Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy

Connecting the dots: Exploring appendiceal endometriosis in women with diaphragmatic endometriosis

OBJECTIVES

This study aims to ascertain the prevalence of appendiceal endometriosis (AppE) in patients diagnosed with diaphragmatic endometriosis (DiaE), compare it with the prevalence in patients without DiaE, and delineate the anatomical distribution of endometriotic lesions within these cohorts.

STUDY DESIGN

Comparison of the characteristics of patients with AppE and DiaE with the characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A cohort of 1765 patients with histologically confirmed endometriosis INTERVENTIONS: Evaluation of correlations between demographic, clinical, and surgical variables of AppE patients with DiaE and without DiaE. We performed appendectomies selectively, in the presence of gross abnormalities of the appendix, such as endometriotic implants, edema, tortuosity, and discoloration of the organ.

MEASUREMENTS

Patients' characteristics were evaluated using basic descriptive statistics (chi-square test or Fisher's exact test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between patient characteristics and the presence of DiaE and AppE.

MAIN RESULTS

Within a cohort of 1765 patients with histologically confirmed endometriosis, 31 were identified with AppE (1.8 %), and 83 with DiaE (4.7 %). The prevalence of DiaE was significantly elevated at 30.1 % (25/83), among patients with AppE compared to those without AppE, who showed a DiaE prevalence of 7.2 % (6/83). The calculated odds ratio for DiaE given the presence of AppE was 5.5, 95 % CI 2.1-14.4, p = 0.0004, and risk ratio was 4.2, 95 % CI 1.8-9.6, p = 0.0008, indicating a profound association. Surgical interventions did not lead to significant perioperative or postoperative complications. In the group with DiaE, the left ovary was affected in 96 % of cases (24/25), p < 0.05, the right ureter in 80 % of cases (20/25), p < 0.01 (in 19/25 only the serosa was affected, due to external compression of an endometriotic nodule of the parametrium). Concurrent AppE and right diaphragm was found in 92 % of cases (23/25 patients), p < 0.001. The concurrent presence of DiaE and AppE was often associated with severe endometriosis, rASRM IV 72 % OR = 3, 95 % CI (1.216-7.872).

CONCLUSION

The investigation delineates a marked association between AppE and DiaE, with an odds ratio of 5.5 and risk ratio of 4.2, suggesting a markedly increased likelihood of DiaE in patients with AppE. These statistics significantly substantiate the notion that AppE can serve as a predictive marker for DiaE, underscoring the necessity for a meticulous intraoperative assessment of diaphragmatic regions in patients diagnosed with AppE. The absence of a significant correlation between the depth of DiaE infiltration and the presence of AppE implies that the detection of AppE should prompt a thorough search for DiaE, regardless of the perceived severity of the endometriosis or preoperative results of diaphragmatic MRI.

Tailoring radicality in diaphragmatic surgery for deep endometriosis: A matter of choice

Diaphragmatic endometriosis (DpE) is a rare disease localization which represents an important clinical challenge. The main criticisms toward the proper DpE management consist of poor consensus on both surgical indications and the choice between different surgical techniques available to treat the disease. Furthermore, only weak recommendations are provided by current guidelines and surgical management is mostly based on surgeon's experience. As consequence, the lack of standardization about the surgical treatment led to the risk of under- or over-treatments in patients suffering from this form of endometriosis. The latest evidence-based data suggest to adopt a lesion-oriented surgical approach serving as a guide in daily surgical activities, in order to ensure a tailored radicality and reduce the rate of surgery-related complications. Diaphragmatic endometriosis surgery should be performed only by expert surgeons with an extensive oncogynecologic expertise since it represents a technically demanding procedure. A multidisciplinary approach is also mandatory in order to adequately select and treat these patients by minimizing the risk of additional morbidity.

Robotic-assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients

STUDY OBJECTIVE

To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE).

DESIGN

Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database.

SETTING

Tertiary referral center. Endometriosis care center.

PATIENTS

Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023.

INTERVENTIONS

Robotic excision of severe DE.

MEASUREMENT AND MAIN RESULTS

Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery.

CONCLUSION

In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

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

RESEARCH QUESTION

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases

OBJECTIVE

The aim of this study was to investigate and present the clinical characteristics of diaphragm endometriosis, to approach the pathogenetic mechanisms, and to answer the question of whether this disease can be considered an extended form of pelvic endometriosis.

STUDY DESIGN

It was a retrospective comparative one-to-one analysis of 202 cases. Two groups of patients were compared: Group 1 patients with diaphragm endometriosis vs Group 2 (control group) with pelvis endometriosis, each with 101 patients.

RESULTS

Patients with diaphragm endometriosis had extreme significantly higher prevalence of severe pelvis endometriosis included deep infiltrated endometriosis and severe adhesions in term of complete Douglas obliteration (p value = 0.0001). There was neither age nor BMI difference in two groups. Besides of cyclic shoulder or upper abdomen pain there was no difference of symptoms.

CONCLUSION

Diaphragm endometriosis is a rare condition with an approximate prevalence of 1.1% of all endometriosis cases. Since the symptoms are very specific and patients do not associate the pain with diaphragmatic endometriosis, the symptoms should be asked about explicitly. If patients with diaphragmatic endometriosis have no symptoms, the lesions do not necessarily need to be removed. The pathogenesis is still unclear. The authors of this study consider this disease to be an extended form of severe pelvic and deep infiltrated endometriosis. However, the right-side dominance still cannot be explained. Further research is needed to fully understand the origin of diaphragmatic endometriosis.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

OBJECTIVE

The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria.

DESIGN

A diagnostic accuracy study was employed based on a prospective observational design.

PARTICIPANTS

All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered.

SETTING

The study was conducted at endometriosis referral hospitals.

METHODS

We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard.

RESULTS

In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively.

LIMITATIONS

The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives.

CONCLUSIONS

TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Prospective diagnostic test accuracy of transvaginal ultrasound posterior approach for uterosacral ligament and torus uterinus deep endometriosis

OBJECTIVE

To determine the diagnostic test accuracy of transvaginal ultrasound (TVS) using a standardized technique for the diagnosis of deep endometriosis (DE) of the uterosacral ligaments (USLs) and adjacent torus uterinus (TU).

METHODS

This was a prospective diagnostic test accuracy study conducted at the McMaster University Medical Center Tertiary Endometriosis Clinic, Hamilton, ON, Canada. Consecutive participants were enrolled if they successfully underwent TVS and surgery by our team from 10 August 2020 to 31 October 2021. The index test was TVS using a standardized posterior approach performed and interpreted by an expert sonologist. The reference standard included direct surgical visualization on laparoscopy by the same person who performed and interpreted the ultrasound scans. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios were calculated for the TVS posterior approach for each location using the reference standard.

RESULTS

There were 54 consecutive participants included upon completion of laparoscopy and histological assessment. The prevalence of DE for the left USL, right USL and TU was 42.6%, 22.2% and 14.8%, respectively. Based on surgical visualization as the reference standard, TVS demonstrated an accuracy of 92.6% (95% CI, 82.1-97.9%), sensitivity of 82.6% (95% CI, 61.2-95.1%), specificity of 100% (95% CI, 88.8-100%), PPV of 100% and NPV of 88.6% (95% CI, 76.1-95.0%) for diagnosing DE in the left USL. For DE of the right USL, TVS demonstrated an accuracy of 94.4% (95% CI, 84.6-98.8%), sensitivity of 75.0% (95% CI, 42.8-94.5%), specificity of 100% (95% CI, 91.6-100%), PPV of 100% and NPV of 93.3% (95% CI, 84.0-97.4%). For DE of the TU, TVS demonstrated an accuracy of 100% (95% CI, 93.4-100%), sensitivity of 100% (95% CI, 63.1-100%), specificity of 100% (95% CI, 92.3-100%), PPV of 100% and NPV of 100%.

CONCLUSIONS

We observed high diagnostic test accuracy of the evaluated standardized TVS technique for assessing DE of the USLs and TU. Further studies evaluating this technique should be performed, particularly with less experienced observers, before considering this technique as the standard approach. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The appendix in endometriosis

BACKGROUND

In the most severe stage of endometriosis, Stage IV, intestinal involvement is common. The true prevalence of endometriotic disease of the appendix in this population is not well described. A macroscopically normal looking appendix may harbour endometriosis.

AIMS

Our study aims to assess the role of routinely performing appendicectomy in Stage IV endometriosis surgery, and the histopathological prevalence of true appendiceal endometriosis in this population.

METHODS

This is a retrospective study of women undergoing surgery for Stage IV endometriosis between 2018 to 2022 in a tertiary public hospital in New South Wales, Australia. Patient demographics, age and post-operative complications were retrospectively retrieved from hospital medical records. Inclusion criteria were women with Stage IV endometriosis who underwent routine appendicectomy as part of their endometriosis surgery. Exclusion criteria were women who did not have Stage IV endometriosis, those who had cancer surgery or emergency surgery for endometriosis. The primary outcome of this study was to determine the incidence of appendiceal endometriosis. Secondary outcomes included post-operative complications and length of stay.

RESULTS

Sixty-seven patients were included. The mean age was 36 years. All patients also underwent bowel resection for colorectal endometriosis. There were 35.8% who had confirmed appendiceal endometriosis on histopathology. Post-operative complications included port site infections, colitis, urinary tract infection and ureteric injury. There were no complications related to appendicectomy. Mean length of stay was 4.4 days.

CONCLUSION

Laparoscopic appendicectomy can be safely performed at time of laparoscopic surgical excision of Stage IV endometriosis and should be routinely considered in a subset of Stage IV endometriosis patients with colorectal involvement undergoing surgery.

True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation

STUDY OBJECTIVE

To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE).

DESIGN

Comparison of characteristics of patients with diaphragmatic endometriosis (DE) with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A total of 1372 patients with histologically proven endometriosis.

INTERVENTIONS

Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the χ2 test and the Mann-Whitney t test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65 of 1372). There was no significant difference between the 2 groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often preoperatively (27.7% vs 1.8%, p <.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (revised American Fertility Society III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p <.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p <.05).

CONCLUSION

Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.

Primary high-grade serous cancer arising from uterosacral ligament endometriosis: two case reports

Although high-grade serous cancer (HGSC) accounts for >70% of ovarian epithelial cancers, it is rarely associated with endometriosis. No previous study has reported an association between the malignant transformation of uterine ligament endometriosis and HGSC. Here, we reported two cases of Chinese female patients with HGSC arising from endometriosis in the uterosacral ligament. They had a long-term history of endometriosis and dysmenorrhea. Both were diagnosed with HGSC at stage IIB. They underwent operations and six cycles of chemotherapy with paclitaxel and carboplatin and have remained disease-free to date. Genomic analysis showed no known/suspected pathogenic variations or somatic homologous recombination deficiency in the two cases. In conclusion, these rare cases of HGSC from endometriosis might indicate a new origin of ovarian type II carcinoma. Patients with a long-term history of endometriosis and sudden aggravation of dysmenorrhea or vaginal bleeding should be aware of the possibility of endometriotic malignant transformation.

Distribution of tubal endometriosis: A 10-year retrospective study

AIM

To investigate the distribution of tubal endometriosis (EM) in the right and left sides and four parts of the fallopian tube.

METHODS

A retrospective, cross-sectional study was conducted on patients with tubal EM at the Fourth Affiliated Hospital of Guangxi Medical University from October 2011 to September 2021. Chi-square and binomial tests were used for analysis.

RESULTS

Thirty-four patients (53.97%) had tubal resection due to EM (EM group). Twenty-nine patients (46.03%) had tubal resection due to non-EM (non-EM group). Thirty-two patients (50.80%) had left fallopian tube EM, 21 (33.33%) had right fallopian tube EM, and 10 (15.87%) had bilateral fallopian tube EM, with significant differences among them (p = 0.000). In the EM group, 15 patients (44.12%) had left fallopian tube EM, 13 (38.23%) had right fallopian tube EM, and 6 (17.65%) had bilateral fallopian tube EM (p = 0.052). In the non-EM group, statistically different (p = 0.001) diagnoses of left fallopian tube EM, right fallopian tube EM, and bilateral fallopian tube EM were 17 (58.62%), 8 (27.59%), and 4 (13.79%), respectively. In the EM group, 18 patients (52.94%) were in the ampullary region; 16 (47.06%) were in the nonampullary region (p = 0.864). In the non-EM group, 22 cases (75.86%) were in the ampullary region and 7 (24.14%) were in the nonampullary region, with a significant difference between them (p = 0.008).

CONCLUSIONS

The incidence of left fallopian tube EM was higher than that of right and bilateral fallopian tube EM. The incidence of tubal ampullary EM was higher than that of nonampullary region.

Tubal Endometriosis: From Bench to Bedside, A Scoping Review

Tubal endometriosis (EM) refers to the detection of ectopic endometrial implants on tubes. It may cause a significant defect of the tubes, translating into dysmenorrhea, pelvic pain, and infertility. We aimed to evaluate the disease characteristics, prevalence, histopathological findings and genetic profile of patients with tubal EM. A thorough search of three electronic databases was performed for studies that presented outcomes of patients with tubal EM. Thirteen studies (four observational, seven case reports, two genetic) were considered eligible for inclusion. The prevalence of tubal EM ranged from 6.9% to 69%. The predominant symptoms for referral of patients were infertility and abdominal pain. Women of reproductive age underwent salpingectomy for the management of the disease. Only one case of malignant transformation was recorded in a 60-year-old patient. The prevalence of tubal EM ranges depending on the indication for surgery, the presence of concomitant pelvic EM and the type of diagnosis and treatment. Further, more extensive, larger studies are warranted to evaluate the impact of tubal EM in the progression and prognosis of EM, the effect of salpingectomy in the improvement of disease-related symptoms and to designate the group of patients that could benefit from risk-reducing salpingectomy based on the risk of developing ovarian malignancy.

Preservation of the inferior mesenteric artery in laparoscopic nerve-sparing colorectal surgery for endometriosis

Laparoscopic rectosigmoid resection for endometriosis is usually performed with the section of the inferior mesenteric artery (IMA) distal to the left colic artery (low-tie ligation). This study was to determine outcomes in IMA-sparing surgery in endometriosis cases. A single-center retrospective study based on the analysis of clinical notes of women who underwent laparoscopic rectosigmoid segmental resection and IMA-sparing surgery for deep infiltrating endometriosis with bowel involvement between March the 1st, 2018 and February the 29th, 2020 in a referral hospital. During the study period, 1497 patients had major gynecological surgery in our referral center, of whom 253 (17%) for endometriosis. Of the 100 patients (39%) who had bowel endometriosis, 56 underwent laparoscopic nerve-sparing rectosigmoid segmental resection and IMA-sparing surgery was performed in 53 cases (95%). Short-term complications occurred in 4 cases (7%) without any case of anastomotic leak. Preservation of the IMA in colorectal surgery for endometriosis is feasible, safe and enables a tension-free anastomosis without an increase of postoperative complication rates.

Role of ultrasonographic parameters for predicting tubal involvement in infertile patients affected by endometriosis: A retrospective cohort study

INTRODUCTION

Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging criteria have been clearly described for different organs study. However, no specific ultrasonographic signs of tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental, therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to analyze ultrasonographic signs useful for detection of this condition.

MATERIAL AND METHODS

It is a single-center, retrospective cohort study. All 500 consecutive infertile women who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included transvaginal ultrasound and was compared to intraoperative findings and histologic study.

RESULTS

The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasonographic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI, 5-23%) and 99% (95%CI, 98-100%), respectively. If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was considered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85-98%), 97% (95%IC, 93-99%) and 31% (95%CI, 27-36%), respectively.

DISCUSSION

Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensitivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers such as endometrioma and/or periadnexal adhesions.

Mapping of endometriosis in patients with unilateral endometrioma

To map the distribution of the sites most affected by endometriosis in patients with unilateral ovarian endometriomas.A descriptive case series of 84 patients with unilateral endometriomas undergoing laparoscopy for the treatment of endometriosis. To evaluate the distribution of the sites of endometriosis lesions, the peritoneal compartments were divided into 5 zones: zone 1/the anterior compartment, including the anterior uterine serosa, vesicouterine fold, round ligament, and bladder; zone 2/the lateral compartment, including the left and right ovary, ovarian fossa, tubes, mesosalpinx, uterosacral ligaments, parametrium, and the ureter; zone 3/the posterior compartment, including posterior uterine serosa, the pouch of Douglas, posterior vaginal fornix, and bowel; zone 4 consisting of the abdominal wall; and zone 5 consisting of the diaphragm.Of the 5 zones evaluated, the lateral compartment (zone 2) was the most affected, with 60.7% of the patients having dense adhesions around the left ovarian fossa and 57.1% around the right ovarian fossa. The ovarian endometriomas were more commonly found on the left side (54.8%) compared to the right (45.2%). In the posterior compartment (zone 3), the posterior cul-de-sac was obliterated in 51.2% of the patients. In the anterior compartment (zone 1), there were lesions in the vesicouterine fold in 30.9% of the patients and in the bladder in 19%. Lesions were found in the abdominal wall (zone 4) and diaphragm (zone 5) in 21.4% and 10.7% of patients, respectively.Unilateral endometriomas are important markers of the severity of endometriosis.

Intraoperative Ultrasound for Bowel Deep Infiltrating Endometriosis: A Preliminary Report

The decision to perform either conservative surgery or segmental bowel resection for bowel deep infiltrating endometriosis (DIE) is made intraoperatively, after a preoperative assessment, based on the nodule's features. We introduce a technique to evaluate DIE bowel nodules using laparoscopic intraoperative ultrasound (US) during laparoscopic radical treatment of 9 cases of DIE invading the bowel. Once the bowel lesion was isolated, an intraoperative 12-4-MHz US transducer was placed on the surface of the nodules to study their US features and to gain measurements. Deep infiltrating endometriosis nodules appear at intraoperative US as hypoechoic elliptical lesions with a clear definition of margins and the depth of infiltration of the rectal wall.

Clinical characteristics of urinary tract endometriosis: A one-year national series of 232 patients from 31 endometriosis expert centers (by the FRIENDS group)

OBJECTIVE

To review prospectively the clinical characteristics of patients suffering from urinary tract endometriosis (UTE) in France, in 2017.

STUDY DESIGN

We conducted a prospective observational multicenter study including women managed surgically for UTE in 31 French endometriosis expert centers (FRIENDS group) from January 1, 2017 to December 31, 2017. We distinguished patient with isolated bladder endometriosis ("IBE") or isolated ureteral endometriosis ("IUE") and patients associating both locations (mixed locations "ML"). Surgeons belonging to FRIENDS group enrolled patients by filling a 24 items questionnaire the day of the surgery and 6 weeks later. Data on the locations of UTE, preoperative assessment, urinary symptoms and associated pelvic locations were collected in a single anonymized database.

RESULTS

A total of 232 patients from 31 centers were included. IBE concerned 82 patients (35.3%), IUE 126 patients (54.4%) ML 24 patients (10.3%). 111 patients reported urinary symptoms (47.8%). IUE was more often asymptomatic than the rest of the locations (59.5% versus 43.3%, OR 1,92, p = 0.017). Associated deep infiltrating endometriosis (DIE) lesions were found in 193 patients (83.1%). IUE was significantly associated with other DIE lesions (82.5% versus 66%, OR2.4, p = 0.006), particularly with rectum or sigmoid nodules (57.1% versus 36.8%, OR 2.3, p = 0.002) and retrocervical space nodules (31.7% versus 19.8%, OR 1.9, p = 0.05).

CONCLUSION

Our study reports the second largest series of patients operated from a UTE and shows that ureteral location seems more frequent, less symptomatic and more frequently associated to other DIE locations than bladder endometriosis.

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group)

STUDY OBJECTIVE

To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017.

DESIGN

Multicenter retrospective cohort pilot study.

SETTING

Departments of gynecology at 31 expert endometriosis centers.

PATIENTS

All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]).

INTERVENTIONS

Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database.

MEASUREMENTS AND MAIN RESULTS

A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis).

CONCLUSION

The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study

INTRODUCTION

Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed.

METHODS

We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE.

RESULTS

50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients.

CONCLUSION

The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Ultrasound Imaging of Abdominal Wall Endometriosis: A Pictorial Review

Endometriosis is a debilitating disease characterized by endometrial glands and stroma outside the endometrial cavity. Abdominal wall endometriosis (AWE) indicates the presence of ectopic endometrium between the peritoneum and the skin, including subcutaneous adipose tissue and muscle layers, often following obstetric and gynecological surgical procedures. AWE is a not infrequent gynecological surgical complication, due to the increasing number of cesarean sections worldwide. In this pictorial review, we discuss the importance of medical history and physical examination, including the main ultrasound features in the diagnosis of AWE.

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery

Ultrasound is an effective tool to detect and characterize lesions of the uterosacral ligament, parametrium, and paracervix. They may be the site of diseases such as endometriosis and the later stages of cervical cancer. Endometriosis and advanced stages of cervical cancer may infiltrate the parametrium and may also involve the ureter, resulting in a more complex surgery. New functional, surgical anatomy requires the complete diagnostic description of retroperitoneal spaces and tissues that contain vessels and nerves. Most endometriosis lesions and cervical cancer spread involve the cervical section of the uterosacral ligament, which is close to tissues, namely the parametrium and paracervix, which contain vessels and important nerves and nerve anastomoses of the inferior hypogastric plexus. Efferent fibers of the plexus travel to the rectum, uterus, rectovaginal ligament, deep vesicouterine ligament, and bladder. These efferent fibers are essential for bladder and rectal functionality so tailored nerve-sparing surgery became a standard approach for treating deep infiltrating endometriosis and cervical cancer. An accurate diagnosis by ultrasound has significant clinical impact and is important for appropriate treatment. In this article, we try to establish a common terminology between imaging diagnostic and modern surgical anatomy.

Kallistatin Inhibits Anoikis Resistance and Metastasis of Ectopic Endometrium Cells by Modulating MnSOD and Caspase 3 Signaling

Endometriosis (EM) is a disease that involves active endometrial cell invasion and migration which is an important reason for infertility. Anoikis resistance is the most important prerequisite for EM, but the molecular mechanism is not yet clear. Kallistatin (KS) is one kind of serine protease inhibitors which had extensive biological function including anti-inflammatory, antioxidant stress, anti-angiogenesis, and anti-tumor. Our preliminary data showed that the level of KS in EM patients' endometrial tissue and blood were much lower than control (non-EM) patients without endometriosis. Interestingly, the decrease of KS is correlated with the severity of endometriosis. Moreover, kallistatin recombinant protein could increase the anoikis rate of ectopic endometrium cells (EESCs), and then inhibits its metastasis and invasion. Mechanically, our data show that the EESCs have lower intracellular reactive oxygen species (ROS) production and KS can elevate the ROS levels significantly. Further, KS modulate expression of MnSOD and caspase 3 signaling in EESCs grown in suspended conditions. These findings reveal novel mechanisms of KS in inducing anoikis and metastasis in EESCs, thus inhibiting EM progression by regulation of MnSOD and caspase 3 signaling. Our findings suggest that KS is a significant protein with prospects for application in EM.

Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center's experience on 215 patients

BACKGROUND

Diaphragmatic endometriosis (DE) is a rare and often misdiagnosed condition. Most of the times it is asymptomatic and due to the low accuracy of diagnostic tests, it is almost always detected during surgery for pelvic endometriosis. Its management is challenging and, until now, there are not guidelines about its treatment.

METHODS

We describe a consecutive series of patients with DE managed by laparoscopy and videothoracoscopy (VATS) in our referral center in a period of 15 years. We developed a flow-chart classifying DE implants in foci, plaques and nodules and proposing an algorithm with the aim of standardizing the surgical approach.

RESULTS

215 patients were treated for DE. Lesions were almost always localized on the right hemidiaphragm (91%), and the endometriotic implants were distributed as: foci in 133 (62%), plaques in 24 (11%) and nodules in 58 patients (27%), respectively. In all cases of isolated pleural involvement, concomitant diaphragmatic hernia or lesions of the thoracic side of the diaphragm VATS was performed, alone or combined with laparoscopy, resulting in a total of 26 procedures. Following the proposed algorithm, specific surgical techniques were identified as the better approaches for the different types of the lesion, such as Argon Beam Coagulation and diathermocoagulation for diaphragmatic foci, peritoneal stripping for plaques, and nodulectomy or full-thickness resection of diaphragm for nodules.

CONCLUSIONS

It is crucial to standardize the surgical approach of DE, according to the type of lesion, thus reducing the rate of under- or over-treatments and intra or postoperative complications. This kind of surgery should be performed in a Referral Center by a gynecologic surgeon with oncogynecologic expertise and skills, with the eventual support of a laparoscopic general surgeon, a specialized thoracic surgeon and a trained anesthesiologist.

Ultrasound Differential Diagnosis in Deep Infiltrating Endometriosis of the Urinary Tract

Endometriosis of the urinary tract is a rare condition that may lead to severe complications. At present, the major challenge appears to be the ultrasound differential diagnosis with diseases that can afflict the ureter and the bladder. Preoperative scan findings were compared with surgical and histologic records. Twenty-three cases were selected as being of interest, as they were referred for suspected endometriosis, whereas second-level ultrasound revealed a different disease in some cases. This case series aims to help in becoming familiar with the possible differential diagnosis of lesions of the urinary tract that resemble endometriosis.

Differential Diagnosis of Endometriosis by Ultrasound: A Rising Challenge

Ultrasound is an effective tool to detect and characterize endometriosis lesions. Variances in endometriosis lesions' appearance and distorted anatomy secondary to adhesions and fibrosis present as major difficulties during the complete sonographic evaluation of pelvic endometriosis. Currently, differential diagnosis of endometriosis to distinguish it from other diseases represents the hardest challenge and affects subsequent treatment. Several gynecological and non-gynecological conditions can mimic deep-infiltrating endometriosis. For example, abdominopelvic endometriosis may present as atypical lesions by ultrasound. Here, we present an overview of benign and malignant diseases that may resemble endometriosis of the internal genitalia, bowels, bladder, ureter, peritoneum, retroperitoneum, as well as less common locations. An accurate diagnosis of endometriosis has significant clinical impact and is important for appropriate treatment.

Serum macrophage migration inhibition factor for diagnosing endometriosis and its severity: case-control study

Background

Endometriosis is a long-standing progressive disease that affects women of reproductive age. Macrophage migration inhibitory factor (MIF) is one of non-invasive blood biomarker that was detected in sera of endometriotic patients. The present study aimed to determine the accuracy of serum MIF in diagnosing endometriosis in women with infertility and chronic pelvic pain, and correlate its level to the stage of the disease.

Methods

Observational case-control study conducted at Fayoum University hospital from March 2016 till September 2018. Three hundred women candidate for diagnostic laparoscopy for either infertility or gynecologic chronic pelvic pain were included. The study group included patients with symptoms suggestive of endometriosis or chocolate cyst by ultrasound and proved by laparoscopy and histopathology. The control group included other causes of infertility or pelvic pain. All patients undergone either diagnostic or operative laparoscopy, and before laparoscopy blood sampling for quantitative measurement of macrophage migration inhibitory factor (MIF) protein in serum by ELISA technique.

Results

The level of serum MIF was significantly higher in endometriosis group compared to control group (1.75 ± 1.48 pg/ml and 0.51 ± 0.45 pg/ ml, respectively, P = < 0.001), with a progressive increase with advancing stage (stage I, 1.3 ± 1.03 pg/ml, stage II, 1.7 ± 1.57 pg/ml, stage III, 2.1 ± 1.19 pg/ml and in stage IV, 3.2 ± 2.6 pg/ml). Moreover, in patients presented with pain and infertile patients showed significantly higher levels of serum MIF (1.92 ± 1.13 vs 1.21 ± 1.17 and 1.82 ± 1.13 vs 1.32 ± 0.91 respectively with p-value < 0.001). ROC curve of serum MIF with a cut off value of 0.85 pg/ml or more achieves a sensitivity of 80.6%, specificity of 83.3%, positive predictive value of 82.9% and negative predictive value of 81.2%.

Conclusion

Serum MIF might be a promising marker not only for noninvasive diagnosis of endometriosis but as a target for detecting severity as well.

Fallopian tube endometriosis in women undergoing operative video laparoscopy and its clinical implications

OBJECTIVE

To determine the incidence of fallopian tube endometriosis in patients undergoing laparoscopic surgery with a preoperative diagnosis of endometriosis, pelvic pain, infertility, or cystic adnexal mass.

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecologic oncology and minimally invasive surgery practice.

PATIENT(S)

All patients who underwent surgery for endometriosis from July 2015 to June 2018 were included. Exclusion criteria were age ≥55 years, diagnosis of cancer, laparotomy, previous bilateral salpingectomy, and preoperative diagnosis other than endometriosis, pelvic pain, infertility, or cystic adnexal mass.

INTERVENTION(S)

Subjects were divided by those who did and those who did not have a salpingectomy at the time of surgery.

MAIN OUTCOME MEASURE(S)

Diagnosis of tubal endometriosis was based on macroscopic evidence of endometrial implants on the fallopian tube(s) noted within the operative report and microscopic evidence of endometriosis noted within the pathology report.

RESULT(S)

A total of 444 surgeries were performed and 185 met the study criteria. Among those, 153 (82.7%) had histologically diagnosed endometriosis within the abdominopelvic cavity. The incidence of tubal endometriosis was 11%-12% macroscopically and 42.5% microscopically after salpingectomy. Patients with tubal endometriosis were more likely to have severe disease.

CONCLUSION(S)

Among patients with endometriosis, the incidence of microscopic tubal endometriosis was significantly greater than that of macroscopic disease.

Epithelial-Mesenchymal Transition in Endometriosis-When Does It Happen?

Epithelial-mesenchymal transition (EMT) is an important process of cell remodeling characterized by the gradual loss of the epithelial phenotype and progressive gain of a mesenchymal phenotype. EMT is not an all-or-nothing process, but instead a transition of epithelial to mesenchymal cells with intermediate cell states. Recently, EMT was described in endometriosis, and many EMT-specific pathways like Twist, Snail, Slug, Zinc finger E-box-binding homeobox 1/2 (ZEB1/2), E/N-cadherin, keratins, and claudins are involved. However, as pointed out in this review, a comparison of the eutopic endometrium of women with and without endometriosis yielded only subtle changes of these EMT markers. Furthermore, only very few alterations in cell-cell contacts could be found but without changes in the epithelial phenotype. This suggests only a partial EMT which is not a prerequisite for the detachment of endometrial cells and, thus, not critical for the first step(s) in the pathogenesis of endometriosis. In contrast, the majority of changes in the EMT-related marker expression were found in the ectopic endometrium, especially in the three endometriotic entities, ovarian, peritoneal, and deep infiltrating endometriosis (DIE), compared with the eutopic endometrium. In this review, we examine the most important EMT pathways described in endometriosis and propose that partial EMT might result from the interaction of endometrial implants with their surrounding microenvironment.

Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach

The present review aims to analyse the current data available on the feasibility, safety and effectiveness of the minimally invasive surgical (MIS) treatment of diaphragmatic endometriosis (DE). Through the use of PubMed and Google Scholar database, we conducted a literature review of all available research related to diagnosis and treatment of DE, focussed on the minimally invasive techniques. The studies were selected independently by two authors according to the aim of this review. DE is an under-diagnosed disease affecting between 0.1% and 1.5% of fertile women. It is predominantly multiple, asymptomatic and highly associated with pelvic disease in about 50-90%. MIS techniques seems to be safe, effective and feasible in tertiary advanced endometriosis centre, offering definitive advantages in terms of hospital stay, post-operative pain and return to normal activity by using several surgical techniques as hydro-dissection plus resection, laser CO₂ vaporisation, electrical fulguration, Sugarbaker peritonectomy, partial (shaving) and full-thickness diaphragmatic resection. Symptoms control range from 85% to 100%, with less than 3% of conversion, peri-operative complications and recurrence rate. All cases must be performed by multidisciplinary teams including at least a gynaecologist, thoracic surgeon and anaesthetist. The lack of prospective evaluation of DE interferes with the understanding about the natural history of disease and treatment results. Therefore, the development of adequate evidence-based recommendations about diagnosis, management and follow-up is difficult at this moment.

Imaging Modalities for Diagnosis of Deep Pelvic Endometriosis: Comparison between Trans-Vaginal Sonography, Rectal Endoscopy Sonography and Magnetic Resonance Imaging. A Head-to-Head Meta-Analysis

OBJECTIVES

A meta-analysis, with a head-to-head approach, was carried out to compare the three most common techniques for a deep pelvic endometriosis (DPE) diagnosis. We focused on: transvaginal-sonography (TVS), magnetic-resonance imaging (MRI), and rectal-endoscopy-sonography (RES).

METHODS

Electronic databases were searched from their inception until December 2018. All prospective and well-defined retrospective studies carried out in tertiary referral centers were considered. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesizing Evidence from Diagnostic Accuracy Tests (SEDATE) guidelines. We considered only papers in which at least two imaging modalities were compared in the same set of patients (head-to-head approach). Meta-analysis of diagnostic test accuracy (DTA) was performed separately for each location of interest. Bivariate or univariate approach has been applied when appropriate. We analyze the DTA of TVS vs. MRI, TVS vs. RES, and MRI vs. RES.

RESULTS

Our meta-analysis (17 studies included) showed high-to-moderate DTA of TVS for all endometriosis locations (apart from recto-vaginal septum (RVS)) that were not statistically different from MRI and RES for those localized in the posterior compartment. RES results were more accurate than MRI for RS lesions but less accurate than TVS for other pelvic locations, except for RVS.

CONCLUSIONS

All approaches provide good accuracy with specific strong points. Ultrasonography demonstrated a diagnostic accuracy not inferior to MRI and RES; therefore, it must be considered the primary approach for DPE diagnosis. MRI has to be considered as a valuable approach in settings where highly skilled sonographers are not available. Keypoints: (1) We confirmed the non-inferiority of TVS compared to MRI and RES for the diagnosis of specific pelvic anatomic location of endometriosis lesions. (2) Ultrasonography could be considered the primary approach for DPE diagnosis (less invasive than RES and less expensive than MRI). (3) MRI has to be considered as a valuable approach in settings where skilled sonographers are not available.

Dye diffusion during laparoscopic tubal patency tests may suggest a lymphatic contribution to dissemination in endometriosis: A prospective, observational study

AIM

Women with adenomyosis are at higher risk of endometriosis recurrence after surgery. This study was to assess if the lymphatic vessel network drained from the uterus to near organs where endometriosis foci lied.

METHODS

A prospective, observational study, Canadian Task Force Classification II-2, was conducted at Sacro Cuore Don Calabria Hospital, Negrar, Italy. 104 white women aged 18-43 years were enrolled consecutively for this study. All patients underwent laparoscopy for endometriosis and a tubal dye test was carried out.

RESULTS

Evidence of dye dissemination through the uterine wall and outside the uterus was noted in 27 patients (26%) with adenomyosis as it permeated the uterine wall and a clear passage of the dye was shown in the pelvic lymphatic vessels regardless whether the tubes were unobstructed. Histological assessment of the uterine biopsies confirmed adenomyosis.

CONCLUSION

Adenomyosis is characterized by ectatic lymphatics that allow the drainage of intrauterine fluids (the dye and, perhaps, menstrual blood) at minimal intrauterine pressure from the uterine cavity though the lymphatic network to extrauterine organs. Certainly, this may not be the only explanation for endometriosis dissemination but the correlation between the routes of the dye drainage and location of endometriosis foci is highly suggestive.

Sonographic Differential Diagnosis in Deep Infiltrating Endometriosis: The Bowel

Up to one-third of fertile-age women with severe endometriosis suffer from colonic involvement. Transvaginal ultrasonography has become a first-line diagnostic tool for the study of the pelvis and more specifically for the diagnosis of pelvic endometriosis. Accuracy of pelvic ultrasound for deep endometriosis increases with operator experience, but the difficulties in the differential diagnosis with diseases that can afflict the bowel tract remain a challenge. We reviewed noteworthy cases referred for secondary level diagnosis suspected of bowel endometriosis in which the subsequent ultrasound led to an alternative diagnosis. This case series aims to highlight awareness for both experts and less-experienced operators the possible differential diagnoses of bowel lesions that initially resemble endometriosis.

Magnetic Resonance Colonography May Predict the Need for Bowel Resection in Colorectal Endometriosis

Purpose

To define if MRI findings in patients with deep pelvic endometriosis (DPE) may be predictive for the need of bowel resection.

Material and Methods

A retrospective survey of 196 pelvic MRIs of women who received laparoscopic procedures for DPE was carried out. A pelvic MRI was performed in all patients: it consisted in T2w-TSE sequences in axial, sagittal, and coronal planes and T1w and THRIVE sequences in the axial plane; the exam was completed by MR-Colonography. Intestinal lesions were measured in short and long axis and the degree of stenosis was established. A multivariate logistic regression was used to identify the predictors of intestinal resection.

Results

57/196 patients received an intestinal resection. Multivariate logistic regression demonstrated a predictive value of short axis (Odds-Ratio = 2.29, p = 0.011) and stenosis (Odds-Ratio = 1.20, p = 0.003). ROC analysis showed that a cut-off value of 11 mm for the short axis and 30% for the stenosis may correctly classify, respectively, 96,94% (sensitivity 92,9% and specificity 98,56%) and 97,96% (sensitivity 94,74% and specificity 99,3%) of the cases.

Conclusion

The presence of an endometriotic rectal nodule > 11 mm in short axis causing a stenosis > 30% in pelvic MRI reliably predicts the need of a rectal resection.

Adnexal masses associated with peritoneal involvement: diagnosis with CT and MRI

Given the unique intra-peritoneal anatomic location of the adnexa, tubo-ovarian diseases can commonly spread into the peritoneal cavity. Peritoneal seeding may occur in a spectrum of adnexal conditions including infectious diseases, endometriosis, and benign or malignant primary or secondary ovarian tumors. CT is usually the imaging modality on which the concomitant involvement of the peritoneum and the ovary is depicted. The first diagnosis to be considered by the radiologist is generally peritoneal carcinomatosis from ovarian cancer but other conditions cited above have also to be borne in mind and may be suggested on the basis of careful assessment of CT findings or on further MR findings. MRI may indeed help characterize the lesions in some cases. The purpose of this review is to describe the clinical and imaging patterns of peritoneal involvement that may be found in association with different ovarian lesions. Familiarity with these patterns and diagnoses will help the radiologist narrow the differential diagnosis and make an accurate diagnosis, thus facilitating patient management and avoiding unnecessary invasive treatment.

MR diagnosis of diaphragmatic endometriosis

PURPOSE

To evaluate magnetic resonance imaging (MRI) for diaphragmatic endometriosis diagnosis.

MATERIALS AND METHODS

Over a 2-year period, all diaphragmatic MRI performed in the context of diaphragmatic endometriosis were reviewed. Axial and coronal fat-suppressed T1- and T2-weighted sequences were analyzed by two independent readers for the presence of nodules, plaque lesions, micronodule clustering, or focal liver herniation. MR abnormalities were correlated to surgical findings in women surgically treated. Interobserver agreement was assessed by κ statistics.

RESULTS

Twenty-three women with diaphragmatic endometriosis criteria comprised the population; 14 had surgical confirmation and nine had symptoms relief with hormonal treatment. MRI sensitivity was 83 % (19/23; 95 % confidence interval [CI]: 68, 98) for reader 1 and 78 % (18/23; 95 % CI: 61, 95) for reader 2. Kappa value was 0.86 (95 % CI: 0.47, 1.00). Readers 1 and 2 detected 35 and 36 lesions, respectively, all right-sided and agreed for 32 lesions on the type, location, and signal. Lesions were mostly nodules (23/32, 72 %), predominantly posterior (28/32, 87.5 %) and hyperintense on T1 (20/32, 63 %). MRI was negative for both readers in 2 surgically treated patients with small nodules or isolated diaphragmatic holes.

CONCLUSION

MRI allows diaphragmatic endometriosis diagnosis with 78 to 83 % sensitivity and excellent interobserver agreement.

KEY POINTS

• MRI allows the diagnosis of diaphragmatic endometriosis with up to 83 % sensitivity. • Diaphragmatic endometriosis lesions are better depicted on fat-suppressed T1-weighted sequences. • Diaphragmatic lesions, mostly hyperintense nodules, are right-sided and predominantly posterior. • MRI can help in timely diagnosis of diaphragmatic endometriosis.

Clear cell thymic carcinoma: a case report

Clear cell thymic carcinoma is a rare and invasive tumor of the mediastinum for which there are no uniform treatment guidelines. The combination of carboplatin plus paclitaxel seems to be the most effective regimen for this disease. We report a case of locally advanced clear cell thymic carcinoma treated with this schedule, in which we observed a relevant and rapid tumor shrinkage.