Performance of imaging interpretation, intra- and inter-reader agreement for diagnosis of pelvic endometriosis: comparison between an abbreviated and full MRI protocol.

PURPOSE: To compare the performance of imaging interpretation, intra- and inter-reader agreement between an abbreviated (aMRI) and full (fMRI) MRI protocol for diagnosis of pelvic endometriosis. METHODS: Seventy consecutive fMRI exams performed under suspicion of pelvic endometriosis were selected. Four radiologists (Rd) (1-10 years experience) independently evaluated presence/absence of endometriosis at 9 anatomic sites (AS). The readers evaluated aMRI (coronal T2 TSE volumetric images and axial T1 GRE fat-sat without contrast, extracted from fMRI) and fMRI protocols randomly, with at least 4 weeks interval between readings. The degree of confidence for diagnosis at each AS was evaluated with a 1-3 Likert Scale (1: low; 3: high). Intra- and inter-reader agreement between protocols were evaluated by kappa statistics and took reading experience into account. The gold standard for assessing the performance of imaging interpretation (sensitivity, specificity and accuracy) used a consensus reading of two other Rd (> 15 years experience). RESULTS: There was no significant difference in the accuracy of imaging interpretation between the abbreviated (0.83-0.86) and full (0.83-0.87) protocols (p = 0.15). Intra-reader agreement between protocols ranged from substantial to almost perfect (0.74-0.96). A substantial inter-reader agreement was found for both protocols for readers with similar levels of experience (0.67-0.69) and in the global analysis (0.66 for both protocols). No difference was found in terms of degree of confidence between protocols, for all readers. CONCLUSION: An abbreviated MRI protocol for pelvic endometriosis provided an accuracy of interpretation comparable to that of a complete protocol, with similar degrees of confidence and reproducibility, regardless the level of experience.

Postoperative imaging findings after laparoscopic surgery for deeply infiltrating endometriosis.

Deeply infiltrative endometriosis (DIE) is a common gynecologic disease affecting women of reproductive age and often causing chronic pelvic pain and infertility. Clinical treatment options and preventive actions are ineffective due to the lack of knowledge about the etiology of DIE. Surgical treatment is currently the only alternative to eradicate the disease. Diagnostic imaging plays a crucial role for surgical planning and postoperative evaluation. Transvaginal sonography (TVS) with a dedicated protocol and magnetic resonance imaging (MRI) can be used to evaluate recurrent disease. Extensive pelvic surgery may cause anatomical changes and a variable spectrum of postoperative findings. Residual disease and complications can be also evaluated and are of great importance to estimate pain relief and fertility prognosis. The most common imaging findings following radical surgery for DIE are fibrotic scars in the retrocervical space and bowel anastomosis, absence of the posterior vaginal fornix and loculated fluid in the pararectal spaces. Ovaries are the most frequent site of early recurrence. Complications include infection, hemorrhage, urinary/evacuatory voiding dysfunctions as well as bowel and ureteral stenosis. The purpose of this article is to review the surgical techniques currently used to treat endometriosis in the retrocervical space, vagina, bladder, bowel, ureters, and ovaries and to describe the most common imaging findings including normal aspects, residual disease, complications, and recurrence.

Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation.

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue located outside the uterus and frequently associated with chronic pelvic pain and infertility. It is a polymorphic disease that can be presented as superficial implants, endometriomas and deep lesions that infiltrate the peritoneal surface associated with fibrosis and inflammatory reaction. Diagnosis of deep endometriosis is difficult and delayed, frequently missed in a routine ultrasound. Transvaginal ultrasound is the first-line imaging modality to investigate endometriosis and when performed by an expert in female pelvic imaging can provide a reliable mapping of the affected sites. Bowel preparation can be used to improve the detection of bowel lesions as well as the other sites affected by eliminating artifacts. Surgery has been the mainstay to treat symptomatic endometriosis and preoperative imaging mapping is crucial for better results and to reduce residual disease. The goals of surgery include radical removal of all lesions and the restoration of normal pelvic anatomy. The author describes technical aspects and imaging interpretation of the transvaginal sonography to investigate deeply infiltrative endometriosis.

Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy.

Endometriosis is a common multifocal gynecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. It may occur as invasive peritoneal fibrotic nodules and adhesions or as ovarian cysts with hemorrhagic content. Although findings at physical examination may be suggestive, imaging is necessary for definitive diagnosis, patient counseling, and treatment planning. The imaging techniques that are most useful for preoperative disease mapping are transvaginal ultrasonography (US) after bowel preparation, and magnetic resonance (MR) imaging. Initial transvaginal US is a reliable technique for detecting rectosigmoid endometriotic lesions. MR imaging is indicated as a complementary examination in complex cases of endometriosis with extensive adhesions and ureteral involvement. Peritoneal endometriotic implants are typically hypoechoic on transvaginal US images and demonstrate low signal intensity on T2-weighted MR images. Endometriotic implants most commonly are found in retrocervical and rectosigmoid sites, followed by the vagina, bladder, and ureters. Cysts with low-level internal echoes and echogenic peripheral foci at transvaginal US are suggestive of endometriomas. MR imaging has high specificity for identifying endometriomas, which are characterized by high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Correlation of the radiologic imaging features of endometriotic lesions with their laparoscopic appearances may help improve individual proficiency in the radiologic diagnosis of endometriosis.

Transvaginal US after bowel preparation for deeply infiltrating endometriosis: protocol, imaging appearances, and laparoscopic correlation.

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis.

OBJECTIVE: To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE). METHODS: This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed. RESULTS: DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%). CONCLUSION: MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.

Endometriose pélvica: aspectos à ressonância magnética e correlação com laparoscopia e anatomia patológica / Pelvic endometriosis: correlation among magnetic resonance imaging, laparoscopy and pathological findings

Introdução: A endometriose é uma doença ginecológica comum, caracterizada pela presença de tecido endometrial glandular e/ou estromal fora dos limites uterinos. Acomete principalmente as mulheres na idade reprodutiva e representa causa freqüente de dor pélvica crônica e infertilidade. O diagnóstico representa um dos maiores problemas no contexto clínico desta doença, sendo o mapeamento dos focos de extrema importância na escolha da modalidade terapêutica e no prognóstico da paciente. Este estudo teve por finalidade avaliar a capacidade da ressonância magnética (RM) da pelve para o diagnóstico pré-operatório da endometriose nos ovários, região retrocervical, reto-sigmóide, bexiga, ureteres e vagina em correlação aos achados de laparoscopia e de anatomia patológica, além de descrever os aspectos de imagem da doença nestes sítios à RM. Métodos: O presente estudo, transversal, observacional e prospectivo, efetuado em 92 pacientes do sexo feminino com suspeita clínica de endometriose profunda, foi realizado de novembro de 2005 a julho de 2007. As pacientes foram procedentes do Serviço de Ambulatório de Endometriose do Departamento de Ginecologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), e tinham idades entre 20 e 52 anos (média de 33 anos). As imagens de RM foram analisadas independentemente por dois radiologistas experientes e o diagnóstico estabelecido através de consenso entre eles. Endometriose foi diagnosticada quando foram identificados cistos ovarianos com elevado sinal em T1 e baixo sinal em T2 (shading) ou nódulos peritoniais de baixo sinal em T2 localizados na região retrocervical, reto-sigmóide, bexiga, ureteres e vagina. Os achados da RM foram comparados com aqueles obtidos na laparoscopia e anatomia patológica. Foram avaliados os valores de sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia da RM para o diagnóstico da endometriose...

Introduction: Endometriosis is a prevalent gynecological disease characterized by the presence of endometrial glandular and/or stromal tissue outside the uterine boundaries. This disorder causes infertility and it is the most common cause of chronic pelvic pain affecting women in the reproductive age. Appropriate clinical diagnosis and pelvic imaging information regarding the spread and the infiltration of the lesions remains a major diagnostic challenge. The objectives of this study were to describe magnetic resonance imaging (MRI) aspects of endometriosis in the most commonly affect sites and to evaluate the accuracy of the pre-operative MRI findings with those obtained at surgery and pathology. Methods: This prospective, transversal and observational study included 92 women with clinical suspicion of deeply infiltrative endometriosis and was carried out between November 2005 and July 2007. Women aged 20 and 52 (mean 33) years old were followed at the Serviço de Ambulatório de Endometriose do Departamento de Ginecologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). Two experienced radiologists evaluated the magnetic resonance (MR) images independently and provided consensus reading. Endometriosis was defined as ovarian cysts with high signal intensity on T1-weighted images and low signal intensity on T2 (shading) and nodule or masses that appeared as hypointense areas on T2-weighted images in the following locations: retrocervical space, rectosigmoid, bladder, ureters and vagina. MR findings were compared with those obtained at laparoscopy and pathology. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MRI for prediction of deep pelvic endometriosis were assessed. Results: Endometriomas and deep infiltrative endometriosis were confirmed at histopathology in 77 (83.7%) out of 92 patients. In 15 women there were only superficial peritoneal lesions...

Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.

BACKGROUND: Deeply infiltrating endometriosis affecting the retrocervical region and the rectosigmoid generally requires surgical treatment. Clinical examination, transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) are useful in the preoperative diagnosis of the involvement of these sites. The objective of this study was to evaluate the capacity of digital vaginal examination, TVUS and MRI to diagnose rectosigmoid and retrocervical involvement. METHODS: A total of 104 patients with clinically suspected endometriosis were submitted to clinical examination, pelvic MRI and TVUS until 3 months prior to videolaparoscopy and the findings of these methods were matched with histopathological confirmation of endometriosis. RESULTS: Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%. CONCLUSIONS: TVUS had better sensitivity, specificity, PPV, NPV and accuracy in cases of deep retrocervical and rectosigmoid endometriosis when compared with MRI and digital vaginal examination, confirming that it is an important preoperative examination for the definition of surgical strategies.