Preoperative ultrasound diagnosis of deep endometriosis: importance of the examiner's expertise and lesion size

Comparison of clinical and ultrasound examinations in assessing the parametria in patients with deep infiltrating endometriosis: a multicentre prospective study

RESEARCH QUESTION

How do clinical rectovaginal examination and transvaginal ultrasound examination perform in the diagnosis of parametrial infiltration in patients with endometriosis?

DESIGN

This was a multicentre prospective observational study. Patients with suspected deep endometriosis at clinical examination and/or at ultrasound evaluation and scheduled for surgery were included. Following multicentre multidisciplinary meetings, consensus was obtained on terms and methodology to define the parametrium at pelvic anatomy, ultrasound and surgery. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios were calculated for clinical and ultrasound examinations with respect to surgery.

RESULTS

In total, 195 women were selected for the present study and 164 were included in the analysis. Ultrasound examination had good to high specificity (>80%) for all parameters, except the left lateral parametrium (78.8%). The sensitivity of ultrasound examination was good to high for fixity of the right and left ovaries, uterosacral ligaments, retrocervix and rectovaginal space; and low for the anterior and lateral parametria, vagina, bladder and bowel. Clinical examination had good to high specificity for fixity of the left ovary, anterior parametrium, right uterosacral ligament, retrocervix and vagina; and low specificity for fixity of the right ovary, lateral parametrium, left uterosacral ligament and rectovaginal space. The sensitivity of clinical examination was good for the uterosacral ligaments and rectovaginal space, and low for the remaining parameters.

CONCLUSION

Ultrasound examination provided good specificity for all the parameters, but sensitivity was low for the anterior and lateral parametria. Clinical examination provided good specificity for the anterior and posterior parametria, but sensitivity was low for the anterior and lateral parametria. Further prospective studies are needed to validate this methodology and confirm the results.

Nodular image in the appendix observed on ultrasound: endometriosis or neuroendocrine neoplasia?

Objective

To evaluate the association between clinical and imaging with surgical and pathological findings in patients with suspected neuroendocrine tumor of appendix and/or appendix endometriosis.

Methods

Retrospective descriptive study conducted at the Teaching and Research Institute of Hospital Israelita Albert Einstein, in which medical records and databases of patients with suspected neuroendocrine tumor of appendix and/or endometriosis of appendix were analyzed by imaging.

Results

Twenty-eight patients were included, all of which had some type of appendix alteration on the ultrasound examination. The pathological outcome of the appendix found 25 (89.3%) lesions compatible with endometriosis and three (10.7%) neuroendocrine tumors. The clinical findings of imaging and surgery were compared with the result of pathological anatomy by means of relative frequency.

Conclusion

It was possible to observe a higher prevalence of appendix endometriosis when the patient presented more intense pain symptoms. The image observed on ultrasound obtained a high positive predictive value for appendicular endometriosis.

Homozygous C677T Methylenetetrahydrofolate Reductase (MTHFR) Polymorphism as a Risk Factor for Endometriosis: A Retrospective Case-Control Study

This study was conducted to evaluate the role of methylenetetrahydrofolate reductase (MTHFR) C677T homozygous polymorphism as a risk factor for endometriosis. A retrospective case-control study was conducted from January 2020 to December 2022 on all patients attending the gynecological outpatient clinic of our institution who had performed an MTHFR polymorphisms test. Patients with endometriosis were considered cases, while those without endometriosis were considered controls. The presence of an MTHFR C677T homozygous polymorphism was defined as exposure. Risk factors for endometriosis were considered confounders in a binomial logistic regression, with endometriosis diagnosis as the dependent variable. Among the 409 included patients, 106 (25.9%) cases and 303 (74.1%) controls were identified. A higher rate of MTHFR C677T homozygous polymorphism was found in patients with endometriosis (24.5% vs. 15.8%, p = 0.0453), with an adOR of 1.889 (95% CI 1.076-3.318, p = 0.0269) at the binomial logistic regression. A history of no previous pregnancy was associated with an endometriosis diagnosis (adOR 2.191, 95% CI 1.295-3.708, p = 0.0035). An MTHFR C677T homozygous polymorphism could be considered a risk factor for endometriosis. Epigenetic modifications may be the most important mechanism explaining the observed association through the processes of altered DNA methylation and reduced activity of antioxidant systems.

Diagnostic Accuracy of Transvaginal Sonography for Deeply Infiltrating Endometriosis and Pouch of Douglas Obliteration in the Presence or Absence of Ovarian Endometrioma

Background: Endometriosis is one of the most common gynecological diseases worldwide. Significant attention has been drawn to this multiorgan and often painful disorder. Objectives: This study aimed to examine the accuracy of transvaginal sonography (TVS) in the diagnosis of deeply infiltrating endometriosis (DIE) with respect to the presence or absence of ovarian endometrioma (OE). Patients and Methods: This cross-sectional study was performed on all patients undergoing TVS before gynecological laparoscopy. With pathological confirmation as the standard reference, the diagnostic accuracy of TVS for DIE and pouch of Douglas (POD) obliteration was compared with that of laparoscopy in the anterior and posterior pelvic compartments with respect to the presence or absence of OE. Agreement between TVS and laparoscopy was evaluated for each case, and Cohen’s kappa statistic was measured for each site of involvement. Moreover, sensitivity, specificity, negative and positive predictive values, and likelihood ratios of TVS were calculated, with laparoscopy as the reference test. Results: A total of 110 patients, with a mean age of 37.20 ± 7.16 years, were recruited in this study. The accuracy, sensitivity, and negative predictive value of TVS for the diagnosis of DIE and POD obliteration were estimated at 89.5%, 58.3%, and 88.9% in the anterior pelvic compartment and 93.3%, 92%, and 70.6% in the posterior pelvic compartment, respectively. Nevertheless, TVS showed lower sensitivity for detecting pelvic adhesions and peritoneal cysts compared to laparoscopy. The presence of OE did not significantly increase the accuracy of TVS for the diagnosis of DIE or POD obliteration (P > 0.05). Conclusion: The present study showed that TVS is an adequately accurate and non-invasive diagnostic tool for the detection and mapping of DIE and POD obliteration, regardless of the presence of OE. TVS may waive the need for exploratory laparoscopy in DIE or at least facilitate precise pre-procedural DIE mapping.

Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study

OBJECTIVE

To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis.

DESIGN

A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy.

SETTING

Academic hospital.

PATIENT(S)

Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution.

INTERVENTION(S)

Patients who underwent ≥1 cesarean section after surgery for endometriosis.

MAIN OUTCOME MEASURES

The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis.

RESULTS

Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96).

CONCLUSION

A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of uterosacral ligaments/torus uterinus, rectovaginal septum and vaginal deep endometriosis

STUDY QUESTION

Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis?

SUMMARY ANSWER

The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent.

WHAT IS KNOWN ALREADY

The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis.

STUDY DESIGN SIZE DURATION

A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology.

PARTICIPANTS/MATERIALS SETTING METHODS

All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32-82%) and 95% (95% CI 90-98%), respectively, and for all MRI techniques were 81% (95% CI 66-90%) and 83% (95% CI 62-94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30-80%) and 100% (95% CI 92-100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29-74%) and 98% (95% CI 95-99%), respectively, and for all MRI techniques were 64% (95% CI 40-83%) and 98% (96% CI 93-99%). Pooled analyses were not possible for other imaging modalities.

LIMITATIONS REASONS FOR CAUTION

There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease.

WIDER IMPLICATIONS OF THE FINDINGS

MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women's and Children's Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics.

REGISTRATION NUMBER

Prospective registration with PROSPERO (CRD42017059872) was obtained.

Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis

OBJECTIVE

To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis.

METHODS

A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872).

RESULTS

Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28-79%), 99 % (95 % CI 98-100%), 54.5 (95 % CI 18.9-157.4), 0.46 (95 % CI 0.25 - 0.85) and 119 (95 % CI 24-577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23-82%), 99 % (96 % CI 97-100%), 48.8 (95 % CI 13.1-181.4), 0.47 (95 % CI 0.23 - 0.98), and 104 (95 % CI 15-711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool.

CONCLUSIONS

Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.

Correlation between ultrasound findings and laparoscopy in prediction of deep infiltrating endometriosis (DIE)

BACKGROUND

Detailed pre-operative description of endometriotic lesions by non-invasive methods is an important tool for accurate diagnosis and effective treatment of the disease. Transvaginal ultrasound (TVUS) is a sensitive method for diagnosis of deep infiltrating endometriosis (DIE); however, it is highly operator-dependent and consistent results require adequately trained and experienced clinicians.

AIMS

The aim of the study is to assess the accuracy of TVUS in predicting DIE by comparing it with laparoscopic findings. We also compared US done in the community by general radiologists with examinations done by specialist gynaecologists.

MATERIALS AND METHODS

A retrospective cohort study of patients who underwent laparoscopy for excision of possible endometriosis between July 2014 to February 2019 who had a TVUS prior to laparoscopy.

RESULTS

A total of 119 patients were included. TVUS was shown to be useful in detecting all but bladder DIE. Community TVUS was no better than chance at identifying most DIE (area under the curve (AUC) of 0.48-0.60) except in the detection of ovarian endometriomas and adhesions (AUC = 0.84). Specialist TVUS correctly identified most DIE with greatest utility for DIE in rectosigmoid (AUC = 0.85, P < 0.000), followed by pouch of Douglas/pouch of Douglas adhesions (AUC = 0.82, P < 0.000), ovarian endometriomas/ovarian adhesions (AUC = 0.79, P < 0.000), uterosacral ligaments (AUC = 0.75, P < 0.000) and rectovaginal septum (AUC = 0.69, P < 0.05).

CONCLUSION

Specialist TVUS is informative in examining the presence of DIE particularly in posterior compartments which may increase surgical complexity. Community TVUS is significantly less beneficial; however, it is more accessible to the general public. This adds to the argument that increasing access to DIE-TVUS appears favourable.

Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents

STUDY OBJECTIVE

To quantify in adolescents the prevalence of dysmenorrhea and other symptoms found to be suggestive of future diagnosis of endometriosis, in particular their impact on monthly absenteeism from school/work, activity impairment, and sexual life and to quantify the awareness of endometriosis in adolescents.

DESIGN

Cross-sectional study.

SETTING

Academic institution.

PATIENTS

Adolescents (n = 250) aged 14-20 years referring to 3 family Counseling services.

INTERVENTIONS

Participants completed an anonymous questionnaire.

MAIN OUTCOME MEASURES

Prevalence of dysmenorrhea and absenteeism from school/work during menses. Other outcomes were impairment of daily activities, dyspareunia, and awareness of endometriosis as a pathologic condition.

RESULTS

68% (170/250) of the participants complain of dysmenorrhea, 12% (30/250) lose days of school/work monthly because of dysmenorrhea, 13% (33/250) complain of intermenstrual pain which limits daily activities, 27% (56/208) of the adolescents who are sexually active complain of dyspareunia, 82% (203/250) have never heard about endometriosis and 80% (200/250) would like to know more about it. A significant association was found between severe dysmenorrhea, absenteeism from school/work, and basic level of education. Absence from school/work during menses showed an adjusted odds ratio for severe dysmenorrhea about 28 times greater than those who did not declare absenteeism (95%CI 7.898-98.920, P<.000).

CONCLUSIONS

The rates of dysmenorrhea and school absenteeism caused by dysmenorrhea are high. According to recent studies these patients are at higher risk of further development of endometriosis, whereas the knowledge of the disease is low among the adolescents investigated, so those involved with adolescents both in the health profession and particularly in schools and Family Counseling Services should be educated about endometriosis and its symptoms to reduce the significant lag time between symptoms and diagnosis.