Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma

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.

Ultrasonography in the Differentiation of Endometriomas from Hemorrhagic Ovarian Cysts: The Role of Texture Analysis

The ultrasonographic (US) features of endometriomas and hemorrhagic ovarian cysts (HOCs) are often overlapping. With the emergence of new computer-aided diagnosis techniques, this is the first study to investigate whether texture analysis (TA) could improve the discrimination between the two lesions in comparison with classic US evaluation. Fifty-six ovarian cysts (endometriomas, 30; HOCs, 26) were retrospectively included. Four classic US features of endometriomas (low-level internal echoes, perceptible walls, no solid components, and less than five locules) and 275 texture parameters were assessed for every lesion, and the ability to identify endometriomas was evaluated through univariate, multivariate, and receiver operating characteristics analyses. The sensitivity (Se) and specificity (Sp) were calculated with 95% confidence intervals (CIs). The texture model, consisting of seven independent predictors (five variations of difference of variance, image contrast, and the 10th percentile; 100% Se and 100% Sp), was able to outperform the ultrasound model composed of three independent features (low-level internal echoes, perceptible walls, and less than five locules; 74.19% Se and 84.62% Sp) in the diagnosis of endometriomas. The TA showed statistically significant differences between the groups and high diagnostic value, but it remains unclear if the textures reflect the intrinsic histological characteristics of the two lesions.

Models including serum CA-125, BMI, cyst pathology, dysmenorrhea or dyspareunia for diagnosis of endometriosis

AIM

To evaluate preoperative levels of CA-125 and HE4 in patients with endometriosis-like symptoms and to construct diagnostic models.

PATIENTS

Prospective case-control study included 124 endometriosis patients and 97 control patients.

MATERIALS & METHODS

Logistic regression was used to construct diagnostic models based on serum biomarker levels and clinical data.

RESULTS

A model with CA-125, BMI, information on cysts and dyspareunia had an area under the curve value of 0.836, sensitivity of 74.0% and specificity of 81.3%. The second model included CA-125, BMI, information on cysts and dysmenorrhea and had an area under the curve value of 0.819, sensitivity of 74.8% and specificity of 79.2%.

CONCLUSION

Constructed models have the potential for noninvasive diagnosis of endometriosis, and might be translated into clinical practice after additional validation.

Combination of the non-invasive tests for the diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series.

OBJECTIVES

To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear.

AUTHORS' CONCLUSIONS

None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

Past, present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Blood biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive or minimally invasive tests available in clinical practice to accurately diagnose endometriosis. Although other reviews have assessed the ability of blood tests to diagnose endometriosis, this is the first review to use Cochrane methods, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To evaluate blood biomarkers as replacement tests for diagnostic surgery and as triage tests to inform decisions on surgery for endometriosis. Specific objectives include:1. To provide summary estimates of the diagnostic accuracy of blood biomarkers for the diagnosis of peritoneal, ovarian and deep infiltrating pelvic endometriosis, compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as these databases to 20 April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more blood biomarkers with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two authors independently collected and performed a quality assessment of data from each study. For each diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis, and we calculated sensitivity and specificity estimates. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient datasets were available. The predetermined criteria for a clinically useful blood test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of ≥ 0.95 and a specificity of ≥ 0.50, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of ≥ 0.50 and a specificity of ≥ 0.95, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

We included 141 studies that involved 15,141 participants and evaluated 122 blood biomarkers. All the studies were of poor methodological quality. Studies evaluated the blood biomarkers either in a specific phase of the menstrual cycle or irrespective of the cycle phase, and they tested for them in serum, plasma or whole blood. Included women were a selected population with a high frequency of endometriosis (10% to 85%), in which surgery was indicated for endometriosis, infertility work-up or ovarian mass. Seventy studies evaluated the diagnostic performance of 47 blood biomarkers for endometriosis (44 single-marker tests and 30 combined tests of two to six blood biomarkers). These were angiogenesis/growth factors, apoptosis markers, cell adhesion molecules, high-throughput markers, hormonal markers, immune system/inflammatory markers, oxidative stress markers, microRNAs, tumour markers and other proteins. Most of these biomarkers were assessed in small individual studies, often using different cut-off thresholds, and we could only perform meta-analyses on the data sets for anti-endometrial antibodies, interleukin-6 (IL-6), cancer antigen-19.9 (CA-19.9) and CA-125. Diagnostic estimates varied significantly between studies for each of these biomarkers, and CA-125 was the only marker with sufficient data to reliably assess sources of heterogeneity.The mean sensitivities and specificities of anti-endometrial antibodies (4 studies, 759 women) were 0.81 (95% confidence interval (CI) 0.76 to 0.87) and 0.75 (95% CI 0.46 to 1.00). For IL-6, with a cut-off value of > 1.90 to 2.00 pg/ml (3 studies, 309 women), sensitivity was 0.63 (95% CI 0.52 to 0.75) and specificity was 0.69 (95% CI 0.57 to 0.82). For CA-19.9, with a cut-off value of > 37.0 IU/ml (3 studies, 330 women), sensitivity was 0.36 (95% CI 0.26 to 0.45) and specificity was 0.87 (95% CI 0.75 to 0.99).Studies assessed CA-125 at different thresholds, demonstrating the following mean sensitivities and specificities: for cut-off > 10.0 to 14.7 U/ml: 0.70 (95% CI 0.63 to 0.77) and 0.64 (95% CI 0.47 to 0.82); for cut-off > 16.0 to 17.6 U/ml: 0.56 (95% CI 0.24, 0.88) and 0.91 (95% CI 0.75, 1.00); for cut-off > 20.0 U/ml: 0.67 (95% CI 0.50 to 0.85) and 0.69 (95% CI 0.58 to 0.80); for cut-off > 25.0 to 26.0 U/ml: 0.73 (95% CI 0.67 to 0.79) and 0.70 (95% CI 0.63 to 0.77); for cut-off > 30.0 to 33.0 U/ml: 0.62 (95% CI 0.45 to 0.79) and 0.76 (95% CI 0.53 to 1.00); and for cut-off > 35.0 to 36.0 U/ml: 0.40 (95% CI 0.32 to 0.49) and 0.91 (95% CI 0.88 to 0.94).We could not statistically evaluate other biomarkers meaningfully, including biomarkers that were assessed for their ability to differentiate endometrioma from other benign ovarian cysts.Eighty-two studies evaluated 97 biomarkers that did not differentiate women with endometriosis from disease-free controls. Of these, 22 biomarkers demonstrated conflicting results, with some studies showing differential expression and others no evidence of a difference between the endometriosis and control groups.

AUTHORS' CONCLUSIONS

Of the biomarkers that were subjected to meta-analysis, none consistently met the criteria for a replacement or triage diagnostic test. A subset of blood biomarkers could prove useful either for detecting pelvic endometriosis or for differentiating ovarian endometrioma from other benign ovarian masses, but there was insufficient evidence to draw meaningful conclusions. Overall, none of the biomarkers displayed enough accuracy to be used clinically outside a research setting. We also identified blood biomarkers that demonstrated no diagnostic value in endometriosis and recommend focusing research resources on evaluating other more clinically useful biomarkers.

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.

New serum biomarkers for detection of endometriosis using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

This study used proteomic fingerprint technology, combining nano-sized magnetic beads with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS), to screen for potential protein biomarkers for the diagnosis of endometriosis. Serum proteins from 126 patients with endometriosis and 120 healthy controls were profiled and compared. Biomarker pattern software identified 46 discriminating mass-to-charge m/z ratio peaks that were related to endometriosis. The model constructed by the software, based on three of these peaks (m/z 5988.7, 7185.3 and 8929.8), generated excellent separation between the endometriosis and control groups. The sensitivity was 91.4% and the specificity 95.0%. Blind testing on a second series of serum samples from patients with endometriosis and healthy controls indicated a sensitivity of 89.3% and a specificity of 90.0%. Biomarkers for endometriosis can be discovered in serum by MALDI-TOF-MS in combination with nano-sized magnetic beads. The pattern of combined markers provides a powerful and reliable diagnostic method for endometriosis, with high sensitivity and specificity.

“Tenderness-guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain

OBJECTIVE

To determine the accuracy of transvaginal ultrasonography (TVUS) using a modified "tenderness-guided" approach in the diagnosis of deep endometriosis of the cul-de-sac, retrocervical region, and rectovaginal septum.

DESIGN

Prospective study.

SETTING

Academic department of obstetrics and gynecology.

PATIENT(S)

Fifty women scheduled for laparoscopy for chronic pelvic pain.

INTERVENTION(S)

All patients underwent TVUS. The modified tenderness-guided approach consisted of TVUS combined with the introduction of 12 mL of ultrasound transmission gel (instead of the usual 4 mL) in the probe cover to create a stand-off to visualize the near-field area. The posterior fornix was evaluated accurately with an up-and-down sliding movement of the probe. In addition, when the patient indicated that tenderness was evoked by the probe's pressure, the sliding movement was stopped, and particular attention was paid to the painful site for detection of endometriosis lesions.

MAIN OUTCOME MEASURE(S)

Sensitivity, specificity, and kappa values.

RESULT(S)

Using this approach, we obtained a specificity of 95% with a sensitivity of 90%, associated with a very high kappa value of 0.86 (95% CI, 0.56-0.91).

CONCLUSION(S)

Our new TVUS approach appears to be an accurate, inexpensive, and less invasive method for the diagnosis of deep endometriosis.

Plasma urocortin levels in the diagnosis of ovarian endometriosis

OBJECTIVE

Urocortin is a neuropeptide, member of the corticotropin-releasing hormone family, that is produced by the human endometrium. Ovarian endometrioma is a prevalent gynecologic disorder still lacking specific serum markers. In the present study we measured systemic levels of urocortin to assess the diagnostic performance of its determination in distinguishing endometriomas from other benign ovarian cysts.

METHODS

Plasma urocortin was measured by radioimmunoassay in women with ovarian endometrioma (n=40) and in women with benign, nonendometriotic ovarian cysts (n=40). The diagnostic accuracy of urocortin measurement was evaluated by receiver operating characteristic curve and compared with the standard marker, CA 125. To support the local origin of the peptide, we also evaluated its localization in endometriomas by immunohistochemistry and its concentrations in cyst fluid and peritoneal fluid of 12 women with endometrioma.

RESULTS

Plasma urocortin levels were twice as high in women with endometrioma (median 49 pg/mL, interquartile range 41-63 pg/mL) than in the control group (19 [15-23] pg/mL, P<.001) and significantly higher in the cystic content of endometriomas than in the peritoneal fluid and plasma (P<.05). The peptide was immunolocalized in endometrioma glands and stromal capillary vessels. Elevated plasma urocortin levels detected 88% of the cases of endometrioma with 90% specificity, whereas CA 125 detected only 65% of the cases with the same specificity.

CONCLUSION

Plasma urocortin is increased in women with endometriomas, and its measurement may be useful for the differential diagnosis of endometrioma compared with other benign ovarian cysts.

LEVEL OF EVIDENCE

II.

GnRH agonist and antagonist protocols for stage I–II endometriosis and endometrioma in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To investigate the outcomes of intracytoplasmic sperm injection (ICSI) cycles after controlled ovarian hyperstimulation (COH) with GnRH antagonist or GnRH agonist (GnRH-a) in mild-to-moderate endometriosis and endometrioma.

DESIGN

Prospective randomize trial.

SETTING

A private IVF center.

PATIENT(S)

A total of 246 ICSI cycles in 246 patients were divided into three groups: women with mild-to-moderate endometriosis (n = 98); women who had ovarian surgery for endometrioma (n = 81); women with endometrioma and no history of previous surgery (n = 67).

INTERVENTION(S)

Patients in each group were randomized to COH with either triptrolein or cetrorelix.

MAIN OUTCOME MEASURE(S)

Clinical parameters, characteristics of COH, and ICSI results were analyzed.

RESULT(S)

Outcomes of COH with both GnRH antagonist and GnRH-a were similar in patients with mild-to-moderate endometriosis. Implantation rates were 15.9% vs. 22.6% and clinical pregnancy rates were 27.5% vs. 39% with GnRH antagonist and GnRH-a protocols, respectively, in patients who had ovarian surgery for endometrioma. Implantation rates were 12.5% vs. 14.8% and clinical pregnancy rates were 20.5% vs. 24.2% with GnRH antagonist and GnRH-a protocols, respectively, in patients with endometrioma and no history of ovarian surgery.

CONCLUSION(S)

Considering the implantation and clinical pregnancy rates, COH with both GnRH antagonist and GnRH-a protocols may be equally effective in patients with mild-to-moderate endometriosis and endometrioma who did and did not undergo ovarian surgery.

[Endometriosis imaging]

Pelvic endometriosis primarily affects the ovaries, pelvic peritoneum, utero-sacral ligaments, Douglas pouch, vagina, rectum and bladder. Clinical assessment is difficult, and imaging proves necessary to determine location and extent of the disease. We review pelvic endometriosis with regards to imaging modalities: technical considerations, imaging patterns, diagnostic performance and respective place of ultrasound and MRI.

Detection of endometriosis with the use of plasma protein profiling by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry

In this prospective case-control study, we determined the role of surface-enhanced laser desorption and ionization time-of-flight mass spectrometry in the detection of histologically proven endometriosis. In the plasma of the group with endometriosis, there were 20 different protein peaks, and the classifier showed a sensitivity of 87.5% and a specificity of 80% in the diagnosis of endometriosis.

Imaging in gynecology

This chapter summarizes the diagnostic performance (sensitivity, specificity, positive and negative likelihood ratios) of ultrasound, computer tomography, and magnetic resonance imaging in the diagnosis of various gynecological diseases and tumors. Positron emission tomography is not discussed. Imaging in infertility, in the diagnosis of Mullerian duct anomalies and in gynecological oncology (staging of gynecological cancers, diagnosis of recurrence of gynecological cancer, diagnosis of trophoblastic tumors) is not dealt with. Ultrasound is the first-line imaging method for discrimination between viable intrauterine pregnancy, miscarriage and tubal pregnancy in women with bleeding and/or pain in early pregnancy, for discrimination between benign and malignant adnexal masses and for making a specific diagnosis in adnexal tumors (e.g. dermoid cyst, endometrioma, hemorrhagic corpus luteum, etc.), for diagnosing intracavitary uterine pathology in women with bleeding problems, and for confirming or refuting pelvic pathology in women with pelvic pain. Magnetic resonance imaging can have a role as a secondary test in the diagnosis of adenomyosis, 'deep endometriosis' (e.g. endometriosis in the rectovaginal septum or in the uterosacral ligaments), and in the diagnosis of extremely rare types of ectopic pregnancy (e.g. in the spleen, liver or retroperitoneum).

Acoustic streaming in ovarian cysts

OBJECTIVE

The purpose of this study was to investigate the hypothesis that endometriomas do not show acoustic streaming and then to quantify the streaming velocity of the particles within ovarian cysts that do show acoustic streaming.

METHODS

Ovarian cysts greater than 2 cm in diameter, with internal echoes seen on B-mode sonography, were prospectively evaluated for the presence of acoustic streaming. If acoustic streaming was present, a 2-mm pulsed Doppler sample volume was then placed within the distal portion of the cyst, and the streaming velocity was recorded. Follow-up included review of subsequent sonographic examinations, surgical notes, and histopathologic reports, with the latter being considered the final results if available.

RESULTS

Acoustic streaming was detected in 10 (38%) of 26 ovarian cysts, but of the 10 endometriomas, none (0%) showed acoustic streaming (P = .002). Acoustic streaming was detected in 86% (n = 6) of cystadenomas. Four of these were serous cystadenomas, which all showed acoustic streaming, with a velocity range of 1.5 to 3.6 cm/s. Two mucinous cystadenomas showed acoustic streaming with velocities of 0.8 and 2.0 cm/s.

CONCLUSIONS

Endometriomas appear as cysts containing homogeneous, low-level, "ground glass" echoes on gray scale sonography. Other types of ovarian cysts can also have these appearances. Endometriomas do not show acoustic streaming. Cystadenomas may have streaming velocities within a defined range. Acoustic streaming assessment may therefore prove to be an additional useful tool in assessing ovarian cysts and in completely excluding endometrioma as a diagnosis if a cyst shows acoustic streaming.

Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis

OBJECTIVE

To determine the accuracy of transvaginal sonography (TVS) for the diagnosis of deep pelvic endometriosis.

METHODS

In a prospective study, 142 women with clinical signs of endometriosis underwent TVS followed by surgical and histopathological investigations. The presence and extent of endometriosis involving the uterosacral ligaments, vagina, rectovaginal septum, intestines, bladder and ovaries shown by TVS were compared with surgical and histological findings. The sensitivity, specificity, predictive values and accuracy of TVS for predicting deep pelvic endometriosis were assessed.

RESULTS

Ovarian and deep pelvic endometriosis were found by surgery and histology in respectively 83 (58.5%) and 79 (55.6%) of the 142 patients. The sensitivity, specificity, and positive and negative predictive values of TVS for the diagnosis of deep pelvic endometriosis were 78.5%, 95.2%, 95.4% and 77.9%, respectively. The sensitivity and specificity of TVS for endometriotic involvement of the uterosacral ligaments, vagina, rectovaginal septum and intestines were 70.6% and 95.9%, 29.4% and 100%, 28.6% and 99.3%, and 87.2% and 96.8%, respectively. The sensitivity and specificity of TVS for bladder involvement were 71.4% and 100%, respectively.

CONCLUSION

TVS accurately diagnoses intestinal and bladder endometriosis, but is less accurate for uterosacral, vaginal and rectovaginal septum involvement.

Diagnosis of endometriosis: pelvic endoscopy and imaging techniques

Although laparoscopy is the gold standard for the diagnosis of endometriosis, the need for this invasive diagnostic tool is a major stumbling-block in both effective clinical management and for research into this common and debilitating disease. As visual inspection of the pelvis has also major limitations, particularly for the diagnosis of posterior pelvis, bowel and bladder endometriosis, it is not surprising that considerable efforts are being made to improve the diagnosis by imaging techniques. Peritoneal endometriosis and ovarian endometriomata are predominantly haemorrhagic lesions. During laparoscopy, these lesions are readily identified by the presence of old or recent bleeding. Both transvaginal sonography and magnetic resonance (MR) imaging have a low sensitivity for the diagnosis of peritoneal and ovarian implants and adhesions. Transvaginal sonography is useful in the diagnosis of ovarian endometriomata, providing the diameter is larger than 2 cm. As transvaginal sonography costs less than MR imaging, transvaginal sonography might be the preferred method of confirming a sizeable endometrioma. Posterior pelvis endometriosis is an infiltrating adenomyotic lesion with microendometriomata. High-resolution transvaginal ultrasonography, and in particular MR imaging, are increasingly used to diagnose the presence and extent of infiltrating lesions and the involvement of rectosigmoid and ureters.

Use of morphology to characterize and manage common adnexal masses

The use of grey-scale ultrasound morphology to characterize a pelvic mass may also be called 'pattern recognition'. The grey-scale ultrasound image provides us with the same information as that obtained by the surgeon or pathologist when he or she cuts a surgical specimen to see what it looks like inside. Many pelvic masses have such a typical macroscopic appearance that a fairly confident diagnosis can be made on the basis of their macroscopic appearance alone, i.e. on the basis of their grey-scale ultrasound image. This is true of most dermoid cysts, endometriomas, corpus luteum cysts, hydrosalpinges and peritoneal pseudocysts, and of many paraovarian cysts and benign solid ovarian tumours, for example, fibromas, fibrothecomas, thecofibromas, thecomas and Brenner tumours. A mass with irregularities should always evoke suspicion of malignancy. A mass that is completely smooth is almost certainly benign. Papillary projections--considered a strong sign of malignancy--are more common in borderline tumours than in invasive cancers but may also be seen in benign tumours, for example, in adenofibromas. They explain many false-positive ultrasound diagnoses of malignancy. Pattern recognition is superior to all other ultrasound methods (e.g. simple classification systems, scoring systems, mathematical models for calculating the risk of malignancy) for discrimination between benign and malignant extrauterine pelvic masses. Today's often too liberal use of transvaginal ultrasound gives clinicians problems. Many adnexal masses that probably would have remained undetected before the ultrasound era are now found incidentally at transvaginal ultrasound examination in women without symptoms of an adnexal tumour. The natural history of incidentally detected pelvic masses with benign ultrasound morphology is not known. Therefore, the optimal management of such tumours is also unknown.

The diagnosis of functional ovarian cysts using transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler

OBJECTIVES

To investigate the role of transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler in the differentiation between functional cysts and other adnexal masses.

STUDY DESIGN

Two hundred and eighty-seven consecutive persistent adnexal masses were submitted to B-mode transvaginal ultrasonography associated with color and power Doppler imaging. Plasma CA125 concentrations were measured before surgery.

RESULTS

According to the obtained logistic regression equation, the presence of anechoic tumors without echogenic portions or septa and CA125 <25IU/ml was associated with a 75% probability of presence of follicular cysts. The visualization of fine trabecular jelly-like content or of a heterogeneous mass with hypoechoic content, absent or only peripheral arterial flow, and age <40 years was associated with a 56% probability of presence of luteal cysts.

CONCLUSIONS

Addition of findings to B-mode ultrasonography can help to differentiate functional cysts from other adnexal masses.

Staging of Pelvic Endometriosis: Role of Sonographic Appearance in Determining Extension of Disease and Modulating Surgical Approach

STUDY OBJECTIVE

To estimate whether laparoscopic staging of endometriosis can be predicted by ultrasound findings.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

One hundred twenty-one women with histologically confirmed sonographic diagnosis of endometriomas.

INTERVENTIONS

Ultrasonographic staging and laparoscopic assessment.

MEASUREMENTS AND MAIN RESULTS

All patients underwent transvaginal and/or transrectal sonographic evaluation of ovarian endometriomas and other sonographic markers (anatomic sites and their relation to abdominovaginal palpation, adhesions, deep or infiltrating nodules) to stage the disease before surgery. These results were compared with laparoscopic staging. Concordance between methods was 83.5%. Specificity and sensitivity of ultrasonographic staging of stages 3 and 4 disease were 86% and 82% and 76% and 91%, respectively.

CONCLUSION

Ultrasonographic findings can predict pelvic extension and stage of endometriosis.

Noninvasive diagnosis of endometriosis: the role of imaging and markers

Endometriosis is defined by the presence of endometrial tissue outside the uterus. Clinical and basic research in endometriosis has been hampered severely by the lack of accurate noninvasive diagnostic techniques. Transvaginal ultrasonography, MRI, and endometrial and serum markers have the potential to facilitate the diagnosis and can be useful in the follow-up of patients. Endometriosis research has entered the postgenomic era, and powerful genomic and proteomic technology is being applied in the search for novel diagnostic and therapeutic approaches. This article explores the recent advances in imaging techniques and the development of diagnostic molecular markers of endometriosis.

A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis

OBJECTIVE

To evaluate transvaginal and transabdominal ultrasound scanning, with or without Doppler, as a diagnostic test for the accurate diagnosis of pelvic endometriosis.

METHODS

The MEDLINE (1966-2001) and EMBASE (1980-2001) databases were searched for relevant studies, published in English. Only studies fulfilling predefined criteria were selected. An assessment of quality was made for each study, and data were then reanalyzed using likelihood ratios to determine the usefulness of the test.

RESULTS

In total, 67 papers were identified using the search strategy, of which 17 described relevant studies. Of these, seven fulfilled the inclusion criteria. All seven related to the use of transvaginal gray-scale imaging in the diagnosis of ovarian endometriomata specifically, rather than endometriosis. The positive likelihood ratios ranged from 7.6 to 29.8, and the negative likelihood ratios ranged from 0.1 to 0.4. Confidence intervals were wide. One paper addressed the use of conventional color Doppler with ultrasound: the positive likelihood ratio was 1.2, with a negative likelihood ratio of 0.4. One paper assessed the use of color Doppler energy imaging, and showed a positive likelihood ratio of 33.5 and a negative likelihood ratio of 0.1.

CONCLUSIONS

Transvaginal ultrasound appears to be a useful test both to make and to exclude the diagnosis of an ovarian endometrioma.

The characterization of common ovarian cysts in premenopausal women

OBJECTIVES

The evaluation of the predictive value of transvaginal ultrasound in the assessment of benign adnexal pathology in premenopausal women, based on the recognition of characteristic morphologic patterns particular to endometriotic and dermoid ovarian cysts.

METHODS

This was a prospective study. All premenopausal women undergoing surgery for a suspected ovarian cyst underwent a transvaginal ultrasound examination in the week prior to surgery. Between June 1997 and January 2000, 132 women underwent surgery for a suspected ovarian endometrioma or dermoid cyst. The endpoints were either the direct visualization of the cyst wall and contents at surgery, or the histologic evaluation of removed tissues.

RESULTS

Of 83 suspected endometriomas (11 bilateral), 80 were confirmed at surgery and of 68 suspected benign cystic teratomas (eight bilateral), 66 were confirmed by histology. The positive predictive value of transvaginal ultrasonography for the diagnosis of endometrioma and dermoid cysts was 96.4% and 97.1%, respectively. The false positive rates were 3.8% and 3.0%, respectively. There were no malignancies in either group.

CONCLUSIONS

Based on the recognition of characteristic ultrasound patterns alone, the positive predictive value of transvaginal ultrasonography for the diagnosis of these common, benign cysts in premenopausal women is very high and can be used reliably to select women for appropriate surgery.

Endometriomas: diagnostic performance of US

PURPOSE

To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated.

RESULTS

There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%).

CONCLUSION

An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.

Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven

AIM

To review the Leuven data on endometriosis to demonstrate the shifts that occurred over the years in diagnosis of endometriosis, classification of women with endometriosis and thus in interpretation of results.

RESULTS

The contributions to the LUF syndrome, to non-pigmented endometriosis, to cystic ovarian endometriosis, to deep endometriosis, to endometriosis as an immunologic disease and to the development of an animal model of endometriosis, illustrate the persistent interest in endometriosis over 20 years. Using these data it can be shown how progressively the recognition of endometriosis caused important shifts from women who in the beginning of this period were classified as normal, to women who later became classified as having minimal or mild endometriosis. This was caused initially by the active search for small typical lesions and later by the recognition of non-pigmented lesions as endometriosis. The second important shift was caused by the recognition that deep endometriosis is not only a frequent disease, but that these women are predominantly classified as having mild to moderate endometriosis and even as women without endometriosis. The third shift is still ongoing, since the deep lesions reported become progressively smaller, by the "enthusiasm" of the surgeons, and by the introduction of a menstrual clinical exam. A fourth bias in the literature concerns the diagnosis and treatment of cystic ovarian endometriosis. Together with these shifts in recognition and treatment of endometriosis, our understanding of the physiopathology of endometriosis has changed. This is illustrated by the new concepts which have emerged over this period. These are, the focal treatment of cystic ovarian endometriosis, the concept that mild endometriosis could be a normal physiological condition and the endometriotic disease theory.

CONCLUSION

To interpret the data of the literature we should be aware of the shifts that have occurred in the classification of endometriosis over the past 20 years, and which still can hamper the comparison of results between research groups.

Levels of antibodies to transferrin and alpha 2-HS glycoprotein in women with and without endometriosis

PROBLEM

To establish an enzyme-linked immunosorbent assay (ELISA) for determining the levels of antibodies to transferrin and alpha 2-HS glycoprotein in the serum of women with and without endometriosis.

METHOD OF STUDY

Serum samples were obtained from 105 normal women, who were randomly selected for a population-based epidemiologic study, and 123 patients with active endometriosis. An ELISA using transferrin and alpha 2-HS glycoprotein as antigens was established.

RESULTS

The levels of antibodies to transferrin and alpha 2-HS glycoprotein in the serum of patients with endometriosis were approximately 21 times higher than those in the serum of control subjects without endometriosis. Only 2% of control subjects had false positive levels of these antibodies, and 5% of patients with endometriosis had false negative levels of these antibodies (specificity, 98.1 and 98.1, respectively, for anti-transferrin and anti-alpha 2-HS glycoprotein; sensitivity, 95 and 96.7, respectively, for anti-transferrin and anti-alpha 2-HS glycoprotein).

CONCLUSIONS

Patients with endometriosis have significantly higher levels of antibodies to transferrin and alpha 2-HS glycoprotein than control subjects. Testing women for antibodies to transferrin and alpha 2-HS glycoprotein will provide a specific noninvasive diagnosis of endometriosis.

The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma

OBJECTIVE

To assess the diagnostic accuracy of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler in differentiating ovarian endometriomas from other nonendometriotic masses.

DESIGN

Prospective study with pathological confirmation of sonographic diagnosis.

SETTING

Department of Obstetrics and Gynecology at a university hospital.

PATIENT(S)

A series of 78 consecutive patients diagnosed as having an adnexal mass and scheduled for surgery, between January 1995 and March 1996.

INTERVENTION(S)

Transvaginal ultrasonography and color velocity imaging and pulsed Doppler was performed before surgery in all patients. A total of 82 masses were diagnosed (four patients had bilateral masses). CA-125 plasma levels were measured in all patients. Ultrasound diagnosis was compared with definitive histopathological diagnosis.

MAIN OUTCOME MEASURE(S)

The presence of a round-shaped homogeneous cyst with low-level echoes was considered as sonographic diagnosis of ovarian endometrioma. The typical vascular pattern from endometrioma was considered as "pericystic flow at the level of the ovarian hilius." The sensitivity, specificity, and positive and negative predictive values were calculated for transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler.

RESULT(S)

Twenty-seven (32.9%) of the 82 masses were proven to be ovarian endometriomas. Morphological assessment diagnosed correctly 24 (88.9%) of 27 endometriomas (false-positive rate: 9%). Typical flow pattern was present in 90.5% of endometriomas (false-positive rate: 80%). CA-125 levels in patients with endometrioma (45.6 +/- 6.3 U/mL; mean +/- SEM) were significantly higher than in patients with nonendometriotic masses (26.5 +/- 5.5 U/mL). The sensitivity, specificity, and positive and negative predictive values of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler were 88.9%, 91%, 84.2%, and 94.5%, and 76.2%, 88.9%, 82.4%, and 82.4%, respectively. For CA-125 levels, using a cutoff > or = 35 U/mL, these figures were 79.3%, 84.6%, 79.3%, and 84.6%, respectively.

CONCLUSION(S)

The use of color velocity imaging and pulsed Doppler does not improve the diagnostic accuracy of transvaginal ultrasonography alone in the diagnosis of ovarian endometrioma.