Top

Published in:

Open Access 01-04-2018 | Pictorial Review

Endometriosis: clinical features, MR imaging findings and pathologic correlation

Authors: Pietro Valerio Foti, Renato Farina, Stefano Palmucci, Ilenia Anna Agata Vizzini, Norma Libertini, Maria Coronella, Saveria Spadola, Rosario Caltabiano, Marco Iraci, Antonio Basile, Pietro Milone, Antonio Cianci, Giovanni Carlo Ettorre

Published in: Insights into Imaging | Issue 2/2018

Abstract

Objective

We illustrate the magnetic resonance imaging (MRI) features of endometriosis.

Background

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extrapelvic endometriosis may rarely occur. Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Conclusion

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Teaching Points

• Endometriosis includes ovarian endometriomas, peritoneal implants and deep pelvic endometriosis.

• MRI is a second-line imaging technique after US.

• Deep pelvic endometriosis is associated with chronic pelvic pain and infertility.

• Endometriosis is characterized by considerable diagnostic delay.

• MRI is the best imaging technique for preoperative staging of endometriosis.

Bazot M, Bharwani N, Huchon C et al (2017) European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 27(7):2765–2775. https://doi.org/10.1007/s00330-016-4673-z CrossRefPubMed

Coutinho A Jr, Bittencourt LK, Pires CE et al (2011) MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics 31(2):549–567. https://doi.org/10.1148/rg.312105144 CrossRefPubMed

Chamié LP, Blasbalg R, Pereira RM, Warmbrand G, Serafini PC (2011) Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 31(4):E77–100. https://doi.org/10.1148/rg.314105193 CrossRefPubMed

Adamson GD, Kennedy SH, Hummelshoj L (2010) Creating solutions in endometriosis: global collaboration through the world endometriosis research foundation. J Endometriosis 2:3–6

Di Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi Mucelli R (2015) Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur J Radiol 84(4):568–574. https://doi.org/10.1016/j.ejrad.2014.12.017 CrossRefPubMed

Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ (1991) Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765CrossRefPubMed

Cosma S, Salgarello M, Ceccaroni M et al (2016) Accuracy of a new diagnostic tool in deep infiltrating endometriosis: positron emission tomography-computed tomography with 16α-[18F]fluoro-17β-estradiol. J Obstet Gynaecol Res 42(12):1724–1733. https://doi.org/10.1111/jog.13117 CrossRefPubMed

Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara I, Daraï E (2009) Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis. Fertil Steril 92(6):1825–1833. https://doi.org/10.1016/j.fertnstert.2008.09.005 CrossRefPubMed

Hsu AL, Khachikyan I, Stratton P (2010) Invasive and noninvasive methods for the diagnosis of endometriosis. Clin Obstet Gynecol 53(2):413–419. https://doi.org/10.1097/GRF.0b013e3181db7ce8 CrossRefPubMedPubMedCentral

10.

Chapron C, Fauconnier A, Vieira M et al (2003) Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 18(1):157–161CrossRefPubMed

11.

Gui B, Valentini AL, Ninivaggi V, Marino M, Iacobucci M, Bonomo L (2014) Deep pelvic endometriosis: don’t forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features. Abdom Imaging 39(3):622–632. https://doi.org/10.1007/s00261-014-0091-3 CrossRefPubMed

12.

Del Frate C, Girometti R, Pittino M, Del Frate G, Bazzocchi M, Zuiani C (2006) Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. Radiographics 26(6):1705–1718CrossRefPubMed

13.

Miller EJ, Fraser IS (2015) The importance of pelvic nerve fibers in endometriosis. Womens Health (Lond) 11(5):611–618. https://doi.org/10.2217/whe.15.47 CrossRef

14.

Woodward PJ, Sohaey R, Mezzetti TP Jr (2001) Endometriosis: radiologic-pathologic correlation. Radiographics 21(1):193–216CrossRefPubMed

15.

Maccagnano C, Pellucchi F, Rocchini L et al (2012) Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int 89(3):249–258. https://doi.org/10.1159/000339519 CrossRefPubMed

16.

Tham WP, Busmanis I, Tan WC, Kwek JW (2016) Polypoid endometriosis of post vaginal fornix: utility of MRI imaging of pelvis with diffusion weighted imaging for diagnosis. Med J Malaysia 71(3):144–146PubMed

17.

Busard MP, van der Houwen LE, Bleeker MC et al (2012) Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion. Abdom Imaging 37(4):549–557. https://doi.org/10.1007/s00261-011-9790-1 CrossRefPubMed

18.

Redwine DB (2002) Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril 77:288–296CrossRefPubMed

19.

Rousset P, Gregory J, Rousset-Jablonski C et al (2016) MR diagnosis of diaphragmatic endometriosis. Eur Radiol 26(11):3968–3977CrossRefPubMed

20.

Nezhat C, Main J, Paka C, Nezhat A, Beygui RE (2014) Multidisciplinary treatment for thoracic and abdominopelvic endometriosis. JSLS 18(3). https://doi.org/10.4293/JSLS.2014.00312

21.

Mannan K, Altaf F, Maniar S, Tirabosco R, Sinisi M, Carlstedt T (2008) Cyclical sciatica: endometriosis of the sciatic nerve. J Bone Joint Surg Br 90(1):98–101CrossRefPubMed

22.

Pham M, Sommer C, Wessig C et al (2010) Magnetic resonance neurography for the diagnosis of extrapelvic sciatic endometriosis. Fertil Steril 94(1):351.e11–351.e14. https://doi.org/10.1016/j.fertnstert.2009.12.046 CrossRef

23.

Possover M, Chiantera V (2007) Isolated infiltrative endometriosis of the sciatic nerve: a report of three patients. Fertil Steril 87(2):417.e17–417.e19CrossRef

24.

Pastore AL, Palleschi G, Silvestri L et al (2015) Endoscopic rendezvous procedure for ureteral iatrogenic detachment: report of a case series with long-term outcomes. J Endourol 29(4):415–420. https://doi.org/10.1089/end.2014.0474 CrossRefPubMed

25.

Takeuchi M, Matsuzaki K, Nishitani H (2008) Susceptibility-weighted MRI of endometrioma: preliminary results. AJR Am J Roentgenol 191(5):1366–1370. https://doi.org/10.2214/AJR.07.3974 CrossRefPubMed

26.

Bis KG, Vrachliotis TG, Agrawal R, Shetty AN, Maximovich A, Hricak H (1997) Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls. Radiographics 17(3):639–655CrossRefPubMed

27.

Scardapane A, Lorusso F, Bettocchi S et al (2013) Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography. Radiol Med 118(2):323–338. https://doi.org/10.1007/s11547-012-0850-6 CrossRefPubMed

28.

Siegelman ES, Oliver ER (2012) MR imaging of endometriosis: ten imaging pearls. Radiographics 32(6):1675–1691. https://doi.org/10.1148/rg.326125518 CrossRefPubMed

29.

Saavalainen L, Heikinheimo O, Tiitinen A, Härkki P (2016) Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013. Gynecol Surg 13(4):435–444. https://doi.org/10.1007/s10397-016-0958-0 CrossRefPubMedPubMedCentral

30.

Seracchioli R, Raimondo D, Di Donato N et al (2015) Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod 30(4):833–839. https://doi.org/10.1093/humrep/deu360 CrossRefPubMed

31.

Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P (2017) Bladder endometriosis: a systematic review of pathogenesis, diagnosis, treatment, impact on fertility, and risk of malignant transformation. Eur Urol 71(5):790–807. https://doi.org/10.1016/j.eururo.2016.12.015 CrossRefPubMed

32.

Kruger K, Gilly L, Niedobitek-Kreuter G, Mpinou L, Ebert AD (2014) Bladder endometriosis: characterization by magnetic resonance imaging and the value of documenting ureteral involvement. Eur J Obstet Gynecol Reprod Biol 176:39–43CrossRefPubMed

33.

Donnez J, Nisolle M, Squifflet J (2002) Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 77:32–37CrossRefPubMed

34.

Bosev D, Nicoll LM, Bhagan L et al (2009) Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol 182:2748–2752CrossRefPubMed

35.

Butticè S, Laganà AS, Mucciardi G et al (2016) Different patterns of pelvic ureteral endometriosis. What is the best treatment? Results of a retrospective analysis. Arch Ital Urol Androl 88(4):266–269. https://doi.org/10.4081/aiua.2016.4.266 CrossRefPubMed

36.

Seracchioli R, Mabrouk M, Manuzzi L et al (2008) Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 15:435CrossRefPubMed

37.

Viala-Trentini M, Maubon A, Filhastre M, Georges P, Rouanet J-P (2006) Imagerie de l’hypofertilité de la femme. EMC Encyclopédie Médico-Chirurgicale (Elsevier SAS, Paris), Radiodiagnostic – Urologie-Gynécologie, 34–620-E-10

38.

Kuligowska E, Deeds L 3rd, Lu K 3rd (2005) Pelvic pain: overlooked and underdiagnosed gynecologic conditions. Radiographics 25(1):3–20CrossRefPubMed

39.

Foti PV, Attinà G, Spadola S et al (2016) MR imaging of ovarian masses: classification and differential diagnosis. Insights Imaging 7(1):21–41. https://doi.org/10.1007/s13244-015-0455-4 CrossRefPubMed

40.

Ghezzi F, Raio L, Cromi A et al (2005) "kissing ovaries": a sonographic sign of moderate to severe endometriosis. Fertil Steril 83(1):143–147CrossRefPubMed

41.

Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2:CD009591. https://doi.org/10.1002/14651858.CD009591.pub2 PubMed

42.

Balaban M, Idilman IS, Toprak H, Unal O, Ipek A, Kocakoc E (2015) The utility of diffusion-weighted magnetic resonance imaging in differentiation of endometriomas from hemorrhagic ovarian cysts. Clin Imaging 39(5):830–833. https://doi.org/10.1016/j.clinimag.2015.05.003 CrossRefPubMed

43.

Lee NK, Kim S, Kim KH et al (2016) Diffusion-weighted magnetic resonance imaging in the differentiation of endometriomas from hemorrhagic cysts in the ovary. Acta Radiol 57(8):998–1005. https://doi.org/10.1177/0284185115609805 CrossRefPubMed

44.

Singh SS, Suen MW (2017) Surgery for endometriosis: beyond medical therapies. Fertil Steril 107(3):549–554. https://doi.org/10.1016/j.fertnstert.2017.01.001 CrossRefPubMed

45.

Foti PV, Ognibene N, Spadola S et al (2016) Non-neoplastic diseases of the fallopian tube: MR imaging with emphasis on diffusion-weighted imaging. Insights Imaging 7(3):311–327. https://doi.org/10.1007/s13244-016-0484-7 CrossRefPubMedPubMedCentral

46.

Medeiros LR, Rosa MI, Silva BR et al (2015) Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet 291(3):611–621. https://doi.org/10.1007/s00404-014-3470-7 CrossRefPubMed

47.

Namimoto T, Awai K, Nakaura T, Yanaga Y, Hirai T, Yamashita Y (2009) Role of diffusion-weighted imaging in the diagnosis of gynecological diseases. Eur Radiol 19(3):745–760. https://doi.org/10.1007/s00330-008-1185-5 CrossRefPubMed

48.

Bazot M, Gasner A, Ballester M, Daraï E (2011) Value of thin-section oblique axial T2-weighted magnetic resonance images to assess uterosacral ligament endometriosis. Hum Reprod 26(2):346–353. https://doi.org/10.1093/humrep/deq336 CrossRefPubMed

49.

Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Darai E (2008) Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol 15:235–240CrossRefPubMed

50.

Vercellini P, Aimi G, Busacca M, Apolone G, Uglietti A, Crosignani PG (2003) Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial. Fertil Steril 80(2):310–319CrossRefPubMed

51.

Pereira RM, Zanatta A, Serafini PC, Redwine D (2010) The feasibility of laparoscopic bowel resection performed by a gynaecologist to treat endometriosis. Curr Opin Obstet Gynecol 22(4):344–353. https://doi.org/10.1097/GCO.0b013e32833beae0 CrossRefPubMed

52.

Yoon JH, Choi D, Jang KT et al (2010) Deep rectosigmoid endometriosis: “mushroom cap” sign on T2-weighted MR imaging. Abdom Imaging 35(6):726–731CrossRefPubMed

53.

De CC, Corona R, Schonman R et al (2010) Bowel resection for deep endometriosis: a systematic review. BJOG 118(3):285–291

54.

Busard MP, Pieters-van den Bos IC, Mijatovic V, Van Kuijk C, Bleeker MC, van Waesberghe JH (2012) Evaluation of MR diffusion-weighted imaging in differentiating endometriosis infiltrating the bowel from colorectal carcinoma. Eur J Radiol 81(6):1376–1380. https://doi.org/10.1016/j.ejrad.2011.03.038 CrossRefPubMed

55.

Siquara De Sousa AC, Capek S, Amrami KK, Spinner RJ (2015) Neural involvement in endometriosis: review of anatomic distribution and mechanisms. Clin Anat 28(8):1029–1038. https://doi.org/10.1002/ca.22617 CrossRefPubMed

56.

Niro J, Fournier M, Oberlin C, Le Tohic A, Panel P (2014) Endometriotic lesions of the lower troncular nerves. Gynecol Obstet Fertil 42(10):702–705. https://doi.org/10.1016/j.gyobfe.2014.08.003 CrossRefPubMed

57.

Reis FM, Monteiro CS, Carneiro MM (2017) Biomarkers of pelvic endometriosis. Rev Bras Ginecol Obstet 39(3):91–93. https://doi.org/10.1055/s-0037-1601398 CrossRefPubMed

58.

Vercellini P, Giudice LC, Evers JL, Abrao MS (2015) Reducing low-value care in endometriosis between limited evidence and unresolved issues: a proposal. Hum Reprod 30(9):1996–2004. https://doi.org/10.1093/humrep/dev157 CrossRefPubMed

Title: Endometriosis: clinical features, MR imaging findings and pathologic correlation
Authors: Pietro Valerio Foti
Renato Farina
Stefano Palmucci
Ilenia Anna Agata Vizzini
Norma Libertini
Maria Coronella
Saveria Spadola
Rosario Caltabiano
Marco Iraci
Antonio Basile
Pietro Milone
Antonio Cianci
Giovanni Carlo Ettorre
Publication date: 01-04-2018
Publisher: Springer Berlin Heidelberg
Published in: Insights into Imaging / Issue 2/2018
Electronic ISSN: 1869-4101
DOI: https://doi.org/10.1007/s13244-017-0591-0

At a glance: The STEP trials

Springer Medicine

Endometriosis: clinical features, MR imaging findings and pathologic correlation

Abstract

Objective

Background

Conclusion

Teaching Points

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Background

Conclusion

Teaching Points

Please log in to get access to this content

Other articles of this Issue 2/2018

Letter from the new Editor-in-Chief for Insights into Imaging

Hyperechoic breast images: all that glitters is not gold!

Imaging of the scrotum: beyond sonography

Collaboration, campaigns and champions for appropriate imaging: feedback from the Zagreb workshop

Imaging of non-neoplastic duodenal diseases. A pictorial review with emphasis on MDCT

ESR paper on the proper use of mobile devices in radiology