% intramural component.  This fibroid is\nstable in size since ___.  Apparent increase in size on recent\nultrasound from ___ is favored to be related to differences in\nmeasurement technique rather than true growth.  No concerning features.\n2.  Sigmoid diverticulosis."
        },
        {
            "input": "MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:\n\nA complex perirectal/ perianal transsphincteric fistula is again seen. The\nfistula takes a horseshoe configuration along the anterior lower rectum,\napproximately 4.7 cm above the verge (series 4, image 23, 22). The left track\ntakes a transsphincteric course inferiorly, communicating with a 21 x 15\nischiorectal fossa collection (series 4, image 24) which has decreased in size\nsince the ___ MRI examination. The tract extends slightly more\ninferiorly and laterally since the ___ examination (series 4, image 26) but\ndoes not appear to exit.\n\nThe right track branches into superior and inferior components. The superior\ntrack extends along the right aspect of the internal sphincter (series 4,\nimage 21), measuring up to 3.4 x 1.4 cm (series 4, image 21), demonstrating\nhigh signal intensity on T2 weighted sequences with extensive contrast\nenhancement (series 9, image 24), compatible with granulation tissue,\nextending through the right levator ani (series 4, image 22), overall\nprogressed since the ___ examination. The inferior track again\ndemonstrates an inverted-Y configuration (series 4, image 29), with an\nunchanged short medial limb ending blindly, and the lateral limb measuring up\nto 10 mm in thickness, smaller since the ___ examination (series 4,\nimage 28), communicating with a track exiting the right perineum (series 4,\nimage 36).\n\nA previously-seen large right perineal fluid collection from the ___\nexamination has resolved.\n\nNo new fistula is detected.\n\nThe seminal vesicles, prostate, and bladder are normal. There is moderate\nfibrofatty thickening throughout the rectum, compatible with chronic\ninflammatory bowel disease (series 4, image 14). There is no bowel\nobstruction.\n\nThere is no intrapelvic free fluid. Prominent intrapelvic lymph nodes are\nunchanged.\n\n\nThere are no bony lesions concerning for malignancy or infection.\n\nA small left hydrocele is present (series 4, image 27).",
            "output": "1. Complex perirectal/ perianal transsphincteric fistula, with right\nsupralevator extension, arising from the anterior lower rectum, and exiting\nthe right perineum. A right superior track containing extensive granulation\ntissue has enlarged since ___. The left transsphincteric track extends more\nlaterally and inferiorly into the ischiorectal rfsince ___, without exit,\nwith an associated left ischiorectal fossa collection now slightly smaller.\n2. A large right perineal fluid collection seen on the ___ examination has\nresolved.\n3. Chronic inflammation of the rectum, with fibrofatty wall thickening, in\nkeeping with known history of Crohn's disease.\n4. No new fluid collection.\n5. Small left hydrocele."
        },
        {
            "input": "A complex perirectal/ perianal intersphincteric fistula is again seen and\noverall is similar compared with ___. The fistula takes a horseshoe\nconfiguration along the anterior lower rectum, approximately 4 cm above the\nanal verge (3:16), with 2 tracks extending inferoposteriorly. The left track\ntakes a transsphincteric course posteroinferiorly and ends in a region of\nphlegmonous inflammation measuring 2.1 x 1.5 cm without significant fluid\ncollection (8:22). The right-sided track follows also a posteroinferior\ncourse, ending as well in a 2.1 x 1.4 cm area of phlegmonous inflammation\nwithout fluid collection (8:19), also similar to prior. However, there is a\nnew 6 mm collection microabscess communicating with the right sided tract of\nthe horseshoe fistula (series 9 image 14), which was not present on the prior.\n\nFurthermore, a second fistulous tract is redemonstrated, with a communication\nbetween the tract and the anal mucosa approximately 2 cm from the anal verge\nat the 10 o'clock position.  This tract is also similar to prior and follows\nan inferior course, ending in a 2.7 x 1.1 cm area of phlegmonous inflammation\napproximately 3 cm below the anus in the right posteromedial perineal region. \nThere is no organized fluid collection in this region.  Moreover, the\nfistulous tract leading to this phlegmon has a communication with the skin at\nthe perineum (series 3, image 26) right above the phlegmon.\n\nNo new fistula is detected.\n\nThe seminal vesicles, prostate, and bladder are normal. There is moderate\nfibrofatty thickening throughout the rectum, compatible with chronic\ninflammatory bowel disease. There is no bowel obstruction.\n\nThere is no intrapelvic free fluid. Prominent intrapelvic lymph nodes are\nunchanged.\n\nThere are no bony lesions concerning for malignancy or infection.",
            "output": "1.  Overall, there is similar appearance of the complex perirectal and\nperianal intersphincteric fistula with horseshoe configuration ending in areas\nof phlegmonous inflammation in the ischiorectal fossae bilaterally.  A new 5\nmm micro abscess communicates with the right sided branch of this complex\nfistula and represents the only significant appreciable change compared with\n___.\n\n2.  Also similar in appearance is the fistulous tract containing a small\namount of fluid, communicating with the anal mucosa at the 10 o'clock position\napproximately 2 cm from the anal verge ending in a region of phlegmonous\ninflammation in the right perineum.  There is no fluid collection related to\nthis fistula.  A communication between the fistulous tract and the skin of the\nright perineum is demonstrated.\n\n3. Chronic inflammation of the rectum, with fibrofatty wall thickening, in\nkeeping with known history of Crohn's disease."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 10.8 x 4.3 x 5.3.    A C-section scar\nis noted at the lower uterine segment.\nThe endometrium is normal in thickness for age and measures 1.0 cm.\nThe junctional zone is not thickened.\n\nA 9 mm nabothian cyst is noted in the cervix.  There is no evidence of cystic\nlesions in the vagina or urethra.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nMultiple dilated pelvic veins are is seen bilaterally.  The vessels are\npatent.\nA cluster of lymph nodes in the right inguinal region appear benign in\nmorphology (5:7).\nThe bladder is underdistended.  Partially imaged loops of bowel are normal in\ncaliber.",
            "output": "No cystic lesions are seen in the vagina or urethra."
        },
        {
            "input": "Study is limited by patient respiratory motion artifact.\n\nPostoperative changes are demonstrated in the anterior pelvic/abdominal wall,\nwith foci of susceptibility.\n\nPost supracervical hysterectomy. Small cystic appearing foci are demonstrated\nwithin the margin of the remaining cervix, nonspecific, possibly\npostoperative. No free pelvic fluid. No apparent pelvic adenopathy, largest\nright external iliac node measures 9 mm, ovoid with fatty hilum.\n\nThe right ovary measures 6.3 x 3.4 x 4.3 cm, and demonstrates mild enhancement\nof ovarian parenchyma with normal parenchymal signal. Multiple relatively\nsimple cystic appearing foci measure up to 2.4 x 2.2 cm, with a thin internal\nseptation versus two adjacent cystic structures.  A 17 mm probable involuting\ncyst with peripheral enhancement is noted, likely a corpus luteum. Adjacent\nfoci of susceptibility are present, representing calcification versus\nhemosiderin.\n\nDecompressed bladder without apparent mass.\n\nNo suspicious osseous lesions.",
            "output": "1.  6.3 cm right ovary with follicular activity.  While there are no\nconcerning features on MR, the size of the ovary is atypical and comparison\nwith prior outside imaging for growth or change is recommended (not currently\navailable on PACS).  If prior cross-sectional imaging is not available for\ncomparison, a 6 month followup pelvic MRI could be considered to assess for\nstability.\n2.  No free pelvic fluid or definite pelvic adenopathy."
        },
        {
            "input": "The patient is status post left salpingo-oophorectomy and supracervical\nhysterectomy. Few small Nabothian cysts are seen within the cervix. The right\novary is identified in the right lower quadrant adherent to the right anterior\nabdominal wall and with presence of fibrous adhesions. The ovary is slightly\nenlarged when compared to the prior study. The maximum diameter measures 5.5\ncm on the current study where it measured 5 cm previously. There is also\nslight interval increase in the size of a hemorrhagic cyst in the ___\nthe ovary which on the current study measures 2.4 cm while it measured 2.2 cm\npreviously. Also better appreciated on the current study is the presence of a\nhydrosalpinx on the right which is located on the right lateral aspect of the\novary. Also this has increased in size with the largest diameter on the\ncurrent study measuring 2.2 cm while it measured 1.4 cm previously. The\nurinary bladder is decompressed but does not show any gross abnormalities. Few\noblong-shaped obturator lymph nodes and external iliac lymph nodes are\nidentified but there is no evidence of lymphadenopathy.\nThe visualized portions of the axial skeleton an GI tract are unremarkable.",
            "output": "1. Status post hysterectomy and left salpingo-oophorectomy. The right ovary is\nslightly enlarged when compared to the prior MRI study from ___ and\nnow measures 5.5 cm. . There is also an associated enlarging right\nhydrosalpinx. The internal hemorrhagic cyst in the right ovary is also\nslightly enlarged. No concerning solid components are present."
        },
        {
            "input": "Pelvic veins are widely patent.  No filling defects are identified. Low\ncaliber of bilateral common femoral veins may relate to volume state.\n\nScattered hepatic cysts are identified.  There is also a medium-size simple\nappearing cyst in the spleen.  A number of small renal cysts appear simple. \nPancreas and adrenals are unremarkable.  Gallbladder appears normal.\n\nStomach and visualized small bowel are unremarkable.  Mildly prominent stool\ncontent is noted throughout the colon.\n\nSmall to medium size gonadal varices are bilateral.  At uterus and adnexa are\notherwise unremarkable.  Bladder appears normal.  No lymphadenopathy or free\nfluid.\n\nBone marrow signal intensities are unremarkable.",
            "output": "No evidence of venous thrombosis."
        },
        {
            "input": "Again noted is a complex perianal fistula, originating from the 6 o'clock\nposition, approximately 3.5 cm above the anal verge (4:23, 901:63).  With\ntract extending through the left intersphincteric space, through the external\nsphincter, and superiorly and anteriorly through the fibers of the left\nlevator ani, to contact the prostate (902:56), without intra prostatic\nextension.\n\nThere is rim enhancing fluid collection, in the left sub-levator ani region,\nwith T2 hyperintense central fluid, measuring 2.5 x 1.4 cm (6:20), previously\n1.4 x 1.2 cm (5:17).\n\nFrom this collection arises a posterior sinus tract, that extends into the\nleft ischiorectal fossa, which diameter has increased compared to prior (8 mm\nversus 5 mm) and now demonstrates higher T2 hyperintense signal, with small\npockets of fluid within the tract, new compared to prior, with stable\nextensive stranding and edema throughout the ischiorectal fossa.\n\nAs before, from the posterior and inferior aspect of the fistula, at the\napproximate 7 o'clock position, arises a sinus tract that extends in an\nintersphincteric fashion to the right gluteal cleft, without a skin defect\n(___).  There is no fluid within this tract, as before.\n\nThe perianal and perirectal collections do not open into the anal or rectal\nmucosa.\n\n\nThere is redemonstration of a 2.3 cm prostatic cyst.\n\nThe appearances of the bladder, seminal vesicles and rectum are unremarkable.\n\nThere are no significantly enlarged pelvic lymph nodes.",
            "output": "1. Complex perianal fistula with left-sided transsphincteric and\nsuprasphincteric extension contacting the left aspect of the prostate, with\nmarkedly increased size of rim enhancing abscess, that lies immediately\nposterior to the left levator ani, now measuring 2.5 x 1.4 cm, previously 1.4\nx 1.2 cm.\n2. The posterior sinus component of the fistula that extends into the left\nischiorectal fossa, has increased in diameter and now demonstrates small\npockets of fluid within the tract, new compared to prior.\n3. The inferior intersphincteric component/sinus tract extending to the right\ngluteal region is grossly unchanged compared to prior.\n4. Stable 2.3 cm prostatic cyst."
        },
        {
            "input": "There is increased T2 signal with some enhancement around the right greater\ntrochanter with ovoid areas of signal hypo intensity consistent with right\ngreater trochanteric bursitis with possible calcific bursitis.\n\nThere is increased signal at the L4-L5 disc space and endplate concavity at\nthe left aspect of the superior L5 endplate with some increased T2 signal and\nenhancement.  (10:22, 06:22). This is new compared to CT torso from ___.\n\nGeneral marrow heterogeneity likely secondary to red marrow.\n\nNo hip joint effusion is identified. The proximal hamstring tendon origins are\nnormal. The musculature is normal in bulk and signal.\n\nThe SI joints are normal. The pubic symphysis is normal.\n\nLimited evaluation of the intrapelvic structures is unremarkable.  TURP defect\nis noted.",
            "output": "1.  No right thigh masses identified.\n2.  Findings consistent with right greater trochanteric bursitis with \npossible calcific tendinitis.\n3.  Abnormal signal at L4-L5 disc space with endplate irregularity and signal\nabnormality at the superior L5 endplate.  This is new since CT in ___ and may\nreflect a Schmorl's node.  Recommend dedicated lumbar spine MRI for further\nevaluation.\n\nRECOMMENDATION(S):  MRI lumbar spine."
        },
        {
            "input": "INTRAPELVIC BOWEL: There is predominantly circumferential hyperenhancement\ninvolving approximately 1.7 cm of the mid anal canal mucosa and submucosa\n(series 13, image 1; series 9, images 53-60).  Inferior to this, there is a\nshort segment of normal mucosal and submucosal enhancement followed by an\napproximately 8 mm distal segment of abnormal anterior mucosal and submucosal\nenhancement (series 13, image 1; series 9, images 63-66).\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.5 x 3.0 x 4.1 cm..\nThe endometrium is normal in thickness for age and measures 4 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.  There is an\nunchanged simple appearing 2.2 cm paraovarian cyst (series 5, image 5).\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The urinary bladder is unremarkable.  No distal\nhydroureter.\n\nVASCULATURE: The imaged pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous or soft tissue\nlesions.",
            "output": "1. Nonspecific anal mucosal and submucosal enhancement, possibly reflecting\nsmall hemorrhoids or anitis.  No abscess or perianal fistula.\n2. No definite evidence of pouchitis."
        },
        {
            "input": "The prostate gland measures 6.0 x 6.6 x 6.7 cm (AP x SI x TV), yielding a\ncalculated volume of 139 cc. The central gland is enlarged and shows a\nheterogenous swirled and whorled appearance with well defined nodules,\nindicative of BPH.\nThere is no evidence of focal abscess within the prostate gland.\nSeminal vesicles are grossly normal.\nNo overt pelvic lymphadenopathy.\nThere is mild circumferential thickening and trabeculation of the urinary\nbladder wall, likely on a background of chronic outlet obstruction.\n\nVisualized bowel is unremarkable.\n\nNo marrow replacing process.",
            "output": "Background BPH and prostatic enlargement, with urinary bladder wall thickening\ncompatible with features of chronic outlet obstruction.  No focal prostate\nabscess is identified on today's study."
        },
        {
            "input": "There is low symmetric T1 signal within the proximal femurs, bilaterally\nhowever there is increased edema and asymmetric enhancement within the right\nfemoral head and neck.  Geographic, irregular hypoenhancement of the\nanterosuperior aspect of the right femoral head at the site of associated gas\nwithin the femoral head on prior CT, is concerning for necrotizing infection. \nMild edema and abnormal enhancement is noted within medial aspect of the\nacetabula, bilaterally (series 12, image 14).\n\nThere is a moderate right hip joint effusion with associated right iliopsoas\nbursitis.  There is extensive abnormal enhancement and edema extending along\nthe iliopsoas muscle deep into the pelvis, compatible with myositis and\niliopsoas bursitis.  There is extensive edema and abnormal enhancement in the\nproximal right thigh centered about the hip joint involving the adductor,\nabductors and quadriceps musculature.  Extensive soft tissue edema extends\ninferiorly about the thigh most pronounced anteriorly about the rectus femoris\ncompatible with cellulitis and fasciitis.\n\nAbnormal enhancement edema is noted within the obturators internus musculature\nleft greater than right (series 4, image 25).  Soft tissue edema and\nenhancement within the left gluteus minimus and possibly extending into the\nanterior gluteus medius at the posterior aspect of the left acetabulum (series\n4, image 17, series 11, image 20).  Symmetric abnormal enhancement edema is\nnoted in the medial gluteal maximus musculature adjacent to the sacrum (series\n4, image 14).\n\nThere appears to be either a G-tube or J-tube in place.  There is extensive\nthickening, soft tissue edema and abnormal enhancement within the left rectus\nabdominus musculature (series 11, image 2, series 9, image 5).\n\nThe tendons about the hips are unremarkable. The gluteal and proximal\nhamstring tendons are normal in appearance.\n\nProbable trace right greater trochanteric bursitis, reactive versus\ninfectious.\n\nTrace fluid is noted in the pelvis, which is within normal limits given the\npatient's age.  Gas within the non-dependent portion of the urinary bladder\ncould be from recent instrumentation, but correlation is needed to exclude\ninfection.  Prominent right pelvic sidewall lymph nodes measure up to 8 mm. \nOtherwise, no gross abnormalities.",
            "output": "1.  Right hip septic arthritis with concern for right proximal femoral and\nacetabular osteomyelitis.  Hypoenhancing portions of the femoral head are\nconcerning for necrotizing infection.  Extensive edema and abnormal\nenhancement tracking deep into the pelvis along the iliopsoas, compatible with\nmyositis and bursitis.  No deep fluid collection within the pelvis.  Extensive\nmyositis centered about the right hip.\n2.  Additional areas of soft tissue edema and enhancement within the bilateral\ngluteus maximi and the left gluteus minimus and left obturator internus,\nconcerning for myositis, possibly traumatic with infection not excluded.\n3.  Questionable bone marrow edema and abnormal enhancement within the medial\nleft acetabulum.  Correlate for any evidence of left hip infection.\n4.  Left rectus abdominus muscle edema and hyperenhancing, concerning for\nmyositis, surrounding what appears to be a percutaneous feeding tube.  This is\nsuboptimally evaluated as the feeding tube is only seen on the periphery of\nthe study.  Recommend clinical correlation.\n5.  Gas within the urinary bladder may be due to recent instrumentation but\ninfection is not excluded."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and enlarged, measuring 16.7 x 10.9 x 12.2 cm.\nA large, 10.4 x 9.5 x 10.3-cm, well-circumscribed, complex, predominantly\nT2-hyperintense, T1-hypointense cystic mass with numerous irregular, thick,\nand slightly nodular enhancing septations occupies the intramural anterior\nuterine fundus (series 3, image 18 ; series 2, image 23; series 12, image 44;\nseries 16, image 44).  Several of the internal septations anteriorly\ndemonstrate restricted diffusion (Series 9, image 45; series 10, image 14). \nNo intrinsic T1 hyperintensity to suggest acute hemorrhage.  No susceptibility\nartifact is identified within the mass to suggest hemosiderin or old\nhemorrhage.  No evidence of signal loss on opposed phase images to indicate\nthe presence of bulk fat within the mass.\n\nA 1.5 x 1-cm T1 and T2 hypointense, ovoid enhancing mass in the right\nposterior uterine wall is consistent with a fibroid and appears intramural;\nhowever, a submucosal component cannot be completely excluded (series 14,\nimage 48; series 3, image 23; series 12, image 48).\n\nThe endometrium is normal in thickness for age and measures 1 mm with trace\nphysiologic amount of fluid (see series 3, image 20).\nThe junctional zone is not obviously thickened.\n\nThe right ovary is visualized and appears within normal limits (series 4,\nimage 29). The left ovary is equivocally visualized and appears within normal\nlimits (series 4, image 24).  No concerning adnexal mass.\n\nNo free fluid in the pelvis.\n\nLYMPH NODES: No pelvic sidewall or iliac lymphadenopathy.  No inguinal\nlymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The partially distended urinary bladder is\nunremarkable.  The distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized loops of bowel in the pelvis are\nunremarkable without abnormal wall thickening or enhancement.  The rectum is\nunremarkable.  No evidence of bowel obstruction.\n\nVASCULATURE: The visualized iliac arteries and veins appear patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous signal abnormality suspicious\nfor malignancy.  The visualized pelvic wall appears normal.",
            "output": "1.  Interval slight growth of a now 10.4 x 9.5 x 10.3-cm intramural uterine\nfundal complex cystic mass with multiple thick internal enhancing septations,\nsome with restricted diffusion.  While a degenerating fibroid is a\npossibility, given interval growth, post-menopausal status, and atypical\nappearance, including the presence of thick enhancing septations, neoplasm\nremains a possibility, and surgical consultation is recommended.\n2.  1.5-cm right posterior fibroid that appears predominantly intramural;\nhowever, a submucosal component cannot be completely excluded.\n3.  No concerning adnexal mass.\n4.  No lymphadenopathy.\n\nRECOMMENDATION(S):  Surgical consultation regarding potential excision of the\nuterine lesion. If surgery is not pursued, continued MRI follow-up is\nrecommended.\n\nNOTIFICATION:   The impression and recommendation above was entered by Dr.\n___ on ___ at 15:02 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "Approximately 5 cm from the anal verge at the right-anterior wall of the\ndistal rectum a mass is demonstrated, measuring 1.6 cm in diameter. The mass\nis hyperintense on T2WI relative to the muscularis propria(8:15) and\ndemonstrates restricted diffusion (06:59) and hypoenhancement relative to the\nrectal mucosa (1102:53). The T2 hypointensity of the muscularis propria is\nintact (8:15, 600:16). Minimal linear strands of T2 hypointensity along the\nright anterior rectal wall are compatible with desmoplastic reaction (8:15).\nThis is consistent with T2 lesion.\nNo enlarged mesorectal lymph nodes are demonstrated.\n\nThe prostate gland is enlarged and demonstrates the swirled nodular appearance\nof within prostatic hyperplasia.\nThe seminal vesicles demonstrate T2 hypointensity and intrinsic T1\nhyperintensity, consistent with proteinaceous contents.\nThe urinary bladder wall is trabeculated, secondary to chronic outlet\nobstruction.\nBilateral fat containing inguinal hernias are demonstrated.\nThe bone marrow signal is normal.",
            "output": "1. Distal rectal mass located 5 cm from the anal verge at the right-anterior\nrectal wall, with preserved muscularis propria. No enlarged lymph nodes.\nRadiologic stage T2 N0.\n2. Benign prostatic hyperplasia."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is retroverted and measures 6.2 x 3.4 x 4.7 cm.  There is a 2.1 x\n1.6 x 1.5 cm uniformly enhancing posterior intramural uterine fibroid near the\nfundus (501:44, 3:16).  There is thickening of the uterosacral ligament and\nsurrounding fascia suggesting endometriosis.\nThe endometrium is normal in thickness for age and measures 2 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary contains a simple cyst superiorly that measures up to 1.5 x 1.2\nx 1.5 cm (04:15: 3:8).  Inferiorly and medially, there is a dermoid that\ncontains microscopic fat measuring up to 1.5 x 1.1 cm (04:16).  Inferiorly and\nlaterally, there is a T2 and T1 hypointense lesion with low-level enhancement\nmeasuring up to 1.7 x 1.4 cm (04:18).\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: Unremarkable.\n\nBLADDER AND DISTAL URETERS: There is irregularity and nodularity of the\nanterior wall of the bladder near the dome with architectural distortion and\nan area that is T2 hypointense and T1 isointense to slightly hyperintense with\nminimal enhancement (03:14, ___.  There are no specific suspicious\nfeatures and this most likely represents endometriosis implant.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: A hemangioma is noted within the L4\nvertebral body (05:15).",
            "output": "1. Left ovary contains a simple cyst, a small dermoid, and a T2 hypointense\nlesion most consistent with a fibroma, ___ tumor.  No\nsuspicious ovarian lesion is identified.\n2. Findings of endometriosis including fascial thickening with a probable\nimplant along the anterior surface of the bladder wall.\n3. Fibroid in the uterine fundus."
        },
        {
            "input": "The uterus is anteverted with approximate ___ of 12.4 x 6.4 x 8.1 cm.\nThere are at least 7 uterine fibroids. The largest is intramural, seen in the\nanterior left aspect of the fundus with ___ of 5 x 4.6 x 3.7 cm. There\nalso 2 large fibroids which have a submucosal component. One is seen within\nthe anterior superior uterine wall with less than 50% of the fibroid extending\ninto the endometrial cavity (04:19). This fibroid has ___ of 4 x 4.2 x\n3.1 cm. A 3.9 x 3.2 x 3.7 cm fibroid is seen and extending from the right\nlower uterine segment lateral wall into the endometrial cavity with\napproximately 90% of the fibroid being intracavitary (05:15). Each of these 3\ndominant fibroids are heterogeneous in T2 signal, and demonstrate central lack\nof enhancement, consistent with degeneration. The anterior and partially\nsubmucosal fibroid has a central T1 hyperintensity, consistent with carneous\ndegeneration.\n\nThere is a 2.7 cm intramural anterior fundal fibroid which is markedly low in\nT2 signal without internal enhancement, consistent with an entirely\ndegenerated fibroid.\n\nThree subserosal fibroids are noted measuring up to 2.7 cm. Each of these is\navidly enhancing and viable.\n\nThe endometrial cavity is significantly widened by fluid and\nintracavitary/submucosal fibroids. This has maximum diameter of 3.4 cm\n(03:12).\n\nThe junctional zone is normal in thickness.  There is no abnormal uterine\nenhancement to suggest active endometritis.\n\nThe cervix demonstrates a small amount of fluid within the endocervical canal\nbut is otherwise unremarkable.\n\nAs was seen previously, there is complex cystic change associated with each\nadnexa. There are bilateral hydrosalpinges. The right fallopian tube mildly\ndistended with T1 and T2 hyperintense material, positioned superiorly at the\nlevel of the uterine fundus (3:10). The left fallopian tube is moderately\ndistended with layering gradation of T2 signal material.  Each has mild wall\nhyperenhancement, though less than expected for frank pyosalpinges.\n\nEach adnexa is tethered towards midline by T2 hypointense material\ndemonstrating intermediate to increased signal intensity on T1 weighted\nprecontrast images (05:21). This material along the posterior uterine wall\nalso tethers adjacent rectum (3:13). The appearance is compatible with deep\npelvic endometriosis with associated desmoplastic reaction.\n\nThere is a trace amount of free pelvic fluid, located adjacent of the left\nadnexa.  The bladder and urethra are normal in appearance.\n\nSmall left pelvic wall nodes are noted, presumably reactive in etiology. \nOsseous structures are unremarkable per patient's age. No concerning osseous\nlesion is seen.",
            "output": "1. Multifibroid uterus, including a 3.9 cm intracavitary fibroid, with\nvariable degrees of degeneration as detailed above.\n2. Extensive pelvic endometriosis, including deep, infiltrating endometriosis\nof the cul de sac tethering the bilateral adnexa and adjacent rectum.\nBilateral dilated fallopian tubes with complex contents, left greater than\nright, reflecting endometriosis or debris.\n3. Moderate but thin wall hyperenhancement reflects inflammation, likely\nsecondary to endometriosis, and less than expected for frank pyosalpinges,\nthough indistinguishable from low-grade infection on imaging."
        },
        {
            "input": "OSSEOUS STRUCTURES AND SOFT TISSUES:\n\nPatient status post left proximal femoral fixation hardware placement with\nsusceptibility artifact slightly limiting evaluation of the adjacent\nstructures.  In addition, the area of reported palpable mass, is not\ndemarcated by skin marker and there is suboptimal field view of the sagittal\nimages.  However, within these limitations:\n\nThere is an ill-defined 1.0 x 3.1 cm heterogeneously T1 hypointense, stir\nheterogeneous, nonenhancing lesion in the deep left gluteal subcutaneous\ntissues (4:11, 5:11, 8:11, 9:11).  Additionally, there is some surrounding\nregional enhancing soft tissue edema (9:11).  There is also increased\nasymmetry of the subcutaneous fat within the left gluteal soft tissues.  Note\nthere are additional subcutaneous linear hypointensities in the lateral\nsubcutaneous tissues of the at the level hip, which are likely postsurgical.\n\nNo evidence of suspicious osseous lesions.\n\nThere are mild lumbosacral and bilateral sacroiliac joint degenerative\nchanges.  No evidence of sacroiliitis.  Incidental note is made of a few small\nperineural cysts at the level of approximately S3.\n\nThere is diffuse subcutaneous edema.\n\nABDOMEN: The partially imaged right kidney appears have either peripelvic\ncysts or dilated calices, with possibly a dilated renal pelvis (7:5).\n\nUTERUS AND ADNEXA: Patient status post hysterectomy. The uterus is not\nvisualized. Bilateral adnexa unremarkable. No significant pelvic free fluid.\n\nLYMPH NODES: No lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: A rectal tube is visualized.  Colonic\ndiverticulosis without evidence of acute diverticulitis.   Otherwise,\nunremarkable.\n\nVASCULATURE: Patent.",
            "output": "Limited examination as stated above.  However, within these limitations:\n\n1.   Possible 1.0 x 3.1 cm ill-defined T1 hypointense left gluteal\nsubcutaneous lesion, however indeterminate, possibly area of fibrosis or\npostsurgical changes.  Additionally there are probable postsurgical changes in\nthe subcutaneous tissues of the lateral aspect of the left hip.  Consider\nradiographs for evaluation for calcification/ossification.  Dedicated\nultrasound in the region of palpable abnormality may add additional\ninformation.\n2. Partially imaged right kidney demonstrates peripelvic cysts versus\nhydronephrosis.  Renal ultrasound is recommended for further evaluation.\n3.  Colonic diverticulosis without evidence of acute diverticulitis.\n4. Diffuse subcutaneous edema, more pronounced in the left gluteal region."
        },
        {
            "input": "Bones: Alignment appears preserved.  No bone marrow signal abnormality no\nfracture.  No mass is identified.  Sacral neural foramina appear preserved.\n\nMild degenerative changes of the lower lumbar spine.\n\nSoft tissues: Mild to moderate amount of nonspecific presacral edema.  Large\namount of stool seen within the rectal vault.  2 small bladder diverticula\nmove the posterior superior right bladder measuring up to 1 cm.  Tubular fluid\nstructure adjacent to the lateral superior aspect of the bladder (image 7:1)\nmay represent partially visualized ureter from transplant kidney.  Diffuse\nmuscle edema.\n\nPartially visualized transplant kidney in the left low abdomen demonstrates\nmoderate to severe hydronephrosis.",
            "output": "1.  No mass or fracture visualized of the sacrum.\n2.  Large amount of stool is seen within the rectal vault.\n3.  Partially visualized left transplant kidney demonstrates moderate to\nsevere hydronephrosis.  Correlation with prior imaging or history of\nhydronephrosis is recommended.  Ultrasound could be considered for further\nevaluation if clinically indicated.\n\nNOTIFICATION:  The findings were discussed with Dr.  ___, M.D. by ___\n___, M.D. on the telephone on ___ at 7:50 am, 20 minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS:\nThe uterus is anteverted, measuring 17 x 5.5 x 7.5 cm.\n(note: measurement includes the cervix and any exophytic fibroids).\n\nEndometrium: Homogeneous, measuring 11 mm\nJunctional zone: 8 mm without focal thickening.\n\nFIBROIDS:\n\nFibroid burden: ___\nFibroid enhancement: Homogeneous\n\nSubmucosal fibroids (all submucosal fibroids are listed below):\n\nAt least 5 intramural fibroids deforms the endometrial cavity, but there is no\npredominant submucosal fibroids which herniates into the submucosal cavity.\n\nThe three dominant fibroids are:\n1.      size 9.8 x 7.3 x 6.9 cm homogeneous enhancement, exophytic subserosal,\nfindings\n2.      size 2.2 x 2.7 x 3.4 cm homogeneous enhancement, exophytic subserosal,\nleft fundus\n3.      size 2.4 x 2.2 x 2.9 cm homogeneous enhancement, exophytic subserosal,\nanterior body\n\nNo cornual or cervical fibroids are detected.\n\nVascular supply to the uterus: Uterine arteries.\n\nOVARIES:\nNormal size with normal follicular activity bilaterally.\nInvoluting corpus luteum cyst in the right ovary.\n\nThere is no intrapelvic free fluid.",
            "output": "Multi fibroid uterus as described above"
        },
        {
            "input": "Please note the study is somewhat degraded by patient motion artifact.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Mild bone marrow edema is seen within the\nleft iliac bone and left sacral ala, presumably related to recent bone marrow\naspiration.  Asymmetric soft tissue edema within the sciatic notch, extending\nanterior to the sacrum, and tracking along the sacral plexus is new as\ncompared to CT abdomen pelvis dated ___.  There is minimal\nenhancement within this tissue after contrast.  No drainable fluid collection\nis identified.  Edema is additionally seen within the adductor muscles\nbilaterally, within the piriformis muscle on the left, and in the left gluteal\nmuscles as well.\n\nUTERUS AND ADNEXA: A 2 x 2.2 cm heterogeneously enhancing round mass is seen\nwithin the endometrial canal within the uterus (802:47).  Additionally, a 6.6\nx 5.1 cm right adnexal mass is again seen, similar in size as compared to\n___, and demonstrates an irregular area of central nonenhancement,\ncompatible with necrosis.\n\nLYMPH NODES: No pathologically enlarged pelvic sidewall inguinal\nlymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Intrapelvic loops of large and small bowel are\nnormal in course and caliber.\n\nVASCULATURE: Pelvic vasculature is widely patent.",
            "output": "Please note that the study is somewhat degraded by patient motion artifact.\n\n\n1. Bone marrow edema within left iliac bone and left sacral ala are presumably\nrelated to recent bone marrow aspiration.\n2. Asymmetric soft tissue edema in the sciatic notch, tracking anterior to the\nsacrum, and along the sacral plexus is new from ___.  No drainable\nfluid collection is identified.  These findings may represent sequela of\nrecent bone marrow aspiration, such as hematoma or infection.  Recommend\nneurosurgery consultation for further evaluation of the patient.\n3. Heterogeneously enhancing mass in the endometrial canal should be further\nevaluated with pelvic ultrasound.  This may reflect a polyp or other\nendometrial lesion.\n4. Right adnexal mass with central necrosis appears similar in size to\n___, and may represent a partially necrotic broad ligament fibroid,\nhowever this should be further evaluated with pelvic ultrasound as well.\n\nRECOMMENDATION(S):\n1. Asymmetric soft tissue edema in the sciatic notch, tracking anterior to the\nsacrum, and along the sacral plexus is new from ___. No drainable\nfluid collection is identified. These findings may represent sequela of recent\nbone marrow aspiration, such as hematoma or infection. Recommend neurosurgery\nconsultation for further evaluation of the patient.\n2. Heterogeneously enhancing mass in the endometrial canal should be further\nevaluated with pelvic ultrasound.\n3. Right adnexal mass with central necrosis appears similar in size to\n___, and may represent a partially necrotic broad ligament fibroid,\nhowever this should be further evaluated with pelvic ultrasound as well.\n\nNOTIFICATION:  The findings were discussed with ___, by ___, M.D.\non the telephone on ___ at 8:48 pm, 10 minutes after discovery of the\nfindings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.6 x 6.1 x 8.1 cm.  There is focal\nthickening of the anterior junctional zone and intramural cysts, suggestive of\nadenomyosis.  The junctional zone measures up to 1.8 cm at this level.  The\nendometrium is within normal limits for age.\n\nA few diminutive intramural fibroids measuring up to 1.6 cm are seen.\nThe cervix and nondistended vagina are unremarkable.  A low anterior C-section\nscar is noted.\n\n\nThe hemorrhagic lesions seen in the right adnexum on CT corresponds to a 2.9\ncm endometrioma.  No solid features are seen.  There are thick and en-plaque\nadhesions between the adnexa, posterior uterus and rectosigmoid colon\nsuggestive of deep invasive endometriosis.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There are no enlarged pelvic lymph nodes.\n\nBLADDER AND DISTAL URETERS: There is endometriosis in the anterior compartment\nof the pelvis superior to the bladder evidence by thick adhesions and\nen-plaque hypointense T2 signal.\n\nRECTUM AND INTRAPELVIC BOWEL: No bowel obstruction.  No findings of mural\nbowel wall endometriosis in the rectosigmoid colon.\n\nVASCULATURE: The central iliac vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is a 1.6 cm nodule just of midline\nof the anterior pelvic wall involving the left rectus abdominus compatible\nwith abdominal wall endometriosis at the level of the ___ incision.",
            "output": "The prior right adnexal hemorrhagic lesion corresponds to a 2.9 cm right\novarian endometrioma.  There are additional findings of deep invasive and\npelvic wall endometriosis and described above.\n\nSmall uterine fibroids and adenomyosis."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus appears normal.\nThe right ovary is visualized and appears within normal limits.\nLeft adnexal mass measuring 22 x 29 mm in the axial plane and 21 mm in the\ncraniocaudal plane which seems to contain fatty tissue evidence by ___ ink\nartefact surrounding the lesion on the out of phase imaging and has apparent\ndecreased signal intensity on the fat-sat imaging (but no pre fat sat imaging\navailable).\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No lymphadenopathy\n\nBLADDER AND DISTAL URETERS: The bladder is collapsed.  The distal ureters are\nnot dilated.\n\nRECTUM AND INTRAPELVIC BOWEL: No rectal wall masses.  Colonic diverticula, but\nno features of diverticulitis.\n\nVASCULATURE: Normal arterial structures.  No venous filling defects to suggest\ndeep venous thrombosis.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No aggressive bony lesions.",
            "output": "No deep venous thrombosis.\n\nLeft adnexal mass measuring 22 x 29 x 21 mm is suggestive of a dermoid, but is\nincompletely evaluated on this MRV study.  Correlation with pelvic ultrasound\nadvised."
        },
        {
            "input": "Dysmorphic bladder with a very thickened bladder wall and postsurgical\nchanges.  Assessment is limited without contrast.\n\nLeft ureter is not present.\n\nRight ureter is dilated at its mid aspect with a small papillary projection\nand the distal ureter is completely filled with soft tissue which shows\nrestricted diffusion.\n\nMinimal free pelvic fluid.\n\nLYMPH NODES: No enlarged node\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits\n\nVASCULATURE: Within normal limits\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No osseous lesion.  No soft tissue mass.",
            "output": "Right ureter is dilated at its mid aspect.  There is a small papillary\nprojection at the mid-distal aspect and the distal ureter is completely filled\nwith soft tissue which is concerning for recurrent malignancy.\n\nDysmorphic bladder with a very thickened bladder wall and postsurgical\nchanges. Assessment is limited without contrast but not malignancy is\nidentified."
        },
        {
            "input": "The patient is status post multiple treatments of low grade bladder cancer.\nAlong the luminal surface of the anterior bladder wall there is a polypoid\nexcrescence.  This has ___ of 6 x 7 x 8 mm (11:16 and 9:12), with\nintermediate T2 signal.  Best appreciated on the sagittal images, this lesion\nappears to extend into the thickened anterior bladder wall.  There are T2\nhypointense spiculations which extend beyond the wall, into the adjacent fat. \nWhile associated tethering of adjacent bowel (9:9) and architectural\ndistortion of the fat planes, may suggest post treatment change and scarring,\nthere is apparent restricted diffusion within this entire region, rather than\nonly the small luminal nodule.  This finding is highly concerning for\nextension of tumor beyond the bladder.  Evaluation is limited given lack of\nintravenous contrast and priors for comparison.\n\nThere is also a small outpouching of bladder lumen anteriorly into the region\nof T2 hypointense material, thought to represent a diverticulum (09:15).\n\nSmall lymph nodes are noted within the external iliac region (9:12). Given\ntheir small size, these are nonspecific and comparison to prior is would be\nhelpful to determine level of concern.\n\nThe left kidney and ureter are surgically absent. There is marked right\nhydroureteronephrosis.  The dilated and tortuous of the right ureter is the\nwithout filling defect or focal wall thickening. It a remains dilated to the\nlevel of the unusual bladder insertion anterolaterally (09:10).  No\nobstructing mass lesion is seen at the ureterovesicular junction, although a\nsmall mass could be occult in the absence of contrast.  There may potentially\nbe a stricture at this level accounting for upstream dilation.\n\nThe uterus is anteverted and retroflexed with normal zonal anatomy.  Uterine\nsize is within normal limits for presumed postmenopausal female. Each ovary is\nnormal in size.\n\nThere is mild thinning of the right renal parenchyma.  The noncontrast\nappearance of the parenchyma is otherwise unremarkable.\n\nThe visualized liver, spleen, pancreas and adrenal glands are unremarkable.\n\nThere is a small focus of susceptibility along the posterior lateral aspect of\nthe upper right kidney.  This may relate to a dropped clip.",
            "output": "8mm intraluminal polypoid mass along the anterior wall of the bladder with\nfeatures highly concerning for invasion through the wall.  Superimposed post\ntherapeutic changes may contribute to extensive tethering and architectural\ndistortion.  Small left anterior pelvic nodes are nonspecific.\n\nSolitary right kidney with marked hydroureteronephrosis, extending to the\nureteropelvic junction in an unusual anterolateral position.  No obstructing\nmass is identified (although evaluation limited without contrast).  A\nstricture could account for this appearance."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7 x 3.4 x 5.7 cm.\nThe fundal contour of the uterus is flat to slightly convex with a combined\nmuscular and fibrous septum extending to the external cervical os, compatible\nwith a complete septate uterus.  The distance of the muscular stroma from the\nuterine fundus to the beginning of the fibrous septum measures 3.2 cm.\n\nThe endometrium is normal in thickness for age and measures 5 mm.\nThe junctional zone is not thickened.\n\nThe right ovary is visualized and appears within normal limits.\nThe left ovary is visualized and appears within normal limits.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: No suspicious pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder and distal ureters are normal without\nfocal mass or wall thickening.\n\nRECTUM AND INTRAPELVIC BOWEL: Within normal limits.\n\nVASCULATURE: Visualized portions of the iliac vessels are normal in caliber\nand patent bilaterally.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue mass\nlesions.",
            "output": "Complete septate uterus containing a combined muscular and fibrous septum as\ndescribed above."
        },
        {
            "input": "There has overall been expected post embolization response of multiple\nfibroids. Largest is located posterolaterally on the right, bridging the lower\nuterine segment and cervix. This remains located within the wall, without\nluminal extension or prolapse. While previously T2 hypointense, this is now\nincreasingly heterogeneous with high T1 signal.  There is no residual\nenhancement of this fibroid following contrast administration, consistent with\ncarneous degeneration. Intrafibroid hemorrhage results in mild increase in\nsize, with current axial ___ of 5.5 x 6.4 cm.\n\nA right subserosal exophytic fibroid has decreased from 4.0 x 5.6 cm to 3.4 x\n5.4 cm, with central areas of nonenhancement. Several additional intramural\nfibroids are also no longer enhancing.\n\nThere is no fluid or blood within the endometrial and endocervical canals. No\nfree fluid is identified within the pelvis.\n\nEach ovary is normal in size, signal and enhancement. The venous structures of\nthe pelvis are patent, with unchanged prominence, particularly on the left.\n\nThe visualized bowel loops are unremarkable. Mild degenerative changes noted\nat the lower lumbar spine with a central annular tear seen at the L5-S1\nintervertebral disc (02:21)",
            "output": "Expected response of multiple fibroids to recent uterine artery embolization,\nwith decreased enhancement of all fibroids and carneous degeneration of the\nlargest intramural fibroid spanning the posterior lateral right lower uterine\nsegment and cervix. There is no prolapsing fibroid. Given the position of\nthese fibroids, the exact etiology of patient's left lower quadrant pain is\nunclear."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 7.8 x 4.1 x 4.5 cm.  An IUD appears\nappropriately positioned in the uterus.\nThe endometrium is normal in thickness for age and measures 7 mm.\nThe junctional zone is not thickened.\n\nThe left ovary is asymmetrically enlarged measuring 3.9 x 2.9 cm.  The left\novary contains a 3.0 x 2.5 cm rim enhancing T2 hyperintense lesion likely\nrepresenting a corpus luteum.  The left ovarian stroma is T2 bright compatible\nwith edema without evidence of hemorrhage or abnormal enhancement.\n\nThe right ovary is visualized and appears within normal limits and measures\n1.9 x 1.5 cm.\n\nTrace pelvic free fluid is within physiologic limits.\n\nLYMPH NODES: There is no pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The distal ureters and bladder appear\nunremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic bowel appear\nunremarkable.\n\nVASCULATURE: The visualized iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no drainable fluid collection in\nthe perineum or pelvis.\nThere is a 5.2 mm T2 hyperintense lesion and the clitoris (series 4, image 22)\nthat demonstrates low level enhancement with central speck of non enhancement\nand is likely a phlegmon.  There is T2 hyperintense signal within the clitoris\nextending into the labia, right greater than left with no tract extending\nbeyond the skin of the labia into the surrounding subcutaneous tissues.",
            "output": "1. 5.2 mm phlegmon with surrounding edema in the region of the clitoris and\nadjacent labial skin without an inflammatory tract or abscess extending into\nthe deeper perineal soft tissues.  No drainable abscess outside of the\nclitoris in the perineal soft tissues.  No enlarged inguinal or pelvic lymph\nnodes.\n2. Asymmetrically enlarged left ovary with stromal edema and a corpus luteum. \nThis less likely represents ovarian torsion in the absence of pelvic pain or\nother symptoms.\n3.  IUD in appropriate position in the uterus.\n\nNOTIFICATION:   The findings were discussed with ___, M.D. by\n___, M.D. on the telephone on ___ at 11:37 am, 10 minutes\nafter discovery of the findings."
        },
        {
            "input": "ANUS AND RECTUM:\n\nINTERNAL ANAL OPENING:\n\nLocation (quadrant and clock face) in supine position: Posterior at 6 o'clock\nDistance from anal verge:  Approximately 1.8 cm\nRelation to the internal sphincter: Involving middle third of sphincter\n\nFISTULA TRACT:\n\nMaximum tract diameter:  1.8 x 1.3 cm right intersphincteric abscess\nFistula type (Parks classification):  Intersphincteric\nDescription: Complex fistula with multiple branches.  Essentially at the level\nof the fistula origin, there is a horseshoe tract extending between\napproximately 3 o'clock and 10 o'clock (series 101, image 71).\n\n-At the right aspect of the intersphincteric horseshoe tract, there is an\nintersphincteric abscess, which extends craniocaudally between the anal verge\nand the anorectal junction (series 4, image 22; series 3, image 18).  The\nabscess measures up to 5.0 x 1.8 x 1.3 cm (series 802, image 56; series 4,\nimage 22) with inflammation extending to involve the right levator ani\nmuscles.\n-At the inferior left aspect of the intersphincteric horseshoe, there is a 9 x\n5 mm intersphincteric abscess (series 801, image 74; series 4, image 24).\n-Extending inferiorly from the midline aspect of the intersphincteric\nhorseshoe, a small ramification descends and probably communicates with the\nposterior midline anal verge at 6 o'clock (series 801, images 71-81).\n\nHyperintensity of the tract on T2: Marked\nEnhancement of the tract: No central enhancement compatible with a\nfluid-filled tract\n\nOTHER FINDINGS:\n\n\n\nAbscess: Yes, as described above\nOther loops of intrapelvic bowel or better assessed on the MR enterography\nperformed 4 days prior.\n\n\nUTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures approximately 5.3 x 3.1 x 5.2 cm..\nThe endometrium is thickened and measures up to 9 mm.  There is irregular\nenhancing endometrial soft tissue along the posterior uterine body measuring\napproximately 8 x 5 x 8 mm (series 3, image 16; series 4, image 16; series 5,\nimage 9; series 802, image 27).\nThe junctional zone is not thickened.\nThe ovaries are unremarkable for patient age.\n\nLYMPH NODES: No pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The urinary bladder and distal ureters are\nunremarkable.  Small amount of pelvic free fluid is noted.\n\nVASCULATURE: The imaged pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous or soft tissue\nlesions.",
            "output": "1. Complex intersphincteric perianal fistulizing disease, including two\nintersphincteric abscesses measuring 5.0 x 1.8 x 1.3 cm and 9 x 5 mm.  The\nlargest right perianal abscess extends craniocaudally between the anal verge\nand the anorectal junction with inflammation involving the right levator ani.\n2. There is an 8 mm enhancing endometrial lesion along the posterior uterine\nbody which may reflect an endometrial polyp with carcinoma not excluded. \nRecommend correlation with endometrial biopsy.\n\nRECOMMENDATION(S):  There is an 8 mm enhancing endometrial lesion along the\nposterior uterine body which may reflect an endometrial polyp but endometrial\ncarcinoma is not excluded.  Recommend endometrial biopsy."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: There is some enhancing granulation tissue near\nthe anal verge, without evidence of a residual fistula.  The intrapelvic bowel\nloops are unremarkable.  No drainable collection.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are unremarkable.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate and seminal vesicles are\nwithin normal limits.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nVASCULATURE: The pelvic vasculature is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There are no suspicious osseous lesions.",
            "output": "Post-surgical changes related to prior fistulotomy, without evidence of\nresidual or new perianal fistula.  No drainable collection."
        },
        {
            "input": "There is a known soft tissue mass along the left pelvic sidewall that measures\napproximately 6.0 x 4.2 x 2.8 cm CC x AP x TV (702:58, 2:7).  This is\nhypointense on T1 weighted imaging, heterogeneously hyperintense on T2\nweighted imaging, and demonstrates heterogeneous, predominantly peripheral\nenhancement likely reflecting internal necrosis.\n\nThere is tumor infiltration of the L4 and L5 nerves on the left (2:8, 2:10). \nThere is soft tissue in very close proximity to the left S1 nerve anterior to\nthe sacroiliac joint, and tumor infiltration cannot be excluded (4:30,\n702:55).  The mass contacts the left iliacus muscle and sacrum with no\nextension into the sciatic notch.\n\nShort segments of the left internal and external iliac arteries become\nirregular and attenuated as they courses through the mass (701: 63, 65), which\nwas better seen on prior CT. However, the arteries appears patent distally.  \nThe left common iliac vein is completely occluded by the mass.\n\nThe left ureter is partially encased the mass (702:63), with diffuse ureteral\nwall thickening and enhancement throughout its course, likely reactive to the\nureteral stent.  There is no hydroureteronephrosis.\n\nLYMPH NODES: There are a few prominent lymph nodes surrounding and proximal to\nthe tumor (702:64, 702:32).\n\nUTERUS AND ADNEXA: Patient is status post hysterectomy and bilateral\nsalpingo-oophorectomy.\n\nBLADDER AND DISTAL URETERS: The bladder is unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: Normal in caliber.\n\nVASCULATURE: Other than attenuation of the left internal iliac artery, the\nremainder of the visualized pelvic vasculature appears patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No focal osseous lesions are identified.",
            "output": "6 cm infiltrative partially necrotic mass along the left pelvic sidewall\nencasing the distal L4 and L5 nerves, and possibly contacting the S1 nerve\nanterior to the left SI joint.  Short segment irregularity and attenuation of\nthe left internal iliac artery as it courses through the mass, which appears\npatent distally.  Partial encasement of the stented left ureter. Occlusion of\nthe left common iliac vein."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nPatient is status post hysterectomy and bilateral salpingo-oophorectomy.\nThe known soft tissue mass along the left pelvic sidewall is much smaller\nincise currently measuring approximately 2.1 x 2.0 cm, previously 4.2 x 2.8 cm\n(1102:46) with mostly peripheral enhancement delineating an area of central\nnecrosis.  This mass continues to be in close proximity to the left L4 nerve\nwith definitive encasement of the left L5 nerve root left ureter (03:13).\n\nLYMPH NODES: The previously mentioned small lymph nodes are no longer seen. \nNo other pelvic lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder is not distended.  The left ureter has\nan indwelling stent with is patent, with redemonstration of parietal\nenhancement throughout.\n\nRECTUM AND INTRAPELVIC BOWEL: Diverticula seen in the sigmoid colon with no\nassociated inflammatory signs.  The rectum is unremarkable.\n\nVASCULATURE: The visualized pelvic vasculature appears patent.  The left\ncommon iliac vein is attenuated though patent in the current study.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions are seen in\nthe visualized skeleton.",
            "output": "Status post hysterectomy with bilateral salpingo-oophorectomy due to\nendometrial cancer.\nInterval decrease in size of a known metastatic mass in the left deep pelvis\nas compared to prior study ___, still encasing the left L5 nerve\nroot.  No pelvic lymphadenopathy is identified in the current study."
        },
        {
            "input": "Posterior to the anus is a 19 x 13 x 20 mm intersphincteric collection, just\nabove the anal verge, demonstrating high internal signal intensity on T2\nweighted sequences, with rim enhancement (series 5, image 22, series 101 image\n81), with an internal 3 mm focus of high in signal intensity on T1 weighted\nprecontrast images (series 7, image 80), representing trace hematoma or\ndebris.  Allowing for differences in imaging technique, the collection appears\nminimally changed since the ___ CT examination. A linear focus of\nenhancement projecting from the 6 o'clock position of the lower anus\n(posterior, lithotomy) is likely a tiny sinus track (series ___, image 81). \nA track extends from the inferior aspect of this collection to exit the right\nperineum (series 801, image 91).\n\nThere is moderate mucosal enhancement throughout the lower and mid rectum\n(series 10,801 image 59), reflecting active inflammation. Mild sigmoid wall\nthickening without wall hyperenhancement reflects chronic inflammation.\n\nThere is no intrapelvic free fluid. The bladder is normal.\n\nThere are no bony lesions concerning for malignancy or infection.",
            "output": "1. 19 x 20 x 13 mm intersphincteric abscess arising from a 6 o'clock\n(posterior, lithotomy) track from the lower anus, with a tract extending from\nthe inferior aspect of the collection to the right perineum.\n2. Moderate lower/mid rectal active inflammation, and mild sigmoid chronic\ninflammation, reflecting known history of Crohn's disease."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is midline and measures 8.1 x 3.6 x 4.5 cm.\nThe endometrium is normal in thickness for age and measures 2-3 mm.\nThe junctional zone is not thickened.\n\nArising from the right ovary is a large simple cyst measuring 8.0 x 7.2 cm. \nNo enhancing septations or mural nodularity is identified.  The left ovary is\nnormal in appearance and contains small follicles.\n\nNo pelvic free fluid.\n\nLYMPH NODES: No pelvic sidewall or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder is grossly normal.\n\nRECTUM AND INTRAPELVIC BOWEL: Visualized loops of small and large bowel are\nwithin normal limits.\n\nVASCULATURE: Visualized vasculature within the pelvis is patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No acute or aggressive osseous lesions\nare demonstrated.",
            "output": "8.0 x 7.2 cm simple cyst arising from the right ovary, as seen on recently\nperformed pelvic ultrasound.  No concerning features are identified.\n\nFollowup-up ultrasound in ___ weeks is recommended to assess for any change in\nsize.  If this cyst persists and further imaging surveillance is desired, a\nfollow-up pelvic MRI in ___ months could be considered.\n\nRECOMMENDATION(S):  Pelvic ultrasound in ___ weeks time."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 5.6 x 2.5 x 4.2 cm.\nThe endometrium is normal in thickness for age and measures 3 mm.\nThe junctional zone is not thickened.\n\nThe right ovary measures 3.5 x 2.4 cm, previously 2.2 x 2.0 cm on an MRI of\nthe pelvis from ___.  The ovary is homogeneous on T2 weighted imaging\nwith a few small peripheral T2 hyperintense foci, possibly small follicles. \nOn diffusion-weighted imaging, the ovary demonstrates slightly more restricted\ndiffusion than would be expected.  Postcontrast imaging demonstrates relative\n___ of the ovary, diffusely.  There is no discrete mass.\n\nThe left ovary is visualized and appears within normal limits.\n\nLYMPH NODES: There is no pelvic sidewall or inguinal lymphadenopathy.\n\nBLADDER:  The urinary bladder is normal.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum and intrapelvic loops of bowel are\nnormal in caliber.  No mesenteric fluid.\n\nVASCULATURE: The iliac vessels are normal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osseous lesions are foci of\nbone marrow edema.",
            "output": "Nonspecific, abnormal appearance of the right ovary, which has grown in size\ncompared to the pelvic MRI from ___, and demonstrates slightly more\nrestricted diffusion that would be expected.\n\nIf surgical excisional biopsy is not being considered, six-month follow-up MRI\nof the pelvis with and without contrast would be recommended for surveillance.\n\nRECOMMENDATION(S):  If surgical management is not being considered, six-month\nfollow-up contrast enhanced MRI of the pelvis would be is recommended for\nsurveillance.\n\nNOTIFICATION:  The impression and recommendation above was entered by Dr.\n___ on ___ at 14:02 into the Department of Radiology critical\ncommunications system for direct communication to the referring provider."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus none visualized.  There is no adnexal abnormality.\n\nLYMPH NODES: No evidence of lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: Bladder is mildly distended.  There is no distal\nhydroureter.\n\nRECTUM AND INTRAPELVIC BOWEL: Large amount of stool seen within the rectum. \nOtherwise, the visualized small and large bowel loops appear unremarkable\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Mild degenerative changes seen in the\nhips. No evidence of fracture or dislocation identified.  There is no bone\nmarrow edema.  Mild-to-moderate degenerative changes are seen along the\nvisualized lumbosacral spine.",
            "output": "1. Mild degenerative in the hips.  No evidence of fracture of the right hip or\ncoccyx.\n2. Post hysterectomy."
        },
        {
            "input": "The study is motion degraded.  Additionally, there is distortion of the\nmagnetic field along the superior aspect of the field of view, limiting\nevaluation of the superior portion of the iliac crest.  Bone marrow signal in\nthe pelvis is diffusely heterogeneous on T1 weighted images without suspicious\nfocal lesions.  There is no definite bone marrow signal abnormality on STIR. \nThe femoroacetabular joints are congruent bilaterally.  There is no\nsignificant effusion.\n\nThere is moderate subcutaneous and fascial edema in the right lower extremity\nand scrotum.  There is mild subcutaneous and fascial edema in the left lower\nextremity.  There is mild edema in the mid back and paraspinal musculature. \nThere is no fluid collection.  Redemonstrated are bilateral prominent inguinal\nlymph nodes are likely reactive.  A fat containing left inguinal hernia is\nalso unchanged.",
            "output": "1. Moderate subcutaneous and fascial edema in the right lower extremity and\nscrotum and mild edema in the left lower extremity and the mid back is\nnonspecific, but can be seen with cellulitis.  There is mild patchy\nnonspecific edema in the musculature.  There is no evidence of a rim enhancing\nfluid collection to suggest abscess formation.\n2. Mildly heterogeneous red bone marrow signal in the pelvis without\nsuspicious focal lesions or evidence of osteomyelitis."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL: There is a perianal fistula, extending from\napproximately 6 o'clock posteriorly (image 24, series 5).  This originates\napproximately 5.9 cm proximal to the verge.  This extends posteriorly, across\nthe puborectalis, into a focus of granulation tissue, measuring approximately\n1.3 cm AP by 2.4 cm transverse.\n\nThere is a small blind ending tract the extends anterior and superior, along\nthe puborectalis (images 21 and 22 of series 5).\n\nThe dominant arborization extends anterior and inferiorly, to the gluteal\ncleft (image 33-35, series 5), where it may externally fistulize with the\nskin.\n\nA smaller, infrasphincteric second fistula extends from approximately 1\no'clock, directly inferiorly, to the anterior inferior gluteal cleft,\ninfrasphincteric, where it joins the dominant fistula.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are within normal\nlimits.  No wall thickening or stones.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate is mildly enlarged. \nSeminal vesicles are grossly normal.\n\nLYMPH NODES:  No abnormally enlarged intrapelvic lymph nodes.\n\nVASCULATURE: Intrapelvic vascular structures are within normal limits.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions. \nPostsurgical changes are seen along the anterior abdominal wall.",
            "output": "1. Transsphincteric fistula, crossing the puborectalis at 6'oclock, extending\nTo the skin in the inferior anterior gluteal cleft.  Direct inspection is\nrecommended for presence of cutaneous fistulization.  No abscess or drainable\ncollection.\n2.  Blind ending arborization of the above described transsphincteric fistula,\nending superolaterally, along the puborectalis on the right.\n3.  Smaller, intersphincteric second fistula, without definite external\nfistulization, terminating in the inferior anterior gluteal cleft, joining the\ndominant fistula (infrasphincteric)."
        },
        {
            "input": "RECTUM AND INTRAPELVIC BOWEL:\nThere is a perianal fistula extending from 5 o'clock (series 12:41)\nposteriorly.  On the left, this extends posteriorly and transphincterically\nand across the puborectalis muscle, minimally changed from MRI ___.  There is also a intersphincteric blind-ending tract on the right\n(series 12:44), new.  There is ___ in the left branch which extends\ninferiorly. There is an area of granulation tissue inferiorly which measures\n4.4 x 2.8 cm in transverse ___ (series 12:41), increased in size from\nMRI ___, previously measuring 2.3 x 1.9 cm.  Abutting the left\nbranch inferiorly, there is a rim enhancing fluid collection measuring 2.2 x\n1.3 cm (series 12:69), new since ___ and likely representing an\nabscess.  Extending right and inferiorly from the granulation tissue in the\nright gluteal cleft, there is rim enhancing fluid collection measuring 2.7 x\n1.6 cm (series 12:66), new since ___, also likely representing an\nabscess.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are within normal\nlimits.\n\nPROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate is mildly enlarged. \nSeminal vesicles are unremarkable.\n\nLYMPH NODES: There is no lymphadenopathy in the pelvis.\n\nVASCULATURE: The major vessels of the pelvis are patent and grossly\nunremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Susceptibility artifact from bilateral\ntotal hip arthroplasties are noted.  There is no suspicious osseous\nabnormality.",
            "output": "1. Originating at 5 o'clock, there is a left transsphincteric perianal fistula\ncrossing the puborectalis and extending to the left inferior gluteal cleft.  A\n___ is noted.  This is grossly unchanged from MRI pelvis ___.\n2. Right-sided intersphincteric blind ending tract extending from 5 o'clock is\nnew since ___.\n3. Abscesses centered in the left and right gluteal cleft measuring 2.2 x 1.3\ncm (series 12:69) and 2.7 x 1.6 cm (series 12:66) which are new as compared to\n___.\n4. Area of granulation tissue inferiorly to the origin of the fistula\nmeasuring 4.4 x 2.8 cm is increased from ___, previously\nmeasuring 2.3 x 1.9 cm."
        },
        {
            "input": "ANUS AND RECTUM:\n\nNumber of fistulas: 1\n\nFistula number 1:\n\nINTERNAL ANAL OPENING:\n\nLocation (quadrant and clock face) in supine position: Left posterolateral at\n5 o'clock position\nDistance from anal verge: 6 cm\nRelation to the internal sphincter: Involving superior third of sphincter\n\nFISTULA TRACT:\n\nMaximum tract diameter:  8 mm\nFistula type (Parks classification):  Transphincteric\nSecondary branches: Multiple branches.  The fistula courses posteriorly and\nforms multiple branches in the intersphincteric space.  There is a left-sided\nbranch which courses anterosuperiorly, and ends blindly in the left\npuborectalis muscle (series 5, image 17 and series 4, image 14).  There is a\n___ within a second, left-sided, transsphincteric branch, which courses\ninferiorly and exits the left gluteal fold (series 5, image 22, and series 4,\nimage 19).  There is a right-sided transsphincteric branch, which communicates\nwith the left-sided inferior branch in the posterior ischioanal fossa, and\nalso courses inferiorly, blind-ending in the right medial gluteal fold,\nwithout clear exit.  There is extensive, irregularly marginated, T2\nhyperintense granulation tissue associated with the confluence of the\nright-sided and left-sided transsphincteric branches.\nExit site: Left gluteal fold\nHyperintensity of the tract on T2: Marked\nEnhancement of the tract: The left-sided, intersphincteric branch demonstrates\nno central enhancement, compatible with a fluid-filled tract.  The right-sided\nbranch demonstrates high T2 signal intensity and central enhancement,\ncompatible with granulation tissue, with minimal fluid component.  Extensive,\nirregularly marginated granulation tissue at the confluence of the right-sided\nand left-sided transsphincteric branches in the posterior ischioanal fossa\nmeasures approximately 4.4 x 2.8 cm in greatest axial dimension (series 10,\nimage 43), not significantly changed from prior.\n\nOTHER FINDINGS:\n\n\n\nAbscess: Yes.  There is a 2.6 x 1.2 cm area of phlegmon in the right medial\ngluteal fold (series 10, image 73), unchanged in size from prior but\ndemonstrating interval loss of central fluid component.  There is new\nextension of phlegmon/inflammation anteriorly and inferiorly along the right\ngluteal fold (series 10, images 80-85), with a new 2.1 x 1.0 cm rim-enhancing\nabscess in inferomedial right gluteal fold (series 10, image 83).  An\napproximately 2.0 x 1.1 cm rim-enhancing abscess in the left medial gluteal\nfold is not significantly changed in size but demonstrates a minimally\nincreased central fluid component.\nRectal and sigmoid wall inflammation: Yes\nPresence of ___, drains or prior surgery: No",
            "output": "Transsphincteric fistula with multiple branches as described, rising from the\n5 o'clock position of the anal canal.  Extensive, irregularly marginated\ngranulation tissue associated with the confluence of right-sided and\nleft-sided transsphincteric branches in the posterior ischioanal fossa is not\nsignificantly changed from prior.  2.6 x 1.2 cm area of phlegmon in the right\nmedial gluteal fold demonstrates interval loss of central fluid component. \nHowever there is new extension of phlegmon/inflammation anteriorly and\ninferiorly along the right gluteal fold, with a new 2.1 x 1.0 cm abscess in\nthe inferomedial right gluteal fold.  A 2.0 x 1.1 cm abscess in the left\nmedial gluteal fold is minimally changed from prior."
        },
        {
            "input": "There is a 6.6 x 6.4 x 6.5 cm lesion in the right sacral ala extending across\nthe sacroiliac joint to involve the right iliac bone.  The lesion is\npredominantly low signal on T1 weighted images and demonstrates heterogeneous\nsignal on T2 weighted images.  There is solid enhancement with areas of\nnecrosis centrally.  The lesion compresses and likely invades the right\niliacus muscle.  There is also tumor extension to the right common iliac vein\nto the level of L4-5 disc space (series 11, image ___.  The lesion also\nextends to the S1/S2 vertebral bodies involving the right S1 and S2 neural\nforamen, displacing and likely invading the right S1 and S2 nerve roots.\n\nThere is likely impingement of the right sciatic nerve with edema visualized\nin the nerve.  There is also prominent increased STIR signal involving the\nright gluteal muscles likely secondary to nerve impingement.\n\nThere is likely an insufficiency fracture involving the anterior S2 sacrum,\nbest seen on the sagittal images (series 5, image 17).\n\nThe partially visualized intrapelvic structures are grossly unremarkable.",
            "output": "1. Right sacral enhancing mass invading the right sacroiliac joint, right\niliac bone, right iliacus muscle, right common iliac vein, right S1/S2 neural\nforamens/nerve roots with impingement of the right sciatic nerve.\n2. Right gluteal muscles edema secondary to right sciatic nerve impingement.\n3. Likely insufficiency fracture involving the anterior S2 sacrum."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and retroflexed and measures 7.6 x 5.9 x 4.9 cm.\nThe endometrium is normal in thickness for age and measures 9 mm.\nThe junctional zone is not thickened.\n\nBoth ovaries are visualized and appears within normal limits.There is no free\nfluid or evidence of pelvic scarring.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy per\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters appear normal.\n\nRECTUM AND INTRAPELVIC BOWEL:  A linear enhancing focus anterior and right to\nthe anus does not obviously surface to the skin, vagina, or large bowel and\nmay represent a prominent blood vessel (1302:80).\n\nVASCULATURE: The internal external iliac arteries are well opacified and\nnormal in caliber.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Bone marrow signal is normal without\nfocal lesion.",
            "output": "1. Retroflexed uterus.  No evidence of endometriosis or findings specific for\nadenomyosis.\n2. Linear enhancing focus adjacent to the anus does not obviously surface to\nthe skin, vagina, or large bowel and likely represents a vessel assuming there\nis no clinical suspicion for perianal fistulous disease."
        },
        {
            "input": "There is a 7.4 x 7.5 by 7.5 cm exophytic, sub serosal uterine fibroid, which\narises from the lower uterine segment and does not appear to involve the\ncervix. It exerts mass effect upon the bladder superiorly.  There is also a\nsmaller, subcentimeter fibroid seen in the uterine fundus. There is a 4.0 x\n1.4 cm area involving the anterior uterus, which is not consistent with a\nfibroid and most likely represents scar related to the patient's prior\nC-section or myomectomy.\n\n\n\nThere is a 1.7 x 1.5 cm cystic lesion in the right adnexa, which most likely\nrepresents a dominant follicle if the patient is premenopausal. There are also\nfew subcentimeter cystic lesions in the left adnexa, which are consistent with\nnormal ovarian follicles. The rectum and sigmoid colon are normal appearing.\nThere is no pelvic sidewall lymphadenopathy.  There is a minimal amount of\nfree fluid in the pelvis, which is physiologic.",
            "output": "1. 7.4 x 7.5 x 7.5 cm exophytic, sub serosal uterine fibroid which arises from\nthe lower uterine segment and does not involve the cervix.\n2. 1.7 x 1.5 cm cystic lesion in the right adnexa, which most likely\nrepresents a dominant follicle at the patient is premenopausal. However, if\nthe patient is postmenopausal recommend followup with ultrasound in ___ year."
        },
        {
            "input": "Examination is limited by motion artifact and incomplete fat saturation.\n\nThere are numerous enhancing T1 hypointense, STIR hyperintense lesions\nscattered throughout the pelvis, sacrum, and the visualized portion of the\nlumbar spine.  The largest lesions in pelvis are along the superior pubic\nrami, measuring 19 mm on left and 14 mm on the right (series 9, images 32 and\n33).  There is a small amount of fluid at the pubic symphysis.\n\nThere are multiple new lesions in the visualized portion of the lumbar spine\nas compared to the prior lumbar spine MRI of ___, largest in the L3\nvertebral body measuring 24 mm (series 6, image 21).  The vertebral body\nheights are preserved.\n\nA 9.8 mm intramedullary lesion is also noted in the proximal right femoral\nshaft which does not appear to involve the cortex (Series 7, image 19).  There\nis a possible subtle lesion in the lower left femoral neck posteriorly\n(05:36), or it abuts the cortex.\n\nAdditionally, there are multiple patchy and ill-defined intramedullary foci of\nenhancement within the femurs bilaterally. There is no evidence of fracture.\n\nBilateral femoroacetabular joints are intact.  There is no hip joint effusion.\nThere is symmetric fatty infiltration of the tensor fascia ___ muscles,\nwithin normal limits.  On the right, there is mild herniation of the muscle\nbelly through the adjacent fascia which appears focally thickened (series 9,\nimage 39).  There is no definite abnormal enhancement in this region although\nevaluation is somewhat limited by incomplete fat saturation.\n\nThere is sigmoid diverticulosis without evidence of acute diverticulitis.  A\n12 mm rounded focus of hyperintense T1 signal that completely suppresses on\nfat saturated sequences and only demonstrates a thin peripheral enhancement is\nof unclear etiology but may represent a prominent focus of fat or fat necrosis\n(series 5, image 21).  There is no pelvic lymphadenopathy.  Mild\ntrabeculations are noted along the bladder wall.  Central gland hyperplasia is\nnoted in the prostate.",
            "output": "1.  Numerous scattered enhancing intramedullary osseous lesions throughout the\npelvis and visualized spine as described are consistent with patient's\nreported history of multiple myeloma.  The largest lesions lie within the\nbilateral superior pubic rami.  In the proximal femora, 1 lesion is seen\nwithin the medullary cavity of the the right subtrochanteric femoral\ndiaphysis, and a second possible lesion is seen within left femoral neck\nposteriorly, abutting the cortex.\n\n2.  Many of the lesions in the visualized portion of the lumbar spine are new\ncompared to the ___ L-spine MRI examination, but are not fully\nassessed on this nondedicated examination.\n\n3.  Apparent partial herniation of the right tensor fascia ___ muscle through\nthe adjacent focally thickened fascia is of unclear clinical\nsignificance--question primary muscle herniation or post surgical change. \nPlease correlate with any prior history of trauma or surgery."
        },
        {
            "input": "Bones: Scattered areas of T2 hyperintensity and T1 hypointensity throughout\nthe pelvis and visualized lower lumbar spine likely represent foci of multiple\nmyeloma.  There is a 1.6 x 1.0 cm lesion within the left superior pubic ramus.\nThere is a 1.0 x 0.8 cm lesion within the right superior pubic ramus.  There\nis a 6 mm lesion within the L5 vertebral body (image 3:8).  There is a 9 mm\nlesion within the left transverse process of L4 (image 05:21). Overall these\nlesions are relatively unchanged size, however a 6 mm lesion within the\nsubtrochanteric region of the right proximal femoral (image 3:52) appears\ndecreased in size, previously measuring approximately 10 mm.  Several other\nlesions are identified.\n\nNo fractures are identified.  Alignment appears preserved.  Mild degenerative\nchanges of the bilateral hips with subchondral cystic change of the left\nacetabulum.\n\nSoft tissues: Muscle bulk and signal about the pelvis appears relatively well\npreserved.  Small amount of fluid within the left iliopsoas bursa.  Mild\nincreased signal of the right proximal hamstring tendons.\n\nSimilar appearance of right tensor fascia ___ muscle herniation through the\nsuperficial fascia and similar nodular fascial thickening adjacent which is\npartially imaged.\n\nOther: Scattered rounded foci of signal void on localizer images and the upper\nabdomen are likely artifactual. 2.2 cm lesion within the L3 vertebral body,\nseen only on localizer images, is better evaluated on same day lumbar spine\nMRI.",
            "output": "1.  No evidence of fracture of the pelvis.\n2.  Multiple osseous lesions consistent with patient's known multiple myeloma.\nOverall lesions appears similar in size to ___ with 1 lesion in the\nright proximal femur which appears slightly decreased in size.\n3.  Small amount of fluid within the left iliopsoas bursa, similar to prior\nexam.\n4.  Mild right proximal hamstrings tendinosis.\n4. Similar appearance of right tensor fascia ___ muscle herniation through\nthe superficial fascia and similar nodular fascial thickening adjacent which\nis partially imaged."
        },
        {
            "input": "There are several rounded T1 low and T2 high enhancing marrow replacing\nlesions throughout the pelvis and proximal femurs.  There is a 15 mm enhancing\nlesion within the right iliac bone, best seen on series 8, image 6 which is\nthe site of prior targeted CT biopsy from ___.  There is mild edema\nadjacent to the lesion compatible with the biopsy track.  Additional smaller\nfoci are seen within the right supra-acetabular region, best seen on series 8,\nimage 15.  There is a 15 mm lesion within the left acetabulum medial wall,\nbest seen on series 3, image 19 which was also avid on the prior PET scan.\n\nThere are additional rounded lesions within the right proximal femur which in\nconglomerate measures 3.5 cm.  This also correlates with FDG avidity on the\nprior study.  13 mm lesion is seen in the left proximal femur, best seen on\nseries 5, image 38 and also correlates with FDG uptake on the prior study. \nThese lesions are all relatively occult on the prior CT scan.\n\nThere are no signs for pathologic fracture.  There is no avascular necrosis. \nThere is a trace amount of fluid within the right hip.  The bladder is\ndistended.  There is calcification adjacent to the right tensor fascia ___\nlikely sequela of prior old injury.  There are mild degenerative changes of\nthe pubic symphysis and of the lower lumbar spine.  Bilateral small fatty\ninguinal hernias are seen.",
            "output": "1.  Several enhancing rounded marrow replacing lesions throughout the pelvis\nand proximal femurs.  The largest lesion is in the right proximal femur,\nmeasures 3.5 cm, and demonstrates FDG avidity.  There is also a 15 mm right\niliac lesion which is status post biopsy and also demonstrates FDG avidity. \nThese lesions are occult on the CT scan.\n2.  Mild degenerative changes at the pubic symphysis and of the lower lumbar\nspine."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus has an unicornuate morphology with a left rudimentary non\ncommunicating horn.\nThe right lateral horn is unremarkable with normal appearing endometrium and\ncervix.\n\nThe left rudimentary horn contains a 2.3 x 3.5 cm non enhancing fluid\ncollection in the endometrial cavity demonstrating isointense T2 signal,\nmildly hyperintense T1 signal suggestive of hemorrhagic component.\n\nThere is a large tubular serpiginous structure in the pelvis measuring up to\n8.7 x 7.4 cm containing hyperintense T1 nonenhancing signal suggestive of a\nhematosalpinx.\n\nThere are also bilateral subcentimeter endometriomas in the adnexa which are\notherwise unremarkable.\n\nMultiple punctate hyperintense T1 foci are seen throughout the pelvic located\naround the anterior and posterior horns of the uterus as well as posteriorly\nin the cul-de-sac suggestive of endometrial implants.  There is also thickened\nof the posterior ligament of the uterus suggestive of deep endometriosis.\n\nLYMPH NODES: No adenopathy.\n\nBLADDER: Unremarkable.  The left kidney is not visualized.\n\nRECTUM AND INTRAPELVIC BOWEL: Unremarkable.\n\nVASCULATURE: Unremarkable.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Unremarkable.",
            "output": "1. The uterus has an unicornuate morphology with a left rudimentary\nnoncommunicating horn containing blood products.\n2. Pelvic endometriosis with a large hematosalpinx.\n3. The left kidney is not visualized on this evaluation.  It's presence could\nbe confirmed by abdominal ultrasound."
        },
        {
            "input": "The uterus is anteverted and retroflexed with approximate ___ of 14 x\n4.8 x 6.1 cm. There is thinning of the anterior lower uterine segment with a\n1.7 cm long segment of T2 hypointense scar tissue but paucity of myometrium. \nThis appearance is compatible with prior cesarean section and subsequent\ndehiscence. Uterine zonal anatomy is preserved throughout. No focal lesions\nappreciated.\n\nThe left adnexa is unremarkable.\n\nThe right adnexa is associated with a tubular fluid-filled structure,\nconsistent with a hydrosalpinx. This has maximum diameter of 9 cm\ncaudocranially (5:11), and transverse ___ of 4.5 x 3.9 cm. This is\nunchanged in size and configuration dating back to ___.  The contents\nare T2 hyperintense, T1 hypointense and nonenhancing. No blood products,\ncomplexity or enhancing nodular components are identified. Ovarian tissue\nalong the medial aspect of this hydrosalpinx is unremarkable.\n\nThere is no free pelvic fluid her identified lymphadenopathy. The visualized\nbowel loops are unremarkable.\n\nNote is made of diastasis of the abdominal rectus the vasculature and bulging\nlinea ___ without discrete defect/ hernia.\n\nThe urinary bladder is decompressed but otherwise normal in appearance. There\nare bilateral cystic structures along the distal aspect of the vagina,\nposterolaterally. The larger is seen on the left with ___ of 1.7 x 2 x\n2.4 cm. On the right the lesion has maximal diameter of 1.3 cm.  Each is T2\nhyperintense, T1 intermediate in signal and nonenhancing. These are most\nconsistent with bilateral Bartholin's gland cyst.\n\nOsseous structures are unremarkable.",
            "output": "Stable right hydrosalpinx, measuring up to the and 9 cm, without complexity or\nconcerning features.\n\nThe bilateral Bartholin's gland cysts without evidence of superinfection."
        },
        {
            "input": "There is no bone marrow edema, fracture line or marrow replacing lesion\nidentified.  There is no joint effusion.  Subchondral cystic changes are\npresent at the superior acetabula, right greater than left.  Mild enthesopathy\nat the bilateral greater trochanters with mild gluteal tendinosis.  Additional\nmild tendinosis of the right hamstrings tendon at the ischial tuberosity.\n\nThere is a tear of the anterior superior labrum (representative image 06:11). \nThere are multiple paralabral cysts\nand a small amount of fluid tracking from the torn labrum to the soft tissues\njust anterior to the acetabulum with the largest cyst measuring 15 mm in\nmaximum dimension.  There is blunting and degenerative change involving the\nposterior labrum without identifiable tear.\n\nHigh-grade cartilage defects involving the superior acetabular cartilage with\nassociated subchondral edema.  Muscle bulk is normal without significant fatty\nreplacement.  No pathologically enlarged or morphologically suspicious\nappearing iliac chain or inguinal nodes.\n\nMultiple uterine masses are consistent with fibroids seen on recent ultrasound\nwith the largest measuring up to 2.4 cm (coronal series 3, image 3).\n\nThere is facet arthropathy and trace effusion at left L4-L5 and right L5-S1.",
            "output": "1. Tear of the anterior superior labrum of the right hip with associated\nparalabral cysts.\n2. Moderate osteoarthritic changes involving the right hip with high-grade\nacetabular cartilage defects superiorly with underlying subchondral edema.\n3. Mild degenerative changes involving the left hip.\n4. Mild tendinosis of the gluteal tendons at their insertion on the greater\ntrochanter and the hamstrings insertion at the ischial tuberosity.\n5. Fibroid uterus."
        },
        {
            "input": "UTERUS AND ADNEXA:\nThe uterus is anteverted and measures 9.9 x 6.8 x 8.2 cm.  There is a Foley\ncatheter within the endometrial canal and heterogeneous material in the\nfundus, some of which presumably represents retained products of conception.\n\nThere are serpiginous vessels within the myometrium of the right anterolateral\nuterine fundus/ body and an apparent early draining vein which empties into\nthe right internal iliac vein, compatible with an AV fistula.  There is active\nextravasation of contrast into the fundal canal.\n\nThe right ovary is visualized on series 5, images 7 and 8 and appears within\nnormal limits.\nThe left ovary is visualized on series 5, images ___ and appears within\nnormal limits.\n\nA small amount of free fluid is within physiologic limits.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: There is a small amount of gas in the bladder,\npresumably from recent Foley catheter.  The bladder is otherwise unremarkable.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum is normal in appearance.  Intrapelvic\nbowel loops are normal in caliber.\n\nVASCULATURE: The iliac vessels are normal in caliber and patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesion is\nidentified.",
            "output": "Serpiginous vessels within the myometrium of the right anterolateral uterine\nfundus/ body and an early draining vein which empties into the right internal\niliac vein, compatible with an AV malformation/fistula.  Active bleeding into\nthe fundal canal, and heterogeneous material presumably representing retained\nproducts of conception.\n\nNOTIFICATION:  The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 5:12 ___, 20 minutes after\ndiscovery of the findings."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 6.5 x 4.7 x 5.6 cm.\n\nThe endometrium is normal in thickness for age and measures 5 mm.  Previously\nseen retained products and/or blood clot within the endometrial canal on MRI\nfrom ___ have passed.\nThe junctional zone is not thickened.\nThere is heterogeneity and mild diffuse hyper enhancement of the myometrium\n(series 13, image 207), presumably reactive.  There is no evidence of\nrecurrent uterine AVM/fistula.\n\nThe right and left ovaries are within normal limits.  Note is made of a corpus\nluteal cyst in the right ovary.\n\nThere is trace free fluid around the right ovary.\n\nLYMPH NODES: There is no pelvic or inguinal lymphadenopathy.\n\nBLADDER AND DISTAL URETERS: The bladder and distal ureters are within normal\nlimits.\n\nRECTUM AND INTRAPELVIC BOWEL: The rectum is within normal limits.  Intrapelvic\nbowel loops are nondilated.\n\nVASCULATURE: The iliac vessels are patent.\n\nOSSEOUS STRUCTURES AND SOFT TISSUES: Bone marrow signal is normal.  No\nsuspicious osseous lesion is identified.",
            "output": "1.  Interval resolution of previously seen retained products and/or blood clot\nwithin the endometrial canal.\n\n2.  Heterogeneity and mild hyperenhancement of the myometrium, presumably\nreactive.  No evidence of recurrent uterine AVM/fistula."
        },
        {
            "input": "UTERUS AND ADNEXA:\n\nThe uterus is anteverted and measures 8.9 x 5.3 x 7.9 cm.\n\nThe endometrium is distended containing nonvascular components which are hypo\nintense on T2 weighted imaging and having components which are also slightly\nhyperintense on T1 weighted imaging, overall measuring approximately 2.9 x 2.1\nx 3.0 cm.\n\nAfter the administration intravenous contrast, there is no internal\nenhancement within the filling defects distending the endometrium.  There is\nno abnormal uterine hypervascularity suggesting the presence of residual\narteriovenous fistula or malformation.  There is mild and non masslike\nheterogeneous subendometrial enhancement, likely reactive.\n\nNo evidence of significant uterine infarction after embolization.\n\n\nThe right ovary is visualized and contains a dominant follicle measuring 2 cm.\nThe left ovary is visualized and appears within normal limits.\n\nNo significant pelvic free fluid.\n\nThe bladder is not particularly distended appears grossly unremarkable.\n\nThere is no pelvic lymphadenopathy.",
            "output": "1.  Nonvascular retained products of conception distending the endometrial\ncanal.  This likely represents a combination of hematoma and perhaps necrotic\ntissue.\n2.  No evidence of residual vascular lesion or arterial venous\nfistula/malformation."
        }
    ]
}