Feasibility of 3.0 T pelvic MR imaging in the evaluation of endometriosis

doi:10.1016/j.ejrad.2011.03.049

European Journal of Radiology

Volume 81, Issue 6, June 2012, Pages 1381-1387

https://doi.org/10.1016/j.ejrad.2011.03.049 Get rights and content

Abstract

Introduction

Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3 T magnetom system MRI in the evaluation of endometriosis.

Materials and methods

Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0 T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard.

Results

MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%).

Conclusion

Introduction

Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. It is defined as the presence of epithelial tissue and endometrial stroma outside the uterus, whose prevalence is not well defined; it is estimated to occur with an incidence around 5–10%, including both symptomatic and asymptomatic patients [1], [2], [3]. The pathogenesis is still unknown, therefore a multifactor basis is supposed. Three theories of histogenesis have been proposed:

a)
The metastasis theory, focused on retrograde menstrual or surgical implantation, lympathic and vascular spread, better explains the ovarian and peritoneal localization.
b)
The metaplastic differentiation of the coelomic epithelium, which ultimately develops into endometrial tissue, would explain the deep localization.
c)
The induction theory proposes that undefined biochemical factors induce undifferentiated peritoneal cells which develop into endometrial tissue [4].

In the last decade several etiological factors have been evaluated, such genetic factors, environmental factors, endocrine factors and immunological factors which extent the research field. Earlier classification divided endometriosis in externa and interna, which is actually defined as adenomyosis, while the external endometriosis is simply identified as endometriosis. The anatomopathological evaluation identify microscopic foci or wider cystic endometriosis whose correct name would be endometriomas; although the two terms are equally used, it is important to underline the difference between the two type of lesions, indeed the latter represents the association of adhesion and endometrial implants. The most frequent sites of implantation are ovaries (76%), cul de sac (69%), broad ligaments (47%), uterosacral ligaments (36%), uterus (11%), fallopian tubes (6), sigmoid colon (4%), ureters (3%) and small intestine (0.5%) [5]. Deep endometriosis is defined as the presence of invasive endometriosis implants extended for more than 5 mm from the peritoneal surface into the nearest structures; it is often associated to fibrosis and hyperplastic muscles [6]. Symptoms comprehend chronic pelvic pain in a wide range of severity, dyspareunia, dysmenorrhea, dysuria, rectal pain and infertility. Laparoscopy represents the standard technique for the evaluation and classification of endometriosis, otherwise the wide space resolution offered by magnetic resonance (MR) allows to identify implants outside the adnexal, undetected on ultrasound (US). The radiologist therefore is often requested to characterize the lesions, contributing to define the genesis of the pain. The role of 1.5 T MRI in the evaluation of endometriosis has been widely demonstrated, but only in the last years, the 3 T magnetom system has been applied on the evaluation of the female pelvis [6], [7], [8]. To the best of our knowledge, however, there are only poor papers regarding endometriosis diagnosed by 3 T unit. The increased signal-to-noise ratio (SNR), obtained with the higher field strength, lows the acquisition time, reducing the voxel volume and obtaining images with higher resolution. In the detection and staging of endometriosis, it leads a better definition of the pelvic female anatomy, characterization of the shape, localization of the implants and visualization of the adhesion. The aim of this study is to define the role of 3 T magnetom system MRI in the evaluation of endometriosis.

Section snippets

Materials and methods

The study was approved by our local board and a written informed consent was obtained from all the participating. Between February 2010 and September 2010 46 women, aged between 20 and 43 years (mean age 30.4 years) underwent an MRI 3.0 T examination. We enrolled in the study patients with transvaginal (TV) ultrasound examination positive for endometriosis, patients with chronic pelvic pain, symptomatic patients with negative ultrasound examination and infertile patients. Creatinine blood levels

Results

MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. Regions interested by endometriosis lesions were rectovaginal septum (12 patients), posterior vaginal fornix (8 patients), serosal rectosigmoid surface (5 patients), rectouterine ligaments (right 1 patients; left 2 patients), bladder surface (2

Discussion

Laparoscopy remains the standard technique to evaluate the endometriosis, necessary for diagnosis and treatment of both endometriosis and adhesions [9], [10], [11]. Laparoscopy is however associated with some risks for young women. Moreover in some cases, adhesions of the cul-de-sac-region make surgery difficult [12]. In the last two decades several diagnostic techniques have been proposed in order to identify alternative techniques able to evaluate etiology of pelvic pain and infertility and

Conclusions

Pelvic MRI performed with 3 T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments. T2 w FSE sequences resulted useful in the evaluation of deep implants and adhesions. However, studies based on wider population and with optimal correction of technical parameters are necessary in order to increase the diagnostic

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MRI of endometriosis
2023, Magnetic Resonance Imaging of The Pelvis: A Practical Approach
Endometriosis is a common gynecologic disorder frequently associated with pelvic pain and infertility. While the diagnosis of endometriosis was traditionally made by diagnostic laparoscopy, there has been a recent shift towards using preoperative imaging, either specialized ultrasound or pelvic magnetic resonance (MR) imaging to identify lesions, guide management and optimize surgical planning. In this chapter we will review consensus MR imaging protocol recommendations. MR features of endometriomas and deep infiltrative endometriosis will be described and illustrated with imaging examples. A comprehensive approach to image interpretation and factors to consider when reporting MR studies for endometriosis will be reviewed. MR imaging of endometriosis in the setting of special conditions such as pregnancy, the postoperative setting and malignancy will also be discussed.
Endometriosis: A multimodal imaging review
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Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non – gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains.
Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability.
Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity.
Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.
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Citation Excerpt :
Claustrophobia may represent a limitation and could be overcome by procubitus setting, without or with additional medical treatment [15]. Most published studies use a 1.5T magnet, but few publications using 3.0 T suggested promising results [7,13,16–19]. At 3.0 T, improved signal-to-noise ratio (SNR) results in the acquisition of high-spatial resolution images and accurate detection of all lesions of DE [7,13,16].
Endometriosis is a common gynecological condition of unknown etiology, which mainly affects women of reproductive age. The commonest site of gastrointestinal endometriosis is the rectosigmoid colon. Involvement of the sigmoid, cecum, appendix, and small bowel are less common, but one third of rectosigmoid endometriosis is associated with right-sided extra-pelvic bowel endometriosis. Intestinal endometriosis represents one of the most severe forms of deep endometriosis (DE).
Magnetic resonance imaging (MRI) is recommended as a second-line technique in the preoperative workup of DE, especially for gastrointestinal endometriosis. An optimal MRI protocol is required for a complete mapping of endometriotic lesions. MRI could be used as a triage test in the diagnosis of rectosigmoid colon endometriosis. Magnetic resonance enterography should be additionally performed requiring a specific additional MRI protocol for the evaluation of multicentric intestinal endometriotic lesions.
Except other imaging techniques, the aim of this chapter is to expose indications for MRI, technical requirements, patient preparation, MRI protocols, and criteria for the diagnosis of intestinal endometriosis.
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Pelvic MRI staging of endometriosis at 3 T without patient preparation or anti-peristaltic: Diagnostic performance outcomes
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Thomeer et al. [11] reports a prospective cohort study of 40 women in which a 3 T MRI system was accurate in detecting endometriosis in women who were given an intravenous anti-spasmodic, with a region-level sensitivity and specificity of 63% and 97% respectively. In another study using anti-spasmodic and contrast agents, Manganaro et al. [12] achieved sensitivity and specificity of 97% and 100% respectively with a 3 T MRI system. However, current reported evidence for the optimal use of a 3 T MRI system is still limited compared to published standards that are based on a 1.5 T MRI system, and there is little published data concerning 3 T systems in women without any pre-imaging preparation [13].
Endometriosis is a disease of significant burden among pre-menopausal women characterised by the appearance of functional endometrial tissue in locations outside the uterus. Deep infiltrating endometriosis (DIE) is an invasion of the endometriotic lesion that exceeds 5 mm in depth into the peritoneum. In most cases, pelvic MRI is the imaging modality of choice for the pre-operative workup for DIE to guide surgery. The recommended standard for pelvic MRI images is at 1.5 T with patient preparations in the form of laxatives, anti-spasmodics and/or rectal contrast. However, there appears to be equally diagnostic quality imaging obtainable with a 3 T system using fast imaging acquisition without any patient preparation. This reduces imaging time, movement artefacts, is more comfortable for the patient and is easier for workflow coordination. This study aims to confirm that this approach reaches diagnostic performance outcomes comparable to reported international standards, particularly in the detection of endometriotic bowel lesions, in order to guide surgical pre-operative planning.
Pre-operative diagnostic radiology reports were identified by a search of the Radiology Information System (RIS) for all pelvic MRI studies performed at a tertiary referral centre, King Edward Memorial Hospital for Women, between January 2015 to April 2017 that contained the keyword “endometriosis”. Reported sites of endometriotic deposits at MRI findings were tallied based on anatomical location and correlated to laparoscopic surgical report findings and/or pathology report as a reference standard. Pooled sensitivities and specificities were then calculated and compared with established studies.
Ninety-eight MRI studies were identified, of which 76 identified DIE and 22 were normal studies. Sixty-one patients did not have a surgical or pathology record. Of the remainder who underwent laparoscopy, operative and/or pathology reports were obtainable in 37 female patients, with a median age of 35 years (range: 24 to 49 years). The average time interval from MRI report to surgical operation was 195 days (range: 5 to 563 days). Middle compartment estimated sensitivity was 79.4% (95% CI = (69.4%, 89.4%)), specificity 95.1% (95% CI = (91.2%, 98.9%)). Posterior compartment estimated sensitivity was 76.5% (95% CI = (66.4%, 86.6%)), specificity 99.4% (95% CI = (98.1%, 100%)). Overall sensitivity 76.9% (95% CI = (69.7%, 84.0%)), specificity 98.5% (95% CI = (97.3%, 99.6%)). Sensitivity and specificity of detecting bowel endometriosis were estimated to be 94.4% (95% CI = (83.9%, 100%) and 94.7% (84.7%, 100%)) respectively.
Using a 3 T MRI system without patient preparation is feasible and achieves benchmark diagnostic performance outcomes in the pre-operative assessment for DIE, especially in detecting posterior compartment lesions and bowel DIE to correctly guide surgical planning.
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Feasibility of 3.0 T pelvic MR imaging in the evaluation of endometriosis

Abstract

Introduction

Materials and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Int J Gynaecol Obstet

Fertil Steril

Fertil Steril

Eur J Radiol

Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography

Abdom Imaging

The diagnosis and treatment of deep infiltrating endometriosis

Dtsch Arztebl Int

Endometriosis

N Engl J Med

Endometriosis: radiologic–pathologic correlation

Radiographics

Endometriosis: contribution of 3.0-T pelvic MR imaging in preoperative assessment-initial results

Radiology

MR Imaging of the female pelvis at 3 T

Magn Reson Imaging Clin

Pelvic imaging using a T1 w fat-suppressed three-dimensional dual echo Dixon technique at 3 T

J Magn Reson Imaging

Chronic abdominal pain: the role of adhesions and benefit of laparoscopic adhesiolysis

Gynecol Surg

Diagnostic laparoscopy, infertility, and endometriosis-5 years experience

Gynecol Surg