Feasibility of 3.0T pelvic MR imaging in the evaluation of endometriosis

CAR/CSAR Practice Statement on Pelvic MRI for Endometriosis

The Canadian Association of Radiologists (CAR) Endometriosis Working Group was tasked with providing guidance and benchmarks to ensure the quality of technique and interpretation for advanced imaging modalities associated with diagnosing endometriosis. Advanced pelvic ultrasound is essential in diagnosing and mapping pelvic endometriosis, but pelvic MRI serves as an excellent imaging tool in instances where access to advanced ultrasound is limited, or an alternative imaging modality is required. Despite the known utility of MRI for endometriosis, there is no consensus on imaging protocol and patient preparation in Canada. To improve patient care and support excellence in imaging, the Working Group has developed recommendations for the use of pelvic MRI to assess for endometriosis with an aim to standardize MRI technique for use in both community and academic practices across Canada. The guidelines provide recommendations regarding imaging technique and patient preparation for pelvic MRI, along with suggestions for structured reporting of pelvic MRI for endometriosis.

Best Practices: Ultrasound Versus MRI in the Assessment of Pelvic Endometriosis

Endometriosis is a common yet morbid disease. Imaging plays an important role in diagnosis and treatment planning. Both ultrasound (US) and MRI are used to detect disease. We performed a literature review to assess whether one is superior. A total of 33 studies from the 4482 identified in the initial search were found to assess the efficacy of US and/or MRI in detecting pelvic endometriosis. Most studies were performed at centers with extensive experience with endometriosis, using dedicated US and MRI protocols. A wide range of sensitivities and specificities were reported, but overall weighted means of diagnostic statistics for US and MRI were similar. The choice of dedicated US versus dedicated MRI in the evaluation of endometriosis should therefore be based on the expertise in the region. The data also showed US had better accuracy than MRI for identifying the depth of wall invasion in bowel-wall disease, whereas MRI better depicted pelvic-wall and extraperitoneal disease than US. Routine US and MRI protocols performed worse than dedicated US and MRI protocols, which may account for delays in diagnoses. Clinical and research efforts directed at improving the sensitivity of routine imaging for diagnosing deep endometriosis could improve patient access to appropriate care.

The Impact of Evolving Endometriosis Guidelines on Diagnosis and Observational Health Studies

STUDY QUESTION

Do recent changes in European Society of Human Reproduction and Embryology (ESHRE) clinical guidelines result in more comprehensive diagnosis of women with endometriosis?

SUMMARY ANSWER

The latest shift in clinical guidelines results in diagnosis of more women with endometriosis but current ESHRE diagnostic criteria do not capture a sizable percentage of women with the disease.

WHAT IS KNOWN ALREADY

Historically, laparoscopy was the gold standard for diagnosing endometriosis, a complex gynecological condition marked by a heterogeneous set of symptoms that vary widely among women. More recently, changes in clinical guidelines have shifted to incorporate imaging-based approaches such as transvaginal sonography and magnetic resonance imaging.

STUDY DESIGN SIZE DURATION

Retrospective, observational cohort study of women aged 15-49 years diagnosed with endometriosis in the United States (US) between January 1, 2013, and December 31, 2023.

PARTICIPANTS/MATERIALS SETTING METHODS

Data sources include US insurance claims data from the Merative™ MarketScan® Commercial Database (CCAE), Merative™ MarketScan® Multi-State Medicaid Database (MDCD), Optum® de-identified Electronic Health Record dataset (Optum® EHR), and electronic health record (EHR) data from a large academic medical center in New York City (CUIMC EHR). To examine the potential impact of expanding clinical criteria for the diagnosis of endometriosis, we validated and compared five cohort definitions based on different sets of diagnostic guidelines involving combinations of surgical confirmation, diagnostic imaging, guideline-recognized symptoms, and other symptoms commonly reported among women with endometriosis. We performed pairwise comparisons between cohorts and applied Bonferroni corrections to account for multiple comparisons.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified 491,048 women with a diagnosis of endometriosis across the CCAE, MDCD, Optum EHR, and CUIMC EHR datasets. Each cohort definition demonstrated strong positive predictive value (0.84-0.96), yet only 15-20% of cases were identified by all 5 cohort definitions. Women diagnosed with endometriosis based on imaging and symptoms were three years younger, on average, than women with a diagnosis based on surgical confirmation (mean age = 35 years [SD = 9] vs 38 years [SD = 8]; p<0.001). Women in cohorts based only on symptoms were two years younger than those based on surgery (36 years [SD = 8] vs 38 years [SD = 8]; p<0.001). More than one-fourth of cases presented with endometriosis-related symptoms but lacked surgical or imaging-related documentation required by ESHRE guideline criteria. Pain was reported among nearly all women with endometriosis. Abdominal pain and pain in the pelvis were the most prevalent (ranging from 69% to 90% of women in each cohort). Among approximately 2-5% of all endometriosis cases (14,795 total), women presented with pelvic and/or abdominal pain but none of the other symptoms noted in clinical guidelines.

LIMITATIONS REASONS FOR CAUTION

Our study has potential biases associated with documentation practices and secondary data use of insurance claims and EHR data. Further, the phenotyping algorithms used rely on clinical codes that do not necessarily capture all ESHRE diagnostic criteria for endometriosis and may not be generalizable to women with atypical presentation of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

High positive predictive value among all five cohort definitions despite poor overlap among cases identified illustrates both the heterogeneous presentation of the disease and importance of expanding diagnostic criteria. For example, cohorts derived from updated guidelines identified younger patients at time of diagnosis. Women diagnosed based on imaging had higher rates of emergency room visits while patients diagnosed via laparoscopy had a larger number of hospitalizations. The substantial number of cases with pelvic and/or abdominal pain but none of the other symptoms noted in clinical guidelines underscores the continued need for improved access to timely and appropriate care, particularly among those with non-classical symptoms, different care-seeking patterns, or lack of available surgical intervention.

Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies

INTRODUCTION

The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis.

METHODS

PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity.

RESULTS

Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison p-value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies.

CONCLUSION

TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.

Diagnostic MRI for deep pelvic endometriosis: towards a standardized protocol?

OBJECTIVES

To assess the diagnostic efficacy of an MRI protocol and patient preparation in detecting deep pelvic endometriosis (DPE).

MATERIAL AND METHODS

The cohort is from the ENDOVALIRM database, a multicentric national retrospective study involving women who underwent MRI followed by pelvic surgery for endometriosis (reference standard). Two senior radiologists independently analyzed MRI findings using the deep pelvic endometriosis index (dPEI) to determine lesion locations. The study evaluated the impact of bowel preparation, vaginal and rectal opacification, MRI unit type (1.5-T or 3-T), additional sequences (thin slice T2W or 3DT2W), and gadolinium injection on reader performance for diagnosing DPE locations. Fisher's exact test assessed differences in diagnostic accuracy based on patient preparation and MRI parameters.

RESULTS

The final cohort comprised 571 women with a mean age of 33.3 years (± 6.6 SD). MRI with bowel preparation outperformed MRI without bowel preparation in identifying torus/uterosacral ligament (USL) locations (p < 0.0001) and rectosigmoid nodules (p = 0.01). MRI without vaginal opacification diagnosed 94.1% (301/320) of torus/USL locations, surpassing MR with vaginal opacification, which diagnosed 85% (221/260) (p < 0.001). No significant differences related to bowel preparation or vaginal opacification were observed for other DPE locations. Rectal opacification did not affect diagnostic accuracy in the overall population, except in patients without bowel preparation, where performance improved (p = 0.04). There were no differences in diagnostic accuracy regarding MRI unit type (1.5-T/3-T), presence of additional sequences, or gadolinium injection for any endometriotic locations.

CONCLUSION

Bowel preparation prior to MRI examination is preferable to rectal or vaginal opacification for diagnosing deep endometriosis pelvic lesions.

CLINICAL RELEVANCE STATEMENT

Accurate diagnosis and staging of DPE are essential for effective treatment planning. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols. Optimizing MRI protocols for diagnostic performance with appropriate opacification techniques will help diagnose deep endometriosis more accurately.

KEY POINTS

Evaluating deep endometriosis in collapsible organs such as the vagina and rectum is difficult. Bowel preparation and an absence of vaginal opacification were found to be diagnostically beneficial. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols.

ACR Appropriateness Criteria® Endometriosis

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Magnetic Resonance Imaging of Endometriosis: The Role of Advanced Techniques

Endometriosis is a chronic inflammatory disease that affects about 10% of women, and it is characterized by the presence of endometrial tissue outside the uterine cavity. Associated symptoms are dyspareunia, chronic pelvic pain, and infertility. The diagnosis of endometriosis can be challenging due to various clinical and imaging presentations. Laparoscopy is the gold standard for the diagnosis, but it is an invasive procedure. The literature has increasingly promoted a switch to less invasive imaging techniques, such as ultrasound and magnetic resonance imaging (MRI). The latter, also in relation to the latest technological advances, allows a comprehensive and accurate assessment of the pelvis and it can also identify sites of endometriosis that escape laparoscopic evaluation. Furthermore, MRI has been found to be more accurate than other imaging techniques in relation to its improved sensitivity and specificity in identifying disease sites, also due to the role of new emerging sequences. This article aims to review the current role of advanced MRI applications in the assessment of endometriosis.

The application value of LAVA-flex sequences in enhanced MRI scans of nasopharyngeal carcinoma: comparison with T1WI-IDEAL

Introduction

Magnetic resonance imaging (MRI) staging scans are critical for the diagnosis and treatment of patients with nasopharyngeal cancer (NPC). We aimed to evaluate the application value of LAVA-Flex and T1WI-IDEAL sequences in MRI staging scans.

Methods

Eighty-four newly diagnosed NPC patients underwent both LAVA-Flex and T1WI-IDEAL sequences during MRI examinations. Two radiologists independently scored the acquisitions of image quality, fat suppression quality, artifacts, vascular and nerve display. The obtained scores were compared using the Wilcoxon signed rank test. According to the signal intensity (SI) measurements, the uniformity of fat suppression, contrast between tumor lesions and subcutaneous fat tissue, and signal-to-noise ratio (SNR) were compared by the paired t-test.

Results

Compared to the T1WI-IDEAL sequence, LAVA-Flex exhibited fewer artifacts (P<0.05), better visualization of nerves and vessels (P<0.05), and performed superior in the fat contrast ratio of the primary lesion and metastatic lymph nodes (0.80 vs. 0.52, 0.81 vs. 0.56, separately, P<0.001). There was no statistically significant difference in overall image quality, tumor signal-to-noise ratio (SNR), muscle SNR, and the detection rate of lesions between the two sequences (P>0.05). T1WI-IDEAL was superior to LAVA-Flex in the evaluation of fat suppression uniformity (P<0.05).

Discussion

LAVA-Flex sequence provides satisfactory image quality and better visualization of nerves and vessels for NPC with shorter scanning times.

Three Types of Endometriosis: Pathogenesis, Diagnosis and Treatment. State of the Art

At present, there is no curative treatment for endometriosis. Medical management and surgical treatment do not provide long-term relief. A detailed understanding of its pathophysiology is mandatory in order to facilitate both the diagnosis and treatment. The delay that typically precedes proper diagnosis (6 to 7 years) is probably one of the most challenging aspects of endometriosis management. In 2012, the total cost per woman due to endometriosis was estimated to be 9579€ per year in a multicenter study across the USA and Europe. According to their physiopathology and their localization, ectopic endometrial lesions, consisting of endometrial glands and stroma, can be divided into three different types: superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The following paper aims to review the available data in the literature on the pathogenesis, diagnosis, and treatment of different types of endometriosis.

Endometriosis: A multimodal imaging review

Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non - gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains. Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability. Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity. Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

The role of three-dimensional MRI in the differentiation between angular pregnancy and interstitial pregnancy

Background

In clinical practice it is an ongoing challenge to distinguish between angular pregnancy and interstitial pregnancy. With the three-dimensional (3D) magnetic resonance imaging (MRI) being increasingly used, it is worth exploring its role in differentiating angular pregnancy from interstitial pregnancy. This study aims to investigate how 3D MRI can help reveal the differences between these two special pregnancies in the early diagnosis.

Methods

We reviewed and analyzed the 3D MRI images of 50 patients with interstitial pregnancy and 55 patients with angular pregnancy retrospectively. Imaging features were identified to compare these two special pregnancies, and the ROC (Receiver Operating Characteristic) analysis was conducted to assess the diagnostic performance.

Results

The significant differences of the 3D MRI imaging features between interstitial pregnancy and angular pregnancy were found in the outline of uterus cavity (p < 0.001), involvement of junctional zone (p < 0.001), the signal of surroundings (p = 0.005), the relationship with round ligament (p = 0.042), and the overlying myometrial thickness (p = 0.041). Furthermore, the multivariate logistic regression analysis identified a series of significant indicators for angular pregnancy, including the junctional zone involvement, being-surrounded by hyper/iso-intensity on 3D images, and the asymmetric outline of uterus cavity. Combining these three imaging features, the AUC (Area under the Curve) of ROC curve was 0.87 in distinguishing interstitial pregnancy from angular pregnancy.

Conclusions

This study suggests that 3D MRI can help distinguish angular pregnancy from interstitial pregnancy in clinical practice, with the advantages that conventional MRI or ultrasound does not have. Through the significant image features, 3D MRI plays an important role in improving the timing of diagnosis, avoiding unnecessary interventions, and preventing hemorrhage in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04470-z.

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background

Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning.

Objective

To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI).

Methods

Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors.

Results

Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis.

MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants.

Conclusion

The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

Evaluation of Iterative Denoising 3-Dimensional T2-Weighted Turbo Spin Echo for the Diagnosis of Deep Infiltrating Endometriosis

OBJECTIVES

The primary end point of this study was to evaluate the image quality and reliability of a highly accelerated 3-dimensional T2 turbo spin echo (3D-T2-TSE) sequence with prototype iterative denoising (ID) reconstruction compared with conventional 2D T2 sequences for the diagnosis of deep infiltrating endometriosis (DIE). The secondary end point was to demonstrate the 3D-T2-TSE sequence image quality improvement using ID reconstruction.

MATERIAL AND METHODS

Patients were prospectively enrolled to our institution for pelvis magnetic resonance imaging because of a suspicion of endometriosis over a 4-month period. Both conventional 2D-T2 (sagittal, axial, coronal T2 oblique to the cervix) and 3D-T2-TSE sequences were performed with a scan time of 7 minutes 43 seconds and 4 minutes 58 seconds, respectively. Reconstructions with prototype ID (3D-T2-denoised) and without prototype ID (3D-T2) were generated inline at the end of the acquisition. Two radiologists independently evaluated the image quality of 3D-T2, 3D-T2-denoised, and 2D-T2 sequences. Diagnosis confidence of DIE was evaluated for both 3D-T2-denoised and 2D-T2 sequences. Intraobserver and interobserver agreements were calculated using Cohen κ coefficient.

RESULTS

Ninety female patients were included. Both readers found that the ID algorithm significantly improved the image quality and decreased the artifacts of 3D-T2-denoised compared with 3D-T2 sequences (P < 0.001). A significant image quality improvement was found by 1 radiologist for 3D-T2-denoised compared with 2D-T2 sequences (P = 0.002), whereas the other reader evidenced no significant difference. The interobserver agreement of 3D-T2-denoised and 2D-T2 sequences was 0.84 (0.73-0.95) and 0.78 (0.65-0.9), respectively, for the diagnosis of DIE. Intraobserver agreement for readers 1 and 2 was 0.86 (0.79-1) and 0.83 (0.76-1), respectively. For all localization of DIE, interobserver and intraobserver agreements were either almost perfect or substantial for both 3D-T2-denoised and 2D-T2 sequences.

CONCLUSIONS

Three-dimensional T2-denoised imaging is a promising tool to replace conventional 2D-T2 sequences, offering a significant scan time reduction without compromising image quality or diagnosis information for the assessment of DIE.

Can New ENZIAN Score 2020 Represent a Staging System Improving MRI Structured Report?

Structured reporting systems for endometriotic disease are gaining a central role in diagnostic imaging: our aim is to evaluate applicability and the feasibility of the recent ENZIAN score (2020) assessed by MRI. A total of 60 patients with suspected tubo–ovarian/deep endometriosis were retrospectively included in our study according to the following criteria: availability of MR examination; histopathological results from laparoscopic or surgical treatment; patients were not assuming estro-progestin or progestin therapy. Three different readers (radiologists with 2-, 5-, and 20-years of experience in pelvic imaging) have separately assigned a score according to the ENZIAN score (revised 2020) for all lesions detected by magnetic resonance imaging (MRI). Our study showed a high interobserver agreement and feasibility of the recent ENZIAN score applied to MRI; on the other hand, our experience highlighted some limitations mainly due to MRI’s inability to assess tubal patency and mobility, as required by the recent score (2020). In view of the limitations which arose from our study, we propose a modified MRI-ENZIAN score that provides a complete structured reporting system, more suitable for MRI. The high interobserver agreement of the recent ENZIAN score applied to MRI confirms its validity as a complete staging system for endometriosis, offering a shared language between radiologists and surgeons.

Can Dynamic Contrast-enhanced MRI Contribute to Improved Assessment of Rectosigmoid Involvement in Deep Infiltrating Endometriosis?

BACKGROUND/AIM

To determine whether a prototypical compressed-sensing volume-interpolated breath-hold (csVIBE) provides diagnostic value in detecting rectosigmoid infiltration in deep infiltrating endometriosis (DIE).

PATIENTS AND METHODS

csVIBE was employed in 151 women undergoing pelvic magnetic resonance imaging, of whom 43 had undergone surgery for suspected endometriosis. The accuracy of T2-weighted BLADE and BLADE/csVIBE, additional diagnostic value of csVIBE, and diagnostic confidence were rated by two readers. Additionally, the presence of the "mushroom cap sign" was assessed on BLADE and csVIBE.

RESULTS

The diagnostic accuracy, sensitivity, and specificity of BLADE and BLADE/csVIBE were not significantly different between Readers A and B. For both readers, the confidence in the diagnosis increased with csVIBE, but this increase in the odds ratio was not significant for both readers. Both readers preferred csVIBE over BLADE with regard to detection of the "mushroom cap sign."

CONCLUSION

csVIBE may provide a diagnostic benefit for surgical strategy selection through better delineation of the "mushroom cap sign."

Application study of 3D LAVA-Flex on lumbar intervertebral disc degeneration

Background

Degeneration of the intervertebral discs are very common diseases, indicating the specific or malignant changes in intervertebral disc component, structure and function. Imaging examination is currently used to evaluate the severity of lumbar intervertebral disc degeneration. This study was designed to investigate the diagnostic value of 3D LAVA-Flex in lumbar intervertebral disc degeneration.

Material and methods

Sagittal 3D LAVA-Flex and T2WI scans were performed in 45 patients with lumbar intervertebral disc degeneration. On T2WI, the degenerated intervertebral disc in every patient was evaluated using Pfirrmann grade. Then, the patients were re-evaluated using 3D LAVA-Flex with considerations of the distinction of nucleus pulposus and annulus fibrosus, hypointense signal of intervertebral disc and height of intervertebral disc. The evaluation results were compared between 3D LAVA-Flex and T2WI. Virtual endoscopy was also performed to evaluate the degenerated intervertebral disc.

Results

The intermediate–intense signal of nucleus pulposus and complete ring-shaped hyperintense signal of annulus fibrosus were found and the distinction of nucleus pulposus and annulus fibrosus was clear in the normal intervertebral disc on 3D LAVA-Flex. The incidence of linear hypointensity of narrowed intervertebral space (65/91) was higher than that of normal intervertebral space (4/134) (P = 0.000). A good consistency was shown between the LAVA-Flex grade and T2WI-based Pfirrmann grade. Virtual endoscopy based on 3D LAVA-Flex could help clearly show the anatomic relationship between the degenerated disc and intervertebral foramen.

Conclusions

3D LAVA-Flex and T2WI show similar efficacy in evaluating lumbar intervertebral disc degeneration. 3D LAVA-Flex-based virtual endoscopy possesses great potential in the study of intervertebral disc abnormalities.

Magnetic Resonance Imaging in endometriosis-associated pain

INTRODUCTION

Endometriosis affects 10%-15% of women in reproductive age and may cause no-cyclic chronic pelvic pain, dysmenorrhea, dyspareunia, urinary tract symptoms, and it is frequently associated with infertility. The peak of incidence is between 24 and 29 years old and the clinical diagnosis of endometriosis is generally delayed by 6-7 years. Laparoscopy with surgical biopsies is the "gold standard" for the diagnosis of endometriosis, with histological verification of endometrial ectopic glands and/or stroma. However, nowadays two different non-invasive modalities are routinely used for a presumptive diagnosis: Transvaginal Ultrasound (TVUS) and Magnetic Resonance Imaging (MRI).

EVIDENCE ACQUISITION

A structured search using PubMed was performed starting from October 2020 and including all relevant original and review articles published since 2000. The search used the following key word combinations: "Endometriosis MRI" AND "DIE and MRI" (45); "MRI endometriosis and Pelvic Pain" OR "Endometriosis and MRI technical development" (296). Ultimately, 87 articles were deemed relevant and used as the literature basis of this review.

EVIDENCE SYNTHESIS

TVUS represents the first imaging approach for endometriosis showing a good diagnostic performance but it is highly operator dependent. MRI is a second level examination often used in complex cases indeterminate after TVUS and in pre-operative planning. MRI is considered the best imaging technique for mapping endometriosis since it provides a more reliable map of deep infiltrating endometriosis than physical examination and transvaginal ultrasound. We have analyzed and described the main forms of endometriosis: adnexal endometriosis, adenomyosis, peritoneal implants and deep infiltrating endometriosis, showing their appearance in the two imaging modalities.

CONCLUSIONS

Endometriosis is one of the most common gynecologic disorders correlated to chronic pelvic pain whose treatment is still today complex and controversial. In this context, MRI has become an important additional non-invasive tool to investigate cases of chronic pelvic pain related to deep infiltrating endometriosis (DIE) with or without neural involvement.

Value of 3D MRI and Vaginal Opacification for the Diagnosis of Vaginal Endometriosis

Objective: The aim of the study was to evaluate three-dimensional (3D) T2 MRI before and after vaginal opacification (VO) by gel (3DT2VO) and the additional value of 3DT1 with fat-suppression (3DT1FS) MRI in the diagnosis of vaginal endometriosis.

Methods: In this study conducted from 2010 to 2013, 51 patients scheduled for surgical treatment of endometriosis underwent MRI 1 day before surgery. Three readers (novice, intermediate, expert) were asked to retrospectively diagnose vaginal endometriosis independently and blindly using four different readings (i.e., 3DT2, 3DT2VO, 3DT2 with 3DT1FS, 3DT2VO with 3DT1FS). Vaginal endometriosis diagnosis was positive on observation of a thickening of vaginal walls on 3DT2 with or without high-signal-intensity spots on 3DT2 and/or 3DT1FS. The reference standard was surgery and histology. Descriptive analysis, Chi-square test, and ROC curves were used for statistical analysis.

Results: For all readers, the combination of 3DT2 and 3DT1FS significantly improved the diagnosis of vaginal endometriosis compared with 3DT2 (p = 0.002, p = 0.02, and p = 0.003). 3DT2VO significantly improved diagnosis for the intermediate reader (p = 0.01). High-signal-intensity spots on 3DT1FS had a sensitivity of 50–63.6%, specificity of 86.2–96.6%, and high positive likelihood ratios (14.5-Inf).

Conclusion: 3DT2 in association with 3DT1FS appears to be the best 3D MRI protocol for the diagnosis of vaginal endometriosis, whatever the level of experience of readers. The additional value of 3DT2VO is variable among the readers.

MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature

OBJECTIVES

Our objective was to establish the primary mode of imaging and MR protocols utilised in the preoperative staging of deeply infiltrating endometriosis in centres accredited by the British Society of Gynaecological Endoscopy (BSGE).

METHODS

The lead consultant radiologist in each centre was invited to complete an online survey detailing their protocols.

RESULTS

Out of 49 centres, 32 (65%) responded to the survey. Two centres performed transvaginal ultrasound as the primary method for preoperative staging of deeply infiltrating endometriosis and the remainder performed MRI. 21/25 centres did not recommend a period of fasting prior to MRI and 22/25 administered hyoscine butylbromide. None of the centres routinely offered bowel preparation or recommended a specific pre-procedure diet. 21/25 centres did not time imaging according to the woman's menstrual cycle, and instructions regarding bladder filling were varied. Rectal and vaginal opacification methods were infrequently utilised. All centres preferentially performed MRI in the supine position - six used an abdominal strap and four could facilitate prone imaging. Just under half of centres used pelvic-phased array coils and three centres used gadolinium contrast agents routinely. All centres performed T1W with fat-suppression and T2W without fat-suppression sequences. There was significant variation relating to other MR sequences depending on the unit.

CONCLUSIONS

There was significant inconsistency between centres in terms of MR protocols, patient preparation and the sequences performed. Many practices were out of line with current published evidence.

ADVANCES IN KNOWLEDGE

Our survey demonstrates a need for evidence-based standardisation of imaging in BSGE accredited endometriosis centres.

Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis

PURPOSE

To estimate the benefit of pelvic magnetic resonance (MR) imaging after routine pelvic ultrasound (US) in patients with pathologically or surgically proven endometriosis.

METHODS

Patients with surgically or pathologically proven endometriosis who had routine pelvic US followed by pelvic MR within 6 months prior to surgery were included. Patients were excluded if they had previously confirmed endometriosis, pregnancy, or surgery > 6 months after MR. The detection rate of endometriosis by pelvic US and MR was compared to the surgical/pathological reference standard.

RESULTS

83 female patients (mean age 40 ± 9) met inclusion criteria and had surgical/pathological confirmation of endometriosis. The mean time interval between pelvic US and MR was 33 ± 43 days, with 64 ± 69 days between MR examination and surgery. US detected endometriosis in 22% (18/83) of patients compared to 61% (51/83) for MR (p < 0.0001). 51% (33/65) of patients with a negative pelvic US exam had a positive MR. MR identified additional sites or sequela in the majority of patients with a positive US (14/18; 78%), including extraovarian locations [e.g., fallopian tubes 7/18 (39%), uterus 7/18 (39%), uterine ligaments 6/18 (33%), posterior cul de sac 5/18 (28%), pelvic side walls 5/18 (28%), abdominal wall 1/18 (6%)] and sequela [ovarian tethering 5/18 (28%), 6/18 (33%) bowel adhesive disease, posterior cul de sac obliteration 2/18 (11%), hydrosalpinx 2/18 (11%), and hydronephrosis 1/18 (6%)]. 3 T MR detected endometriosis in 33/46 (72%) patients compared to 18/37 (49%) for 1.5 T MR (p = 0.03).

CONCLUSION

Pelvic MR imaging had a higher detection rate of surgically/pathologically proven endometriosis and provides more information about disease location and sequela compared to routine pelvic US.

Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

Efficacy of Laparoscopic Partial Cystectomy with a Transurethral Resectoscope in Patients with Bladder Endometriosis: See-Through Technique

PURPOSE

Bladder endometriosis (BE) is rare. Deep invasive endometriosis is difficult to control with medications alone; such cases need surgical treatment. Good results of laparoscopic partial cystectomy with a transurethral (TU) resectoscope by the see-through technique for patients with BE are reported.

MATERIALS AND METHODS

From January 2008 to February 2016, 12 cases of symptomatic BE were seen in our institution. The chief complaints of 9 cases were micturition pain during menstruation. Preoperative cystoscopy showed a bladder mass with blueberry spots. All surgeries were performed under general anesthesia. Laparoscopic surgery was performed with a fan of 4 ports in the lower abdomen. First, the uterus and bilateral ovaries were checked. Then, the TU resectoscope was inserted. When the affected bladder wall was identified, it was again observed with the laparoscopic light source off, which made it possible to observe the twilight leaking inside from the bladder. This twilight came from the light source of the TU resectoscope via the unaffected bladder wall. In contrast, the thickness of the affected wall prevented the light from inside the bladder from passing through it. We call this the "see-through technique." The tumor was then safely dissected with both laparoscopic and TU resection procedures. Finally, the bladder was sutured by laparoscopic procedures using absorbable sterile surgical suture. The urethral catheter was removed after cystography 7 days after the operation.

RESULTS

The surgical margins of all cases were negative. There has been no recurrence of BE so far in any patients. There were no major adverse events perioperatively and the urinary symptoms improved in all cases.

CONCLUSIONS

By laparoscopic partial cystectomy assisted with a TU resectoscope and see-through technique, the edge of BE could be easily and precisely identified. These procedures are effective and safe for BE surgical treatment.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas

OBJECTIVE

The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas.

METHODS

Guidelines for imaging uterine leiomyomas were defined based on a survey distributed to all members of the working group, an expert consensus meeting at European Congress of Radiology (ECR) 2017 and a critical review of the literature.

RESULTS

The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed.

CONCLUSIONS

MRI offers an outstanding and reproducible map of the size, site and distribution of leiomyomas. A standardised imaging protocol and method of reporting ensures that the salient features are recognised. These imaging guidelines are based on the current practice among expert radiologists in the field of female pelvic imaging and also incorporate essentials of the current published MR literature of uterine leiomyomas.

KEY POINTS

• MRI allows comprehensive mapping of size and distribution of leiomyomas. • Basic MRI comprise T2W and T1W sequences centered to the uterus. • Standardized reporting ensures pivotal information on leiomyomas, the uterus and differential diagnosis. • MRI aids in differentiation of leiomyomas from other benign and malignant entities, including leiomyosarcoma.

The Complementary Role of Imaging and Tumor Biomarkers in Gynecological Cancers: An Update of the Literature

Gynecological tumors, including endometrial, cervical and ovarian cancer, have increased in incidence over time. The widespread introduction of screening programs and advances in diagnostic imaging methods has lead to a progressive increase in gynecological cancer detection. Accurate diagnosis and proper monitoring of disease remain the primary target for a successful treatment. In the last years, knowledge about cancer biomarkers has considerably increased providing great opportunities for improving cancer detection and treatment. In addition, in the last few years there has been an important development of imaging techniques. Nowadays, a multimodal approach including the evaluation of serum tumor biomarkers combined with imaging techniques, seems to be the best strategy for assessing tumor presence, spread, recurrence, and/or the response to treatment in female cancer patients In this review we provide an overview of the application of biomarkers combined with novel imaging methods and highlight their roles in female cancer diagnosis and follow-up.

Cystoscopy-assisted laparoscopy for bladder endometriosis: modified light-to-light technique for bladder preservation

Introduction

Endometriosis is a disease with causes still unclear, affecting approximately 15% of women of reproductive age, and in 1%-2% of whom it may involve the urinary tract. The bladder is the organ most frequently affected by endometriosis, observed around 85% of the cases. In such cases, the most effective treatment is partial cystectomy, especially via videolaparoscopy.

Study Objective, Design, Size and Duration

In order to identify and delimit the extent of the intravesical endometriosis lesion, to determine the resection limits, as well as to perform an optimal reconstruction of the organ aiming for its maximum preservation, we performed a cystoscopy simultaneously with the surgery, employing a modified light-to-light technique in 25 consecutive patients, from September 2006 to May 2012.

Setting

Study performed at Campinas Medical Center – Campinas – Sao Paulo – Brazil.Participants/materials, setting and methods: Patients aged 27 to 47 (average age: 33.4 years) with deep endometriosis with total bladder involvement were selected for the study. The technique used was conventional laparoscopy with a transvaginal uterine manipulator and simultaneous cystoscopy (the light-to-light technique). A partial videolaparoscopic cystectomy was performed with cystoscopy-assisted vesical reconstruction throughout the entire surgical time. The lesions had an average size of 2.75cm (ranging from 1.5 to 5.5cm). The average surgical time was 137.7 minutes, ranging from 110 to 180 minutes.

Main Results

Postoperative follow-up time was 32.4 months (12-78 months), with clinical evaluation and a control cystoscopy performed every six months. No relapse was observed during the follow-up period.

Conclusions

A cystoscopy-assisted partial laparoscopic cystectomy with a modified light-to-light technique is a method that provides adequate identification of the lesion limits, intra or extravesically. It also allows a safe reconstruction of the organ aiming for its maximum preservation.

European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis

Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence.

KEY POINTS

• This report provides guidelines for MRI in endometriosis. • Minimal and optimal MRI acquisition protocols are provided. • Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.

Role of 3.0 Tesla magnetic resonance hysterosalpingography in the diagnostic work-up of female infertility

BACKGROUND

Imaging evaluation plays a crucial role in the diagnostic work-up of female infertility. In recent years, the possibility to evaluate tubal patency using 1.5 Tesla magnetic resonance (1.5T MR) has been studied.

PURPOSE

To assess the feasibility of 3.0 Tesla magnetic resonance (3.0T MR) hysterosalpingography and its role in the diagnostic work-up of female infertility and to evaluate if this fast "one-stop-shop" imaging approach should be proposed as a first-line examination.

MATERIAL AND METHODS

A total of 116 infertile women were enrolled in this prospective study; all underwent 3.0T MR hysterosalpingography. After standard imaging of the pelvis, tubal patency was assessed by acquiring 3D dynamic time-resolved T1-weighted (T1W) sequences during manual injection of 4-5 mL of contrast solution consisting of gadolinium and normal sterile saline. Images were evaluated by two radiologists with different experience in MR imaging (MRI).

RESULTS

The examination was successfully completed in 96.5% of cases, failure rate was 3.5%. Dynamic sequences showed bilateral tubal patency in 64.3%, unilateral tubal patency in 25.9%, and bilateral tubal occlusion in 9.8%. Extratubal abnormalities were found in 69.9% of patients. Comprehensive analysis of morphological and dynamic sequences showed extratubal abnormalities in 43.1% of patients with bilateral tubal patency.

CONCLUSION

3.0T MR hysterosalpingography is a feasible, simple, fast, safe, and well-tolerated examination, which allows evaluation of tubal patency and other pelvic causes of female infertility in a single session, and it may thus represent a "one-stop-shop" solution in female infertility diagnostic work-up.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

HE4 in the differential diagnosis of ovarian masses

Ovarian masses, a common finding among pre- and post-menopausal women, can be benign or malignant. Ovarian cancer is the leading cause of death from gynecologic malignancy among women living in industrialized countries. According to the current guidelines, measurement of CA125 tumor marker remains the gold standard in the management of ovarian cancer. Recently, HE4 has been proposed as emerging biomarker in the differential diagnosis of adnexal masses and in the early diagnosis of ovarian cancer. Discrimination of benign and malignant ovarian tumors is very important for correct patient referral to institutions specialized in care and management of ovarian cancer. Tumor markers CA125 and HE4 are currently incorporated into the "Risk of Ovarian Malignancy Algorithm" (ROMA) with menopausal status for discerning malignant from benign pelvic masses. The availability of a good biomarker such as HE4, closely associated with the differential and early diagnosis of ovarian cancer, could reduce medical costs related to more expensive diagnostic procedures. Finally, it is important to note that HE4 identifies platinum non-responders thus enabling a switch to second line chemotherapy and improved survival.

Increased dose single-agent gemcitabine in platinum-taxane resistant metastatic ovarian cancer

CONCLUSION

In platinum–taxane resistant epithelial ovarian cancer (EOC), we aimed to determine the effectiveness.

PATIENTS AND METHODS

Between 2004 and 2013, patients afflicted with platinum–taxane resistant EOC and who were administered a 30-minute i.v. infusion of single-agent gemcitabine at a dose of 1,250 mg/m2 on the 1st, 8th and 15th days, every 28 days, were examined retrospectively.

RESULTS

Twenty-six patients with platinum–taxane resistant EOC were included in the study. The overall survival (OS) was 48 months. The median survival after becoming platinum–taxane resistant was 16 months for the study population. Median time to progression (TTP) and median survival after becoming platinum–taxane resistant for patients who received second-line treatment were 3.3 months and 16 months, respectively; for patients who received third-line treatment with gemcitabine, these were 3.7 months and 19 months, respectively. Administration of gemcitabine as second- and third-line chemotherapy in platinum–taxane resistant EOC, provides similar TTP and OS outcomes (p = 0.4, p = 0.9) with a similar response and toxicity rate.

CONCLUSIONS

Second- and third-line gemcitabine at a dose of 1,250 mg/m2 on days 1, 8 and 15 every 28 days as a 30-minute i.v. infusion in platinum–taxane resistant EOC is an effective treatment option with a tolerable and manageable toxicity.

Impaired uterine artery flow associated with the presence of ovarian endometrioma: preliminary results of a prospective study

BACKGROUND

Aim of this prospective, case-control study was to evaluate uterine arteries' blood flow before and after laparoscopic surgery in patients with ovarian endometriosis and its possible correlation with infertility.

METHODS

We prospectively enrolled 110 women of reproductive age; 69 with ovarian endometriomas and scheduled for surgery, and 41 controls. At enrolment, a detailed medical, gynecologic and obstetric history was collected. Fertility and pregnancy desire were assessed. All patients underwent complete physical and gynecologic examination. Transvaginal ultrasound with Doppler color flow was performed to evaluate Resistance Index (RI) of uterine arteries during the secretory phase, at enrolment (T0) and 3 months after laparoscopic surgery (T1).

RESULTS

Among cases, 27 patients were excluded because they did not meet the inclusion criteria. At enrolment (T0) unilateral or bilateral flow alterations (RI ≥ 0.8) were found in 38 out of 42 patients with ovarian endometriosis (90%), whereas in the control group only 17 women (41%) had Doppler alterations. The difference in uterine artery RI values between cases and controls was statistically significant (P < 0.0001). A statistically significant improvement in uterine artery flow (P <0.0001) was found 3 months after surgical treatment of endometriosis. Nineteen patients with endometriosis (45%) were infertile before surgery; all of them presented uterine artery Doppler alterations at T0. After surgery the pregnancy rate was significantly higher in patients who presented uterine artery flow normalization than in those with persistent uterine artery flow alterations (p = 0.002).

CONCLUSIONS

A strong correlation was found between uterine artery flow abnormalities and ovarian endometriosis. Uterine artery flow improvement following surgery seems to increase the probabilities of achieving pregnancy.

Is CA72-4 a useful biomarker in differential diagnosis between ovarian endometrioma and epithelial ovarian cancer?

Background. Surgical excision of ovarian endometriomas in patients desiring pregnancy has recently been criticized because of the risk of damage to healthy ovarian tissue and consequent reduction of ovarian reserve. A correct diagnosis in cases not scheduled for surgery is therefore mandatory in order to avoid unexpected ovarian cancer misdiagnosis. Endometriosis is often associated with high levels of CA125. This marker is therefore not useful for discriminating ovarian endometrioma from ovarian malignancy. The aim of this study was to establish if the serum marker CA72-4 could be helpful in the differential diagnosis between ovarian endometriosis and epithelial ovarian cancer. Methods. Serums CA125 and CA72-4 were measured in 72 patients with ovarian endometriomas and 55 patients with ovarian cancer. Results. High CA125 concentrations were observed in patients with ovarian endometriosis and in those with ovarian cancer. A marked difference in CA72-4 values was observed between women with ovarian cancer (71.0%) and patients with endometriosis (13.8%) (P < 0.0001). Conclusions. This study suggests that CA72-4 determination can be useful to confirm the benign nature of ovarian endometriomas in women with high CA125 levels.

Prospective evaluation of 3T MRI findings for primary adnexal lesions and comparison with the final histological diagnosis

PURPOSE

We prospectively investigated the diagnostic accuracy of magnetic resonance imaging (MRI) at 3.0 Tesla (3T) for the detection of suspected primary adnexal masses in a large cohort of patients.

METHODS

This prospective clinical study included 223 patients with suspected gynaecological disease who were referred for 3T MRI assessments before laparoscopy or laparotomy. Fifty-nine patients were excluded. All detected adnexal pathologies on MRI were categorized into the four groups (endometric cysts, teratomas, benign tumours and malignant tumours). Histological findings were used as the comparative reference standard. As measures to detect or rule out primary adnexal masses, accuracy, sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were determined by lesion-based evaluations.

RESULTS

The reference standard method detected 141 primary adnexal lesions in 125 patients. The areas under the receiver operating characteristic curve of the lesion-based evaluations for endometric cysts, teratomas, benign lesions and malignant lesions were 92.8, 93.6, 95.1 and 94.4 %. Lesion-based evaluation yielded an accuracy of 90.3 %, sensitivity of 92.7 %, specificity of 89.3 %, PPV of 77.6 % and NPV of 96.8 % in differentiating malignancies from non-malignant lesions. The diagnostic value of 3T MRI for detecting malignancies was superior to that for benign tumours.

CONCLUSIONS

3T MRI well categorize the characteristics of primary adnexal lesions and may be a reliable modality for distinguishing malignancies from benign tumours.

The use of HE4, CA125 and CA72-4 biomarkers for differential diagnosis between ovarian endometrioma and epithelial ovarian cancer

Background

Endometriosis is frequently associated with high levels of CA125. This marker is therefore not useful for discriminating ovarian endometrioma from ovarian malignancy. The aim of this study was to establish a panel of complementary biomarkers that could be helpful in the differential diagnosis between ovarian endometriosis or other ovarian benign masses and ovarian cancer.

Methods

Blood samples from 50 healthy women, 17 patients with benign ovarian tumors, 57 patients with ovarian endometrioma and 39 patients with ovarian cancer were analyzed and serum values were measured for the following biomarkers: CA125, HE4 and CA72-4.

Results

Serum CA125 concentration was elevated in both patients with ovarian endometriosis and ovarian cancer but not in patients with other benign ovarian masses. HE4 was never increased in patients with endometriosis or benign masses whereas it was significantly higher in all patients with ovarian cancer (p < 0.05). A marked difference in CA72-4 values was observed between women with ovarian cancer (67%) and those with endometriosis (p < 0.05).

Conclusions

The results of the study suggest that HE4 and CA72-4 determination is the best approach to confirm the benign nature of ovarian endometrioma in women with high CA125 levels.

Fat suppression strategies in MR imaging of breast cancer at 3.0 T: comparison of the two-point Dixon technique and the frequency selective inversion method

PURPOSE

To compare two fat suppression methods in contrast-enhanced MR imaging of breast cancer at 3.0 T: the two-point Dixon method and the frequency selective inversion method.

MATERIALS AND METHODS

Forty female patients with breast cancer underwent contrast-enhanced three-dimensional T1-weighted MR imaging at 3.0 T. Both the two-point Dixon method and the frequency selective inversion method were applied. Quantitative analyses of the residual fat signal-to-noise ratio and the contrast noise ratio (CNR) of lesion-to-breast parenchyma, lesion-to-fat, and parenchyma-to-fat were performed. Qualitative analyses of the uniformity of fat suppression, image contrast, and the visibility of breast lesions and axillary metastatic adenopathy were performed.

RESULTS

The signal-to-noise ratio was significantly lower in the two-point Dixon method (P < 0.001). All CNR values were significantly higher in the two-point Dixon method (P < 0.001 and P = 0.001, respectively). According to qualitative analysis, both the uniformity of fat suppression and image contrast with the two-point Dixon method were significantly higher (P < 0.001 and P = 0.002, respectively). Visibility of breast lesions and metastatic adenopathy was significantly better in the two-point Dixon method (P < 0.001 and P = 0.03, respectively).

CONCLUSION

The two-point Dixon method suppressed the fat signal more potently and improved contrast and visibility of the breast lesions and axillary adenopathy.

A promise in the treatment of endometriosis: an observational cohort study on ovarian endometrioma reduction by N-acetylcysteine

Urged by the unmet medical needs in endometriosis treatment, often with undesirable side effects, and encouraged by N-acetylcysteine (NAC) efficacy in an animal model of endometriosis and by the virtual absence of toxicity of this natural compound, we performed an observational cohort study on ovarian endometriosis. NAC treatment or no treatment was offered to 92 consecutive Italian women referred to our university hospital with ultrasound confirmed diagnosis of ovarian endometriosis and scheduled to undergo laparoscopy 3 months later. According to patients acceptance or refusal, NAC-treated and untreated groups finally comprised 73 and 72 endometriomas, respectively. After 3 months, within NAC-treated patients cyst mean diameter was slightly reduced (−1.5 mm) versus a significant increase (+6.6 mm) in untreated patients (P = 0.001). Particularly, during NAC treatment, more cysts reduced and fewer cysts increased their size. Our results are better than those reported after hormonal treatments. Twenty-four NAC-treated patients—versus 1 within controls—cancelled scheduled laparoscopy due to cysts decrease/disappearance and/or relevant pain reduction (21 cases) or pregnancy (1 case). Eight pregnancies occurred in NAC-treated patients and 6 in untreated patients. We can conclude that NAC actually represents a simple effective treatment for endometriosis, without side effects, and a suitable approach for women desiring a pregnancy.

Location-dependent value of pelvic MRI in the preoperative diagnosis of endometriosis

OBJECTIVES

To investigate the value of magnetic resonance imaging (MRI) in the preoperative diagnosis of specific anatomical locations of endometriosis.

STUDY DESIGN

Between July 2008 and April 2011, 152 women (mean age 33.5 ± 6.1 years) with clinical and sonographic suspicion of endometriosis underwent pelvic MRI using T2 and unenhanced T1 sequences with and without fat saturation. Two radiologists interpreted the following regions by consensus according to a standardized protocol: ovaries, vagina, pouch of Douglas, rectosigmoid colon, uterosacral ligament (USL), bladder, peritoneum, and other pelvic regions. The results of MRI were retrospectively correlated with the laparoscopic and histopathologic findings. The main outcome parameters, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (LR+) and the negative likelihood ratio (LR-), were determined.

RESULTS

Sensitivity, specificity, PPV, NPV, accuracy, positive and the negative likelihood ratio were 87.6%, 84.6%, 94.3%, 70.2%, 86.8%, 5.69 and 0.15 for the pouch of Douglas (vagina: 81.4%, 81.7%, 79.2%, 83.8%, 81.6%, 4.45, 0.23; rectosigmoid colon: 80.2%, 77.5%, 80.2%, 77.5%, 78.9%, 3.56, 0.25; USL: 77.5%, 68.2%, 77.5%, 68.2%, 73.7%, 2.44, 0.33; ovaries: 86.3%, 73.6%, 78.4%, 82.8%, 80.3%, 3.27, 0.19; urinary bladder: 81.0%, 94.7%, 70.8%, 96.9%, 92.8%, 15.15, 0.20; peritoneum: 35.3%, 88.1%, 60.0%, 73.0%, 70.4%, 2.97, 0.73). All endometriotic implants at other localization were detected (abdominal wall in 4, groin in one patient).

CONCLUSIONS

The value of MRI in preoperative diagnosis of endometriosis is dependent on the location of endometriosis. The highest accuracy was found in bladder endometriosis and the lowest in peritoneal endometriosis.

The Role of 3.0T MRI in the Assessment of Deep Endometriosis Located on the Uterosacral Ligaments

Purpose

To assess the diagnostic accuracy of 3.0T magnetic resonance imaging (MRI) in assessing the involvement of uterosacral ligaments (USLs) in deep infiltrating endometriosis (DIE).

Methods

Between July 2010 and July 2012, 42 women, aged between 19 and 45 years (mean age 28 years), with a diagnosis of cystic ovarian endometriosis and scheduled for laparoscopic treatment, underwent pre-operative 3.0-T MRI examination. USL was considered normal when it was not visible or when it was thin and regular.

Results

We found USL involvement in 20/42 cases: 4/20 had bilateral involvement, 16/20 had monolateral involvement; in the right ligament in 9/16 cases and in the left in 7/16. Asymmetric morphology was found in 17 patients with an arciform shape associated with increased thickness of the ligament. A thickness >3 mm was considered positive. These patients also presented thickening of the torus uterinus region. In three cases complete cul de sac obliteration led to loss of tissue plane which hindered identification of the USLs. Comparison with laparoscopy findings enabled us to achieve the following statistical values: 94.7% sensitivity, 91.3% specificity, 90.0% positive predictive value, 95.4% negative predictive value, and 93% diagnostic accuracy.

Conclusions

Optimal visualization of USLs was obtained on para-axial scans on T2W and T1W sequences which allowed an optimal anatomic visualization. In our study we demonstrated that 3.0T imaging enabled an optimal assessment of USL involvement to select patients for the correct kind of surgery or follow-up of these patients.