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Keckstein J, Hoopmann M, Merz E, Grab D, Weichert J, Helmy-Bader S, Wölfler M, Bajka M, Mechsner S, Schäfer S, Krentel H, Hudelist G. Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis. Arch Gynecol Obstet 2023; 307:5-19. [PMID: 36367580 PMCID: PMC9837004 DOI: 10.1007/s00404-022-06766-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022]
Abstract
Gynecological ultrasonography plays a central role in the management of endometriosis. The rapid technical development as well as the currently increasing evidence for non-invasive diagnostic methods require an updated compilation of recommendations for the use of ultrasound in the management of endometriosis. The present work aims to highlight the accuracy of sonography for diagnosing and classifying endometriosis and will formulate the present list of key messages and recommendations. This paper aims to demonstrate the accuracy of TVS in the diagnosis and classification of endometriosis and to discuss the clinical applications and consequences of TVS findings for indication, surgical planning and assessment of associated risk factors. (1) Sophisticated ultrasound is the primary imaging modality recommended for suspected endometriosis. The examination procedure should be performed according to the IDEA Consensus. (2) Surgical intervention to confirm the diagnosis alone is not recommended. A preoperative imaging procedure with TVS and/or MRI is strongly recommended. (3) Ultrasound examination does not allow the definitive exclusion of endometriosis. (4) The examination is primarily transvaginal and should always be combined with a speculum and a bimanual examination. (5) Additional transabdominal ultrasonography may enhance the accuracy of the examination in case of extra pelvic disease, extensive findings or limited transvaginal access. (6) Sonographic assessment of both kidneys is mandatory when deep endometriosis (DE) and endometrioma are suspected. (7) Endometriomas are well defined by sonographic criteria. When evaluating the ovaries, the use of IOTA criteria is recommended. (8) The description of sonographic findings of deep endometriosis should be systematically recorded and performed using IDEA terminology. (9) Adenomyosis uteri has sonographically well-defined criteria (MUSA) that allow for detection with high sensitivity and specificity. MRI is not superior to differentiated skilled ultrasonography. (10) Classification of the extent of findings should be done according to the #Enzian classification. The current data situation proves the best possible prediction of the intraoperative situs of endometriosis (exclusive peritoneum) for the non-invasive application of the #Enzian classification. (11) Transvaginal sonographic examination by an experienced examiner is not inferior to MRI diagnostics regarding sensitivity and specificity in the prediction of the extent of deep endometriosis. (12) The major advantage of non-invasive imaging and classification of endometriosis is the differentiated planning or possible avoidance of surgical interventions. The recommendations represent the opinion of experts in the field of non-invasive and invasive diagnostics as well as therapy of endometriosis. They were developed with the participation of the following national and international societies: DEGUM, ÖGUM, SGUM, SEF, AGEM/DGGG, and EEL.
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Affiliation(s)
- J Keckstein
- Endometriosis Clinic Dres, Jörg und Sigrid Keckstein, Richard Wagner Strasse18, Villach, Austria.
- Department of Obstetrics and Gynaecology, Medical University Ulm, Ulm, Germany.
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany.
- AGEM, Arbeitsgemeinschaft Endometriose of the DGGG, Berlin, Germany.
- EEL, European Endometriosis League, Unterhaching, Germany.
| | - M Hoopmann
- Department of Obstetrics and Gynaecology, Medical University Tübingen, Tübingen, Germany
| | - E Merz
- Centre for Ultrasound and Prenatal Medicine, Frankfurt, Germany
| | - D Grab
- Department of Obstetrics and Gynaecology, Medical University Ulm, Ulm, Germany
| | - J Weichert
- Department of Obstetrics and Gynaecology, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - S Helmy-Bader
- Department of Obstetrics and Gynaecology, Medical University Vienna, Vienna, Austria
- ÖGUM, Österreichische Gesellschaft für Ultraschall in der Medizin, Vienna, Austria
| | - M Wölfler
- Department of Obstetrics and Gynaecology, Centre for Endometriosis, Medical University Graz, Graz, Austria
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany
- ÖGUM, Österreichische Gesellschaft für Ultraschall in der Medizin, Vienna, Austria
| | - M Bajka
- OB/GYN Volketswil, Volketswil, Switzerland
- SGUM, Schweizer Gesellschaft für Ultraschall in der Medizin, Aarau, Switzerland
| | - S Mechsner
- Department of Gynaecology, Endometriosis Centre Charité, Charite Berlin University Hospital, Berlin, Germany
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany
- AGEM, Arbeitsgemeinschaft Endometriose of the DGGG, Berlin, Germany
| | - S Schäfer
- Department of Gynaecology and Obstetrics, University Hospital Muenster, Münster, Germany
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany
- AGEM, Arbeitsgemeinschaft Endometriose of the DGGG, Berlin, Germany
- EEL, European Endometriosis League, Unterhaching, Germany
| | - H Krentel
- Department of Obstetrics and Gynaecology, Bethesda Hospital Duisburg, Duisburg, Germany
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany
- AGEM, Arbeitsgemeinschaft Endometriose of the DGGG, Berlin, Germany
- EEL, European Endometriosis League, Unterhaching, Germany
| | - G Hudelist
- Department of Gynaecology, Centre for Endometriosis, Hospital St. John of God, Vienna, Austria
- Rudolfinerhaus Private Clinic and Campus, Vienna, Austria
- SEF, Scientific Endometriosis Foundation (Stiftung Endometrioseforschung), Westerstede, Germany
- ÖGUM, Österreichische Gesellschaft für Ultraschall in der Medizin, Vienna, Austria
- EEL, European Endometriosis League, Unterhaching, Germany
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Hudelist G, Valentin L, Saridogan E, Condous G, Malzoni M, Roman H, Jurkovic D, Keckstein J. What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis. Facts Views Vis Obgyn 2021; 13:331-338. [PMID: 35026095 PMCID: PMC9148714 DOI: 10.52054/fvvo.13.4.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging). OBJECTIVES To highlight the advantages and disadvantages of the three classification systems. METHODS This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis. CONCLUSIONS A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.
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Falzone L, Scandurra G, Lombardo V, Gattuso G, Lavoro A, Distefano AB, Scibilia G, Scollo P. A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review). Int J Oncol 2021; 59:53. [PMID: 34132354 PMCID: PMC8208622 DOI: 10.3892/ijo.2021.5233] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023] Open
Abstract
Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.
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Affiliation(s)
- Luca Falzone
- Epidemiology and Biostatistics Unit, National Cancer Institute‑IRCCS Fondazione G. Pascale, I‑80131 Naples, Italy
| | | | | | - Giuseppe Gattuso
- Department of Biomedical and Biotechnological Sciences, University of Catania, I‑95123 Catania, Italy
| | - Alessandro Lavoro
- Department of Biomedical and Biotechnological Sciences, University of Catania, I‑95123 Catania, Italy
| | | | - Giuseppe Scibilia
- Unit of Obstetrics and Gynecology, Cannizzaro Hospital, I‑95126 Catania, Italy
| | - Paolo Scollo
- Unit of Obstetrics and Gynecology, Cannizzaro Hospital, I‑95126 Catania, Italy
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4D Doppler Ultrasound in High Grade Serous Ovarian Cancer Vascularity Evaluation-Preliminary Study. Diagnostics (Basel) 2021; 11:diagnostics11040582. [PMID: 33805053 PMCID: PMC8064103 DOI: 10.3390/diagnostics11040582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of the study was to evaluate the usefulness of 4D Power Doppler tissue evaluation to discriminate between normal ovaries and ovarian cancer tumors. This was a prospective observational study. Twenty-three cases of surgically confirmed ovarian High Grade Serous Carcinoma (HGSC) were analyzed. The control group consisted of 23 healthy patients, each matching their study-group counterpart age wise (±3 years) and according to their menopausal status. Transvaginal Doppler 4D ultrasound scans were done on every patient and analyzed with 3D/4D software. Two 4D indices-volumetric Systolic/Diastolic Index (vS/D) and volumetric Pulsatility Index (vPI)-were calculated. To keep results standardized and due to technical limitations, virtual 1cc spherical tissue samples taken from the part with highest vascularization as detected by bi-directional Power Doppler were analyzed for both groups of ovaries. Values of volumetric S/D indices and volumetric PI indices were statistically lower in ovarian malignant tumors compared to normal ovaries: 1.096 vs. 1.794 and 0.092 vs. 0.558, respectively (p < 0.001). The 4D bi-directional Power Doppler vascular indices were statistically different between malignant tumors and normal ovaries. These findings could support the rationale for future studies for assessing this technology to discriminate between malignant and benign tumors.
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Tsakiridis I, Dagklis T. Evolution of a corpus luteum cyst: how to avoid a pitfall due to its varying appearance. J OBSTET GYNAECOL 2019; 40:1184-1185. [PMID: 31847656 DOI: 10.1080/01443615.2019.1693526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Nandy S, Mostafa A, Hagemann IS, Powell MA, Amidi E, Robinson K, Mutch DG, Siegel C, Zhu Q. Evaluation of Ovarian Cancer: Initial Application of Coregistered Photoacoustic Tomography and US. Radiology 2018; 289:740-747. [PMID: 30204078 PMCID: PMC6283286 DOI: 10.1148/radiol.2018180666] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 01/19/2023]
Abstract
Purpose To assess transvaginal coregistered photoacoustic tomography (PAT) and pulse-echo US for diagnosis of ovarian cancer based on functional parameters provided by PAT. Materials and Methods Between February 2017 and December 2017, 26 ovarian masses from 16 participants were successfully imaged in vivo by multispectral photoacoustic imaging, including nine invasive epithelial ovarian cancers (six serous carcinomas and three endometroid adenocarcinomas), three other tumors (two borderline serous tumors and one sex cord-stromal tumor), and 14 benign and normal (hereafter referred to as benign/normal) ovaries. The relative total hemoglobin concentration (rHbT) and mean oxygen saturation (sO2) shown at PAT were used to characterize the ovaries identified at US. Results The average rHbT was 1.9 times higher for invasive epithelial cancers than for the benign/normal ovaries (P = .01). Additionally, the rHbT distribution was extensive in invasive epithelial cancers, but was scattered in benign/normal ovaries. However, the rHbT of two borderline serous tumors and one stromal tumor was in the same range as that of benign/normal ovaries. The mean sO2 of invasive epithelial cancers, and of the borderline and stromal tumors, was 8.2% lower than that of benign/normal ovaries (P = .003). Discussion Invasive epithelial ovarian cancers showed higher and extensive tumor vascularity and lower oxygen saturation than benign and normal ovaries. Two borderline noninvasive serous and one stromal tumor showed low oxygen saturation compared with benign and normal ovaries. ©RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
| | | | - Ian S. Hagemann
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - Matthew A. Powell
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - Eghbal Amidi
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - Kathryn Robinson
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - David G. Mutch
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - Cary Siegel
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
| | - Quing Zhu
- From the Department of Biomedical Engineering, Washington University,
One Brookings Dr, Mail Box 1097, St Louis, MO 63130 (S.N., A.M., E.A., Q.Z.);
Department of Pathology & Immunology (I.S.H.), Department of Obstetrics and
Gynecology (I.S.H., M.A.P., D.G.M.), and Mallinckrodt Institute of Radiology
(K.R., C.S., Q.Z.), Washington University School of Medicine, St Louis,
Mo
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