European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis

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Abstract

Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence.

Key Points

• This report provides guidelines for MRI in endometriosis.

• Minimal and optimal MRI acquisition protocols are provided.

• Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.

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The online version of this article (doi:10.1007/s00330-016-4673-z) contains supplementary material, which is available to authorized users.

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Most cited references 77

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

T M F O Gonçalves, Sergio Podgaec, Paulo J. Dias … (2007)

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. 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. 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%. 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.

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Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis.

Marc Bazot, Clarisse Lafont, Roman Rouzier … (2009)

To compare the value of physical examination, transvaginal sonography (TVS), rectal endoscopic sonography (RES), and magnetic resonance imaging (MRI) for the assessment of different locations of deep infiltrating endometriosis (DIE). Retrospective longitudinal study. Tertiary university gynecology unit. Ninety-two consecutive patients with clinical evidence of pelvic endometriosis. Physical examination, TVS, RES, and MRI, performed preoperatively. Descriptive statistics, calculation of likelihood ratios (LR(+) and LR(-)) of physical examination, TVS, RES, and MRI for DIE in specific locations confirmed by surgery/histology. The sensitivity and LR(+) and LR(-) values of physical examination, TVS, RES, and MRI were, respectively, 73.5%, 3.3, and 0.34, 78.3%, 2.34, and 0.32, 48.2%, 0.86, and 1.16, and 84.4%, 7.59, and 0.18 for uterosacral ligament endometriosis; 50%, 3.88, and 0.57, 46.7%, 9.64, and 0.56, 6.7%, -, and 0.93, and 80%, 5.51, and 0.23 for vaginal endometriosis; and 46%, 1.67, and 0.75, 93.6%, -, and 0.06, 88.9%, 12.89, and 0.12, and 87.3%, 12.66, and 0.14 for intestinal endometriosis. The MRI performs similarly to TVS and RES for the diagnosis of intestinal endometriosis but has higher sensitivity and likelihood ratios for uterosacral ligament and vaginal endometriosis.

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Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease.

J Buy, Emile Daraï, Isabelle Thomassin … (2004)

To prospectively evaluate the accuracy of magnetic resonance (MR) imaging for the preoperative diagnosis of deep pelvic endometriosis and extension of the disease. One hundred ninety-five patients (mean age, 34.2 years; range, 20-71 years) who were suspected of having pelvic endometriosis were recruited at two institutions. Two experienced radiologists evaluated the MR images independently. Deep pelvic endometriosis was defined as implants or tissue masses that appeared as hypointense areas and/or hyperintense foci on T1- or T2-weighted MR images in the following locations: torus uterinus, uterosacral ligaments (USLs), vagina, rectovaginal septum, rectosigmoid, and bladder. MR imaging results were compared with surgical and pathologic findings. Sensitivity, specificity, predictive values, and accuracy of MR imaging for prediction of deep pelvic endometriosis were assessed. Pelvic endometriosis was confirmed at pathologic examination in 163 (83.6%) of 195 patients. Endometriomas, peritoneal lesions, and deep pelvic endometriosis were diagnosed on the basis of surgical findings, alone or combined with pathologic findings, in 111 (68.1%), 83 (50.9%), and 103 (63.2%) of 163 patients, respectively. Torus uterinus and USL were the most frequent sites of deep pelvic endometriosis. The sensitivity, specificity, positive and negative predictive values, and accuracy of MR imaging for deep pelvic endometriosis were 90.3% (93 of 103), 91% (84 of 92), 92.1% (93 of 101), 89% (84 of 94), and 90.8% (177 of 195), respectively. The sensitivity, specificity, and accuracy, respectively, of MR imaging for the diagnosis of endometriosis in specific sites were as follows: USL, 76% (57 of 75), 83.3% (100 of 120), and 80.5% (157 of 195); vagina, 76% (16 of 21), 95.4% (166 of 174), and 93.3% (182 of 195); rectovaginal septum, 80% (eight of 10), 97.8% (181 of 185), and 96.9% (189 of 195); rectosigmoid, 88% (53 of 60), 97.8% (132 of 135), and 94.9% (185 of 195); and bladder, 88% (14 of 16), 98.9% (177 of 179), and 97.9% (191 of 195). MR imaging demonstrates high accuracy in prediction of deep pelvic endometriosis in specific locations. Copyright RSNA, 2004

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Author and article information

Contributors

M. Bazot: +33 6 06 62 37 88 52 , marc.bazot@tnn.aphp.fr

N. Bharwani: +44 7956243688 , nishat.bharwani@imperial.nhs.uk

C. Huchon: +33660271068 , cyrillehuchon@yahoo.fr

K. Kinkel: +41 79 65 22762 , karen.kinkel-trugli@wanadoo.fr

T. M. Cunha: +351 93 834 87 03 , tmargarida@gmail.com

A. Guerra: +351 96 631 8575 , aguerra@hospitaldaluz.pt

L. Manganaro: +39 06 49972762 , lucia.manganaro@uniroma1.it

L. Buñesch: +34 669 54 82 06 , lbunesch@clinic.ub.es

A. Kido: +81 75 751 3760 , akikido@kuhp.kyoto-u.ac.jp

K. Togashi: +81 75 751 3760 , ktogashi@kuhp.kyoto-u.ac.jp

I. Thomassin-Naggara: +33 6 63067321 , isabelle.thomassin@tnn.aphp.fr

A. G. Rockall: +44 7866 585 476 , a.rockall@imperial.ac.uk

Journal

Journal ID (nlm-ta): Eur Radiol

Journal ID (iso-abbrev): Eur Radiol

Title: European Radiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0938-7994

ISSN (Electronic): 1432-1084

Publication date (Electronic): 5 December 2016

Publication date PMC-release: 5 December 2016

Publication date (Print): 2017

Volume: 27

Issue: 7

Pages: 2765-2775

Affiliations

[1 ]ISNI 0000 0001 2259 4338, GRID grid.413483.9, Department of Radiology, , Tenon Hospital, ; 58 Avenue Gambetta, Paris, 75020 France

[2 ]ISNI 0000 0001 0693 2181, GRID grid.417895.6, Department of Radiology, St Mary’s Hospital, , Imperial College Healthcare NHS Trust, ; 3rd Floor Queen Elizabeth the Queen Mother Building, Praed Street, London, W2 1NY UK

[3 ]Department of Obtetrics and Gynaecology, CHI Poissy Saint-Germain en Laye,Versailles University France, 10 rue du champ Gaillard, 78300 Poissy, France

[4 ]Institut de radiologie, Clinique des Grangettes, 7, chemin des Grangettes, CH 1224 Chêne-Bougeries, Switzerland

[5 ]ISNI 0000 0004 0631 0608, GRID grid.418711.a, Serviço de Radiologia, , Instituto Português de Oncologia de Lisboa Francisco Gentil, ; Rua Prof. Lima Basto, 1099-023 Lisboa, Portugal

[6 ]ISNI 0000 0001 0163 5700, GRID grid.414429.e, Department of Radiology, , Hospital da Luz, ; Lisbon, Portugal

[7 ]GRID grid.7841.a, Department of Radiological Sciences, , Sapienza University of Rome, ; Vle. Regina Elena 324, 00162 Rome, Italy

[8 ]ISNI 0000 0000 9635 9413, GRID grid.410458.c, Department of Radiology (Urogenital Section), , Hospital Clínic Barcelona, ; Villarroel, 170, Barcelona, 08036 Spain

[9 ]ISNI 0000 0004 0531 2775, GRID grid.411217.0, Department of Diagnostic Radiology, , Kyoto University Hospital, ; 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan

[10 ]ISNI 0000 0004 0417 0461, GRID grid.424926.f, Department of Radiology, , The Royal Marsden Hospital, ; Fulham Road, London, SW3 6JJ UK

Article

Publisher ID: 4673

DOI: 10.1007/s00330-016-4673-z

PMC ID: 5486785

PubMed ID: 27921160

SO-VID: 485c9d6e-df2c-4316-86ee-b5653e27c4ec

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 3 June 2016

Date revision received : 5 October 2016

Date accepted : 23 November 2016

Custom metadata

ScienceOpen disciplines: Radiology & Imaging

Keywords: endometriosis,guidelines,magnetic resonance imaging (mri),protocols,evidence-based medicine/standards

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ScienceOpen disciplines: Radiology & Imaging

Keywords: endometriosis, guidelines, magnetic resonance imaging (mri), protocols, evidence-based medicine/standards

European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis

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Abstract

Abstract

Key Points

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Stroke MRI

Most cited references 77

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

Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis.

Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease.

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