Systematic interpretation and structured reporting for pelvic magnetic resonance imaging studies in patients with endometriosis: value added for improved patient care

MRI Features of Pelvic Nerve Involvement in Endometriosis

Endometriosis is a common condition that mostly affects people assigned as female at birth. The most common clinical symptom of endometriosis is pain. Although the mechanism for this pain is poorly understood, in some cases, the nerves are directly involved in endometriosis. Endometriosis is a multifocal disease, and the pelvis is the most common location involved. Nerves in the pelvis can become entrapped and involved in endometriosis. Pelvic nerves are visible at pelvic MRI, especially when imaging planes and sequences are tailored for neural evaluation. In particular, high-spatial-resolution anatomic imaging including three-dimensional isotropic imaging and contrast-enhanced three-dimensional short inversion time inversion-recovery (STIR) fast spin-echo sequences are useful for nerve imaging. The most commonly involved nerves are the sciatic, obturator, femoral, pudendal, and inferior hypogastric nerves and the inferior hypogastric and lumbosacral plexuses. Although it is thought to be rare, the true incidence of nerve involvement in endometriosis is not known. Symptoms of neural involvement include pain, weakness, numbness, incontinence, and paraplegia and may be constant or cyclic (catamenial). Early diagnosis of neural involvement in endometriosis is important to prevent irreversible nerve damage and chronic sensorimotor neuropathy. Evidence of irreversible damage can also be seen at MRI, and radiologists should evaluate pelvic nerves that are commonly involved in endometriosis in their search pattern and report template to ensure that this information is incorporated into treatment planning.

Association between Endometriosis and Surgical Complications among Benign Hysterectomies

STUDY OBJECTIVE

To investigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease.

DESIGN

A retrospective cohort study.

SETTING

The American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

A total of 127 556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomes were compared between patients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach.

MEASURES AND MAIN RESULTS

Of the 127 556 hysterectomies identified, 19 618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory disease and previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis.

CONCLUSION

Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.

Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement

Objectives

The purpose of this investigation was to evaluate the inter- and intraobserver variability of the updated #Enzian classification of endometriosis on MRI and to evaluate the influence of reader experience on interobserver concordance.

Methods

This was a prospective single-center study. All patients were included who received an MRI of the pelvis for evaluation of endometriosis between March and July 2023 and who have provided written informed consent. Images were reviewed independently for endometriosis by three radiologists, utilizing the MRI-applicable categories of the #Enzian classification. Two radiologists had experience in pelvic MRI and endometriosis imaging. One radiologist had no specific experience in pelvic MRI and received a one-hour briefing beforehand.

Results

Fifty consecutive patients (mean age, 34.9 years ±8.6 [standard deviation]) were prospectively evaluated. Interobserver agreement was excellent for diagnosis of deep infiltrating endometriosis (Fleiss' kappa: 0.89; 95% CI 0.73-1.00; p < 0.001) and endometriomas (Fleiss' kappa: 0.93; 95% CI 0.77-1.00; p < 0.001). For the experienced readers, interobserver agreement in the assessment of compartments A, B and C was excellent (κw ranging from 0.84; 95% CI 0.71-0.97; p < 0.001 to 0.89; 95% CI 0.82-0.97; p < 0.001). For the pairings of the experienced readers to the reader without specific experience in pelvic MRI, agreement was substantial to excellent (κw ranging from 0.64; 95% CI 0.44-0.85; p < 0.001 to 0.91; 95% CI 0.84-0.98; p < 0.001). Intraobserver variability was excellent for compartments A, B and C (κw ranging from 0.85; 95% CI 0.73-0.96; p < 0.001 to 0.95; 95% CI 0.89-1.00; p < 0.001).

Conclusion

With sufficient experience, the #Enzian classification enables the achievement of excellent inter- and intraobserver agreement in MRI-based diagnosis of deep infiltrating endometriosis and endometriomas.

MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report

Endometriosis represents one of the most common causes of life-impacting chronic pelvic pain and female infertility. Magnetic resonance imaging (MRI) plays an increasing role in the diagnosis and mapping of endometriosis, while diagnostic laparoscopy currently tends to be reserved for the patients with negative imaging results. The #Enzian, published in 2021, proposes a new comprehensive classification system of endometriosis, combining a complete staging of deep infiltrative endometriosis with the evaluation of peritoneal/ovarian/tubal localizations and the presence of adenomyosis. This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis. Overall, there is a significant matching between MRI features and the #Enzian classification criteria, two different perspectives of endometriosis mapping, with different goals and levels of detail. The main discrepancy lies in the evaluation of tubo-ovarian condition, which is not fully assessable by MRI. Furthermore, as endometriosis is a complex disease, usually multifocal, that can present with a myriad of imaging findings, MRI reporting should be clear and well organized. The authors group, both radiologists and gynecologists, propose a structured MRI report of endometriosis in correlation with the #Enzian classification, merging the detailed anatomical and pre-operative information provided by the MRI with the benefits of a comprehensive classification system of endometriosis in the clinical practice and research field.Critical relevance statement This article addresses in detail the applicability of the #Enzian classification, primarily based on surgical findings, to the MRI evaluation of the endometriosis and proposes a #Enzian-based structured MRI report.

Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score

Importance

Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key.

Objective

To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort.

Design, Setting, and Participants

In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022.

Intervention

Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score.

Main outcomes and measures

Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction.

Results

The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86).

Conclusions and Relevance

The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group

PURPOSE

The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.

Quantifying the Effects of Structured Reporting on Report Turnaround Times and Proofreading Workload in Neuroradiology

RATIONALE AND OBJECTIVES

To assess the effects of a change from free text reporting to structured reporting on resident reports, the proofreading workload and report turnaround times in the neuroradiology daily routine.

MATERIALS AND METHODS

Our neuroradiology section introduced structured reporting templates in July 2019. Reports dictated by residents during dayshifts from January 2019 to March 2020 were retrospectively assessed using quantitative parameters from report comparison. Through automatic analysis of text-string differences between report states (i.e. draft, preliminary and final report), Jaccard similarities and edit distances of reports following read-out sessions as well as after report sign-off were calculated. Furthermore, turnaround times until preliminary and final report availability to clinicians were investigated. Parameters were visualized as trending line graphs and statistically compared between reporting standards.

RESULTS

Three thousand five hundred thirty-eight reports were included into analysis. Mean Jaccard similarity of resident drafts and staff-reviewed final reports increased from 0.53 ± 0.37 to 0.79 ± 0.22 after the introduction of structured reporting (p < .001). Both mean overall edits on draft reports by residents following read-out sessions (0.30 ± 0.45 vs. 0.09 ± 0.29; p < .001) and by staff radiologists during report sign-off (0.17 ± 0.28 vs. 0.12 ± 0.23, p < .001) decreased. With structured reporting, mean turnaround time until preliminary report availability to clinicians decreased by 20.7 minutes (246.9 ± 207.0 vs. 226.2 ± 224.9; p < .001). Similarly, final reports were available 35.0 minutes faster on average (558.05 ± 15.1 vs. 523.0 ± 497.3; p = .002).

CONCLUSION

Structured reporting is beneficial in the neuroradiology daily routine, as resident drafts require fewer edits in the report review process. This reduction in proofreading workload is likely responsible for lower report turnaround times.

Diagnosis of presence and extent of deep infiltrating endometriosis by preoperative MRI-improvement of staging accuracy by expert training

INTRODUCTION

This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI.

RESULTS

Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50).

DISCUSSION

After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.

Structured MRI reporting increases completeness of radiological reports and requesting physicians' satisfaction in the diagnostic workup for pelvic endometriosis

PURPOSE

MRI plays an important role in the diagnosis and surgical planning of pelvic endometriosis (PE), and imaging reports should contain all relevant information (completeness). As structured reports are being increasingly utilized, we aimed to evaluate whether structured MRI reporting increases the quality of reports regarding completeness and, consequently, their perceived value by gynecologists, in comparison to free-text reports. We also aimed to compare the diagnostic performance of both formats.

METHODS

We retrospectively included 28 consecutive women with histologically proven PE who underwent MRI within one month before surgery. Two abdominal radiologists (Rd1/Rd2, 3y/12y experience), blinded to clinical and surgical data, individually elaborated free-text reports and, four months later, structured reports. Completeness (defined as description of six key anatomical sites deemed essential for surgical planning in a consensus of four-blinded external experts) and diagnostic performance (sensitivity and specificity) by site (histology as reference) were compared between reports using the McNemar test. The satisfaction of gynecologists was compared using the marginal homogeneity test.

RESULTS

Structured reporting increased completeness for both Rd1 (rectosigmoid, retrocervical/uterosacral ligament, vagina, and ureter) and Rd2 (vagina, ureter, and bladder) (p < 0.05), without compromising sensitivity or specificity at any of the evaluated sites. Gynecologists' satisfaction was superior with structured reports in most comparisons.

CONCLUSION

Structured MRI reports perform better in fully documenting essential features of PE and are similar in terms of diagnostic performance, therefore having higher potential for surgical planning. Gynecologists found them easier to assess and were more satisfied with the information provided by structured reports.

Endometriosis and Its Myriad Presentations: Magnetic Resonance Imaging-Based Pictorial Review

Endometriosis is a major cause of infertility and pain in females in the reproductive age group. It is a result of ectopic functional endometrial cells outside the uterus. It consists of a spectrum of findings from superficial to deep implants initiating a fibrotic response and resulting in adhesions. Diagnosis of endometriosis is based on clinical history, noninvasive and invasive techniques. The final diagnosis is based on laparoscopy with histopathological confirmation. Ultrasonography is the first line of investigation, followed by magnetic resonance imaging (MRI) in complex cases. MRI is a noninvasive, multiplanar technique that involves no radiation and provides excellent delineation of the disease process. As deep endometriosis has a similar low signal to adjacent normal organs, it can be easily overlooked by radiologists. They should be aware of the spectrum of diseases so as to provide a roadmap for the surgeons. A structured reporting system helps radiologists organize and standardize their reports.

State of the art in abdominal MRI structured reporting: a review

In the management of several abdominal disorders, magnetic resonance imaging (MRI) has the potential to significantly improve patient's outcome due to its diagnostic accuracy leading to more appropriate treatment choice. However, its clinical value heavily relies on the quality and quantity of diagnostic information that radiologists manage to convey through their reports. To solve issues such as ambiguity and lack of comprehensiveness that can occur with conventional narrative reports, the adoption of structured reporting has been proposed. Using a checklist and standardized lexicon, structured reports are designed to increase clarity while assuring that all key imaging findings related to a specific disorder are included. Unfortunately, structured reports have their limitations too, such as risk of undue report simplification and poor template plasticity. Their adoption is also far from widespread, and probably the ideal balance between radiologist autonomy and report consistency of has yet to be found. In this article, we aimed to provide an overview of structured reporting proposals for abdominal MRI and of works assessing its value in comparison to conventional free-text reporting. While for several abdominal disorders there are structured templates that have been endorsed by scientific societies and their adoption might be beneficial, stronger evidence confirming their imperativeness and added value in terms of clinical practice is needed, especially regarding the improvement of patient outcome.

Bladder endometriosis: Preoperative MRI analysis with assessment of extension to ureteral orifices

PURPOSE

The purpose of this study was to retrospectively evaluate the performance of magnetic resonance imaging (MRI) in locating endometriosis implants within the bladder wall with assessment of ureteral orifice extension using surgical findings as standard of reference.

MATERIALS AND METHODS

MRI examinations of 39 consecutive women (mean age: 31.2±5.5 [SD] years; age range: 22-42years) operated in 3 university hospitals for bladder endometriosis over a 6-year period were reviewed by 2 independent readers. Interobserver agreement was assessed using Kappa tests. Results of consensus reading were used to calculate sensitivity, specificity and accuracy of MRI for the diagnosis, location and extent of endometriosis implants using surgical findings as the standard of reference.

RESULTS

Mean bladder repletion volume was 134±110 [SD] mL (range: 21-479mL). The mean largest endometriosis implant diameter was 30±7 [SD] mm (range: 19-41mm). On MR images, 34/39 (87%) endometriosis implants were present in the two anterior thirds of the dome (k=0.45), 31/39 (79%) extended or were present in the posterior third pouch (k=0.92) and 25/39 (64%) extended into the bladder base (k=0.84) with sensitivities of 100% (31/31; 95% confidence interval [CI]: 89-100%), 100% (30/30; 95% CI: 88-100%) and 90% (19/21; 95% CI: 69-98%), respectively, specificities of 83% (5/6, 95% CI: 36-100), 88% (7/8, 95% CI: 47-100%), 87% (13/15; 95% CI: 52-96), respectively and accuracies of 97% (36/37, 95% CI: 86-100%), 97% (37/38; 95% CI: 86-100%), and 89% (32/36; 95% CI: 74-97%), respectively. In 9 (9/25; 36%) patients with bladder base involvement, a zero distance was reported between endometriosis implants and ureteral orifices, all but one presenting with low-to-moderate bladder volumes. In the two patients who needed ureteral resection-reimplantation, ureteral dilation was associated with a zero distance. External adenomyosis was reported in 26/39 (66%) patients (k=0.94).

CONCLUSION

A dedicated preoperative MRI work-up for bladder endometriosis helps accurately depict and locate endometriosis implants. Adequate bladder filling is needed to improve appropriate estimate of the distance between endometriosis implants and ureteral orifices to better predict requirement of ureteral resection-reimplantation.

Rectal endometriosis: predictive MRI signs for segmental bowel resection

OBJECTIVE

To retrospectively determine the accuracy of MRI rectal and pararectal signs in predicting the necessity for segmental resection in the case of lesions located in the rectum.

METHODS

MR images of consecutive patients treated for rectal endometriosis over a 5-year period were reviewed in consensus by two blinded readers. A systematic analysis of 7 rectal (lesion length, transverse axis, thickness and circumference, and presence of a convex base, submucosal oedema and hyperintense cystic areas) and 4 pararectal (posterior vaginal fornix, parametrial, ureteral and sacro-recto-genital septum involvements) signs was performed for each lesion. MRI results were compared to the surgical procedure performed (shaving versus segmental resection).

RESULTS

Among 61 patients studied, 32 received a segmental resection and 29, a shaving. Receiver operating characteristic curve analysis allowed determining cut-off values for length (≥ 32 mm), transverse axis (≥ 22 mm), thickness (≥ 14 mm) and circumference (≥ 3/8 radii). The 7 rectal signs, and only the sacro-recto-genital septum pararectal sign, were significantly associated with segmental resection in univariate analysis, nodular thickness ≥ 14 mm and circumference ≥ 3/8 radii being the most predictive signs (odds ratio 94.5 and 60.4, respectively). These 2 signs remained positively associated with segmental resection in multivariate analysis and, when combined, were predictive of segmental resection with an accuracy of 90.2%.

CONCLUSION

Assessing MRI rectal and pararectal signs may accurately predict the need for segmental resection versus a more conservative approach such as shaving for rectal lesion management.

KEY POINTS

• MRI analysis of rectal endometriosis, taking into account rectal and pararectal signs, may assist surgeons in the decision-making process, in counselling patients regarding the surgical procedure and in adequately allocating resources. • Among rectal signs, nodular thickness ≥ 14 mm and a circumference ≥ 38% were the most predictive signs of segmental resection. • Among pararectal signs, only the sacro-recto-genital septum involvement was significantly associated with segmental resection.

Medical management of endometriosis: what the radiologist needs to know

The role of the radiologist in the diagnosis and management of patients with endometriosis is increasing. Improvement in MRI imaging techniques has improved detection rate of subtle manifestations of endometriosis by radiologists. Therefore, the role of imaging in the diagnosis and follow-up after treatment is also likely to increase. Knowledge of new medical management pathways used in treating patients with endometriosis-related pain is important. The knowledge of various medication regimens will allow radiologists to continue to evaluate baseline disease, and to potentially assess for imaging response/stability to these medications. This article will review the current medical therapies in use in the management of endometriosis-related pain and describe potential imaging-related findings expected with these therapies.

Clinical management of endometriosis

Endometriosis is a disease of reproductive age women that is commonly characterized by symptoms that often negatively impact quality of life. The clinical management of endometriosis remains highly variable and mostly influenced by geographic location, practice patterns, and breadth of clinician experience. This variability in treatment has inspired a trend towards multidisciplinary and specialized care of patients suffering from this disease. Surgical sampling, followed by histologic confirmation of endometrial-like tissue, remains the standard for the definitive diagnosis of endometriosis. However, the high sensitivity and specificity of MRI and ultrasound has shed light on the path towards non-surgical diagnosis of deep infiltrating endometriosis. Molecular variability and intricacy of this disease has limited the development of biologic markers to target for non-invasive diagnosis and pharmacologic therapies. Surgical management of advanced-stage endometriosis can be difficult, mostly secondary to the invasive nature of the disease, and anatomical distortion requiring advanced surgical skills to manage. The high prevalence of chronic pelvic pain and other complex pain syndromes in patients with endometriosis also requires knowledge in the management of these types of issues in order to provide comprehensive care. Menopausal endometriosis, extrapelvic presentation, and potential malignant transformation of lesions are infrequent, requiring a high index of suspicion for timely diagnosis and treatment.