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Miao K, Lv Q, Zhang L, Zhao N, Dong X. Discriminative diagnosis of ovarian endometriosis cysts and benign mucinous cystadenomas based on the ConvNeXt algorithm. Eur J Obstet Gynecol Reprod Biol 2024; 298:135-139. [PMID: 38756053 DOI: 10.1016/j.ejogrb.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE The objective of this study was to develop a deep learning model, using the ConvNeXt algorithm, that can effectively differentiate between ovarian endometriosis cysts (OEC) and benign mucinous cystadenomas (MC) by analyzing ultrasound images. The performance of the model in the diagnostic differentiation of these two conditions was also evaluated. METHODS A retrospective analysis was conducted on OEC and MC patients who had sought medical attention at the Fourth Affiliated Hospital of Harbin Medical University between August 2018 and May 2023. The diagnosis was established based on postoperative pathology or the characteristics of aspirated fluid guided by ultrasound, serving as the gold standard. Ultrasound images were collected and subjected to screening and preprocessing procedures. The data set was randomly divided into training, validation, and testing sets in a ratio of 5:3:2. Transfer learning was utilized to determine the initial weights of the ConvNeXt deep learning algorithm, which were further adjusted by retraining the algorithm using the training and validation ultrasound images to establish a new deep learning model. The weights that yielded the highest accuracy were selected to evaluate the diagnostic performance of the model using the validation set. Receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) was calculated. Additionally, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and odds ratio were calculated. Decision curve analysis (DCA) curves were plotted. RESULTS The study included 786 ultrasound images from 184 patients diagnosed with either OEC or MC. The deep learning model achieved an AUC of 0.90 (95 % CI: 0.85-0.95) in accurately distinguishing between the two conditions, with a sensitivity of 90 % (95 % CI: 84 %-95 %), specificity of 90 % (95 % CI: 77 %-97 %), a positive predictive value of 96 % (95 % CI: 91 %-99 %), a negative predictive value of 77 % (95 % CI: 63 %-88 %), a positive likelihood ratio of 9.27 (95 % CI: 3.65-23.56), and a negative likelihood ratio of 0.11 (95 % CI: 0.06-0.19). The DCA curve demonstrated the practical clinical utility of the model. CONCLUSIONS The deep learning model developed using the ConvNeXt algorithm exhibits high accuracy (90 %) in distinguishing between OEC and MC. This model demonstrates excellent diagnostic performance and clinical utility, providing a novel approach for the clinical differentiation of these two conditions.
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Affiliation(s)
- Kuo Miao
- Department of Ultrasound, Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qian Lv
- Department of Ultrasound, Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Liwei Zhang
- Department of Ultrasound, Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ning Zhao
- Department of Ultrasound, Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xiaoqiu Dong
- Department of Ultrasound, Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
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Metzler JM, Finger L, Burkhardt T, Hodel ME, Manegold-Brauer G, Imboden S, Pape J, Imesch P, Witzel I, Bajka M. Systematic, noninvasive endometriosis diagnosis in transvaginal sonography by the Swiss Society of Ultrasound in Medicine. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 38788738 DOI: 10.1055/a-2241-5233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
We present a new systematic, comprehensive, checklist-based sonographic assessment of endometriosis in the female true pelvis. Emphasis is placed on practical skills teaching. The newly introduced White Sliding Line (WSL) is the core structure. The WSL separates five compartments (anterior, central, posterior, and lateral right and left) containing dedicated endometriosis signs of mobility and morphology to be checked. This approach relies on the 2016 IDEA Consensus and further developments. It directly connects to the 2021 #ENZIAN Classification Standard. In practice, evaluation follows the proposed checklist in all compartments, judging first sliding mobility between organs and structures in a highly dynamic investigation. A rigorous search for deep endometriosis (DE) is then performed. We treat adhesions due to their great clinical importance and possible, reliable diagnosis by TVS as the fifth endometriosis unit, next to endometrioma, DE, adenomyosis, and superficial endometriosis. Including superficial (peritoneal) endometriosis is a future goal.
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Affiliation(s)
- Julian Matthias Metzler
- Gynecology, University Hospital Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Switzerland
| | - Leana Finger
- Faculty of Medicine, University of Zurich, Switzerland
| | - Tilo Burkhardt
- Obstetrics, University Hospital Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Switzerland
| | | | | | - Sara Imboden
- Gynecology, Inselspital University Hospital, Bern, Switzerland
- Faculty of Medicine, University of Bern, Switzerland
| | - Janna Pape
- Gynecological Endocrinology and Reproductive Medicine, Inselspital University Hospital, Bern, Switzerland
- Faculty of Medicine, University of Bern, Switzerland
| | - Patrick Imesch
- Gynecology, University Hospital Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Switzerland
| | - Isabell Witzel
- Gynecology, University Hospital Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Switzerland
| | - Michael Bajka
- Gynecology, University Hospital Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Switzerland
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Werdel R, Mabie A, Evans TL, Coté RD, Schlundt A, Doehrman P, Dilsaver D, Coté JJ. Serum Levels of Interleukins in Endometriosis Patients: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2024; 31:387-396.e11. [PMID: 38428575 DOI: 10.1016/j.jmig.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/01/2024] [Accepted: 02/23/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE The aims of this systematic review and meta-analysis were to produce a comprehensive survey of the serum levels of interleukins (ILs) in untreated people with endometriosis compared with people without endometriosis. DATA SOURCES A systematic literature search of English language studies within Cinahl, Medline Complete, PubMed, and Scopus from inception to May 2023 was performed. METHODS OF STUDY SELECTION We included studies that compared IL serum levels in people with endometriosis to those without endometriosis. Meta-analysis was performed on IL-1RA, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-17A, IL-18, IL-23, and IL-37. TABULATION, INTEGRATION, AND RESULTS The systematic search retrieved 651 studies, of which 77 underwent a full-text review. A total of 30 studies met inclusion criteria for the meta-analysis. IL-1Ra, IL-6, and IL-37 serum levels were 2.56 (95% CI 2.20-2.92, p <.001), 1.38 (95% CI 0.58-2.17, p <.001), and 1.77 (95% CI 1.33-2.20, p <.001) standard deviations higher in the patients with endometriosis compared with patients without endometriosis while IL-23 serum levels 0.40 (95% CI -0.73 to -0.07, p = .02) standard deviations lower, respectively. CONCLUSION There is mounting evidence that ILs, especially IL-6, may be good candidates for unique noninvasive diagnostic tools and/or treatment pathways for endometriosis.
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Affiliation(s)
- Ryan Werdel
- Kansas City University College of Osteopathic Medicine (Werdel), Kansas City, MO; Creighton University School of Medicine, Department of Biomedical Sciences (Werdel), Omaha, NE
| | - April Mabie
- Creighton University School of Medicine, (Mabie and Evans), Omaha, NE
| | - Taylor L Evans
- Creighton University School of Medicine, (Mabie and Evans), Omaha, NE
| | - Remington D Coté
- Creighton University, Department of Biology (R. Coté), Omaha, NE
| | - Andrew Schlundt
- Creighton University, Department of Exercise Science (Schlundt), Omaha, NE
| | - Pooja Doehrman
- Creighton University School of Medicine, Department of Obstetrics & Gynecology (Dr. Doehrman), Phoenix, AZ; CommonSpirit Health, Department of Obstetrics & Gynecology (Drs. Doehrman and J. Coté), Chicago, IL; Arizona College of Medicine, Department of Obstetrics & Gynecology (Dr. Doehrman), Phoenix, AZ
| | - Danielle Dilsaver
- Creighton University School of Medicine, Department of Clinical Research and Public Health (Dilsaver), Omaha, NE
| | - John J Coté
- Creighton University School of Medicine, Department of Obstetrics & Gynecology (Dr. J.Coté), Omaha, NE; CommonSpirit Health, Department of Obstetrics & Gynecology (Drs. Doehrman and J. Coté), Chicago, IL.
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Orlov S, Sladkevicius P, Jokubkiene L. Evaluating the development of endometriosis and adenomyosis lesions over time: An ultrasound study of symptomatic women. Acta Obstet Gynecol Scand 2024. [PMID: 38687177 DOI: 10.1111/aogs.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION There is a gap in knowledge regarding development of endometriosis and adenomyosis lesions visible at transvaginal ultrasound. The objectives were to evaluate if women with symptoms suggestive of endometriosis or adenomyosis but normal ultrasound examination develop endometriosis or adenomyosis lesions visible at ultrasound over time and if alterations of symptoms over time are associated with ultrasound findings at follow-up. MATERIAL AND METHODS This was a prospective cohort study of 100 symptomatic women with normal initial ultrasound examination during 2014-2017 who underwent follow-up ultrasound examination in 2022. Symptoms suggestive of endometriosis were assessed using visual analog scale at both examinations and minimal clinically important difference of 10 mm was considered as a significant alteration. An examiner with expertise in advanced ultrasound examination of endometriosis performed transvaginal ultrasound examinations in accordance with the consensus protocol by the International Deep Endometriosis Analysis group. RESULTS At follow-up ultrasound examination of 100 women, 13 (13% [95% CI 7.1-21.2]) had visible endometriosis or adenomyosis lesions, 8 (8% [95% CI 3.5-15.2]) had endometriosis lesions, and 6 (6% [95% CI 2.2-12.6]) had adenomyosis. At follow-up, women with endometriosis or adenomyosis lesions reported lower intensity of dysmenorrhea and chronic pelvic pain compared to women without lesions (48 mm [IQR 16-79] vs. 73 mm [IQR 46-85] and 45 mm [IQR 26-57] vs. 57 mm [IQR 36-75], p = 0.087 and p = 0.026, respectively). None of the women with endometriosis or adenomyosis lesions reported increased intensity of dysmenorrhea at follow-up, compared to 32/86 women (37%) without lesions (p = 0.008). Increased intensity of chronic pelvic pain tended to be less common in women with lesions compared to those without (3/13 [23%] vs. 35/86 [41%], p = 0.223). CONCLUSIONS Our findings suggest that in symptomatic women, endometriosis and adenomyosis lesions visible at ultrasound may develop over time. However, majority of women remain having normal ultrasound examinations despite symptoms. Exacerbation of dysmenorrhea or chronic pelvic pain during follow-up was not associated with the development of endometriosis or adenomyosis lesions visible at ultrasound, suggesting that even women with less severe symptoms might benefit from a follow-up ultrasound when indicated.
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Affiliation(s)
- Sofie Orlov
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
- Department of Obstetrics and Gynecology, Ystad Hospital, Ystad, Sweden
| | - Povilas Sladkevicius
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
| | - Ligita Jokubkiene
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
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Szabó G, Hudelist G, Madár I, Rigó JJ, Dobó N, Fintha A, Lipták L, Kalovics E, Fancsovits V, Bokor A. Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE - a prospective cohort study. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:61-68. [PMID: 36781162 DOI: 10.1055/a-2034-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To test the accuracy of TVS applying the IDEA approach for suspected rectosigmoid DE and to determine the frequency of other pelvic diseases mimicking DE in patients undergoing surgery. MATERIALS UND METHODS Prospective single center observational study including consecutive women undergoing TVS for clinically suspected rectosigmoid DE followed by conservative or surgical therapy. TVS findings were compared with those obtained by laparoscopy and confirmed histologically. RESULTS Of the 671 included patients, 128 women opted for medical therapy, and 6 patients decided for surgery but did not give consent to participate in the study. 537 women were enrolled in the final analysis. 279 (52 %) exhibited surgically confirmed rectosigmoid DE. The sensitivity and specificity, positive and negative predictive value (PPV, NPV), positive and negative likelihood ratio (LR+/-) and accuracy of TVS for diagnosing DE in the rectosigmoid were 93.5 %, 94.6 %, 94.9 %, 93.1 %, 17.24, 0.07, 94.04 %. 12 women who were clinically suspected for DE and mimicked sonographic signs fulfilling the IDEA criteria did exhibit other pathologies. Diagnoses were as follows: vaginal Gartner duct cyst (3/291;1.0 %), anorectal abscess (3/291; 1.0 %), rectal cancer (2/291;0.7 %), hydrosalpinx (2/291;0.7 %), metastatic endometrial cancer (1/291;0.35 %) and Crohn's disease (1/291;0.35 %). CONCLUSION TVS for diagnosing colorectal DE applying the IDEA criteria is highly accurate for presurgical diagnosis. However, additional pelvic pathologies are encountered in 4-5 % of women attending for suspected rectosigmoid DE. These need to be taken into account when investigating patients for suspected DE.
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Affiliation(s)
- Gábor Szabó
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Gernot Hudelist
- Department of Gynaecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria
- Department of Obstetrics and Gynecology, Rudolfinerhaus Private Clinic and Campus, Vienna, Austria
| | - István Madár
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - János Jr Rigó
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
- Department of Clinical Studies in Obstetrics and Gynecology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - Noémi Dobó
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Attila Fintha
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Laura Lipták
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Emma Kalovics
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Veronika Fancsovits
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Attila Bokor
- Faculty of Medicine, Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
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Ren Q, Yuan M, Wang G. Role of ultrasonography in the evaluation of disease severity and treatment efficacy in adenomyosis. Arch Gynecol Obstet 2024; 309:363-371. [PMID: 37115275 DOI: 10.1007/s00404-023-07034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/01/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Adenomyosis is a benign disorder characterized by the presence of ectopic endometrial glands and stroma within the myometrium. The main clinical manifestations of adenomyosis are dysmenorrhea, menorrhagia, and infertility, which affect patients' quality of life. Recently, with advancements in imaging techniques, magnetic resonance imaging, and ultrasonography have become the main diagnostic tools for adenomyosis. In addition to the diagnosis and differential diagnosis of adenomyosis, ultrasonography can also be used to evaluate the severity of adenomyosis. The emergence of new techniques, such as elastography and contrast-enhanced ultrasonography (CEUS), has significantly improved the accuracy of ultrasound-based diagnosis of adenomyosis. These two imaging tools can also be used for the differential diagnosis of adenomyosis and the evaluation of treatment efficacy after medication or ablation procedure. OBJECTIVE we review the efficacy of ultrasonography as a diagnostic tool for adenomyosis. We also aim to introduce the potential of ultrasound imaging in the evaluation of the severity of this disease, as well as the application of elastography and contrast-enhanced ultrasonography (CEUS) in its diagnosis. RESULTS AND CONCLUSION Our findings reveal the potential value of ultrasonography combined with elastography and/or CEUS as medication guidance and efficacy evaluation tools in the long-term management of adenomyosis.
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Affiliation(s)
- Qianhui Ren
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Jinan, 250000, Shandong, China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Ming Yuan
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Jinan, 250000, Shandong, China
- Gynecology Laboratory, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Guoyun Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Jinan, 250000, Shandong, China.
- Gynecology Laboratory, Shandong Provincial Hospital, Jinan, Shandong, China.
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Harth S, Kaya HE, Zeppernick F, Meinhold-Heerlein I, Keckstein J, Yildiz SM, Nurkan E, Krombach GA, Roller FC. Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement. Front Med (Lausanne) 2023; 10:1303593. [PMID: 38046415 PMCID: PMC10690940 DOI: 10.3389/fmed.2023.1303593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
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.
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Affiliation(s)
- Sebastian Harth
- Department of Diagnostic and Interventional Radiology, Justus Liebig University Giessen, Giessen, Germany
| | - Hasan Emin Kaya
- Department of Radiology, School of Medicine, Görükle Campus, Bursa Uludağ University, Bursa, Türkiye
| | - Felix Zeppernick
- Department of Gynecology and Obstetrics, Justus Liebig University Giessen, Giessen, Germany
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, Justus Liebig University Giessen, Giessen, Germany
| | - Jörg Keckstein
- Endometriosis Clinic Dres. Keckstein, Villach, Austria
- Department of Obstetrics and Gynecology, Medical University Ulm, Ulm, Germany
- SEF, Westerstede, Germany
| | - Selcuk Murat Yildiz
- Department of Diagnostic and Interventional Radiology, Justus Liebig University Giessen, Giessen, Germany
| | - Emina Nurkan
- Department of Diagnostic and Interventional Radiology, Justus Liebig University Giessen, Giessen, Germany
| | - Gabriele Anja Krombach
- Department of Diagnostic and Interventional Radiology, Justus Liebig University Giessen, Giessen, Germany
| | - Fritz Christian Roller
- Department of Diagnostic and Interventional Radiology, Justus Liebig University Giessen, Giessen, Germany
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Kalaitzopoulos DR, Zografou M, Nirgianakis K, Daniilidis A, Krentel H, Eberhard M, Samartzis N. Treatment after endometrioma recurrence: a narrative review. Minerva Obstet Gynecol 2023; 75:449-459. [PMID: 37058320 DOI: 10.23736/s2724-606x.23.05249-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Ovarian endometrioma is a common subtype of endometriosis with a prevalence between 17 and 44%. The reported average recurrence of endometrioma after surgical management is 21.5% after 2 years and 40-50% after 5 years. The aim of this narrative review was to summarize the existing literature focusing on treatment options after endometrioma recurrence in order to provide an evidence-based approach for the clinical practice. EVIDENCE ACQUISITION Three electronic databases (MEDLINE, EMBASE and Cochrane) were searched until September 2022 for eligible studies. EVIDENCE SYNTHESIS The available studies showed that repeated surgery has a negative impact on ovarian function, without improving the fertility outcomes. Transvaginal aspiration as an alternative option for surgery has a high rate of recurrence, which varies from 8.20 to 43.5% depending on the technique used and on the study population. Pregnancy related outcomes were similar between transvaginal aspiration groups and no intervention groups in patients with endometrioma recurrence. Regarding medical treatments, only four studies were found, showing that progestins reduce the pain and the diameter of the ovarian cyst. CONCLUSIONS Recurrent endometrioma is a challenging condition which could be encountered during the care of women with endometriosis. The decision about the treatment-strategy has to be individualized considering family planning status, age, ovarian reserve and transvaginal ultrasound findings. Well-designed randomized clinical trials are needed to export safer conclusions about the most appropriate treatment in each specific condition after endometrioma recurrence.
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Affiliation(s)
| | - Maria Zografou
- Clinic of Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Konstantinos Nirgianakis
- Center for Gynecologic Surgery, Heraklion, Greece
- University Hospital of Berne, Berne, Switzerland
| | - Angelos Daniilidis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Harald Krentel
- Clinic of Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Markus Eberhard
- Department of Obstetrics and Gynecology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
| | - Nicolas Samartzis
- Department of Obstetrics and Gynecology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
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Koninckx PR, Ussia A, Gordts S, Keckstein J, Saridogan E, Malzoni M, Stepanian A, Setubal A, Adamyan L, Wattiez A. The 10 "Cardinal Sins" in the Clinical Diagnosis and Treatment of Endometriosis: A Bayesian Approach. J Clin Med 2023; 12:4547. [PMID: 37445589 DOI: 10.3390/jcm12134547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence-based data for endometriosis management are limited. Experiments are excluded without adequate animal models. Data are limited to symptomatic women and occasional observations. Hormonal medical therapy cannot be blinded if recognised by the patient. Randomised controlled trials are not realistic for surgery, since endometriosis is a variable disease with low numbers. Each diagnosis and treatment is an experiment with an outcome, and experience is the means by which Bayesian updating, according to the past, takes place. If the experiences of many are similar, this holds more value than an opinion. The combined experience of a group of endometriosis surgeons was used to discuss problems in managing endometriosis. Considering endometriosis as several genetically/epigenetically different diseases is important for medical therapy. Imaging cannot exclude endometriosis, and diagnostic accuracy is limited for superficial lesions, deep lesions, and cystic corpora lutea. Surgery should not be avoided for emotional reasons. Shifting infertility treatment to IVF without considering fertility surgery is questionable. The concept of complete excision should be reconsidered. Surgeons should introduce quality control, and teaching should move to explain why this occurs. The perception of information has a personal bias. These are the major problems involved in managing endometriosis, as identified by the combined experience of the authors, who are endometriosis surgeons.
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Affiliation(s)
- Philippe R Koninckx
- Department of OBGYN, Faculty of Medicine, Katholieke University Leuven, 3000 Leuven, Belgium
- Department of OBGYN, Faculty of Medicine, University of Oxford, Oxford OX1 2JD, UK
- Department of OBGYN, Faculty of Medicine, University Cattolica, del Sacro Cuore, 00168 Rome, Italy
- Department of OBGYN, Faculty of Medicine, Moscow State University, 119991 Moscow, Russia
- Latifa Hospital, Dubai 9115, United Arab Emirates
| | - Anastasia Ussia
- Department of OBGYN, Gemelli Hospitals, Università Cattolica, 00168 Rome, Italy
| | | | - Jörg Keckstein
- Endometriosis Centre, Dres. Keckstein, 9500 Villach, Austria
- Faculty of Medicine, University Ulm, 89081 Ulm, Germany
| | - Ertan Saridogan
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London SW7 2BX, UK
| | | | - Assia Stepanian
- Academia of Women's Health and Endoscopic Surgery, Atlanta, GA 30328, USA
| | - Antonio Setubal
- Department of Ob/Gyn and MIGS, Hospital da Luz Lisbon, 1500-650 Lisboa, Portugal
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov, Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 117198 Moscow, Russia
- Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Arnaud Wattiez
- Latifa Hospital, Dubai 9115, United Arab Emirates
- Department of Obstetrics and Gynaecology, University of Strasbourg, 67081 Strasbourg, France
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10
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Konrad L, Fruhmann Berger LM, Maier V, Horné F, Neuheisel LM, Laucks EV, Riaz MA, Oehmke F, Meinhold-Heerlein I, Zeppernick F. Predictive Model for the Non-Invasive Diagnosis of Endometriosis Based on Clinical Parameters. J Clin Med 2023; 12:4231. [PMID: 37445265 DOI: 10.3390/jcm12134231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVES Are other pain symptoms in addition to dysmenorrhea, dyspareunia, dyschezia, dysuria, and chronic pelvic pain correlated to endometriosis and suitable for a clinical prediction model? METHODS We conducted a prospective study from 2016 to 2022, including a total of 269 women with numerous pain symptoms and other parameters. All women filled out two questionnaires and were examined by palpation and transvaginal ultrasound (TVUS). In cases of suspected deep endometriosis, magnetic resonance imaging (MRI) was performed. After the operation, endometriosis was diagnosed by histological examination. RESULTS All in all, 30 significant parameters and 6 significant numeric rating scale (NRS) scores associated with endometriosis could be identified: 7 pain adjectives, 8 endometriosis-associated pain symptoms, 5 pain localizations, 6 parameters from the PainDETECT, consumption of analgesics, and allergies. Furthermore, longer pain duration (before, during, and after menstruation) was observed in women with endometriosis compared to women without endometriosis (34.0% vs. 12.3%, respectively). Although no specific pain for endometriosis could be identified for all women, a subgroup with endometriosis reported radiating pain to the thighs/legs in contrast to a lower number of women without endometriosis (33.9% vs. 15.2%, respectively). Furthermore, a subgroup of women with endometriosis suffered from dysuria compared to patients without endometriosis (32.2% vs. 4.3%, respectively). Remarkably, the numbers of significant parameters were significantly higher in women with endometriosis compared to women without endometriosis (14.10 ± 4.2 vs. 7.75 ± 5.8, respectively). A decision tree was developed, resulting in 0.904 sensitivity, 0.750 specificity, 0.874 positive predictive values (PPV), 0.802 negative predictive values (NPV), 28.235 odds ratio (OR), and 4.423 relative risks (RR). The PPV of 0.874 is comparable to the positive prediction of endometriosis by the clinicians of 0.86 (177/205). CONCLUSIONS The presented predictive model will enable a non-invasive diagnosis of endometriosis and can also be used by both patients and clinicians for surveillance of the disease before and after surgery. In cases of positivety, as evaluated by the questionnaire, patients can then seek advice again. Similarly, patients without an operation but with medical therapy can be monitored with the questionnaire.
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Affiliation(s)
- Lutz Konrad
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Lea M Fruhmann Berger
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Veronica Maier
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Fabian Horné
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Laura M Neuheisel
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Elisa V Laucks
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Muhammad A Riaz
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Frank Oehmke
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Ivo Meinhold-Heerlein
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Felix Zeppernick
- Institute of Gynecology and Obstetrics, Faculty of Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
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11
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Keckstein J, Hoopmann M. Endometriosis, ultrasound and #Enzian classification: the need for a common language for non-invasive diagnostics. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:233-239. [PMID: 37279767 DOI: 10.1055/a-2055-6712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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12
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Padmehr R, Shadjoo K, Mohazzab A, Gorgin A, Karegar R, Jaberipour P, Sehat Z, Maleki N. Transvaginal sonography and surgical findings in the diagnosis of endometriosis individuals: A cross-sectional study. Int J Reprod Biomed 2023; 21:471-480. [PMID: 37560068 PMCID: PMC10407920 DOI: 10.18502/ijrm.v21i6.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/30/2023] [Accepted: 03/11/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Endometriosis is a challenging gynecological disease and a debilitating condition that profoundly affects the individual's quality of life. Besides pathological confirmation, diagnostic laparoscopy has been internationally accepted as the standard method to identify the accurate mapping of endometriosis. Transvaginal sonography (TVS) is the first non-invasive imaging modality to estimate the severity of endometriosis. OBJECTIVE This study aimed to evaluate the accuracy of TVS in affected women compared with surgical findings. MATERIALS AND METHODS This retrospective cross-sectional study surveyed 170 women with deep infiltrating endometriosis (DIE) referred to the endometriosis part of the Avicenna Infertility Center, Tehran, Iran and they underwent TVS followed by laparoscopy. Recorded data of individuals under study in the medical database system were reviewed. Finally, the agreement rate was calculated for ultrasound reports and intraoperative (IO) findings regarding ovarian endometrium, ovarian adhesion, involvement of cul-de-sac, rectovaginal septum, and bowel and ureter. RESULTS 170 women with DIE entered the study. The agreement of TVS and IO findings were 86.76% for left ovarian endometriosis and 70.86% for right ovarian endometriosis, 93.90% for left ovarian adhesion, and 88.90% for right ovarian adhesion, 88.90% for a cul-de-sac, and 84.82% for bowel nodules. The findings, based on a laparoscopic assessment of the pelvic floor, were completely compatible with ultrasound reports (100%). CONCLUSION TVS allows a preoperative evaluation in planning the surgical policy associated. TVS is beneficial for dedicated mapping of DIE; thus, an expert radiologist can aid the surgeon in preoperative evaluation and IO management.
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Affiliation(s)
- Roya Padmehr
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Khadijeh Shadjoo
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Arash Mohazzab
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Atefeh Gorgin
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Roxana Karegar
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Parvin Jaberipour
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Zahra Sehat
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Narges Maleki
- Avicenna Infertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
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13
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Harth S, Roller FC, Zeppernick F, Meinhold-Heerlein I, Krombach GA. Deep Infiltrating Endometriosis: Diagnostic Accuracy of Preoperative Magnetic Resonance Imaging with Respect to Morphological Criteria. Diagnostics (Basel) 2023; 13:diagnostics13101794. [PMID: 37238278 DOI: 10.3390/diagnostics13101794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Several current guidelines recommend imaging in the diagnostic work-up of deep infiltrating endometriosis (DIE). The purpose of this retrospective diagnostic test study was to evaluate the diagnostic accuracy of MRI compared to laparoscopy for the identification of pelvic DIE, considering lesion morphology using MRI. In all, 160 consecutive patients were included who received pelvic MRI for evaluation of endometriosis between October 2018 and December 2020 and underwent subsequent laparoscopy within 12 months of the MRI examination. MRI findings were categorized for suspected DIE using the Enzian classification and were additionally graded using a newly suggested deep infiltrating endometriosis morphology score (DEMS). Endometriosis was diagnosed in 108 patients (all types, i.e., purely superficial and DIE), of which 88 cases were diagnosed with DIE and 20 with solely superficial peritoneal endometriosis (i.e., not deep infiltrating endometriosis/DIE). The overall positive and negative predictive values of MRI for the diagnosis of DIE, including lesions with assumed low and medium certainty of DIE on MRI (DEMS 1-3), were 84.3% (95% CI: 75.3-90.4) and 67.8% (95% CI: 60.6-74.2), respectively, and 100.0% and 59.0% (95% CI: 54.6-63.3) when strict MRI diagnostic criteria were applied (DEMS 3). Overall sensitivity of MRI was 67.0% (95% CI: 56.2-76.7), specificity was 84.7% (95% CI: 74.3-92.1), accuracy was 75.0% (95% CI: 67.6-81.5), positive likelihood ratio (LR+) was 4.39 (95% CI: 2.50-7.71), negative likelihood ratio (LR-) was 0.39 (95% CI: 0.28-0.53), and Cohen's kappa was 0.51 (95% CI: 0.38-0.64). When strict reporting criteria are applied, MRI can serve as a method to confirm clinically suspected DIE.
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Affiliation(s)
- Sebastian Harth
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany
| | - Fritz C Roller
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany
| | - Felix Zeppernick
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany
| | - Gabriele A Krombach
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Klinikstr. 33, 35392 Giessen, Germany
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14
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Masternak M, Grabczak M, Szaflik T, Mroczkowska B, Mokros Ł, Smolarz B, Romanowicz H, Szyłło K. The Utility of Rectal Water Contrast Transvaginal Ultrasound for Assessment of Deep Bowel Endometriosis. Life (Basel) 2023; 13:life13051151. [PMID: 37240796 DOI: 10.3390/life13051151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/23/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
Deep infiltrating endometriosis (DIE) is characterized by the presence of endometrial tissue outside the uterine cavity that infiltrates at least 5-mm deep below the peritoneal layer. Imagining examinations are the first-choice methods to detect DIE. The aim of this study is to assess whether rectal water contrast transvaginal sonography (RWC-TVS) can be a useful tool for the estimation of the size of deep bowel endometriotic nodules. This retrospective study includes 31 patients subjected to RWC-TVS who underwent surgery due to deep bowel endometriosis between January 2021 and December 2022. Nodule dimensions measured via ultrasound were compared to those of histopathological samples taken after surgery. In total, 52% of patients had endometriosis limited only to the intestines, 19% had endometriotic nodules located at uterosacral ligaments and posterior vaginal fornix, 6% at the anterior compartment, and 13% at a different location. Additionally, 6% of patients had nodules at more than two locations. In all but one case, the intestinal nodules could be seen on RWC-TVS images. The largest nodule dimension measured via RWC-TVS and the size of the equivalent histopathological sample correlated (R = 0.406, p = 0.03). Thus, RWC-TVS allows for the detection of DIE and moderate estimation of the nodule sizes and should be practiced during a diagnostic process.
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Affiliation(s)
- Martyna Masternak
- Department of Gynecology, Operative Gynecology and Treatment of Endometriosis, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Malwina Grabczak
- Department of Gynecology, Operative Gynecology and Treatment of Endometriosis, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Tomasz Szaflik
- Department of Gynecology, Operative Gynecology and Treatment of Endometriosis, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Beata Mroczkowska
- Department of Gynecology, Operative Gynecology and Treatment of Endometriosis, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Łukasz Mokros
- Second Department of Psychiatry, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Beata Smolarz
- Laboratory of Cancer Genetics, Department of Pathology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Hanna Romanowicz
- Laboratory of Cancer Genetics, Department of Pathology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Krzysztof Szyłło
- Department of Gynecology, Operative Gynecology and Treatment of Endometriosis, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
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15
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Zheng Z, Zhang S, Zheng C, Wang R, Zhang Y, Chen P, Zhou S, Luo B, Di N. Qualitative and quantitative features of deep endometriosis in contrast-enhanced ultrasound: An initial experience and literature review. Clin Hemorheol Microcirc 2023; 85:73-82. [PMID: 37522202 DOI: 10.3233/ch-231843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE This research aims to present the findings of contrast-enhanced ultrasound (CEUS) in a series of patients with proven deep endometriosis (DE) and provide an updated literature review. MATERIALS AND METHODS Between January 2018 and October 2022, seven patients with DE lesions had their imaging and medical records retrospectively reviewed. Clinical data, recorded images of a standardized conventional B-mode ultrasound, and Sonovue® CEUS were interpreted by two blinded, independent, experienced radiologists in consensus. The enhanced characteristics of the DE lesion on CEUS were also assessed using VueBox® software quantitatively. RESULTS DE lesion appeared as irregular hypoechoic or heterogeneous on conventional ultrasound with dotted blood flow signal on color Doppler. Six of seven DE lesions showed heterogeneous hypo-enhancement in arterial phases. All the lesions showed a heterogeneous washout rapidly that began in the late arterial phase. In quantified analysis, the mean relative peak enhancement compared with adjacent tissue was 0.47±0.25. CONCLUSION Our findings and literature review suggested that CEUS could be a feasible and promising non-invasive modality for diagnosing DE.
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Affiliation(s)
- Zijie Zheng
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shen Zhang
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Cheng Zheng
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ruxue Wang
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yanping Zhang
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Peixin Chen
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shanglan Zhou
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Baoming Luo
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Na Di
- Department of Ultrasound, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
- Department of Ultrasound, the First People's Hospital of Kashi Prefecture, Xinjiang, China
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