Diagnosis of pelvic endometriosis by magnetic resonance imaging using "fat-saturation" technique

Diagnosis and treatment of early-stage endometriosis by Transvaginal Hydro laparoscopy

Background: Transvaginal Hydro Laparoscopy (THL) is known as a minimal invasive procedure allowing endoscopic exploration of the female pelvis. Objective: To evaluate the possibilities of the THL as a tool for early diagnosis and treatment of minimal endometriosis. Materials and methods: A retrospective study of a consecutive series of 2288 patients referred for fertility problems to a tertiary centre for reproductive medicine was undertaken. Mean duration of infertility was 23.6 months (SD ±11-48), mean age of patients was 31.25 (SD± 3.8y). With normal findings at clinical and ultrasound examination patients underwent, as part of their fertility exploration, a THL. Main outcome measures: Evaluation of feasibility, identified pathology and pregnancy rate. Results: Endometriosis was diagnosed in 365 patients (16%); the localisation was higher on the left side (n=237) than on the right side (n=169). Small endometriomas, with diameters between 0.5 and 2 cm, were present in 24.3% (right side in 31, left side 48 and bilateral 10). These early lesions were characterised by the presence of active endometrial like cells and a pronounced neo-angiogenesis. Destruction of the endometriotic lesions with bipolar energy resulted in an in vivo pregnancy rate (spontaneous/IUI) of 43.8% (CPR after 8 months: spontaneous 57.7%; IUI/AID 29.7%). Conclusion: THL allowed in a minimally invasive way an accurate diagnosis of the early stages of peritoneal and ovarian endometriosis with the possibility of offering treatment with minimal damage. What is new? This is the largest series reporting the usefulness of THL for the diagnosis and treatment of peritoneal and ovarian endometriosis in patients without obviously visible preoperative pelvic pathology.

Anogenital distance in adult women is a strong marker of endometriosis: results of a prospective study with laparoscopic and histological findings

STUDY QUESTION

Could anogenital distance (AGD) be a non-invasive marker of endometriosis and correlated to the American Society for Reproductive Medicine revised score (r-ASRM) and ENZIAN classifications?

SUMMARY ANSWER

Surgically and histologically proven endometriosis is associated with a short AGD in women of reproductive age but not correlated either to the severity or to the location of the disease.

WHAT IS KNOWN ALREADY

AGD is a marker of intrauterine androgen exposure and exposure to oestrogen-like chemicals such as phthalates. Moreover, exposure to endocrine disruptors, such as organochlorine chemicals, is associated with endometriosis. It has been suggested that a short AGD in women is associated with an increased risk of endometriosis based on clinical and ultrasound exams.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from January 2018 to June 2019 in a tertiary-care centre including 168 adult women undergoing pelvic surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 168 women included, 98 patients had endometriosis (endometriosis group) and 70 did not (non-endometriosis group). An operator (not the surgeon) measured the distance from the clitoral surface to the anus (AGD-AC) and from the posterior fourchette to the anus (AGD-AF) before surgery using a millimetre accuracy ruler. Endometriosis was diagnosed on exploration of the abdominopelvic cavity, and the r-ASRM and ENZIAN scores were calculated. All removed tissues underwent pathological examination.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean (±SD) AGD-AF measurements were 21.5 mm (±6.4) and 32.3 mm (±8.1), and average AGD-AC measurements were 100.9 mm (±20.6) and 83.8 mm (±12.9) in the endometriosis and non-endometriosis groups (P < 0.001), respectively. Mean AGD-AF and AGD-AC measurements were not related to r-ASRM stage (P = 0.73 and 0.80, respectively) or ENZIAN score (P = 0.62 and 0.21, respectively). AGD-AF had a better predictive value than AGD-AC for discriminating the presence of endometriosis (AUC = 0.840 (95% CI 0.782–0.898) and 0.756 (95% CI 0.684–0.828)), respectively. For AGD-AF, an optimal cut-off of 20 mm had a specificity of 0.986 (95% CI 0.923–0.999), sensitivity of 0.306 (95% CI 26.1–31.6) and positive predictive value of 0.969 (95% CI 0.826–0.998). In multivariable analysis, the diagnosis of endometriosis was the only variable independently associated with the AGD-AF (β = −9.66 mm 95% CI −12.20–−7.12), P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The sample size was relatively small with a high proportion of patients with colorectal endometriosis reflecting the activity of an expert centre. Furthermore, we did not include adolescents and the AGD-AF measurement could be particularly relevant in this population.

WIDER IMPLICATIONS OF THE FINDINGS

The measurement of AGD could be a useful non-invasive tool to predict endometriosis. This could be especially relevant for adolescents and virgin women to avoid diagnostic laparoscopy and empiric treatment.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate

Endometriosis is a benign gynecologic disease defined as the presence of functional endometrial glands and stroma outside the uterine cavity, causing dysmenorrhea, dyspareunia, menstrual irregularities, and infertility. Serum CA-125 measurement is now a consolidated method for diagnosing this condition, and its interpretation has posed a number of problems, particularly regarding utility in diagnosing minimal-mild endometriosis, whereas its value as a diagnostic aid in moderate-severe stages is well recognized. In our cohort, serum CA-125 values were significantly elevated in patients with ovarian and mixed endometriosis lesions (median levels 48 U/mL), compared with those who had exclusively extraovarian foci (median levels 27 U/mL), and so the correlation between this marker and the surgical and pathologic finding of ovarian and deep endometriosis was found to be statistically significant; however, the location did not affect the fertility rate.

Endometriose pélvica: comparação entre imagens por ressonância magnética de baixo campo (0,2 T) e alto campo (1,5 T)

OBJETIVO: Comparar a ressonância de baixo campo (0,2 T) com a de alto campo (1,5 T) na avaliação da endometriose pélvica e adenomiose. MATERIAIS E MÉTODOS: Foram estudadas, prospectivamente, 27 pacientes do sexo feminino com suspeita clínica de endometriose, realizando-se exames de ressonância magnética de alto campo e baixo campo. Um mesmo radiologista realizou a leitura dos exames, iniciando pelo baixo campo, seguido pelo alto campo, usando como padrão-ouro o alto campo. RESULTADOS: Das 27 pacientes estudadas, 18 (66,7%) apresentaram alguma lesão indicativa de endometriose nos exames realizados no alto campo. Foram corretamente diagnosticados pelo baixo campo 14 destas pacientes. Endometriomas, lesões tubárias e focos de endometriose maiores do que 7 mm identificados pelo alto campo foram também identificados no baixo campo, com acurácia, sensibilidade e especificidade de 100%. Das nove pacientes com adenomiose caracterizadas pelo alto campo, oito foram corretamente identificadas pelo baixo campo, com acurácia, sensibilidade e especificidade de 88,9%. CONCLUSÃO: A ressonância de baixo campo apresentou baixa sensibilidade na detecção de pequenos focos de endometriose, alta sensibilidade na detecção de endometriomas e focos de endometriose grandes, e boa acurácia na detecção da adenomiose quando comparada com a ressonância de alto campo.

Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study--Part 1

OBJECTIVE

To determine the value of patient-reported symptoms in diagnosing endometriosis.

DESIGN

A national case-control study.

SETTING

Data from the UK General Practice Research Database for years 1992-2001.

SAMPLE

A total of 5540 women aged 15-55 years, diagnosed with endometriosis, each matched to four controls without endometriosis.

METHODS

Data were analysed to determine whether specific symptoms were highly indicative of endometriosis. Odds ratios for these symptoms were derived by conditional logistic regression analysis.

MAIN OUTCOME MEASURES

Symptoms associated with endometriosis.

RESULTS

The prevalence of diagnosed endometriosis was 1.5%. A greater proportion of women with endometriosis had abdominopelvic pain, dysmenorrhoea or menorrhagia (73%) compared with controls (20%). Compared with controls, women with endometriosis had increased risks of abdominopelvic pain (OR 5.2 [95% CI: 4.7-5.7]), dysmenorrhoea (OR 8.1 [95% CI: 7.2-9.3]), menorrhagia (OR 4.0 [95% CI: 3.5-4.5]), subfertility (OR 8.2 [95% CI: 6.9-9.9]), dyspareunia and/or postcoital bleeding (OR 6.8 [95% CI: 5.7-8.2]), and ovarian cysts (OR 7.3 [95% CI: 5.7-9.4]), and of being diagnosed with irritable bowel syndrome (IBS) (OR 1.6 [95% CI: 1.3-1.8]) or pelvic inflammatory disease (OR 3.0 [95% CI: 2.5-3.6]). Women with endometriosis were also found to consult the doctor more frequently than the controls and were twice as likely to have time off work.

CONCLUSIONS

Specific symptoms and frequent medical consultation are associated with endometriosis and appear useful in the diagnosis. Endometriosis may coexist with or be misdiagnosed as pelvic inflammatory disease or IBS.

Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis

BACKGROUND

We compared the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of deep pelvic endometriosis (DPE), with respect to surgical and histological findings.

METHODS

Longitudinal study of 88 consecutive patients referred for surgical management of DPE, who underwent both MRI and RES pre operatively. The diagnostic criteria were identical for MRI and RES and were based on visualization of hypointense/hypoechoic areas in specific locations. DPE was diagnosed when at least one site was involved. We calculated the sensitivity, specificity, predictive values, accuracy and 95% confidence interval of MRI and RES for DPE.

RESULTS

DPE and endometriomas were present in 97.7 and 39.7% of women, respectively. The sensitivity, specificity and positive and negative predictive values of MRI and RES, respectively, were 84.8 and 45.6%, 88.8 and 40%, 98.5 and 87.8% and 40 and 8.5% for uterosacral endometriosis; 77.7 and 7.4%, 70% and 100, 85.3 and 100% and 89.7 and 70.9% for vaginal endometriosis and 88.3 and 90%, 92.8 and 89.3%, 96.4 and 94.7% and 78.8 and 80.6% for colorectal endometriosis.

CONCLUSIONS

MRI is more accurate than RES for the diagnosis of uterosacral and vaginal endometriosis, whereas the two methods are similarly accurate for colorectal endometriosis.

[Endometriosis imaging]

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

Usefulness and limits of CA-125 in diagnosis of endometriosis without associated ovarian endometriomas

BACKGROUND

The aim of this study was to evaluate the diagnostic significance of CA-125 for endometriosis without ovarian endometriomas.

METHODS

Preoperative serum CA-125 levels were measured in 775 consecutive women diagnosed by laparoscopy or laparotomy with endometriosis, adenomyosis, leiomyomas, or normal pelvis.

RESULTS

Receiver operating characteristic curve analysis revealed that the area under the curve for endometriosis without endometriomas was 0.788, significantly smaller than that for endometriosis with endometriomas (0.935, P < 0.05). In diagnosis of endometriosis without endometriomas, both the maximal accuracy of 78.8% and the maximal diagnostic value of 61.2% were obtained at the cutoff value of 20 U/mL. Negative predictive value was 78.0% at the cutoff value of 20 U/mL, whereas positive predictive value was 92.9% at the cutoff value of 30 U/mL. This range is clearly superior to the empirical single cutoff of 35 U/mL.

CONCLUSIONS

In the diagnosis of endometriosis without endometriomas, combined use of two cutoff values for CA-125, 20 and 30 U/mL, provides improved diagnostic performance. However, the accuracy of using only CA-125 testing for diagnosis is still limited. Serum CA-125 testing can be done during initial screenings of women with possible endometriosis.

A novel technique using magnetic resonance imaging jelly for evaluation of rectovaginal endometriosis

OBJECTIVE

To evaluate the usefulness of the magnetic resonance imaging (MRI) jelly method as a preoperative diagnostic means for patients with rectovaginal endometriosis.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Thirty one patients with suspected rectovaginal endometriosis based on clinical symptoms and the results of preoperative pelvic, rectal, and ultrasonographic examinations, who were scheduled to undergo laparoscopic surgery.

INTERVENTION(S)

Before surgery, jelly for ultrasonography was injected into the vagina and rectum for MRI. The MRI findings were compared with findings obtained through laparoscopic surgery and histopathologic examination of the removed tissues.

MAIN OUTCOME MEASURE(S)

The complete cul-de-sac obliteration and deep lesion confirmed at the time of the laparoscopic surgery were evaluated by the MRI jelly method.

RESULT(S)

For detecting the presence of complete obliteration of the cul-de-sac, the accuracy of the diagnosis of rectovaginal endometriosis attained using the MRI jelly method was sensitivity 90.9% and specificity 77.8%. For the presence of a deep lesion, the sensitivity was 94.1% and specificity 100%.

CONCLUSION(S)

The condition of the cul-de-sac could be imaged clearly via the MRI jelly method. Not only rectovaginal endometriosis presenting with deep lesions, but also complete cul-de-sac obliteration alone could be diagnosed preoperatively at a high rate.

Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathologic examination for the detection of endometriosis

OBJECTIVE

To evaluate the utility of fat-suppressed magnetic resonance imaging (MRI) in the diagnosis of endometriosis.

DESIGN

A prospective clinical trial.

SETTING

A government research hospital.

PATIENT(S)

Forty-eight women with pelvic pain.

INTERVENTION(S)

Magnetic resonance imaging followed by surgical excision and pathologic diagnosis of endometriosis.

MAIN OUTCOME MEASURE(S)

Presence and extent of endometriosis suggested by preoperative MRIs compared with surgical inspection and biopsy.

RESULT(S)

A preoperative MRI in 46 women detected fewer endometriosis lesions than histopathology or laparoscopy (78 vs. 101 vs. 150). Few MRI lesions correlated with those identified by laparoscopy (50 of 150) or pathology (38 of 101). Of 42 women with surgically diagnosed endometriosis, 28 had at least one corresponding abnormality on MRI, 5 had abnormalities that didn't correlate with surgical findings, and 9 had normal MRIs. The sensitivity of MRI in detecting biopsy-proven endometriosis for any woman was 69% (25 of 36), and the specificity was 75%.

CONCLUSION(S)

Although MRI identifies fewer areas of endometriosis than seen at surgery, it suggested endometriosis in 75% of those with at least mild disease. Only 67% of lesions identified at surgery contained histologic evidence of endometriosis.

Comparison of magnetic resonance imaging and transvaginal ultrasonography in diagnosing bladder endometriosis

STUDY OBJECTIVE

To take recent progress in magnetic resonance imaging (MRI) into account to determine its accuracy compared with that of transvaginal ultrasonography (TVUS) in diagnosing bladder endometriosis.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Twelve women with histologically proved bladder endometriosis.

INTERVENTION

Magnetic resonance imaging with body and endocavitary coils and TVUS.

MEASUREMENTS AND MAIN RESULTS

Although TVUS was normal in four patients, MRI enabled endometriotic lesions to be detected in all patients. Magnetic resonance imaging with endocavitary coil established the existence of deep infiltration in three patients when muscularis involvement was not visible with the body coil. In seven women MRI determined how far deep posterior endometriotic lesions extended, whereas with TVUS this was impossible to see. Conclusion. MRI had advantages over TVUS in diagnosing small lesions of associated posterior deep endometriotic lesions. The endocavitary coil gave better results than the phased-array coil for diagnosing deep infiltration. These results are important in that they help guide surgical management.

Deeply infiltrating endometriosis: implications, diagnosis, and management

Deeply infiltrating endometriosis was described in the early part of the last century. Only recently, has there become a greater awareness and understanding of this form of endometriosis aided in part by advances in laparoscopic surgical technology in techniques. The clinical implications of the disease as well as diagnosis and current management are reviewed.

Diagnostic value of radiological tests in chronic pelvic pain

Chronic pelvic pain (CPP) presents a diagnostic as well as a therapeutic challenge to many clinicians. This chapter briefly describes the most frequent identifiable causes for CPP amenable to imaging; explains the most widely-used and widely available radiological tests for CPP; and compares/contrasts each test's utility and accuracy for a given causality. Examples of each imaging modality are included for demonstration purposes, and a summation table cross-references the best diagnostic methods with corresponding disease processes. References from the literature of both radiology and gynaecology were used in preparing this review.

Magnetic resonance imaging and serum CA-125 in evaluating patients with endometriomas prior to medical therapy

OBJECTIVE

To determine whether magnetic resonance imaging (MRI) and serum levels of CA-125 can be used to evaluate patients with endometriomas before initiating medical treatment.

DESIGN

Comparative study before and after medical treatment.

SETTING

Shimane Medical University Hospital, Izumo, Japan.

PATIENTS

Eleven consecutive patients with at least one endometrioma > 10 mm in maximal diameter that was diagnosed by laparoscopy and treated with 900 micrograms/d buserelin acetate for 6 months.

INTERVENTIONS

Magnetic resonance imaging and blood sampling was performed < 2 weeks before laparoscopy.

MAIN OUTCOME MEASURES

Signal intensity of edometrioma/signal intensity of gluteus maximum muscle on T2-weighted image (T2SI:MSI); volume of endometrioma and serum CA-125.

RESULTS

There was a positive linear correlation (r = 0.787) between T2SI:MSI before treatment and the extent of decrease in the volume of endometrioma. There was a negative linear relationship between serum CA-125 before treatment and the mean extent of decrease in the cyst volume (r = 0.678). The reduction in volume of endometrioma and T2SI:MSI before treatment related to the outcome of patients.

CONCLUSION

The T2SI:MSI on MRI and serum CA-125 may be useful for estimating the outcome of patients with endometriomas before initiating medical treatment.