Diagnostic MRI for deep pelvic endometriosis: towards a standardized protocol?

OBJECTIVES: To assess the diagnostic efficacy of an MRI protocol and patient preparation in detecting deep pelvic endometriosis (DPE). MATERIAL AND METHODS: The cohort is from the ENDOVALIRM database, a multicentric national retrospective study involving women who underwent MRI followed by pelvic surgery for endometriosis (reference standard). Two senior radiologists independently analyzed MRI findings using the deep pelvic endometriosis index (dPEI) to determine lesion locations. The study evaluated the impact of bowel preparation, vaginal and rectal opacification, MRI unit type (1.5-T or 3-T), additional sequences (thin slice T2W or 3DT2W), and gadolinium injection on reader performance for diagnosing DPE locations. Fisher's exact test assessed differences in diagnostic accuracy based on patient preparation and MRI parameters. RESULTS: The final cohort comprised 571 women with a mean age of 33.3 years (± 6.6 SD). MRI with bowel preparation outperformed MRI without bowel preparation in identifying torus/uterosacral ligament (USL) locations (p < 0.0001) and rectosigmoid nodules (p = 0.01). MRI without vaginal opacification diagnosed 94.1% (301/320) of torus/USL locations, surpassing MR with vaginal opacification, which diagnosed 85% (221/260) (p < 0.001). No significant differences related to bowel preparation or vaginal opacification were observed for other DPE locations. Rectal opacification did not affect diagnostic accuracy in the overall population, except in patients without bowel preparation, where performance improved (p = 0.04). There were no differences in diagnostic accuracy regarding MRI unit type (1.5-T/3-T), presence of additional sequences, or gadolinium injection for any endometriotic locations. CONCLUSION: Bowel preparation prior to MRI examination is preferable to rectal or vaginal opacification for diagnosing deep endometriosis pelvic lesions. CLINICAL RELEVANCE STATEMENT: Accurate diagnosis and staging of DPE are essential for effective treatment planning. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols. Optimizing MRI protocols for diagnostic performance with appropriate opacification techniques will help diagnose deep endometriosis more accurately. KEY POINTS: Evaluating deep endometriosis in collapsible organs such as the vagina and rectum is difficult. Bowel preparation and an absence of vaginal opacification were found to be diagnostically beneficial. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols.

Surgical and Percutaneous Image-guided Therapies of Abdominal Wall Endometriosis: a Systematic Review of Current Evidence.

OBJECTIVE: Despite various surgical and non-surgical strategies for abdominal wall endometriosis, the lack of definitive guidance on optimal treatment choice leads to clinical uncertainty. This review scrutinizes the safety and efficacy of abdominal wall endometriosis treatments to aid in decision-making. DATA SOURCES: We performed a systematic literature review of PubMed, Embase and Cochrane Library databases from 1947 until December 2023. METHODS OF STUDY SELECTION: A comprehensive literature search identified studies that assessed both surgical and nonsurgical interventions, including high-intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation (RFA), and microwave ablation (MWA). This review is registered in NIHR-PROSPERO (CRD 42023494969). Local tumor control (LTC), local pain relief (LPR) and adverse events (AE) were recorded. TABULATION, INTEGRATION, AND RESULTS: This review included 51 articles among 831 identified. All study designs were considered eligible for inclusion. A total of 2,674 patients are included: 2,219 patients (83%) undergoing surgery, and 455 (17%) undergoing percutaneous interventions (342 HIFU, 103 cryoablation, 1 RFA, 9 MWA). Follow-up length was 18 months in median, ranging from 1 to 235 months. Overall LTC rates ranged from 86% to 100%. Surgical interventions consistently demonstrated the highest rate of LTC with a median rate of 100%, and LPR with a median rate of 98.2% (95% confidence interval [CI]: 93.9-97.7). HIFU showed median LTC and LPR rates, respectively of 95.65% (95% CI, 87.7-99.9) and 76.1% (95% CI, 61.8-90.4); and cryoablation of 85.7% (95% CI, 66.0-99.9) and 79.2% (95% CI, 67.4-91.03). Minor AE were reported after surgery in 17.5% of patients (225/1284) including 15.9% (199/1284) of mesh implantation; 76.4% (239/313) after HIFU; and 8.7 % (9/103) after cryoablation. Severe AE were reported in 25 patients in the surgery group and 1 in the percutaneous group. CONCLUSION: The safety profile and efficacy of nonsurgical interventions support their clinical utility for management of abdominal wall endometriosis.

Resolution of Pain after Percutaneous Image-Guided Cryoablation of Extraperitoneal Endometriosis.

PURPOSE: To retrospectively evaluate the relief of pain after percutaneous image-guided cryoablation of symptomatic extraperitoneal endometriosis (EE). MATERIAL AND METHODS: From 2017 to 2022, cryoablation of EE was performed at a single institution on a total of 47 lesions in 42 consecutive patients (median age, 37 years; interquartile range [IQR], 33-39.5 years). Patient and procedural characteristics were reviewed retrospectively. Tolerance and outcomes in terms of pain and patient satisfaction were evaluated. RESULTS: The median follow-up duration was 13.5 months (IQR, 1.1-37.7 months) after cryoablation. The median pain-free survival rate was 93.8% (95% confidence interval [CI], 77.3-98.4) at 6 months and 82.7% (95% CI, 58.8-93.5) after 12 months. Pain decreased from a median of 8/10 (IQR, 7-9) on the visual analog scale to 0/10 (IQR, 0-1) at the last follow-up (P < .0001). The median Patient Global Impression of Change score recorded at the last follow-up was 1/7 (IQR, 1-2). The efficacy rate of cryoablation to avoid secondary surgery was 92.8% (39/42) per patient and 93.6% (44/47) per nodule treated. Four patients (9.5%, 4/42) experienced an adverse event in the days following the procedure, and 1 patient (2%) experienced a severe adverse event. CONCLUSIONS: Percutaneous cryoablation is safe and effective in significantly reducing pain and obtaining local control of EE.

MRI of Adenomyosis: Where Are We Today?

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

How to improve O-RADS MRI score for rating adnexal masses with cystic component?

OBJECTIVES: To test the performance of the Ovarian-Adnexal Reporting Data System (O-RADS) MRI in characterizing adnexal masses with cystic components and to test new specific MRI features related to cystic components to improve the ability of the O-RADS MRI score to stratify lesions according to their risk of malignancy. METHODS: The EURopean ADnexal study (EURAD) database was retrospectively queried to identify adnexal masses with a cystic component. One junior and 13 radiologists independently reviewed cases blinded to the pathological diagnosis. For each lesion, the size of the whole lesion, morphological appearance, number of loculi, presence of a thickened wall, thickened septae, signal intensity of the cystic components on T1-weighted/T2-weighted/diffusion weighted, mean value of the apparent diffusion coefficient, and O-RADS MRI score were reported. Univariate and multivariate logistic regression analysis was performed to determine significant features to predict malignancy. RESULTS: The final cohort consisted of 585 patients with 779 pelvic masses who underwent pelvic MRI to characterize an adnexal mass(es). Histology served as the standard of reference. The diagnostic performance of the O-RADS MRI score was 0.944, 95%CI [0.922-0.961]. Significant criteria associated with malignancy included an O-RADS MRI score ≥ 4, ADCmean of cystic component > 1.69, number of loculi > 3, lesion size > 75 mm, the presence of a thick wall, and a low T1-weighted, a high T2-weighted, and a low diffusion-weighted signal intensity of the cystic component. Multivariate analysis demonstrated that an O-RADS MRI score ≥ combined with an ADC mean of the cystic component > 1.69, size > 75 mm, and low diffusion-weighted signal of the cystic component significantly improved the diagnostic performance up to 0.958, 95%CI [0.938-0.973]. CONCLUSION: Cystic component analysis may improve the diagnosis performance of the O-RADS MRI score in adnexal cystic masses. KEY POINTS: • O-RADS MRI score combined with specific cystic features (area under the receiving operating curve, AUROC = 0.958) improves the diagnostic performance of the O-RADS MRI score (AUROC = 0.944) for predicting malignancy in this cohort. • Cystic features that improve the prediction of malignancy are ADC mean > 1.69 (OR = 7); number of loculi ≥ 3 (OR = 5.16); lesion size > 75 mm (OR = 4.40); the presence of a thick wall (OR = 3.59); a high T2-weighted signal intensity score 4 or 5 (OR = 3.30); a low T1-weighted signal intensity score 1, 2, or 3 (OR = 3.45); and a low diffusion-weighted signal intensity (OR = 2.12). • An adnexal lesion with a cystic component rated O-RADS MRI score 4 and an ADC value of the cystic component < 1.69 associated with a low diffusion-weighted signal, has virtually a 0% risk of malignancy.

Exploring the challenges for a new classification of adenomyosis.

The availability of non-invasive diagnostic tests is an important factor in the renewed interest in adenomyosis, as the disease can now be more accurately mapped in the uterus without a need for hysterectomy. An agreed system for classifying and reporting the condition will enhance our understanding of the disease and is envisaged to enable comparison of research studies and treatment outcomes. In this review, we assess previous and more recent attempts at producing a taxonomy, especially in view of the latest proposal for subdivision of adenomyosis into an internal and an external variant. In this context, we also explore the uncertainties linked to classifying involvement of the uterovesical pouch, the pouch of Douglas and lesions in the outer myometrium. Two opposing hypotheses are forwarded to explain the pathogenesis of these variants, namely that disease localized in these areas originates from an invasion by uterine adenomyosis of peritoneal organs; alternatively, that lesions present in the outer myometrium originate from peritoneal endometriosis. At the root of debates around these opposing theories of pathogenesis is fragmentary evidence. Because of the limitations of currently available evidence, and until this issue is resolved, broad agreement on a hypothesis to underpin any proposed classification is unlikely.

Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: The recurrence rate after colorectal surgery for endometriosis is up to 50% at 5 years. The aim of the current review and meta-analysis was to assess recurrence associated with shaving, disc excision, and segmental resection for endometriosis with colorectal involvement. DATA SOURCES: A systematic review was performed by searching the PubMed, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science databases for publications before February 28, 2019, using the terms "colorectal endometriosis" and "recurrence" in English. The outcome measure was histologically proven recurrence 1 year after the index surgery. METHODS OF STUDY SELECTION: Studies rated as good or fair by a study quality assessment tool were included. Two reviewers independently assessed the quality of the studies; discrepancies were discussed, and if a consensus was not reached, a third reviewer was consulted. TABULATION, INTEGRATION, AND RESULTS: Of 156 relevant published trials, 41 were systematically reviewed and 4 were included in the meta-analysis. The risk of recurrence was higher after rectal shaving than after both segmental resection (odds ratio [OR], 5.53; 95% confidence interval [CI], 2.33-13.12; I2 = 0%; p = .001) and disc excision for histologically proven recurrence (OR, 3.83; 95% CI, 1.33-11.05; I2 = 0%; p = .01). This difference was not significant when comparing disc excision with segmental resection (OR, 2.63; 95% CI, 0.8-8.65; I2 = 0%; p = .11). CONCLUSION: The current analysis shows that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed. This finding is important when deciding the most appropriate surgical management.

Magnetic Resonance Enterography to Assess Multifocal and Multicentric Bowel Endometriosis.

STUDY OBJECTIVE: To prospectively determine the accuracy of magnetic resonance enterography (MRE) compared with conventional magnetic resonance imaging (MRI) for multifocal (i.e., multiple lesions affecting the same digestive segment) and multicentric (i.e., multiple lesions affecting several digestive segments) bowel endometriosis. DESIGN: A prospective study (Canadian Task Force classification II-2). SETTING: Tenon University Hospital, Paris, France. PATIENTS: Patients with MRI-suspected colorectal endometriosis scheduled for colorectal resection from April 2014 to February 2016 were included. INTERVENTIONS: Patients underwent both 1.5-Tesla MRI and MRE as well as laparoscopically assisted and open colorectal resections. MEASUREMENTS AND MAIN RESULTS: The diagnostic performance of MRI and MRE was evaluated for sensitivity, specificity, positive and negative predictive values, accuracy, and positive and negative likelihood ratios (LRs). The interobserver variability of the experienced and junior radiologists was quantified using weighted statistics. Forty-seven patients were included. Twenty-two (46.8%) patients had unifocal lesions, 14 (30%) had multifocal lesions, and 11 (23.4%) had multicentric lesions. The sensitivity, specificity, positive LR, and negative LR for the diagnosis of multifocal lesions were 0.29 (6/21), 1.00 (23/24), 15.36, and 0.71 for MRI and 0.57 (12/21), 0.89 (23/25), 4.95, and 0.58 for MRE. The sensitivity, specificity, positive LR, and negative LR for the diagnosis of multicentric lesions were 0.18 (1/11), 1.00 (1/1), 15, and 0.80 for MRI and 0.46 (5/11), 0.92 (33/36), 5.45, and 0.60 for MRE. Lower accuracies for MRI compared with MRE to diagnose multicentric (p = .01) and multifocal lesions (p = .004) were noted. The interobserver agreement for MRE was good for both multifocality (κ = 0.80) and multicentricity (κ = 0.61). CONCLUSION: MRE has better accuracy for diagnosing multifocal and multicentric bowel endometriosis than conventional MRI.

Uterine junctional zone thickness in infertile women evaluated by MRI.

PURPOSE: To prospectively evaluate and compare the junctional zone (JZ) and outer myometrial thickness in infertile and healthy nulliparous women at different locations in the uterine wall during the menstrual cycle by magnetic resonance imaging (MRI). MATERIALS AND METHODS: We performed pelvic 1.5T MRI (T2 -weighted turbo spin echo sequences) on 28 infertile women: 5 with infertility of unknown origin, 12 anovulating, and 11 on ovarian stimulation therapy (mean age 28.5, 30.8, and 29.3 years, respectively); and a control group consisting of 18 healthy nulliparous volunteers (mean age 26.4 years). The women with unknown infertility origin and the control group underwent MRI investigations during their follicular, ovulatory, and luteal phase. The JZ and outer myometrial thicknesses were measured at six locations in the uterine wall: anterior and posterior wall of the isthmus, midcorpus, and fundus. RESULTS: The JZ in the anovulating women at the posterior wall of the isthmus (4.2 mm) was significantly thicker compared to the control group (3.2, 3.0, and 2.9 mm, in respectively the three menstrual phases) (P = 0.027). The outer myometrium in the anovulating women was significantly thicker at all measured locations (average 11.5 mm) in comparison to the control group (8.1, 8.0, and 8.5 mm, in respectively the three menstrual phases) (P < 0.050). The infertile women on ovarian stimulation therapy showed a significantly thicker outer myometrium at the anterior wall (isthmus, midcorpus, and fundus) (P < 0.050). CONCLUSION: The results indicate that a thickened JZ, and especially a thickened outer myometrium, might be associated with infertility. LEVEL OF EVIDENCE: 1 J. Magn. Reson. Imaging 2017;45:926-936.

Mid-term outcomes after percutaneous cryoablation of symptomatic abdominal wall endometriosis: comparison with surgery alone in a single institution.

OBJECTIVES: To compare the outcomes of percutaneous image-guided cryoablation of symptomatic abdominal wall endometriosis (AWE) versus surgery alone. METHODS: From 2004 to 2016, cryoablation or surgery alone was performed under local (n = 5) or general anaesthesia (n = 15) for AWE in a single institution in 7 (mean age, 36.1 years) and 13 (mean age, 31.9 years) patients, respectively. Fifteen lesions were treated by cryoablation (mean size, 2.3 cm; range, 0.5-7 cm) and 16 by surgery (2.5 cm; 1.1-3.4 cm). Tolerance, efficacy and patient and procedural characteristics were compared. RESULTS: Median follow-up was 22.5 (range, 6-42) months after cryoablation and 54 (14-149) after surgery. The median procedure and hospitalisation durations were 41.5 min (24-66) and 0.8 days (0-1) after cryoablation, and 73.5 min (35-160) and 2.8 days (1-12 days) after surgery (both P = 0.01). Three patients (23.1%) had severe complications and nine aesthetic sequels (69.2%) after surgery, none after cryoablation (P = 0.05). The median 12- and 24-month symptom free-survival rates were 100% and 66.7% (95% CI, 5.4; 94.5) after cryoablation and 92% (55.3; 98.9) after surgery at both time points (P = 0.45). CONCLUSIONS: Cryoablation presents similar effectiveness to surgery alone for local control of AWE while reducing hospitalisation duration and complications. Any aesthetic sequels were associated with the cryoablation treatment. KEY POINTS: • Hospitalisation is shorter after cryoablation than after surgery of abdominal wall endometriosis. • A significantly lower rate of complications is observed after cryoablation compared to surgery. • Cryoablation of abdominal wall endometriosis presents similar effectiveness to surgery alone. • A significant reduction of pain is observed 6 months after treatment. • A significant reduction of abdominal wall endometriosis is observed at 6 months.

Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate.

Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.

Diagnostic Value of MR Imaging in the Diagnosis of Adnexal Torsion.

PURPOSE: To retrospectively evaluate the diagnostic performance of magnetic resonance (MR) imaging for the diagnosis of adnexal torsion in a series of patients with an equivocal adnexal mass at ultrasonography (US) in the context of acute or subacute pelvic pain. MATERIALS AND METHODS: The institutional ethics committee approved the study and waived informed consent. All patients with acute or subacute pelvic pain who were undergoing MR examination for the exploration of an equivocal adnexal mass (January 2007 to December 2012) with surgical exploration or clinical and radiologic follow-up of at least 3 months were retrospectively included (n = 58). The prospective interpretations were recorded. Additionally, three radiologists who were blinded to the clinical, US, and surgical data retrospectively and independently reviewed MR images. Features associated with adnexal torsion were identified by using univariate and recursive partitioning multivariate analysis. RESULTS: Twenty-two patients (38%) had a diagnosis of adnexal torsion. The accuracy of MR imaging at the time of prospective interpretation was 80.6% (25 of 31 patients) and 85.1% (23 of 27 patients) in acute and subacute torsion, respectively. The accuracy of image interpretation by each retrospective reader was 83.9% (26 of 31 patients), 90.3% (28 of 31 patients), and 83.9% (26 of 31 patients) in the context of acute pelvic pain and 92.6% (25 of 27 patients), 88.9% (24 of 27 patients), and 81.5% (22 of 27 patients) in the context of subacute pelvic pain for readers 1, 2, and 3, respectively. At multivariate analysis, the whirlpool sign (odds ratio = 6.5 [95% confidence interval: 1.36, 31.0], P = .01) and a thickened tube (>10 mm) (odds ratio = 8.2 [95% confidence interval: 1.2, 56.8], P = .03) were associated with adnexal torsion, with substantial interreader agreement (κ = 0.71-0.84 and 0.82-0.86, respectively). The presence of adnexal hemorrhagic content was associated with nonviable ovaries in seven of 10 patients (70%) and with viable ovaries in 12 of 45 patients (27%) (P = .009). CONCLUSION: MR imaging is an accurate technique for the diagnosis of adnexal torsion in patients who have an adnexal mass with acute or subacute pelvic pain.

Contribution of Computed Tomography Enema and Magnetic Resonance Imaging to Diagnose Multifocal and Multicentric Bowel Lesions in Patients With Colorectal Endometriosis.

STUDY OBJECTIVE: To evaluate the diagnostic contribution of the computed tomography (CT) enema and magnetic resonance imaging (MRI) for multifocal (multiple lesions affecting the same segment) and multicentric (multiple lesions affecting several digestive segments) bowel endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). PATIENTS: Eighty-five patients. SETTING: Tenon University Hospital, Paris, France. INTERVENTION: All patients received a preoperative CT enema and underwent MRI interpreted by 2 radiologists. MEASUREMENTS AND MAIN RESULTS: Patients underwent colorectal resection for colorectal endometriosis from February 2009 to November 2012. Nineteen patients (22%) had multifocal lesions, and 11 patients (13%) had multicentric lesions. Six patients (7%) had both multifocal and multicentric lesions. The sensitivity, specificity, and positive and negative likelihood ratios (LRs) of MRI for the diagnosis of multifocal lesions were 0.58, 0.84, 3.55, and 0.5, respectively. The sensitivity, specificity, and positive and negative LRs of the CT enema for the diagnosis of multifocal lesions were 0.64, 0.86, 4.56, and 0.4, respectively. The sensitivity, specificity, and positive LR of MRI for the diagnosis of multicentric lesions were 1, 0.88, and 8.4, respectively. The sensitivity, specificity, and positive and negative LRs of MRI for the diagnosis of multicentric lesions were 0.46, 0.92, 5.6, and 0.59, respectively. No difference was observed between MRI and the CT enema for the diagnosis of multifocal and multicentric colorectal endometriosis. The interobserver agreement was good for MRI and the CT enema (κ = 0.45 and 0.45) for multifocality, and it was poor for both MRI and the CT enema (κ = 0.32 and 0.34) for multicentricity. CONCLUSIONS: Both MRI and the CT enema were able to diagnose multifocal and multicentric bowel endometriosis with similar accuracy.

Surgical and clinical impact of extraserosal pelvic fascia removal in segmental colorectal resection for endometriosis.

STUDY OBJECTIVE: To describe the characteristics of patients with colorectal endometriosis and extraserosal pelvic fascia (EPF) involvement and to assess the effect of EPF resection. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Two hundred twenty-seven patients who underwent segmental colorectal resection to treat symptomatic deep infiltrating endometriosis between 2001 and 2011, with or without EPF resection. INTERVENTIONS: Segmental colorectal resection with or without EPF resection. MEASUREMENTS AND MAIN RESULTS: One hundred twelve patients (49.4%) required EPF resection. In these patients the total American Society for Reproductive Medicine endometriosis scores were higher (p = .004), there were more associated resected lesions of deep infiltrating endometriosis (p <.001), and the operative time was longer (p <.001). They were more likely to require blood transfusion (p = .003) and to experience intraoperative complications (p = .01) and postoperative voiding dysfunction (p = .04). CONCLUSION: EPF infiltration reflects disease severity in patients with colorectal endometriosis. Its removal affects intraoperative morbidity and leads to a higher rate of voiding dysfunction.

Role of protective defunctioning stoma in colorectal resection for endometriosis.

STUDY OBJECTIVE: To evaluate the role of protective defunctioning stoma (PDS) on the occurrence of digestive tract complications after colorectal resection to treat endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: All patients undergoing segmental colorectal resection to treat colorectal endometriosis with and without PDS between 2003 and 2011 at Tenon University Hospital, Paris, France. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at 1, 6, and 12 months postoperatively and each year thereafter. Median follow-up was 60 months. Of 198 patients included for analysis, 53 (27%) had PDS. Overall, 15 (7.5%) digestive tract complications occurred: 9 (4.5%) rectovaginal fistulas and 6 (3%) anastomotic leakages. All rectovaginal fistulas occurred in patients with a low colorectal anastomosis (p < .001) and 88% (8 of 9) in patients with a partial colpectomy (p < .001). PDS was associated with a decrease in the number of rectovaginal fistulas in women undergoing partial colpectomy and low colorectal resection from 27% to 15%, without reaching significance (p = .4). No anastomotic leakage occurred in patients with PDS. CONCLUSION: Our results support that PDS can be omitted in patients with mid-colorectal anastomosis without partial colpectomy. In patients requiring partial colpectomy or partial colpectomy plus low colorectal anastomosis, PDS remains questionable.

[Endometriosis]. / Le caractère cyclique des symptômes avec une recrudescence cataméniale est evocateur. Endométriose.

Endometriosis is a benign disorder affecting 10 to 15% of women of reproductive age. It is defined by the presence of endometrium-like tissue outside the uterus. There are three different entities of endometriosis: superficial endometriosis, ovarian endometriotic cyst and deep infiltrating endometriosis. The main clinical features are dysmenorrhea, chronic pelvic pain and dyspareunia. Endometriosis is also responsible for infertility. Transvaginal sonography and magnetic resonance imaging are required to assess mapping of endometriotic lesions. Medical therapies based on progestins or combined oral contraceptives allow to relief symptoms. Despite a relative efficacy of medical treatment or in case of infertility, surgery is necessary preferentially in specialized centers.

[Imaging of uterine cancer]. / Imagerie des cancers de l'utérus.

Imaging is today crucial for patient management not only thanks to its high sensibility to detect uterine carcinoma (endovaginal ultrasonography for endometrial carcinoma) but also for local staging using pelvic MR imaging (until 2009 recommended by FIGO for both endometrial and cervical carcinoma) and for the evaluation of treatment response under radiochemotherapy especially for cervical carcinoma (using MR imaging and PET-CT).

Apparent diffusion coefficient analysis of solid tissue helps distinguish borderline from invasive malignant adnexal masses rated O-RADS MRI 4.

PURPOSE: The purpose of this study was to evaluate the contribution of apparent diffusion coefficient (ADC) analysis of the solid tissue of adnexal masses to optimize tumor characterization and possibly refine the risk stratification of the O-RADS MRI 4 category. MATERIALS AND METHODS: The EURAD cohort was retrospectively analyzed to select all patients with an adnexal mass with solid tissue and feasible ADC measurements. Two radiologists independently measured the ADC values of solid tissue, excluding necrotic areas, surrounding structures, and magnetic susceptibility artifacts. Significant differences in diffusion quantitative parameters in the overall population and according to the morphological aspect of solid tissue were analyzed to identify its impact on ADC reliability. Receiver operating characteristics curve (ROC) was used to determine the optimum cutoff of the ADC for distinguishing invasive from non-invasive tumors in the O-RADS MRI score 4 population. RESULTS: The final study population included 180 women with a mean age of 57 ± 15.5 (standard deviation) years; age range: 19-95 years) with 93 benign, 23 borderline, and 137 malignant masses. The median ADC values of solid tissue was greater in borderline masses (1.310 × 10-3 mm2/s (Q1, Q3: 1.152, 1.560 × 10-3 mm2/s) than in benign masses (1.035 × 10-3 mm2/s; Q1, Q3: 0.900, 1.560 × 10-3 mm2/s) (P= 0.002) and in benign tumors compared by comparison with invasive masses (0.850 × 10-3 mm2/s; Q1, Q3: 0.750, 0.990 × 10-3 mm2/s) (P < 0.001). Solid tissue corresponded to irregular septa or papillary projection in 18.6% (47/253), to a mural nodule or a mixed mass in 46.2% (117/253), and to a purely solid mass in 35.2% (89/253) of adnexal masses. In mixed masses or masses with mural nodule subgroup, invasive masses had a significantly lower ADC (0.830 × 10-3 mm2/s (Q1, Q3: 0.738, 0.960) than borderline (1.385; Q1, Q3: 1.300, 1.930) (P= 0.0012) and benign masses (P= 0.04). An ADC cutoff of 1.08 × 10-3 mm2/s yielded 71.4% sensitivity and 100% specificity for identifying invasive lesions in the mixed or mural nodule subgroup with an AUC of 0.92 (95% confidence interval: 0.76-0.99). CONCLUSION: ADC analysis of solid tissue of adnexal masses could help distinguish invasive masses within the O-RADS MRI 4 category, especially in mixed masses or those with mural nodule.

Adnexal masses: development and preliminary validation of an MR imaging scoring system.

PURPOSE: To construct and undertake preliminary validation of a magnetic resonance (MR) imaging scoring system designed for use in pelvic MR imaging performed for characterization of adnexal masses that were indeterminate at ultrasonography (US). MATERIALS AND METHODS: The institutional ethics committee approved this retrospective study and granted a waiver of informed consent. The study population comprised 394 women who underwent MR imaging between January 1, 2008, and October 30, 2010, for characterization of 497 adnexal masses that were seen at US. Then, masses were chronologically divided into a training set (329 masses) and a validating set (168 masses). Two radiologists who were blinded to the clinical findings retrospectively evaluated MR imaging criteria for characterization of adnexal masses. In the training set, the positive likelihood ratio (PLR) of malignancy and κ values were calculated for each criterion. The reference standard was surgical pathologic findings or findings at imaging follow-up of at least 1 year. On the basis of the PLR and multivariate analysis, a five-category MR scoring system called the ADNEX MR SCORING system was created and was subsequently tested by six readers with the validating set. RESULTS: There was almost perfect agreement (κ > 0.80) for each MR imaging feature except for grouped septa (κ = 0.558) and thickened regular septa (κ = 0.555). The classification was accurate in both the training set (area under the receiver operating characteristic [ROC] curve [AUC] = 0.981 for reader 1 and 0.961 for reader 2) and the validating set (AUC = 0.964 for reader 1 and 0.943 for reader 2). ROC curve analysis demonstrated that the optimal cutoff point was an ADNEX MR score of 3; an ADNEX MR score of 4 or higher was associated with malignancy with a sensitivity of 93.5% (58 of 62) and a specificity of 96.6% (258 of 267). CONCLUSION: In this study, a reproducible and accurate MR imaging scoring system that has the potential to improve patient care was developed and tested. Multicenter prospective validation of the score is warranted. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121161/-/DC1.

How to differentiate benign from malignant myometrial tumours using MR imaging.

PURPOSE: To retrospectively evaluate the ability of magnetic resonance imaging (MRI) to differentiate malignant from benign myometrial tumours. METHODS: Fifty-one women underwent MRI before surgery for evaluation of a solitary myometrial tumour. At histopathology, there were 25 uncertain or malignant mesenchymal tumours and 26 benign leiomyomas. Conventional morphological MRI criteria were recorded in addition to b 1,000 signal intensity and apparent diffusion coefficient (ADC). Odds ratios (OR) were calculated for each criterion. A multivariate analysis was performed to construct an interpretation model. RESULTS: The significant criteria for prediction of malignancy were high b 1,000 signal intensity (OR = +∞), intermediate T2-weighted signal intensity (OR = +∞), mean ADC (OR = 25.1), patient age (OR = 20.1), intra-tumoral haemorrhage (OR = 21.35), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10.2), menopausal status (OR = 9.7), heterogeneous enhancement (OR = 8) and non-myometrial origin on MRI (OR = 4.9). In the recursive partitioning model, using b 1,000 signal intensity, T2 signal intensity, mean ADC, and patient age, the model correctly classified benign and malignant tumours in 47 of the 51 cases (92.4 %). CONCLUSION: We have developed an interpretation model usable in routine practice for myometrial tumours discovered at MRI including T2 signal, b 1,000 signal and ADC measurement. KEY POINTS: • MRI is widely used to differentiate benign from malignant myometrial tumours. • By combining T2-weighted, b 1,000 and ADC features, MRI is 92.4 % accurate. • DWI may limit misdiagnoses of uterine sarcoma as benign leiomyoma. • Patient age is important when considering a solitary myometrial tumour.