Deep Infiltrating Endometriosis: Diagnostic Accuracy of Preoperative Magnetic Resonance Imaging with Respect to Morphological Criteria

Anogenital distance on MRI does not correlate to surgical diagnosis of endometriosis in patients without prior abdominal surgery

Anogenital distance (AGD) is regarded as a potential biomarker for endometriosis, and a measurement on MRI images has been found to be promising. This study aimed to evaluate the measurement of AGD on MRI to predict the surgical diagnosis of endometriosis. We included 127 patients who received an MRI for endometriosis between October 2018 and February 2023. AGD was measured on MRI by two readers (MRI-AGD-AC: clitoris to anus; MRI-AGD-AF: posterior fourchette to anus). The feasibility and interobserver reliability of AGD measurements were evaluated. Differences in AGD between patient groups were analyzed. The intraclass correlation coefficient estimates indicated a good to excellent reliability of MRI-AGD-AC (0.92; 95% CI: 0.83-0.95) and a poor to good reliability of MRI-AGD-AF (0.68; 95% CI: 0.27-0.83). No statistically significant differences in the mean MRI-AGD-AC and MRI-AGD-AF in patients with and without surgical diagnosis of DIE (p = 0.413; p = 0.110), peritoneal endometriosis with and without DIE (p = 0.641; p = 0.323), and ovarian endometriosis (p = 0.155; p = 0.150) were found. The AUC ranged from 0.475 (95% CI: 0.365-0.584) to 0.586 (95% CI: 0.454-0.718). Thus, AGD does not constitute a valuable biomarker for patients with clinically suspected endometriosis.

Incidental findings on MRI for the evaluation of endometriosis: prevalence and clinical significance

Objectives

This study aimed to analyze the prevalence and clinical significance of incidental findings on MRI for endometriosis. Differences between patients with and without evidence of deep infiltrating endometriosis on MRI were to be examined.

Methods

This was a retrospective, descriptive cross-sectional single-center study. All patients who received a pelvic MRI for endometriosis between April 2021 and February 2023 were included. The presence and frequency of incidental findings were noted after review of all MR images and radiology reports. The potential clinical significance of the findings was analyzed. Differences in the frequency of incidental findings between patients with and without evidence of deep infiltrating endometriosis on MRI were evaluated, utilizing the Chi-square test, Fisher's exact test and Mann-Whitney U-test.

Results

303 consecutive patients (mean age, 33.4 years ± 8.3) were evaluated. Incidental findings were noted in 299/303 (98.7%) patients. Most frequently, ossification of the hip acetabular rim and degenerative changes of the lumbar spine were noted. In 25/303 (8.3%) patients, incidental findings had high clinical significance. For specific incidental findings, significantly higher prevalences were found in patients with than in patients without evidence of deep infiltrating endometriosis on MRI (hip acetabular rim ossification, p = 0.041; annulus fibrosus fissures, p = 0.006; gallstones, p = 0.042).

Conclusions

Incidental findings are very common on pelvic MRI for endometriosis. The detection of incidental findings can lead to the diagnosis of relevant diseases and thus enable early treatment. On the other hand, many incidental findings have no, only minor, or uncertain consequences.

MRI of pelvic endometriosis: evaluation of the mr#Enzian classification and the importance of adenomyosis subtypes

PURPOSE

This study aimed to investigate the utility of the #Enzian classification in magnetic resonance imaging (MRI) for endometriosis assessment, focusing on inter-reader agreement, diagnostic accuracy, and the correlation of adenomyosis with deep endometriosis (DE).

METHODS

This IRB- approved retrospective single-center study included 412 women who underwent MRI evaluation for endometriosis between February 2017 and June 2022. Two experienced radiologists independently analyzed MRI images using the #Enzian classification and assessed the type of adenomyosis, if any. The surgical #Enzian classification served as the gold standard for evaluating preoperative MRI results of 45 patients. Statistical analysis was performed to assess inter-reader agreement and diagnostic accuracy.

RESULTS

Inter-reader agreement was substantial to excellent (Cohen's kappa 0.75-0.96) for most compartments except peritoneal involvement (0.39). The preoperative MRI showed mostly substantial to excellent accuracy (0.84-0.98), sensitivity (0.62-1.00), specificity (0.87-1.00), positive (0.58-1.00) and negative predictive values (0.86-1.00) for most compartments, except for peritoneal lesions (0.36, 0.17, 1.00, 1.00, 0.26 respectively). A trend with a higher prevalence of concordant DE in women with MR features of external adenomyosis compared to those with internal adenomyosis was visible (p = 0.067).

CONCLUSIONS

The mr#Enzian showed mostly high inter-reader agreement and good diagnostic accuracy for various endometriosis compartments. MRI's role is particularly significant in the context of the current paradigm shift towards medical endometriosis treatment. The inclusion of information about the type of adenomyosis in the mr#Enzian classification could enhance diagnostic accuracy and inform treatment planning.

Surgical Treatment of Patients with Endometriosis in the Certified Endometriosis Centers of the DACH Region - A Subanalysis of the Quality Assurance Study QS ENDO pilot

Introduction After puberty, at least 10% of all women and girls suffer from endometriosis. Surgery is useful for both the diagnosis and therapy. To date, quality indicators for the surgical treatment of endometriosis are lacking. QS ENDO aims to record the quality of care provided in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis. In the first phase of the study, QS ENDO real, the reality of care was recorded using a questionnaire. The second phase, QS ENDO pilot, investigated the treatment of patients who underwent surgery in certified endometriosis centers in a defined time-period. Material and Methods The surgical data of 10 patients from each of the 44 endometriosis centers in the DACH region was recorded using an online tool. Collected data included the approach used, the endometriosis phenotype, a description of the surgical site, resection status, histological confirmation, the use of a classification, and any complications. All operations were carried out in October 2016 as the defined time-period. The surgical approaches used were compared with the recommendations in the current guidelines. Results The data of 435 patients with a median age of 34 years were evaluated. 315 (72.4%) were nulliparous. 120 patients had given birth to at least one child and 42.5% (51) of them had delivered their child by caesarean section. About 50% of all patients also had deep infiltrating endometriosis in addition to ovarian endometriosis, and the median NAS score was 7.5. With regards to the surgical treatment, endometriomas were completely resected in 81% (94) of patients. 87.3% of patients underwent resection of peritoneal endometriosis. Forty-one patients had a hysterectomy, with a total hysterectomy carried out in 26 (63.4%) and a supracervical hysterectomy in 15 (36.6%) patients. Of the 59 patients with bowel endometriosis, half had segmental resection and half had shaving of the anterior rectal wall. Complications requiring revision occurred in 0.9% of cases. Conclusion The surgical procedures carried out in the certified endometriosis centers of the DACH region are largely in line with the recommendations for appropriate surgical approaches in the current standard guidelines.

Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement

Objectives

The purpose of this investigation was to evaluate the inter- and intraobserver variability of the updated #Enzian classification of endometriosis on MRI and to evaluate the influence of reader experience on interobserver concordance.

Methods

This was a prospective single-center study. All patients were included who received an MRI of the pelvis for evaluation of endometriosis between March and July 2023 and who have provided written informed consent. Images were reviewed independently for endometriosis by three radiologists, utilizing the MRI-applicable categories of the #Enzian classification. Two radiologists had experience in pelvic MRI and endometriosis imaging. One radiologist had no specific experience in pelvic MRI and received a one-hour briefing beforehand.

Results

Fifty consecutive patients (mean age, 34.9 years ±8.6 [standard deviation]) were prospectively evaluated. Interobserver agreement was excellent for diagnosis of deep infiltrating endometriosis (Fleiss' kappa: 0.89; 95% CI 0.73-1.00; p < 0.001) and endometriomas (Fleiss' kappa: 0.93; 95% CI 0.77-1.00; p < 0.001). For the experienced readers, interobserver agreement in the assessment of compartments A, B and C was excellent (κw ranging from 0.84; 95% CI 0.71-0.97; p < 0.001 to 0.89; 95% CI 0.82-0.97; p < 0.001). For the pairings of the experienced readers to the reader without specific experience in pelvic MRI, agreement was substantial to excellent (κw ranging from 0.64; 95% CI 0.44-0.85; p < 0.001 to 0.91; 95% CI 0.84-0.98; p < 0.001). Intraobserver variability was excellent for compartments A, B and C (κw ranging from 0.85; 95% CI 0.73-0.96; p < 0.001 to 0.95; 95% CI 0.89-1.00; p < 0.001).

Conclusion

With sufficient experience, the #Enzian classification enables the achievement of excellent inter- and intraobserver agreement in MRI-based diagnosis of deep infiltrating endometriosis and endometriomas.