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Ha K, Sheets K, Kedar R, Gooden C, Palmer DA, Mikhail E. Primary Cervical Lymphoma Mimicking Deep Endometriosis. J Minim Invasive Gynecol 2024; 31:357-359. [PMID: 38423501 DOI: 10.1016/j.jmig.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/14/2024] [Accepted: 02/23/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Kristal Ha
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida (Dr. Ha).
| | - Kyle Sheets
- Department of Radiology, University of South Florida, Morsani College of Medicine, Tampa (Drs. Sheets, Kedar), Florida
| | - Rajendra Kedar
- Department of Radiology, University of South Florida, Morsani College of Medicine, Tampa (Drs. Sheets, Kedar), Florida
| | - Casey Gooden
- Pathology, Ruffolo, Hooper & Associates, Tampa, Florida (Dr. Gooden)
| | - Drew A Palmer
- Florida Urology Partners, Tampa, Florida (Dr. Palmer)
| | - Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida (Dr. Mikhail)
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2
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Dantkale KS, Agrawal M. A Comprehensive Review of the Diagnostic Landscape of Endometriosis: Assessing Tools, Uncovering Strengths, and Acknowledging Limitations. Cureus 2024; 16:e56978. [PMID: 38665720 PMCID: PMC11045176 DOI: 10.7759/cureus.56978] [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: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Endometriosis is a prevalent yet often underdiagnosed condition characterized by the presence of endometrial-like tissue outside the uterus, leading to significant morbidity and impaired quality of life. A timely and accurate diagnosis of endometriosis is essential for effective management and improved patient outcomes. This review provides a comprehensive overview of the current diagnostic landscape of endometriosis, including clinical evaluation, imaging modalities, biomarkers, and laparoscopy. The strengths and limitations of each diagnostic approach are critically evaluated, alongside challenges such as delayed diagnosis and misinterpretation of findings. The review emphasizes the importance of multidisciplinary collaboration, standardized diagnostic protocols, and ongoing research to enhance diagnostic accuracy and facilitate early intervention. By addressing these challenges and leveraging emerging technologies, healthcare professionals can improve the diagnosis and management of endometriosis, ultimately enhancing the well-being of affected individuals.
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Affiliation(s)
- Ketki S Dantkale
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Manjusha Agrawal
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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3
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Crivellaro PS, Rehman I, Chang S, Duigenan S, Holmes S, Hurrell C, Kielar AZ, Leonardi M, Pang E, Shergill A, Al-Arnawoot B. Current Practice Patterns, Challenges, and Need for Education in Performing and Reporting Advanced Pelvic US and MRI to Investigate Endometriosis: A Survey by the Canadian Association of Radiologists Endometriosis Working Group. Can Assoc Radiol J 2024; 75:38-46. [PMID: 37336789 DOI: 10.1177/08465371231179292] [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: 06/21/2023] Open
Abstract
Purpose: The Canadian Association of Radiologists (CAR) Endometriosis Working Group developed a national survey to evaluate current practice patterns associated with imaging endometriosis using advanced pelvic ultrasound and MRI to inform forthcoming clinical practice guidelines for endometriosis imaging. Methods: The anonymous survey consisted of 36 questions and was distributed electronically to CAR members. The survey contained a mix of multiple choice, Likert scale and open-ended questions intended to collect information about training and certification, current practices and protocols associated with imaging endometriosis, opportunities for quality improvement and continuing professional development. Descriptive statistics were used to summarize the results. Results: Canadian radiologists were surveyed about their experience with imaging endometriosis. A total of 89 responses were obtained, mostly from Ontario and Quebec. Most respondents were community radiologists, and almost 33% were in their first five years of practice. Approximately 38% of respondents reported that they or their institution performed advanced pelvic ultrasound for endometriosis, with most having done so for less than 5 years, and most having received training during residency or fellowship. 70% of respondents stated they currently interpret pelvic endometriosis MRI, with most having 1-5 years of experience. Conclusion: Many radiologists in Canada do not perform dedicated imaging for endometriosis. This may be due to a lack of understanding of the benefits and limited access to training. However, dedicated imaging can improve patient outcomes and decrease repeated surgeries. The results highlight the importance of developing guidelines for these imaging techniques and promoting a multidisciplinary approach to endometriosis management.
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Affiliation(s)
| | - Iffat Rehman
- Department of Medical Imaging, University of British Columbia, Vancouver, BC, Canada
| | - Silvia Chang
- Department of Medical Imaging, University of British Columbia, Vancouver, BC, Canada
| | - Shauna Duigenan
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Signy Holmes
- Department of Radiology, Max Ready College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Ania Z Kielar
- Joint Department of Medical Imaging, University of Toronto, Toronto ON, Canada
| | - Mathew Leonardi
- Department of Obstetrics & Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Emily Pang
- Department of Medical Imaging, University of British Columbia, Vancouver, BC, Canada
| | - Arvind Shergill
- Department of Medical Imaging, University of British Columbia, Vancouver, BC, Canada
- Department of Medical Imaging, Fraser Health East, Abbotsford Regional Hospital and Cancer Centre, Abbotsford, BC, Canada
| | - Basma Al-Arnawoot
- Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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4
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Lu W, Yang L, Schulberg JD. An Unusual Cause of Small Bowel Obstruction. Gastroenterology 2024; 166:255-258. [PMID: 37813128 DOI: 10.1053/j.gastro.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/23/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Weiwei Lu
- Department of Gastroenterology, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Linda Yang
- Department of Gastroenterology, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Julien D Schulberg
- Department of Gastroenterology, St. Vincent's Hospital Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia.
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5
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Nadeem A, Habte A, Ahsan A, Tariq R, Basaria AAA. Deep Infiltrating Endometriosis: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2897-2904. [PMID: 37578280 DOI: 10.1002/jum.16318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 07/24/2023] [Accepted: 07/30/2023] [Indexed: 08/15/2023]
Abstract
Deep infiltrating endometriosis (DIE) is a subperitoneal intrusion of endometrial tissue. Resulting endometrial nodules may develop on the uterosacral ligament, urinary tract, rectovaginal, and retrocervical areas, and less commonly in the urinary bladder, thoracic, and neural regions. Genetics, age, and environmental factors determine the progression of the disease. DIE manifests with numerous symptoms, which are similar to unrelated diseases, namely dysmenorrhea, dyspareunia, urinary tract infections, and infertility. Transvaginal ultrasound, magnetic resonance imaging, computed tomography, and physical examination may detect and differentiate endometriosis lesions from other diseases. Its clinical management typically involves laparoscopic surgery and hormonal therapy. These are designed to improve the quality of life and to address individual reproductive goals. This pictorial essay aims to provide clinical cases to highlight the characteristic radiological findings in each diagnostic modality and in addition to elucidate the current clinical management of DIE.
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Affiliation(s)
- Abdullah Nadeem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Alexander Habte
- Department of Surgery, Assab Military Hospital, Assab, Eritrea
| | - Areeba Ahsan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Rabeea Tariq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Shenoy-Bhangle AS, Pires-Franco IV, Ray LJ, Cao J, Kilcoyne A, Horvat N, Chamie LP. Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique. Acad Radiol 2023:S1076-6332(23)00608-6. [PMID: 37996365 DOI: 10.1016/j.acra.2023.10.053] [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: 09/22/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023]
Abstract
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.
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Affiliation(s)
- Anuradha S Shenoy-Bhangle
- Harvard Medical School, Massachusetts General Hospital, MassGeneral Brigham Radiology, 55 Fruit Street, WHT-2- 270, Boston, Massachusetts, 02114, USA (A.S.S.B.).
| | | | - Lauren J Ray
- Massachusetts General Hospital, Department of Pathology, 55 Fruit Street, Boston, Massachusetts, 02114, USA (L.J.R.)
| | - Jinjin Cao
- Massachusetts General Hospital, 55 Fruit Street, WHT-2-207, Boston, Massachusetts, 02114, USA (J.C.)
| | - Aoife Kilcoyne
- Massachusetts General Hospital, MassGeneral Brigham Radiology, 55 Fruit Street, WHT-2- 270, Boston, Massachusetts, 02114, USA (A.K.)
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York, 10065, USA (N.H.)
| | - Luciana Pardini Chamie
- Chamie Imagem da Mulher, Casa do Ator street. 1117, 72 suite, São Paulo, 04546-004, Brazil (L.P.C.)
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Baușic AIG, Matasariu DR, Manu A, Brătilă E. Transvaginal Ultrasound vs. Magnetic Resonance Imaging: What Is the Optimal Imaging Modality for the Diagnosis of Endometriosis? Biomedicines 2023; 11:2609. [PMID: 37892983 PMCID: PMC10604115 DOI: 10.3390/biomedicines11102609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
Endometriosis, an intriguing gynecological illness, poses a substantial health concern for women of reproductive age, despite its widespread occurrence and limited comprehension. The objective of this study is to assess the diagnostic precision of transvaginal sonography (TVS) and pelvic magnetic resonance imaging (MRI) for the identification of deep infiltrated endometriosis (DIE). This study encompassed a cohort of 256 patients exhibiting signs and symptoms of endometriosis, with the aim of assessing the diagnostic accuracy over a span of four years. Both TVS and pelvic MRI were employed in the same centers to analyze each subject. The histopathologic analysis and laparoscopy were the most reliable and widely accepted methods for evaluation. TVS is a reliable diagnostic tool for ovarian endometriomas, obviating the necessity for MRI confirmation. The specificity of TVS in diagnosing ovarian endometriomas is 57.14%, while its sensitivity is 93.78%, resulting in an overall accuracy of 84.47%. In relation to parametrial lesions, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: TVS: 9%, 97%, 32%, MRI: 27.14%, 89.19%, and 40.11%. Concerning the uterosacral lesions, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: TVS:14.63%, 94.74%, and 55%, while MRI: 65.88%, 66.30%, and 66.1%. Regarding rectal endometriosis, the sensitivity, specificity, and accuracy of TVS and MRI were as follows: 69.72%, 76.87%, and 73.82% for TVS, and 66.28%, 94.51%, and 80.79% for MRI. The results of the present study indicate that whereas MRI generally exhibits superior capability in assessing the severity of endometriosis, TVS demonstrates sufficient diagnostic accuracy in DIE comparable to MRI.
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Affiliation(s)
- Alexandra Irma Gabriela Baușic
- Department of Obstetrics and Gynecology, Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Obstetrics and Gynecology, “Prof. Dr. Panait Sîrbu” Obstetrics and Gynecology Hospital, 060251 Bucharest, Romania
| | - Daniela Roxana Matasariu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania
| | - Andrei Manu
- Department of Obstetrics and Gynecology, Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Obstetrics and Gynecology, “Prof. Dr. Panait Sîrbu” Obstetrics and Gynecology Hospital, 060251 Bucharest, Romania
| | - Elvira Brătilă
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Obstetrics and Gynecology, “Prof. Dr. Panait Sîrbu” Obstetrics and Gynecology Hospital, 060251 Bucharest, Romania
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Bendifallah S, Dabi Y, Suisse S, Delbos L, Spiers A, Poilblanc M, Golfier F, Jornea L, Bouteiller D, Fernandez H, Madar A, Petit E, Perotte F, Fauvet R, Benjoar M, Akladios C, Lavoué V, Darnaud T, Merlot B, Roman H, Touboul C, Descamps P. Validation of a Salivary miRNA Signature of Endometriosis - Interim Data. NEJM EVIDENCE 2023; 2:EVIDoa2200282. [PMID: 38320163 DOI: 10.1056/evidoa2200282] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: The discovery of a saliva-based micro–ribonucleic acid (miRNA) signature for endometriosis in 2022 opened up new perspectives for early and noninvasive diagnosis of the disease. The 109-miRNA saliva signature is the product of miRNA biomarkers and artificial intelligence (AI) modeling. We designed a multicenter study to provide external validation of its diagnostic accuracy. We present here an interim analysis. METHODS: The first 200 patients included in the multicenter prospective ENDOmiRNA Saliva Test study (NCT05244668) were included for interim analysis. The study population comprised women from 18 to 43 years of age with a formal diagnosis of endometriosis or with suspected endometriosis. Epidemiologic, clinical, and saliva sequencing data were collected between November 2021 and March 2022. Genomewide miRNA expression profiling by small RNA sequencing using next-generation sequencing (NGS) was performed, and a random forest algorithm was used to assess the diagnostic accuracy. RESULTS: In this interim analysis of the external validation cohort, with a population prevalence of 79.5%, the 109-miRNA saliva diagnostic signature for endometriosis had a sensitivity of 96.2% (95% confidence interval [CI], 93.7 to 97.3%), specificity of 95.1% (95% CI, 85.2 to 99.1%), positive predictive value of 95.1% (95% CI, 85.2 to 99.1%), negative predictive value of 86.7% (95% CI, 77.6 to 90.3%), positive likelihood ratio of 19.7 (95% CI, 6.3 to 108.8), negative likelihood ratio of 0.04 (95% CI, 0.03 to 0.07), and area under the receiver operating characteristic curve of 0.96 (95% CI, 0.92 to 0.98). CONCLUSIONS: The use of NGS and AI in the sequencing and analysis of miRNA provided a saliva-based miRNA signature for endometriosis. Our interim analysis of a prospective multicenter external validation study provides support for its ongoing investigation as a diagnostic tool. (Funded by Ziwig and the Conseil Régional d’Ile de France [Grant EX024087]; ClinicalTrials.gov number, NCT05244668.)
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Affiliation(s)
- Sofiane Bendifallah
- Department of Obstetrics and Reproductive Medicine, Tenon Hospital, Paris
- Clinical Research Group Paris 6: Endometriosis Expert Center, Sorbonne University, Sorbonne, France
- INSERM UMR S 938, Centre De Recherche scientifique Saint-Antoine (CRSA), Sorbonne University, Paris
| | - Yohann Dabi
- Department of Obstetrics and Reproductive Medicine, Tenon Hospital, Paris
- Clinical Research Group Paris 6: Endometriosis Expert Center, Sorbonne University, Sorbonne, France
- INSERM UMR S 938, Centre De Recherche scientifique Saint-Antoine (CRSA), Sorbonne University, Paris
| | | | - Léa Delbos
- Department of Obstetrics and Reproductive Medicine-Angers University Hospital, Angers, France
- Endometriosis Expert Center-Pays de la Loire, Angers, France
| | | | - Mathieu Poilblanc
- Department of Obstetrics and Reproductive Medicine, Lyon South University Hospital, Lyon Civil Hospices, Lyon, France
- Endometriosis Expert Center-Steering Committee of the EndAURA Network, Lyon, France
| | - Francois Golfier
- Department of Obstetrics and Reproductive Medicine, Lyon South University Hospital, Lyon Civil Hospices, Lyon, France
- Endometriosis Expert Center-Steering Committee of the EndAURA Network, Lyon, France
| | - Ludmila Jornea
- Sorbonne Université, Paris Brain and Spinal Cord Institute (ICM), Institut national de la santé et de la recherche médicale U1127, CNRS UMR 7225, Assistance publique-Hôpitaux de Paris (APHP)-Pitié-Salpêtrière Hospital, Paris
| | - Delphine Bouteiller
- Genotyping and Sequencing Core Facility, iGenSeq, Paris Brain and Spinal Cord Institute (ICM), Pitié-Salpêtrière Hospital, Paris
| | - Hervé Fernandez
- Department of Obstetrics and Reproductive Medicine, University Hospital (HU) Paris Sud, Kremlin Bicetre APHP, Le Kremlin Bicetre, France
| | - Alexandra Madar
- Department of Obstetrics and Reproductive Medicine, Tenon Hospital, Paris
| | - Erick Petit
- Department of Obstetrics and Reproductive Medicine, Paris Saint Joseph Hospital, Paris
| | - Frédérique Perotte
- Department of Obstetrics and Reproductive Medicine, Paris Saint Joseph Hospital, Paris
| | - Raffaèle Fauvet
- Department of Obstetrics and Reproductive Medicine, Côte De Nacre University Hospital, Caen, France
| | | | - Cherif Akladios
- Department of Obstetrics and Reproductive Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Vincent Lavoué
- Department of Obstetrics, Gynecology and Human Reproduction, University of Rennes, Rennes, France
| | - Thomas Darnaud
- Bastia Hospital Center, Department of Specialised Surgery and Clinical Research, Bastia, France
| | | | - Horace Roman
- Endometriosis Center, Tivoli-Ducos Clinic, Bordeaux, France
| | - Cyril Touboul
- Department of Obstetrics and Reproductive Medicine, Tenon Hospital, Paris
- Clinical Research Group Paris 6: Endometriosis Expert Center, Sorbonne University, Sorbonne, France
- INSERM UMR S 938, Centre De Recherche scientifique Saint-Antoine (CRSA), Sorbonne University, Paris
| | - Philippe Descamps
- Department of Obstetrics and Reproductive Medicine-Angers University Hospital, Angers, France
- Endometriosis Expert Center-Pays de la Loire, Angers, France
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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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10
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Comparison between CT-enterography and MR-enterography for the diagnosis of right-sided deep infiltrating endometriosis of the bowel. Eur J Radiol 2023; 161:110730. [PMID: 36758279 DOI: 10.1016/j.ejrad.2023.110730] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To compare computed tomography-enterography (CTE) and magnetic resonance-enterography (MRE) in the detection of right-sided bowel deep infiltrating endometriosis (DIE). MATERIALS AND METHODS Fifty women with DIE who underwent preoperatively CTE and MRE were included. CTE and MRE were first analyzed separately by two independent readers who analyzed five bowel segments (cecum, appendix, ileocecal junction, distal ileum and proximal small bowel [i.e., proximal ileum and jejunum]) for the presence of DIE and then interpreted in consensus. CTE, MRE and CTE with MRE were compared in terms of sensitivity, specificity and accuracy. Interobserver agreement was assessed with kappa (κ) test. RESULTS Using the reference standard 25 out 250 bowel segments were involved by DIE in 18 women and 225 were free of DIE. Sensitivity, specificity, and accuracy of CTE were 60% (95% confidence interval [CI]: 39-79), 93% (95% CI: 89-96) and 90% (95% CI: 85-93) for Reader 1, respectively, and 52% (95% CI: 31-72), 99% (95% CI: 97-100) and 94% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.564) and specificity (P = 0.181) between readers and fair interobserver agreement (κ = 0.37). For MRE these figures were 52% (95% CI: 31-72), 92% (95% CI: 88-95) and 88% (95% CI: 84-92) for Reader 1 and 60% (95% CI: 39-79), 99% (95% CI: 96-100) and 95% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.157) and specificity (P = 0.061) between readers and fair interobserver agreement (κ = 0.31). Significant differences in sensitivity (20%; 95% CI: 7-41) were found between CTE + MRE vs. CTE alone for Reader 1 and vs. MRE alone for Reader 2 (P = 0.041 for both) CONCLUSION: CTE and MRE have not different sensitivities and convey only fair interobserver agreement but are highly specific for the diagnosis of right-sided bowel DIE. CTE and MRE are complementary because they improve the detection of DIE implants when used in combination.
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11
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MR of Fallopian Tubes. Magn Reson Imaging Clin N Am 2023; 31:29-41. [DOI: 10.1016/j.mric.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Guan Q, Velho RV, Sehouli J, Mechsner S. Endometriosis and Opioid Receptors: Are Opioids a Possible/Promising Treatment for Endometriosis? Int J Mol Sci 2023; 24:ijms24021633. [PMID: 36675147 PMCID: PMC9864914 DOI: 10.3390/ijms24021633] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Endometriosis (EM), defined as the presence of endometrial-like tissue with surrounding smooth muscle cells outside the uterus, is a disregarded gynecological disease reported to affect 6-10% of women of reproductive age, with 30-50% of them suffering from chronic pelvic pain and infertility. Since the exact pathogenic mechanisms of EM are still unclear, no curative therapy is available. As pain is an important factor in EM, optimal analgesia should be sought, which to date has been treated primarily with non-steroidal anti-inflammatory drugs (NSAIDs), metamizole or, in extreme cases, opioids. Here, we review the pain therapy options, the mechanisms of pain development in EM, the endogenous opioid system and pain, as well as the opioid receptors and EM-associated pain. We also explore the drug abuse and addiction to opioids and the possible use of NOP receptors in terms of analgesia and improved tolerability as a target for EM-associated pain treatment. Emerging evidence has shown a promising functional profile of bifunctional NOP/MOP partial agonists as safe and nonaddictive analgesics. However, until now, the role of NOP receptors in EM has not been investigated. This review offers a thought which still needs further investigation but may provide potential options for relieving EM-associated pain.
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Quesada J, Härmä K, Reid S, Rao T, Lo G, Yang N, Karia S, Lee E, Borok N. Endometriosis: A multimodal imaging review. Eur J Radiol 2023; 158:110610. [PMID: 36502625 DOI: 10.1016/j.ejrad.2022.110610] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/07/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non - gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains. Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability. Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity. Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.
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Affiliation(s)
- Juan Quesada
- Department of Obstetrics & Gynecology, Campbelltown Hospital (South-Western Sydney Local Health District), Terry Rd, Campbelltown, NSW 2560, Australia.
| | - Kirsi Härmä
- Department of Diagnostic, Interventional and Pediatric Radiology - University Hospital of Bern, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Shannon Reid
- Western Sydney University, Faculty of Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia; Sonacare Women's Health and Ultrasound, Harrington, NSW 2567, Australia
| | - Tanushree Rao
- Department of Obstetrics & Gynecology at Liverpool Hospital, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Glen Lo
- Department of Radiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; The Western Ultrasound for Women, 1/160a Cambridge St, West Leederville, Perth, WA 6007, Australia.
| | - Natalie Yang
- Department of Radiology, The Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia.
| | - Sonal Karia
- Department of Obstetrics & Gynecology, Campbelltown Hospital (South-Western Sydney Local Health District), Terry Rd, Campbelltown, NSW 2560, Australia.
| | - Emmeline Lee
- Department of Radiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; The Western Ultrasound for Women, 1/160a Cambridge St, West Leederville, Perth, WA 6007, Australia
| | - Nira Borok
- Department of Radiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia.
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Olinger K, Maheshwari E, Shenoy-Bhangle AS, Adejolu M, McGettigan M, Mathew H, Lee KS, Nicola R. Mimics of cancer in pregnancy. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 48:1752-1773. [PMID: 36577923 DOI: 10.1007/s00261-022-03783-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022]
Abstract
Pregnancy is a remarkable time of pronounced growth and development of the fetus. Benign pathologies outside of the uterus, including those containing hormonally responsive tissue which undergo physiologic changes and other incidentally identified lesions, may mimic malignancy on clinical evaluation and imaging. A detailed history and physical exam, ultrasound and non-contrast magnetic resonance imaging features and comparison with prior imaging if available may help to narrow the list of potential differential diagnoses. Follow-up imaging in the postpartum period is often vital to confirm benignity and, in some cases, sampling to confirm the diagnosis is necessary. This review will cover the clinical, pathological and multimodality imaging features of numerous potential mimickers of cancer in the setting of pregnancy organized by organ systems. The goal is to better equip abdominal radiologists to accurately identify benign disease and help guide further imaging or follow-up recommendations to avoid unnecessarily aggressive intervention and improve patient care.
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Affiliation(s)
- Kristen Olinger
- Division of Abdominal Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2021 Old Clinic Building, Chapel Hill, NC, 27599, USA.
| | - Ekta Maheshwari
- Division of Abdominal Imaging, Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15143, USA
| | - Anuradha S Shenoy-Bhangle
- Division of Abdominal Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, 02214, USA
| | - Margaret Adejolu
- Department of Radiology, The Royal Marsden Hospital, London, England, UK
| | | | | | - Karen S Lee
- Division of Abdominal Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Refky Nicola
- Division of Abdominal Imaging, Department of Radiology, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
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Transvaginal Ultrasound vs. Magnetic Resonance Imaging (MRI) Value in Endometriosis Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12071767. [PMID: 35885670 PMCID: PMC9315729 DOI: 10.3390/diagnostics12071767] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/24/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Endometriosis is a widespread gynecological condition that causes chronic pelvic discomfort, dysmenorrhea, infertility, and impaired quality of life in women of reproductive age. Clinical examination, transvaginal ultrasonography (TVS), and magnetic resonance imaging (MRI) are significant preoperative non-invasive diagnosis procedures for the accurate assessment of endometriosis. Although TVS is used as the primary line for diagnosis, MRI is commonly utilized to achieve a better anatomical overview of the entire pelvic organs. The aim of this systematic review article is to thoroughly summarize the research on various endometriosis diagnosis methods that are less invasive. (2) Methods: To find relevant studies, we examined electronic databases, such as MEDLINE/PubMed, Cochrane, and Google Scholar, choosing 70 papers as references. (3) Results: The findings indicate that various approaches can contribute to diagnosis in different ways, depending on the type of endometriosis. For patients suspected of having deep pelvic endometriosis, transvaginal sonography should be the first line of diagnosis. Endometriosis cysts are better diagnosed with TVS, whereas torus, uterosacral ligaments, intestine, and bladder endometriosis lesions are best diagnosed using MRI. When it comes to detecting intestine or rectal nodules, as well as rectovaginal septum nodules, MRI should be the imaging tool of choice. (4) Conclusions: When diagnosing DE (deep infiltrative endometriosis), the examiner’s experience is the most important criterion to consider. In the diagnosis of endometriosis, expert-guided TVS is more accurate than routine pelvic ultrasound, especially in the deep infiltrative form. For optimal treatment and surgical planning, accurate preoperative deep infiltrative endometriosis diagnosis is essential, especially because it requires a multidisciplinary approach.
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Bendifallah S, Dabi Y, Suisse S, Jornea L, Bouteiller D, Touboul C, Puchar A, Daraï E. MicroRNome analysis generates a blood-based signature for endometriosis. Sci Rep 2022; 12:4051. [PMID: 35260677 PMCID: PMC8902281 DOI: 10.1038/s41598-022-07771-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/16/2022] [Indexed: 02/07/2023] Open
Abstract
Endometriosis, characterized by endometrial-like tissue outside the uterus, is thought to affect 2–10% of women of reproductive age: representing about 190 million women worldwide. Numerous studies have evaluated the diagnostic value of blood biomarkers but with disappointing results. Thus, the gold standard for diagnosing endometriosis remains laparoscopy. We performed a prospective trial, the ENDO-miRNA study, using both Artificial Intelligence (AI) and Machine Learning (ML), to analyze the current human miRNome to differentiate between patients with and without endometriosis, and to develop a blood-based microRNA (miRNA) diagnostic signature for endometriosis. Here, we present the first blood-based diagnostic signature obtained from a combination of two robust and disruptive technologies merging the intrinsic quality of miRNAs to condense the endometriosis phenotype (and its heterogeneity) with the modeling power of AI. The most accurate signature provides a sensitivity, specificity, and Area Under the Curve (AUC) of 96.8%, 100%, and 98.4%, respectively, and is sufficiently robust and reproducible to replace the gold standard of diagnostic surgery. Such a diagnostic approach for this debilitating disorder could impact recommendations from national and international learned societies.
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Affiliation(s)
- Sofiane Bendifallah
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France. .,Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France.
| | - Yohann Dabi
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine (CRSA), Sorbonne University, INSERM UMR_S_938, 75020, Paris, France
| | - Stéphane Suisse
- Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France
| | - Ludmila Jornea
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Delphine Bouteiller
- Gentoyping and Sequencing Core Facility, iGenSeq, Institut du Cerveau et de la Moelle épinière, ICM, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Cyril Touboul
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France
| | - Anne Puchar
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France
| | - Emile Daraï
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Clinical Research Group (GRC) Paris 6: Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), Paris, France
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Bendifallah S, Suisse S, Puchar A, Delbos L, Poilblanc M, Descamps P, Golfier F, Jornea L, Bouteiller D, Touboul C, Dabi Y, Daraï E. Salivary MicroRNA Signature for Diagnosis of Endometriosis. J Clin Med 2022; 11:jcm11030612. [PMID: 35160066 PMCID: PMC8836532 DOI: 10.3390/jcm11030612] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Endometriosis diagnosis constitutes a considerable economic burden for the healthcare system with diagnostic tools often inconclusive with insufficient accuracy. We sought to analyze the human miRNAome to define a saliva-based diagnostic miRNA signature for endometriosis. METHODS We performed a prospective ENDO-miRNA study involving 200 saliva samples obtained from 200 women with chronic pelvic pain suggestive of endometriosis collected between January and June 2021. The study consisted of two parts: (i) identification of a biomarker based on genome-wide miRNA expression profiling by small RNA sequencing using next-generation sequencing (NGS) and (ii) development of a saliva-based miRNA diagnostic signature according to expression and accuracy profiling using a Random Forest algorithm. RESULTS Among the 200 patients, 76.5% (n = 153) were diagnosed with endometriosis and 23.5% (n = 47) without (controls). Small RNA-seq of 200 saliva samples yielded ~4642 M raw sequencing reads (from ~13.7 M to ~39.3 M reads/sample). Quantification of the filtered reads and identification of known miRNAs yielded ~190 M sequences that were mapped to 2561 known miRNAs. Of the 2561 known miRNAs, the feature selection with Random Forest algorithm generated after internally cross validation a saliva signature of endometriosis composed of 109 miRNAs. The respective sensitivity, specificity, and AUC for the diagnostic miRNA signature were 96.7%, 100%, and 98.3%. CONCLUSIONS The ENDO-miRNA study is the first prospective study to report a saliva-based diagnostic miRNA signature for endometriosis. This could contribute to improving early diagnosis by means of a non-invasive tool easily available in any healthcare system.
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Affiliation(s)
- Sofiane Bendifallah
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 Rue de la Chine, 75020 Paris, France; (A.P.); (C.T.); (Y.D.); (E.D.)
- Clinical Research Group (GRC) Paris 6, Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), 4 Rue de la Chine, 75020 Paris, France
- Correspondence: ; Tel.: +33-1-56-01-73-18; Fax: +33-1-56-01-73-17
| | | | - Anne Puchar
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 Rue de la Chine, 75020 Paris, France; (A.P.); (C.T.); (Y.D.); (E.D.)
- Clinical Research Group (GRC) Paris 6, Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), 4 Rue de la Chine, 75020 Paris, France
| | - Léa Delbos
- Department of Obstetrics and Reproductive Medicine, Centre Hospitalier Universitaire, 49000 Angers, France; (L.D.); (P.D.)
- Endometriosis Expert Center, Pays de la Loire, 49000 Angers, France
| | - Mathieu Poilblanc
- Department of Obstetrics and Reproductive Medicine, Lyon South University Hospital, Lyon Civil Hospices, 69008 Lyon, France; (M.P.); (F.G.)
- Endometriosis Expert Center, Steering Committee of the EndAURA Network, 75020 Paris, France
| | - Philippe Descamps
- Department of Obstetrics and Reproductive Medicine, Centre Hospitalier Universitaire, 49000 Angers, France; (L.D.); (P.D.)
- Endometriosis Expert Center, Pays de la Loire, 49000 Angers, France
| | - Francois Golfier
- Department of Obstetrics and Reproductive Medicine, Lyon South University Hospital, Lyon Civil Hospices, 69008 Lyon, France; (M.P.); (F.G.)
- Endometriosis Expert Center, Steering Committee of the EndAURA Network, 75020 Paris, France
| | - Ludmila Jornea
- Paris Brain Institute—Institut du Cerveau—ICM, Inserm U1127, CNRS UMR 7225, AP-HP—Hôpital Pitié-Salpêtrière, Sorbonne University, 75020 Paris, France;
| | - Delphine Bouteiller
- Genotyping and Sequencing Core Facility, iGenSeq, Institut du Cerveau et de la Moelle Epinière, Institut du Cerveau, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l’Hôpital, 75013 Paris, France;
| | - Cyril Touboul
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 Rue de la Chine, 75020 Paris, France; (A.P.); (C.T.); (Y.D.); (E.D.)
- Clinical Research Group (GRC) Paris 6, Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), 4 Rue de la Chine, 75020 Paris, France
| | - Yohann Dabi
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 Rue de la Chine, 75020 Paris, France; (A.P.); (C.T.); (Y.D.); (E.D.)
- Clinical Research Group (GRC) Paris 6, Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), 4 Rue de la Chine, 75020 Paris, France
| | - Emile Daraï
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, 4 Rue de la Chine, 75020 Paris, France; (A.P.); (C.T.); (Y.D.); (E.D.)
- Clinical Research Group (GRC) Paris 6, Centre Expert Endométriose (C3E), Sorbonne University (GRC6 C3E SU), 4 Rue de la Chine, 75020 Paris, France
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