Diagnosis of endometriosis with imaging: a review

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.

Progesterone levels do not differ between patients with or without endometriosis/adenomyosis both in those who conceive after hormone replacement therapy-frozen embryo transfer cycles and those who do not

STUDY QUESTION

Do women with endometriosis who achieve a live birth (LB) after HRT-frozen embryo transfer (HRT-FET) have different progesterone levels on the day of transfer compared to unaffected women?

SUMMARY ANSWER

In women achieving a LB after HRT-FET, serum progesterone levels on the day of the transfer did not differ between patients with endometriosis and unaffected patients.

WHAT IS KNOWN ALREADY

In HRT-FET, several studies have highlighted the correlation between serum progesterone levels at the time of FET and LB rates. In the pathophysiology of endometriosis, progesterone resistance is typically described in the eutopic endometrium. This has led to the hypothesis that women with endometriosis may require higher progesterone levels to achieve a LB, especially in HRT-FET cycles without a corpus luteum.

STUDY DESIGN, SIZE, DURATION

We conducted an observational cohort study at the university-based reproductive medicine center of our institution, focusing on women who underwent a single autologous frozen blastocyst transfer after HRT using exogenous estradiol and micronized vaginal progesterone for endometrial preparation between January 2019 and December 2021. Women were included only once during the study period. Serum progesterone levels were measured on the morning of the FET by a single laboratory.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were divided into groups based on whether they had endometriosis or not and whether they achieved a LB. The diagnosis of endometriosis was based on published imaging criteria (transvaginal sonography/magnetic resonance imaging) and/or confirmed histology. The primary outcome was progesterone levels on the day of the HRT-FET leading to a LB in patients with endometriosis compared to unaffected women. Subgroup analyses were performed based on the presence of deep infiltrating endometriosis or adenomyosis.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1784 patients were included. The mean age of the women was 35.1 ± 4.1 (SD) years. Five hundred and sixty women had endometriosis, while 1224 did not. About 179/560 (32.0%) with endometriosis and 381/1224 (31.2%) without endometriosis achieved a LB. Among women who achieved a LB after HRT-FET, there was no significant difference in the mean progesterone level on the day of the HRT-FET between those with endometriosis and those without (13.6 ± 4.3 ng/ml vs 13.2 ± 4.4 ng/ml, respectively; P = 0.302). In the subgroup of women with deep infiltrating endometriosis (n = 142) and adenomyosis (n = 100), the mean progesterone level was 13.1 ± 4.1 ng/ml and 12.6 ± 3.7 ng/ml, respectively, with no significant difference compared to endometriosis-free patients. After adjusting for BMI, parity, duration of infertility, tobacco use, and geographic origin, neither the presence of endometriosis (coefficient 0.38; 95% CI: -0.63 to 1.40; P = 0.457) nor the presence of adenomyosis (coefficient 0.97; 95% CI: -0.24 to 2.19; P = 0.114) was associated with the progesterone level on the day of HRT-FET. Among women who did not conceive, there was no significant difference in the mean progesterone level on the day of the HRT-FET between those with endometriosis and those without (P = 0.709).

LIMITATIONS, REASONS FOR CAUTION

The primary limitation of our study is associated with its observational design. Extrapolating our results to other laboratories or different routes and/or dosages of administering progesterone also requires validation.

WIDER IMPLICATIONS OF THE FINDINGS

This study shows that patients diagnosed with endometriosis do not require higher progesterone levels on the day of a frozen blastocyst transfer to achieve a LB in hormonal replacement therapy cycles.

STUDY FUNDING/COMPETING INTEREST(S)

None declared.

TRIAL REGISTRATION NUMBER

N/A.

Questionnaire-based screening of adolescents and young adult women can identify markers associated with endometriosis

STUDY QUESTION

Do adolescents and young adult women (YAW) with histologically proven endometriosis present a specific clinical history?

SUMMARY ANSWER

Questionnaire screening of adolescents and YAW can identify clinical markers associated with histologically proven endometriosis.

WHAT IS KNOWN ALREADY

Some validated questionaries can contribute to an earlier endometriosis diagnosis in adults. None of these scores, however, have been validated for adolescents or YAW.

STUDY DESIGN, SIZE, DURATION

This was an observational cross-sectional study using prospectively recorded data performed between January 2005 and January 2020 in a single university tertiary referral centre for endometriosis diagnosis and management. After a thorough surgical examination of the abdomino-pelvic cavity, women with histologically proven endometriosis were allocated to the endometriosis group, and symptomatic women without evidence of endometriosis were allocated to the endometriosis-free control group. The endometriotic patients were allocated into two sub-groups according to their age: adolescent (≤20 years) and YAW (21-24 years).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Adolescents and YAW ≤24 years of age were operated for a symptomatic benign gynaecological condition with signed informed consent. A standardized questionnaire was prospectively completed in the month before the surgery and included epidemiological data, pelvic pain scores, family history of endometriosis, and symptoms experienced during adolescence. The study searched for correlations by univariate analysis to determine clinical markers of endometriosis in adolescents and YAW compared with endometriosis-free control patients.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 262 study participants, 77 women were adolescents (≤20 years of age) and 185 patients (70.6%) were YAW. The endometriosis group included 118 patients (45.0%) and 144 (55.0%) were assigned to the control group. A family history of endometriosis, absenteeism from school during menstruation, history of fainting spells during menstruation, and prescription of oral contraceptive pills for intense dysmenorrhea were significantly more frequently observed in the endometriotic patients. The prevalence and mean pain scores for dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain and gastrointestinal and lower urinary tract symptoms were significantly greater in the endometriosis group, as was experienced rectal bleeding.

LIMITATIONS, REASONS FOR CAUTION

The study was performed in a single referral centre that treats patients with potentially more severe disease. This questionnaire was evaluated on a population of patients with an indication for endometriosis surgery, which can also select patients with more severe disease. Women with asymptomatic endometriosis were not considered in this study. These factors can affect the external validity of this study.

WIDER IMPLICATIONS OF THE FINDINGS

Patient interviews are relevant to the diagnosis of endometriosis in adolescents and YAW. Combined with imaging and clinical examination, this approach will enable earlier diagnosis and treatment, while remaining non-invasive and rapid.

STUDY FUNDING/COMPETING INTEREST(S)

The study received no funding from external sources. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Mimics of primary ovarian cancer and primary peritoneal carcinomatosis - A pictorial review

Numerous conditions can mimic ovarian malignancy. Identifying the origin of a pelvic mass or disseminated peritoneal abnormality on imaging is important to ensure that the patient receives optimal management by the appropriate clinical team. Ovarian cancer mimics include infections and other neoplastic processes, for example, actinomycosis, lymphoma, and sarcoma. We will illustrate intraperitoneal and extraperitoneal ovarian and non-ovarian mimics. Primary peritoneal carcinomatosis mimics include processes such as deep infiltrating endometriosis and rare causes such as gliomatosis peritonei and diffuse peritoneal leiomyomatosis. We aim to illustrate the multimodality key imaging appearances of common and rarer types of mimics.

"From the tip to the deep of the iceberg": Parametrial involvement in endometriosis

Deep endometriosis (DE) can be localized in the parametrium, a complex bilateral anatomical structure, sometimes necessitating intricate surgical intervention due to the potential involvement of autonomic nerves, uterine artery, and ureter. If endometriotic ovarian cysts have been considered metaphorically representative of "the tip of the iceberg" concerning concealed DE lesions, it is reasonable to assert that parametrial lesions should be construed as the most profound region of this iceberg. Also, based on a subdual clinical presentation, a comprehensive diagnostic parametrial evaluation becomes imperative to strategize optimal management for patients with suspected DE. Recently, the ULTRAPARAMETRENDO studies aimed to evaluate the role of transvaginal ultrasound for parametrial endometriosis, showing distinctive features, such as a mild hypoechoic appearance, starry morphology, irregular margins, and limited vascularization. The impact of medical therapy on parametrial lesions has not been described in the current literature, primarily due to the lack of adequate detection at imaging. The extension of DE into the parametrium poses significant challenges during the surgical approach, thereby increasing the risk of intra- and postoperative complications, mainly if performed by centers with low expertise and following multiple surgical procedures where parametrial involvement has gone unrecognized. Over time, the principles of nerve-sparing surgery have been incorporated into the surgical DE treatment to minimize iatrogenic damage and potentially reduce the risk of functional complications.

An Indocyanine Green-Based Nanocluster for Imaging Orthodox Endometriosis Lesions with Negative Contrast

Indocyanine green (ICG), as the sole near-infrared dye FDA-approved, is limited in biomedical applications because of its poor photostability, lack of targeting, and rapid removal in vivo. Herein, we presented a nanoformulation of poly-l-lysine-indocyanine green-hyaluronic acid (PIH) and demonstrated that it can image orthodox endometriosis (EM) lesions with a negative contrast. The PIH nanocluster, with an average diameter of approximately 200 nm, exhibited improved fluorescence photostability and antioxidant ability compared to free ICG. In the in vivo imaging, EM lesions were visualized, featuring apparent voids and clear boundaries. After colocalizing with the green fluorescent protein, we concluded that the contrast provided by PIH peaked at 4 h postinjection and was observable for at least 8 h. The negative contrast, clear boundaries, and enhanced observable time might be due to the low permeation of PIH to lesions and the enhanced retention on the surfaces of lesions. Thus, our findings suggest an ICG-based nanoprobe with the potential to diagnose abdominal diseases.

Imaging of Endometriotic Lesions Using cRGD-MN Probe in a Mouse Model of Endometriosis

Approximately 10% of women suffer from endometriosis during their reproductive years. This disease is a chronic debilitating condition whose etiology for lesion implantation and survival heavily relies on adhesion and angiogenic factors. Currently, there are no clinically approved agents for its detection. In this study, we evaluated cRGD-peptide-conjugated nanoparticles (RGD-Cy5.5-MN) to detect lesions using magnetic resonance imaging (MRI) in a mouse model of endometriosis. We utilized a luciferase-expressing murine suture model of endometriosis. Imaging was performed before and after 24 h following the intravenous injection of RGD-Cy5.5-MN or control nanoparticles (Cy5.5-MN). Next, we performed biodistribution of RGD-Cy5.5-MN and correlative fluorescence microscopy of lesions stained for CD34. Tissue iron content was determined using inductively coupled plasma optical emission spectrometry (ICP-OES). Our results demonstrated that targeting endometriotic lesions with RGD-Cy5.5-MN resulted in a significantly higher delta T2* upon its accumulation compared to Cy5.5-MN. ICP-OES showed significantly higher iron content in the lesions of the animals in the experimental group compared to the lesions of the animals in the control group. Histology showed colocalization of Cy5.5 signal from RGD-Cy5.5-MN with CD34 in the lesions pointing to the targeted nature of the probe. This work offers initial proof-of-concept for targeting angiogenesis in endometriosis which can be useful for potential clinical diagnostic and therapeutic approaches for treating this disease.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.

Photoacoustic Imaging Endometriosis Lesions with Nanoparticulate Polydopamine as a Contrast Agent

Endometriosis (EM) is a prevalent and debilitating gynecological disorder primarily affecting women of reproductive age. The diagnosis of EM is historically hampered by delays, owing to the absence of reliable diagnostic and monitoring techniques. Herein, it is reported that photoacoustic imaging can be a noninvasive modality for deep-seated EM by employing a hyaluronic-acid-modified polydopamine (PDA@HA) nanoparticle as the contrast agent. The PDA@HA nanoparticles exhibit inherent absorption and photothermal effects when exposed to near-infrared light, proficiently converting thermal energy into sound waves. Leveraging the targeting properties of HA, distinct photoacoustic signals emanating from the periphery of orthotopic EM lesions are observed. These findings are corroborated through anatomical observations and in vivo experiments involving mice with green fluorescent protein-labeled EM lesions. Moreover, the changes in photoacoustic intensity over a 24 h period reflect the dynamic evolution of PDA@HA nanoparticle biodistribution. Through the utilization of a photoacoustic ultrasound modality, in vivo assessments of EM lesion volumes are conducted. This innovative approach not only facilitates real-time monitoring of the therapeutic kinetics of candidate drugs but also obviates the need for the sacrifice of experimental mice. As such, this study presents a promising avenue for enhancing the diagnosis and drug-screening processes of EM.

Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique

Endometriosis is a chronic inflammatory gynecological condition affecting 10-15% of women in the reproductive age group. The urinary tract is the second most common extragenital organ system affected by endometriosis, and the urinary bladder and ureter are the two most common sites involved. Involvement of the urinary bladder can cause chronic debilitating symptoms, whereas ureteral involvement may lead to asymptomatic loss of renal function. Both conditions are frequently unsuspected, leading to a delay in diagnosis. Therefore, it is important to recognize this entity early, for which knowledge of imaging appearances and techniques is helpful. In this review article, we describe (a) endometriosis background, pathogenesis, definitions and clinical symptoms, (b) imaging appearance, with emphasis on ultrasound and MRI findings of urinary bladder and ureteric endometriosis, (c) ultrasound technique and MRI sequences useful for making the correct diagnosis, (d) overview of the treatment options and key imaging findings that are important to the surgeon for surgical planning, and (e) a structured reporting template useful for multidisciplinary patient management.

Detection of Endometriosis Lesions Using Gd-Based Collagen I Targeting Probe in Murine Models of Endometriosis

PURPOSE

Endometriosis is a chronic condition characterized by high fibrotic content and affecting about 10% of women during their reproductive years. Yet, no clinically approved agents are available for non-invasive endometriosis detection. The purpose of this study was to investigate the utility of a gadolinium-based collagen type I targeting probe (EP-3533) to non-invasively detect endometriotic lesions using magnetic resonance imaging (MRI). Previously, this probe has been used for detection and staging of fibrotic lesions in the liver, lung, heart, and cancer. In this study we evaluate the potential of EP-3533 for detecting endometriosis in two murine models and compare it with a non-binding isomer (EP-3612).

PROCEDURES

For imaging, we utilized two GFP-expressing murine models of endometriosis (suture model and injection model) injected intravenously with EP3533 or EP-33612. Mice were imaged before and after bolus injection of the probes. The dynamic signal enhancement of MR T1 FLASH images was analyzed, normalized, and quantified, and the relative location of lesions was validated through ex vivo fluorescence imaging. Subsequently, the harvested lesions were stained for collagen, and their gadolinium content was quantified by inductively coupled plasma optical emission spectrometry (ICP-OES).

RESULTS

We showed that EP-3533 probe increased the signal intensity in T1-weighted images of endometriotic lesions in both models of endometriosis. Such enhancement was not detected in the muscles of the same groups or in endometriotic lesions of mice injected with EP-3612 probe. Consequentially, control tissues had significantly lower gadolinium content, compared to the lesions in experimental groups. Probe accumulation was similar in endometriotic lesions of either model.

CONCLUSIONS

This study provides evidence for feasibility of targeting collagen type I in the endometriotic lesions using EP3533 probe. Our future work includes investigation of the utility of this probe for therapeutic delivery in endometriosis to inhibit signaling pathways that cause the disease.

Endometriosis and Adolescence: The Impact of Dysmenorrhea

Endometriosis affects approximately 10% of premenopausal women worldwide. Despite its impact on quality of life, the delay in diagnosing this chronic disease is well known. Many patients with endometriosis report having suffered from dysmenorrhea and chronic pelvic pain in adolescence or at a young age. However, this painful symptom is often highly underestimated and considered a normal and transient symptom in young women. The real prevalence of endometriosis in adolescence remains uncertain. Some authors recently described at least one ultrasound feature of endometriosis in 13.3% of a general population of adolescent girls, which increased to 35.3% in young girls with severe dysmenorrhea. Dysmenorrhea is classified as primary dysmenorrhea or secondary dysmenorrhea. Primary dysmenorrhea is defined as a menstrual pain without organic disease, while secondary dysmenorrhea is defined as a menstrual pain associated with organic pelvic pathology. Since endometriosis represents the main cause of secondary dysmenorrhea in adolescents and young women, it is important to determine whether the patient has primary dysmenorrhea or additional suggestive symptoms related to endometriosis. Endometriosis in adolescent patients is a challenging problem with clinical and pathological differences compared with its presentation in premenopausal women. Adolescents and young women with dysmenorrhea and painful symptoms that suggest endometriosis should be referred to dedicated endometriosis centers for an early diagnosis and appropriate medical and surgical management. This paper aims to describe the role of dysmenorrhea in adolescents and the management of these young patients to confirm or exclude endometriosis.

How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach

The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.

A Review of Urinary Tract Endometriosis

PURPOSE OF REVIEW

To describe the presenting signs and symptoms of patients with urinary tract endometriosis (UTE), appropriate workup, and to review medical and surgical therapies for symptom palliation and definitive management.

RECENT FINDINGS

UTE is a condition that clinicians should maintain a high index of suspicion for, as symptoms can be easily misdiagnosed from other causes. Surgical resection of implants appears to offer safe and durable symptom relief. Urinary tract endometriosis may present with symptoms overlapping with interstitial cystitis, nephrolithiasis, bladder overactivity, or recurrent urinary tract infections, and may or may not be cyclical in nature. Cyclical gross hematuria is considered pathognomonic, though final diagnosis must be made after a pathologic review. Without proper diagnosis and treatment, consequences such as silent renal loss from asymptomatic obstruction may result. After the diagnosis is made, initial therapy can be undertaken with hormonal treatment to palliate symptoms (most commonly in the form of combined oral contraceptives), followed by surgical resection for a definitive treatment option.

The Role of Magnetic Resonance Imaging in the Planning of Surgical Treatment of Deep Pelvic Endometriosis

Background

To prospectively evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for the planning of surgical treatment of deep pelvic endometriosis.

Materials and Methods

From January 2020 to December 2021, we evaluated 72 patients with symptoms characteristic of endometriosis to plan appropriate surgical treatment. Sensitivity (Se), specificity (Sp), positive and negative predictive values (VPP/VPN), and the accuracy of MRI for the detection of deep pelvic endometriosis were calculated.

Results

Seventy-two patients (mean age, 35.5 years; range, 20–46 years) suspected of having pelvic endometriosis were recruited. Pelvic endometriosis was confirmed at pathologic examination in 56 (77.7%) of 72 patients. A total of 22 (39.3%) of 56 patients were subjected to video laparoscopy (VLS), and 16 (72.2%) of 22 were treated by surgery. Se, Sp, VPP, and VPN in intestinal endometriosis diagnosis were, respectively, 100%, 93.3%, 100%, and 87.5%, and diagnostic accuracy was 95.4%. MRI Se in ureteral endometriosis diagnosis was 50%, Sp 100%, VPP 100%, VPN 78%, and diagnostic accuracy 82%. MRI Se in endometrioma diagnosis was 92.3%, Sp 100%, VPP 100%, VPN 90%, and diagnostic accuracy 95.4%. MRI Se in rectum-vaginal septum (SRV) endometriosis diagnosis was 80%, Sp 100%, VPP 100% VPN 85.7%, and diagnostic accuracy 91%. The MRI Se in the diagnosis of endometriosis involving ULS was 100%, Sp 92.8%, VPP 89%, VPN 100%, and diagnostic accuracy 95.4%. Complete concordance results in a 100% accuracy for all calculated values in diagnosing bladder endometriosis localizations.

Conclusion

MR imaging demonstrates high accuracy in detecting deep pelvic endometriosis in specific locations. It allows the localization of deep pelvic lesions with highly fibrotic components that are hardly recognizable with other imaging methods and not visible with VLS.

A Review and Case Study of 3D Imaging Modalities for Female Amniote Reproductive Anatomy

Recent advances in non-invasive imaging methods have revitalised the field of comparative anatomy, and reproductive anatomy has been no exception. The reproductive systems of female amniotes present specific challenges, namely their often internal "hidden" anatomy. Quantifying female reproductive systems is crucial to recognising reproductive pathologies, monitoring menstrual cycles, and understanding copulatory mechanics. Here we conduct a review of the application of non-invasive imaging techniques to female amniote reproductive anatomy. We introduce the commonly used imaging modalities of computed tomography (CT) and magnetic resonance imaging (MRI), highlighting their advantages and limitations when applied to female reproductive tissues, and make suggestions for future advances. We also include a case study of micro CT and MRI, along with their associated staining protocols, applied to cadavers of female adult stoats (Mustela erminea). In doing so, we will progress the discussion surrounding the imaging of female reproductive anatomy, whilst also impacting the fields of sexual selection research and comparative anatomy more broadly.

Imaging of Endometriosis: The Role of Ultrasound and Magnetic Resonance

Endometriosis is a chronic gynecological disease characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus. It causes pelvic pain, dysmenorrhea, dyspareunia, or infertility. Diagnosis requires a combination of clinical history, non-invasive and invasive techniques. The aim of the present review was to evaluate the contribution of imaging techniques, mainly transvaginal sonography and magnetic resonance imaging to diagnose different locations and for the most appropriate treatment planning. Endometriosis requires a multidisciplinary teamwork to manage these patients clinically and surgically.

Endometriosis increases the rate of spontaneous early miscarriage in women who have adenomyosis lesions

RESEARCH QUESTION

In women with radiologically diagnosed adenomyosis, is the presence of endometriosis associated with a higher rate of miscarriage?

DESIGN

An observational cohort study of women who received medical care for benign gynaecological conditions between May 2005 and May 2018. Women who had adenomyosis lesions visualized by uterine magnetic resonance imaging (MRI) were included. Women who had never been pregnant were excluded. Women with adenomyosis identified by MRI but who did not have endometriosis lesions (control group) were compared with women with adenomyosis and endometriosis lesions (study group). Primary outcome was rate of a previous history of early miscarriage.

RESULTS

A total of 214 pregnancies in the study group and 53 pregnancies in the control group were analysed. The rate of a previous miscarriage was significantly higher among women with adenomyosis and endometriosis lesions compared with women in the control group (61/214 [28.5%] versus 6/53 [11.3%], respectively, P = 0.009). A multivariable generalized estimating equation logistic regression model, adjusted for adenomyosis and endometriosis phenotypes, found that the association between endometriosis and adenomyosis significantly increased the risk of miscarriage (OR 3.2, 95% CI 1.1 to 9.65). The risk was significantly higher with deep infiltrating endometriosis (OR 4.37, 95% CI 1.32 to 14.53).

CONCLUSIONS

Women affected by endometriosis had a significantly higher rate of previous spontaneous miscarriage than women without endometriosis with adenomyosis lesions identified by MRI. Mechanistic studies are needed to establish the complex link between the presence of endometriosis and adenomyosis and the rate of spontaneous miscarriage.

Isolated Intrinsic Ureteral Endometriosis: A Rare Presentation of Ureteral Obstruction

Intrinsic ureteral endometriosis is a very rare presentation of deep infiltrating endometriosis. It can lead to urinary tract obstruction and loss of renal function. Clinical suspicion and radiologic assessment can aid in preoperative diagnosis and help plan surgical treatment. Herein we report a case of a 29-year-old female who presented with left-sided pelvic and flank pain. Imaging revealed left obstructive uropathy and a left ureteral mass. She underwent laparotomy and resection of the diseased ureter with primary re-anastomosis. Histology confirmed intrinsic ureteral endometriosis. There was subsequently complete resolution on follow-up imaging, with no permanent loss of renal function.

Case report: Caesarean scar endometriosis - A rare entity

Introduction and importance

Caesarean scar endometriosis (CSE) is a rare form of endometriosis due to previous surgical scars from obstetrical and gynecological procedures. The incidence of CSE was 0.08% and quite difficult to diagnose.

Case presentation

A 37-year-old multiparous woman came with intermittent pain in her lower left abdominal region and lump with a bluish color and solid consistency on the left side of the caesarean scar. Ultrasounds findings show a solid mass, measured 45 × 40 × 39 mm with neovascularization color score: 4. In April 2021, we performed mass resection, intraoperatively we found solid mass with no adhesion and infiltration found. Histological examination results confirm external endometriosis from the mass and the fascia was free from endometriosis. The symptoms reported relief after the procedure.

Clinical discussion

Scar endometriosis is largely related to previous abdominal surgery like caesarean section, the mass increase in size during menses and becomes symptomatic. CSE develop ranging 12 months to 21 years and could mimic other hernias or tumor, that's why careful and precise examination is needed. The imaging modality we use in this case was ultrasonography which is the best and most accessible, reliable and cost-effective to diagnose. We performed large surgical excision of the lesion with reconstruction of damaged tissue to prevent recurrence and conversion to malignancy.

Conclusion

Caesarean scar endometriosis should be considered in women of reproductive age with lower abdominal pain and/or mass at the caesarean scar from previous delivery or following obstetric-gynecologic surgery.

•

Caesarean scar endometriosis can be caused by direct implantation from surgery.

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Consider Caesarean scar endometriosis in women with pain and/or mass at the scar

•

Imaging and histopathology is crucial in diagnosing caesarean scar endometriosis.

Differentiation of Endometriomas from Hemorrhagic Cysts at Magnetic Resonance: The Role of Quantitative Signal Intensity Measurements

BACKGROUND

Endometriomas and functional hemorrhagic cysts (FHCs) are a common gynecological encounter.

OBJECTIVE

This study aimed to assess the diagnostic efficiency of magnetic resonance imaging (MRI) using signal intensity measurements in differentiating endometriomas from FHCs.

METHODS

Forty-six patients who underwent pelvic MRI examinations (endometriomas, n=28; FHCs, n=18) were retrospectively included. The "T2 shading" sign was evaluated subjectively and quantitatively by measuring the T1-T2 signal intensity difference and calculating the percentage of signal decrease between T1 and T2-weighted sequences. The resulted values, along with the measurement of the Apparent Diffusion Coefficient (ADC) and the signal intensity on three diffusion- weighted sequences (DWI) (b⁵⁰, b⁴⁰⁰, and b⁸⁰⁰), were compared between groups by using the Mann-Whitney U test. Also, the receiver operating characteristic analysis was performed for the statistically significant results (P<0.016), and the area under the curve (AUC) was also calculated.

RESULTS

The two quantitative assessment methods showed similar efficiency in detecting endometriomas (P<0.001; sensitivity, 100%; specificity, 81.82%; AUC>0.86), outperforming the classic subjective evaluation of the "T2 shading" sign (sensitivity, 92.86%; specificity, 66.67%). ADC (P=0.52) and DWI measurements (P=0.49, P=0.74, and P=0.78) failed to distinguish between the two entities.

CONCLUSION

The quantitative analysis and interpretation of the "T2 shading" sign can significantly improve the differential diagnosis between endometriomas and FHCs.

Surgical management of endometriosis-associated pain

Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.

Diagnosis and Treatment of Vulvo-Perineal Endometriosis: A Systematic Review

Objective: To describe the available knowledge on vulvo-perineal endometriosis including its diagnosis, clinical management and recurrence rate.

Methods: We followed the PRISMA guidelines for Systematic Reviews and our study was prospectively registered with PROSPERO (CRD42020202441). The terms “Endometriosis” and “Perineum” or “Vulva” were used as keywords. Cochrane Library, Medline/Pubmed, Embase and Clinicaltrials.gov were searched. Papers in English, Spanish, Portuguese, French or Italian from inception to July 30, 2020 were considered. Reference lists of included articles and other literature source such as Google Scholar were also manually scrutinized in order to identify other relevant studies. Two independent reviewers screened potentially eligible studies according to inclusion criteria.

Results: Out of 539 reports, 90 studies were eligible including a total of 283 patients. Their mean age was 32.7 ± 7.6 years. Two hundred sixty-three (95.3%) presenting with vulvo-perineal endometriosis have undergone either episiotomy, perineal trauma or vaginal injury or surgery. Only 13 patients (4.7%) developed vulvo-vaginal endometriosis spontaneously i.e., without any apparent condition favoring it. The reasons that motivated the patients to take medical advice were vulvo-perineal cyclical pain increasing during menstruations (98.2% of the patients, n = 278). Out of the 281 patients for whom a clinical examination was described, 274 patients (97.5%) showed a vulvo-perineal nodule, mass or swelling while six presented with bluish cutaneous lesions (2.1%) and 1 with bilateral polyps of the labia minora (0.4%). All but one patients underwent surgical excision of their lesions but only 88 patients (28.1%) received additional hormonal therapy. The recurrence rate was 10.2% (29 patients) considering a median follow-up period of 10 months (based on 61 studies).

Conclusion: In conclusion, vulvo-perineal endometriosis is a rare entity with approximately 300 cases reported in the literature since 1923. With the available knowledge shown in this systematic review, we encourage all practitioners to think about perineal endometriosis in case of perineal cyclical pain with or without previous perineal damage. Diagnosis should be done with clinical exam, perineal ultrasound and pelvic MRI when available. In case of anal sphincter involvement, perianal ultrasound should be performed. Surgical excision of the lesion should be realized in order to remove the lesion and to confirm the diagnosis histologically. Hormonal treatment could be proposed to attempt to decrease the size of a large lesion before surgery or to avoid recurrence of the lesion. As evidence-based approach to the diagnosis, treatment and recurrence rate of affected patients remains a challenge given its low prevalence, the variations in management found in the articles included and the limited quality of available studies, we suggest that a prospective database on vulvo-perineal endometriosis should be generated to increase knowledge but also awareness among healthcare professionals and optimize patients' care.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202441.

Imaging of ureter: a primer for the emergency radiologist

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Skin endometriosis: A case report and review of the literature

Skin endometriosis is a rare disease with variable clinical and histopathological characteristics that depend on hormonal stimuli. The skin is not a common location, as most cases of endometriosis involve pelvic sites, such as the ovaries, peritoneum and bowel. However, the most common extrapelvic site affected is the abdominal wall and this location of the disease is frequently associated with obstetric and gynecologic surgery. Here we report a case of skin endometriosis emerged as a painful subcutaneous nodule located near to the left side of an obstetrical surgery procedure scar. The patient affected was a woman in her reproductive age, with a history of right ovary endometriotic cyst laparoscopically removed and histologically confirmed as a primary endometriosis. Dermatologists should be aware of this condition in any woman with a painful lump located in the proximity of a pelvic surgery-induced scar. Its non-specific clinical appearance may confuse the clinician and may delay the diagnosis and management.

Pelvic MRI for Endometriosis: A Diagnostic Challenge for the Inexperienced Radiologist. How Much Experience Is Enough?

PURPOSE

The purpose of this study was to investigate the impact of radiologist experience on diagnostic performance of pelvic magnetic resonance imaging (MRI) for the evaluation of endometriomas and different localisations of deep pelvic endometriosis (DPE).

MATERIALS AND METHODS

In this prospective study all pelvic MRI examinations performed for pelvic endometriosis from December 2016 to August 2017 were evaluated by readers with different experience levels; junior resident (0-6 weeks of experience in female imaging), senior resident (7-24 weeks), fellow (6-24 months), and expert (10 years) in female imaging for the presence of endometriomas and DPE. Their evaluations were compared with surgery confirmed with pathology. Diagnostic performances of readers with different levels of experience were studied by the means of receiving operating characteristic curves and areas under the curve (AUC) were compared with the ones of the expert reader.

RESULTS

Of 174 patients evaluated, the standard of reference was available for 59, consisting the final population of the study. The AUC for endometriomas, DPE for the posterior and anterior pelvic compartment, for rectosigmoid DPE and for overall evaluation were 0.983, 0.921, 0.615, 0.862, and 0.914 for the expert reader, 0.966 (p = 0.178), 0.805 (p = 0.001), 0.605 (p = 0.91), 0.872 (p = 0.317), and 0.849 (p = 0.0009) for the fellow level, 0.877 (p = 0.002), 0.757 (p < 0.001), 0.585 (p = 0.761), 0.744 (p = 0.239), and 0.787 (p = < 0.001) for the senior resident level and 0.861 (p = 0.177), 0.649 (p < 0.001), 0.648 (p = 0.774), 0.862 (p = 1), and 0.721 (p < 0.001) for the junior resident level.

CONCLUSIONS

According to our results, interpretation of pelvic MRI for DPE should be performed by specialists as; even the performance of radiologists with up to 2 years of experience in female imaging was statistically inferior to that of experts.

Identification of Functional lncRNAs Associated With Ovarian Endometriosis Based on a ceRNA Network

Background

Endometriosis is a common gynecological disease affecting women of reproductive age; however, the mechanisms underlying this condition are not fully clear. The aim of this study was to identify functional long non-coding RNAs (lncRNAs) associated with ovarian endometriosis for potential use as biomarkers and therapeutic targets.

Methods

RNA-seq profiles of paired ectopic (EC) and eutopic (EU) endometrial samples from patients with ovarian endometriosis were downloaded from the publicly available Gene Expression Omnibus (GEO) database. Bioinformatics algorithms were used to construct a network of ovarian endometriosis-related competing endogenous RNAs (ceRNAs) and to detect functional lncRNAs.

Results

A total of 4,213 mRNAs, 1,474 lncRNAs, and 221 miRNAs were identified as being differentially expressed between EC and EU samples, and an ovarian endometriosis-related ceRNA network was constructed through analysis of these differentially expressed RNAs. H19 and GS1-358P8.4 were identified as key ovarian endometriosis-related lncRNAs through topological feature analysis, and RP11-96D1.10 was identified using a random walk with restart algorithm.

Conclusion

Based on bioinformatics analysis of a ceRNA network, we identified the lncRNAs H19, GS1-358P8.4, and RP11-96D1.10 as being strongly associated with ovarian endometriosis. These three lncRNAs hold potential as targets for medical therapy and as diagnostic biomarkers. Further studies are needed to elucidate the detailed biological function of these lncRNAs in the pathogenesis of endometriosis.

Magnetic Resonance Imaging in the Evaluation of Female Infertility

Pelvic MRI plays an important adjunctive role in the clinical workup of female infertility. Hysterosalpingography is the first line imaging modality in evaluation of female infertility, and hysterosalpingo-contrast sonography can also be used to evaluate both the uterine cavity and fallopian tubes. Pelvic MRI can be helpful in the workup of female infertility, particularly in cases of Mullerian duct anomalies, fibroids, adenomyosis, endometriosis, and tubal disease. These conditions and their appearance on imaging will be reviewed in this article.

Infertility in women with bowel endometriosis: first-line assisted reproductive technology results in satisfactory cumulative live-birth rates

OBJECTIVE

To evaluate the assisted reproductive technology (ART) cumulative live-birth rate (LBR) in a cohort of bowel endometriosis patients with no prior history of surgery for endometriosis.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

One hundred and one consecutive infertile bowel-endometriosis patients with no prior history of surgery for endometriosis in whom the diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging.

INTERVENTION(S)

First-line ART.

MAIN OUTCOME MEASURE(S)

Cumulative LBR, with statistical analysis via Kaplan Meier method with a "conservative" method, whereby it was assumed that no live births took place for patients who did not return.

RESULT(S)

Between January 2016 and December 2018, 101 bowel endometriosis patients underwent 176 ART cycles. The mean number of deep-infiltrating endometriosis lesions per patient was 3 ± 0.9, with a mean number of bowel lesions of 1.3 ± 0.6. Seventy-three percent of the patients had associated endometriomas, and 88.1% had associated adenomyosis. Overall, the cumulative LBR after four ART cycles was 64.4%, using the conservative Kaplan-Meier method.

CONCLUSION(S)

The ART cumulative LBR was very satisfactory (64.4%) in bowel endometriosis patients with no prior history of surgery for endometriosis. In light of these data, clinicians should carefully weigh the pros and cons before systematically referring infertile bowel endometriosis patients to fertility-preserving surgery because as first-line ART appears to offer satisfactory results.

Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment

We aim to describe the diagnosis and surgical management of urinary tract endometriosis (UTE). We detail current diagnostic tools, including advanced transvaginal ultrasound, magnetic resonance imaging, and surgical diagnostic tools such as cystourethroscopy. While discussing surgical treatment options, we emphasize the importance of an interdisciplinary team for complex cases that involve the urinary tract. While bladder deep endometriosis (DE) is more straightforward in its surgical treatment, ureteral DE requires a high level of surgical skill. Specialists should be aware of the important entity of UTE, due to the serious health implications for women. When UTE exists, it is important to work within an interdisciplinary radiological and surgical team.

Differentiation of Endometriomas from Ovarian Hemorrhagic Cysts at Magnetic Resonance: The Role of Texture Analysis

Background and Objectives: To assess ovarian cysts with texture analysis (TA) in magnetic resonance (MRI) images for establishing a differentiation criterion for endometriomas and functional hemorrhagic cysts (HCs) that could potentially outperform their classic MRI diagnostic features. Materials and Methods: Forty-three patients with known ovarian cysts who underwent MRI were retrospectively included (endometriomas, n = 29; HCs, n = 14). TA was performed using dedicated software based on T2-weighted images, by incorporating the whole lesions in a three-dimensional region of interest. The most discriminative texture features were highlighted by three selection methods (Fisher, probability of classification error and average correlation coefficients, and mutual information). The absolute values of these parameters were compared through univariate, multivariate, and receiver operating characteristic analyses. The ability of the two classic diagnostic signs ("T2 shading" and "T2 dark spots") to diagnose endometriomas was assessed by quantifying their sensitivity (Se) and specificity (Sp), following their conventional assessment on T1-and T2-weighted images by two radiologists. Results: The diagnostic power of the one texture parameter that was an independent predictor of endometriomas (entropy, 75% Se and 100% Sp) and of the predictive model composed of all parameters that showed statistically significant results at the univariate analysis (100% Se, 100% Sp) outperformed the ones shown by the classic MRI endometrioma features ("T2 shading", 75.86% Se and 35.71% Sp; "T2 dark spots", 55.17% Se and 64.29% Sp). Conclusion: Whole-lesion MRI TA has the potential to offer a superior discrimination criterion between endometriomas and HCs compared to the classic evaluation of the two lesions' MRI signal behaviors.

Risk of small for gestational age is reduced after frozen compared with fresh embryo transfer in endometriosis

RESEARCH QUESTION

What are the perinatal outcomes and especially the risk of small for gestational age (SGA) babies born after frozen versus fresh embryo transfer in mothers affected by endometriosis undergoing treatment with assisted reproductive technology (ART)?

DESIGN

A cohort study conducted between November 2012 and October 2017, in which infertile women with endometriosis undergoing ART and achieving singleton pregnancies that lasted beyond 12 weeks of gestation were included. Pregnancies obtained after a frozen embryo transfer (FET) were compared with those obtained after a fresh embryo transfer. A total of 339 pregnant women were included: 112 patients in the fresh embryo transfer group and 227 in the FET group. The main outcome was the rate of SGA. Secondary analyses were performed for adverse pregnancy outcomes and perinatal complications.

RESULTS

Of the included women, 109/112 (97.3%) and 222/227 (97.8%) delivered a live child after at least 24 weeks of gestation in the fresh and in the frozen embryo transfer groups, respectively (P = 0.53). The risk of SGA decreased after a FET compared with a fresh embryo transfer (odds ratio [OR] 0.49 [0.25-0.98], P = 0.04) after multivariable analysis. The mean birthweight and the gestational age at delivery were not significantly different between the two study groups. Other pregnancy and perinatal complications were not statistically different between the two study populations.

CONCLUSIONS

The present study of endometriosis-affected women found a significantly lower risk of SGA in patients undergoing frozen, mainly blastocyst, embryo transfer compared with patients undergoing fresh, mainly cleavage stage, embryo transfer.

Obstructive rectal endometriosis treated by robot-assisted laparoscopic surgery: a case report

Background

Rectal endometriosis is a rare disease. A definitive diagnosis prior to surgery is often difficult. We encountered a patient with rectal sub-obstructive endometriosis that was treated by robot-assisted laparoscopic low anterior resection.

Case presentation

A 43-year-old woman visited our hospital with suspected stenosis caused by upper rectal cancer. She had a 2-year history of constipation. We were unable to confirm the diagnosis through detailed examinations, including laparoscopy. Robot-assisted laparoscopic low anterior resection with D3 lymph node dissection was performed for both diagnosis and treatment. The postoperative specimen showed a submucosal tumor. The pathological examination confirmed rectal endometriosis.

Conclusions

We herein describe a rare case of obstructive rectal endometriosis that we were unable to diagnose preoperatively. Robotic surgery was useful in this case, which involved extensive pelvic adhesion.

Endometriosis of the Paralumbar Muscles: A Case Report and Literature Review

The objective of this study is to report a case of deep endometriosis of the paralumbar muscles (psoas, multifidus, and erector spinae) and review existing literature on its management. A 34-year-old female with a history of endometriosis was seen for infertility. Paralumbar muscle masses seen on computed tomography (CT) scan were sampled, confirming endometriosis. Gonadotropin-releasing hormone agonist was given for 2 months. The patient was primed for assisted reproduction. A literature review was conducted to provide an understanding of paralumbar muscle endometriosis. To our knowledge, this is the first reported case of multifidus and erector spinae muscle endometriosis and fifth case of psoas muscle endometriosis. Because the available information is scarce, data from the existing literature on deep endometriosis may aid in the diagnosis and management. Magnetic resonance imaging and CT scan are essential imaging techniques to map lesions. Excision seems prudent, but the approach should be individualized depending on the patient's presentation and her preferences.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

ADVANCES IN KNOWLEDGE

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

Endometriosis phenotypes are associated with specific serum metabolic profiles determined by proton-nuclear magnetic resonance

RESEARCH QUESTION

What is the correlation between serum metabolic profile and endometriosis phenotype?

DESIGN

A pilot study nestled in a prospective cohort study at a university hospital, including 46 patients with painful endometriosis who underwent surgery and 21 controls who did not have macroscopic endometriotic lesions. Endometriosis was strictly classified into two groups of 23 patients each: endometrioma (OMA) and deep infiltrating endometriosis (DIE). Serum samples were collected before surgery for metabolomic profiling based on proton-nuclear magnetic resonance spectroscopy in combination with statistical approaches. Comparative identification of the metabolites in the serum from endometriosis patients and from controls was carried out, including an analysis according to endometriosis phenotype.

RESULTS

The serum metabolic profiles of the endometriosis patients revealed significantly lower concentrations of several amino acids compared with the controls, whereas the concentrations of free fatty acids and ketone bodies were significantly higher. The OMA and the DIE phenotypes each had a specific metabolic profile, with higher concentrations of two ketone bodies in the OMA group, and higher concentrations of free fatty acids and lipids in the DIE group.

CONCLUSION

Proton-nuclear magnetic resonance-based metabolomics of serum samples were found to have ample potential for identifying metabolic changes associated with endometriosis phenotypes. This information may improve our understanding of the pathogenesis of endometriosis.

Non-neoplastic conditions mimicking peritoneal carcinomatosis at CT imaging

The general appearance of peritoneal carcinomatosis at abdominal CT and other cross-sectional imaging modalities consists of varying amounts of peritoneal-based soft tissue implants (mass-forming or infiltrative), peritoneal fluid, and occasionally calcification. However, a wide variety of common and uncommon neoplastic and non-neoplastic conditions can closely mimic peritoneal carcinomatosis at imaging. Neoplastic mimics of peritoneal carcinomatosis include primary peritoneal and sub peritoneal tumors, as well as peritoneal lymphomatosis and sarcomatosis.Broad categories of non-neoplastic mimics of peritoneal carcinomatosis include tumor-like conditions, systemic processes, atypical infections, and fat-based conditions. For many entities, suggestive or specific patient information and/or CT imaging findings exist that may allow the radiologist to narrow the differential diagnosis. In this article, we review the salient clinical and cross-sectional imaging features of non-neoplastic mimics of peritoneal carcinomatosis and malignancy, with emphasis on the CT findings and the additional clues that may suggest the correct benign diagnosis.

Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Endometriosis MRI lexicon: consensus statement from the society of abdominal radiology endometriosis disease-focused panel

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

Ellagic acid-Fe nanoscale coordination polymer with higher longitudinal relaxivity for dual-modality T1-weighted magnetic resonance and photoacoustic tumor imaging

Dual-modality contrast agents for T₁-weighted magnetic resonance imaging (MRI) and photoacoustic imaging have attracted substantial attention as they combine the advantages of unlimited penetration depth and high sensitivity. However, most of the reported agents are Gd-based materials that exhibit nephrotoxicity, and few studies have focused on Fe-based materials owing to their lower relaxivity. This work describes the development of an ellagic acid (EA)-Fe nanoscale coordination polymer with high longitudinal relaxivity and strong near-infrared absorption for dual-modality T₁-weighted MRI and photoacoustic imaging. The longitudinal relaxivity (r₁) of the prepared EA-Fe@BSA nanoparticles was 2.54 mM^-1 s^-1, an increase of 185% compared with previously reported gallic acid-Fe nanoparticles. Furthermore, in vitro and in vivo experiments demonstrate that the EA-Fe@BSA NPs are an excellent T₁-weighted MRI and photoacoustic dual-modality contrast agent with the advantages of convenient synthesis and low toxicity, exhibiting great potential for clinical use in tumor imaging.

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.

Endometriosis within the inguinal hernia sac

Endometriosis is characterized by the presence of histologically normal endometrial tissue outside the uterine cavity. Endometriotic implants are usually located in the pelvic organs, but they have been described in almost every location of the female body. It may also be present after cesarean section or other gynecological operations. In this study, we reported a rare case of endometriosis located in an indirect inguinal hernia sac.

Niche role of MRI in the evaluation of female infertility

Infertility is a major social and clinical problem affecting 13-15% of couples worldwide. The pelvic causes of female infertility are categorized as ovarian disorders, tubal, peritubal disorders, and uterine disorders. Appropriate selection of an imaging modality is essential to accurately diagnose the aetiology of infertlity, since the imaging diagnosis directs the appropriate treatment to be instituted. Imaging evaluation begins with hystero- salpingography (HSG), to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at HSG but usually require further characterization with pelvic ultrasound (US), sono-hysterography (syn: hystero-sonography/saline infusion sonography) or pelvic magnetic resonance imaging (MRI), when US remains inconclusive. The major limitation of hysterographic US, is its inability to visualize extraluminal pathologies, which are better evaluated by pelvic US and MRI. Although pelvic US is a valuable modality in diagnosing entities comprising the garden variety, however, extensive pelvic inflammatory disease, complex tubo-ovarian pathologies, deep-seated endometriosis deposits with its related complications, Mulllerian duct anomalies, uterine synechiae and adenomyosis, often remain unresolved by both transabdominal and transvaginal US. Thus, MRI comes to the rescue and has a niche role in resolving complex adnexal masses, endometriosis, and Mullerian duct anomalies with greater ease. This is a review, based on the authors' experience at tertiary care teaching hospitals and aims to provide an imaging approach towards the abnormalities which are not definitively diagnosed by ultrasound alone.