MRI of Endometriosis with Pre and Post- Operative Correlation

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1 MRI of Endometriosis with Pre and Post- Operative Correlation Shannon P. Sheedy, Candice A. Bookwalter, Wendaline M. VanBuren Mayo Clinic Rochester, Department of Radiology SCBT-MR - Nashville, TN September 10, 2017 at 10: MFMER slide-1

2 Relevant Financial Relationships None Off-label/Investigational Uses None 2017 MFMER slide-2

3 I. BACKGROUND Functional endometrial glands and stroma outside of uterine cavity and myometrium Ectopic endometrium responds to hormonal stimulation various degrees of cyclic hemorrhage: inflammation, fibrosis, adhesion formation Physical manifestations are protean: asx to disabling pelvic pain/infertility 2017 MFMER slide-6

BACKGROUND Estimate prevalence of 5-10% (asx and sx) Much

Other sxs depend on location/organs of involvement Symptoms

with adenomyosis, but distinct: No racial predilection

4 BACKGROUND Estimate prevalence of 5-10% (asx and sx) Much higher in patients with chronic pelvic pain and infertility Other sxs depend on location/organs of involvement Symptoms not necessarily correlative w/ disease severity Associated with adenomyosis, but distinct: No racial predilection Increased prevalence in families likely genetic role 2017 MFMER slide-7

5 Reproductive Age Chronic pelvic pain Dyspareunia Infertility < 17 yo Obstructive Mullerian duct anomalies Post menopausal 5% Replacement estrogen therapy 2017 MFMER slide-8

6 BACKGROUND 3 forms: Ovarian endometrioma Superficial peritoneal lesions or non-invasive implants Deep (or solid) infiltrating endometriosis Invasion of endo glands & stroma 5 mm beneath the peritoneal surface Intraoperative images courtesy of Tatnai Burnett, MD 2017 MFMER slide-9

Understand proposed theories of pathogenesis Optimize MR protocols for the detection of DPE Understand MR appearance: endometriomas, serosal peritoneal implants, DPE, extraperitoneal

7 Understand proposed theories of pathogenesis Optimize MR protocols for the detection of DPE Understand MR appearance: endometriomas, serosal peritoneal implants, DPE, extraperitoneal implants and complications Become familiar with a standardized approach of interpretation & reporting Understand how MR interpretation and MDT affect therapeutic considerations 2017 MFMER slide-10

8 THEORIES OF PATHOGENESIS Metastatic theory a. Retgrograde menstruation b. Lymphatic spread c. Hematogenous spread Metaplastic theory d. Coelomic metaplasia Induction theory Other: GFs, impaired immuned response, genetics, stem cells, embryonic rest Woodard et al., RadioGraphics :1, MFMER slide-11

9 LOCATION IMPLANTS ADHESIONS Ovaries 76% 39% CDS 69% 13% Broad lig 47% 43% USL 36% 7% Uterus 11% 3% FTs 6% 26% Sigmoid 4% 12% Ureter 3% 2% SB 0.5% 3% Jenkins et al. Obstet Gynec (1986) Mar;67(3) MFMER slide-12

10 MRI PROTOCOL Sagittal, Axial & Coronal T2W FRFSE Axial SE T1W Axial SE T1W FS+ IP & OP DWI (b=0, 500, 800) Axial pre and mutiphase 3D T1W GRE FS+ C MFMER slide-13

11 Cor SSFSE Sag T2 FSE Ax T2 FSE ENDOMETRIOSIS PROTOCOL Ax T2 FSE FS+ Cor T2 FSE Ax T1 (option I/O phase) DWI (b = 0, 500, 800) Ax and/or sag pre contrast 3D T1W GRE FS+ Multiphase and multiplanar post contrast 3D T1W GRE FS MFMER slide-14

12 MRI PELVIC ANATOMY Anterior compartment Bladder Prevesical space Vesicouterine pouch Vesicovaginal septum Coutinho, A., RG (2011); 31: MFMER slide-15

13 MRI PELVIC ANATOMY Middle compartment Intraoperative images courtesy of Tatnai Burnett, MD 2017 MFMER slide-16

14 MRI PELVIC ANATOMY Posterior compartment Perineal body Torus uterine Rectovaginal septum Rectovaginal pouch 2017 MFMER slide-17

15 2017 MFMER slide-18

16 2017 MFMER slide-19

17 II. ENDOMETRIOMA Ovaries most commonly affected Cyclic hemorrhage into a deep ovarian implant Often bilateral, multifocal US: classic (<30%) diffuse & homogeneous low level internal echoes (95%) uni or multilocular punctate peripheral echogenic wall foci 35% endometriomas vs 6% other cysts no internal BF stable over time Patel et al., Radiology (1999); 210(3): MFMER slide-20

and dermoid plug/rokitansky nodule) fat-fluid layer (may shift) hyperechoic lines and dots (hair)

18 ENDOMETRIOMA Cystic teratoma: 10-15% of ovarian tumors 90% unilateral, usually unilocular Ca2+ (30%) Hyperechoic areas/nodules of varying echogenicity and some with focal acoustic impedance ( tip of iceberg and dermoid plug/rokitansky nodule) fat-fluid layer (may shift) hyperechoic lines and dots (hair) Hemorrhagic cyst: evolve/resolve, fibrin strands thinner, retracting clot, weaker reflectors Cystic neoplasm 2017 MFMER slide-21

19 ENDOMETRIOMA 2017 MFMER slide-22

20 ENDOMETRIOMA MR Hyperintense on T1WI Hyperintense on T1WI FS+ T2 shading S/S : 90-92% / 91-98% 1 Diagnostic accuracy 91-96% 1 S/S : 93% / 45% 2 T2 dark spot Discrete, markedly hypointense foci within the cyst, not within the wall itself S/S oma vs hemorrhagic cyst: 36% / 93% 2 1 Glastonbury CM, Radiology 2002;224(1): Corwin MT, Radiology ); MFMER slide-23

21 T2 SHADING 2017 MFMER slide-24

22 2017 MFMER slide-25

23 KISSING OVARIES R L 2017 MFMER slide-26

24 2017 MFMER slide-27

25 2017 MFMER slide-28

26 ENDOMETRIOSIS ASSOCIATED MALIGNANCY Malignant Transformation is a rare complication (<1% of women with an ovarian endometriosis) Clear cell (14.8%) and endometrioid (66.7%) carcinomas 75% ovarian, 25% extraovarian Younger age onset (10-20 yrs), earlier stage and lower grade better overall survival MR imaging CE+ mural nodules (most sensitive) Disappearance of T2 shading dilution of hemorrhagic fluid by tumor secretions McDermott, S,. RG 2012;32: MFMER slide-29

27 2017 MFMER slide-30

28 Courtesy of Candice Bolan, MD 2017 MFMER slide-31

29 2017 MFMER slide-32

30 DECIDUALIZED ENDOMETRIOMA RIGHT OVARY LEFT OVARY 2017 MFMER slide-33

31 DECIDUALIZED ENDOMETRIOMA 2017 MFMER slide-34

32 III. DEEP INFILTRATING ENDOMETIROSIS subperitoneal invasion by endometriotic lesions >5 mm in depth fibromuscular hyperplasia that surrounds sparse ectopic endometrial glands Responds to hormonal stimulation Various degree of cyclic bleeding Variable inflammatory response and fibrous reaction 2017 MFMER slide-32

33 Deep Infiltrating Endometriosis MR appearance Solid nodules Intermediate T1W, low T2W, irregular and stellate margins due to presence of abundant fibrous tissue and smooth muscle proliferation Soft tissue thickening T2W hypointense T2W hyperintense foci corresponds to dilated ectopic endometrial glands Variable Intrinsic T1W Enhancement Diffusion weighted images 2017 MFMER slide-33

34 Report Template Anterior Compartment Middle Compartment Posterior Compartment Additional Sites vesicouterine pouch prevesicular space rectovaginal septum/pouch vesicovaginal pouch 2017 MFMER slide-34

35 Anterior Compartment Prevesicular space Bladder Ureters prevesicular space 2017 MFMER slide-35

symptoms suprapubic pressure cyclic hematuria history of

36 Anterior Compartment Bladder Extrinsic involvement Intrinsic involvement Symptoms Sag T2W irritative voiding symptoms suprapubic pressure cyclic hematuria history of pelvic surgery in 43% 50% of cases Sag T1W Cor T1W +C 2017 MFMER slide-36

37 Anterior Compartment Bladder - history of pelvic surgery in 43% 50% of cases 34 yr. old with previous C-section 2017 MFMER slide-37

38 Anterior Compartment Ureters Extrinsic most common Never above the pelvic brim Cor Excretory phase Ax T2W Ax Excretory phase 2017 MFMER slide-38

39 Middle Compartment Uterus Uterine Ligaments (broad and round) Vagina Fallopian Tubes Ovaries vesicouterine pouch vesicovaginal pouch 2017 MFMER slide-39

40 Middle Compartment Uterus Serosal implants Sag T1W Sag T1W Ax T1W Sag T1W 2017 MFMER slide-40

41 Middle Compartment Uterus C-section scar Sag T2W Sag T1W 2017 MFMER slide-41

Transmural or mucosal involvement less common

42 Middle Compartment Fallopian Tube 28% of women with endometriosis Most common on the serosal surface Transmural or mucosal involvement less common Hematosalpinx high correlation with endometriosis Ax T1W 2017 MFMER slide-42

43 Middle Compartment Broad ligament Ax T2W Cor T2W 2017 MFMER slide-43

44 Posterior Compartment Rectum Torus Uterinus Uterosacral Ligaments Pouch of Douglas rectovaginal septum/pouch Additional Sites: Posterior vaginal fornix and rectovaginal septum 2017 MFMER slide-44

45 Posterior Compartment Rectum Rectosigmoid most common site of bowel involvement Serosal or deep Rarely invades mucosa Obliteration of the pouch of Douglas Findings: Adhesions, bowel strictures and GI obstruction Sag T2W 2017 MFMER slide-45

46 Posterior Compartment Torus uterinus Not seen unless pathologically thickened T2W hypointense thickening and nodularity Sag T2W 2017 MFMER slide-46

47 Posterior Compartment Uterosacral ligaments Ax T2W Sag T2W Sag T1W 2017 MFMER slide-47

48 Other Appendix Lymph nodes Free Fluid Kidneys Cor T2W Outside the pelvis Cecum, small bowel, inguinal canal, sciatic nerve, anterior abdominal wall, liver, diaphragm, and upper abdomen 2017 MFMER slide-48

49 Appendix Ax +C DW Cor +C Ax T1W +C 2017 MFMER slide-49

50 Standardized Report Anterior Compartment Bladder Middle Compartment Uterus, uterine ligaments, vagina, ovaries, fallopian tubes Posterior Compartment Rectum, torus uterinus, uterosacral ligaments, pouch of Douglas, posterior vaginal fornix, rectovaginal septum Additional sites: appendix, lymph nodes, kidneys, ureters, cecum, small bowel, inguinal canal, anterior abdominal wall, diaphragm, and upper abdomen 2017 MFMER slide-50

51 IV. EXTRAPERITONEAL LOCATIONS Thorax/pleura Abdominopelvic wall/ scar Inguinal Hernia Brain? 2017 MFMER slide-51

52 51 year old female with shortness of breath Aug MFMER slide-52

53 May MFMER slide-53

54 Treatment? 2017 MFMER slide-54

55 41 year old female with previous talc pleurodesis on the right 2017 MFMER slide-55

56 Umbilicus 2017 MFMER slide-56

57 Perihepatic a spectrum 2017 MFMER slide-57

58 63 year old female Case from Mallinckrodt Institute of Radiology 2017 MFMER slide-58

59 Inguinal canal 2017 MFMER slide-59

60 45 year old female with cyclical pain at her C-section scar 2017 MFMER slide-60

61 Treatment? 2017 MFMER slide-61

62 Injection of 25cc ethanol Two year follow-up 2017 MFMER slide-62

63 47 year old female DDx? 2017 MFMER slide-63

64 VI. Surgical considerations/treatment 2017 MFMER slide-64

65 Superficial Endometriosis Treatment: cauterization, evaporation, resection Generally not visualized on MRI, but may occasionally seen restricted diffusion or punctate T1 hyperintensity 2017 MFMER slide-65

66 Superficial endometriosis: cauterization, evaporation, resection 2017 MFMER slide-66

67 Deep Infiltative Endometriosis (DIE) Bowel: DIE involving one layer of bowel at most: shaving DIE 1-3 cm nodule, <50% circumference, single nodule: discoid resection DIE nodule >3 cm or multifocal DIE: segmental resection DIE often requires Surgical Oncology or Colorectal Surgery involvement 2017 MFMER slide-67

68 Partial thickness shaving 2017 MFMER slide-68

69 49. Year old female with rectal bleeding and failed medical management Robotic low anterior resection performed with colorectal surgery 2017 MFMER slide-69

70 31 year old female with obstructive symptoms and rectal bleeding In case there is need for reassurance 2017 MFMER slide-70

71 Flexible Sigmoidoscopy followed by Lower EUS 2017 MFMER slide-71

72 VII. Multidisciplinary rounds 2017 MFMER slide-72

73 Multidisciplinary Rounds: How we do it! Pre-operative MRI scans are reviewed All anatomic areas of interest from the report template are discussed Post-operative MRI scans are reviewed and compared to the surgical and pathologic findings Intraoperative video and photos serve as a teaching guide Concordance between the pre-operative MRI and the postoperative findings are made 2017 MFMER slide-73

74 How this helps Radiology We learn about the our accuracy in describing disease with various presentations (i.e. hemorrhagic or fibrotic) and with respect to their various locations Unique circumstances such as the post-operative pelvis, patients with Crohn s disease or PID may have overlapping presentations, creating limitations We are able to optimize our imaging protocol and develop longitudnal development of interpretive abilities We understand better the medical and surgical management of disease 2017 MFMER slide-74

75 How this helps Gynecology They recognize that pre-operative MRI can greatly assist with operative planning ( presence of Deep Infiltrative Disease, bowel and bladder involvement, and obliterated cul-de-sac Awareness of extent of disease may alter the surgeons performing the case, the surgical location, and reduce the risk of residual disease Develop a relationsghip with radiology to manage complex cases that may undergo medical management and require serveillance 2017 MFMER slide-75

76 How this helps the patient A cohesive, inter-disciplinary care team that learns from a large volume of case, brought together by many physicians Better treatment options for coinciding conditions if recognized in advance (i.e. Mulerian duct anamalies and endometriosis) Ultimately earlier recognition of the disease process with more successful surgical outcomes and fewer repeat operations 2017 MFMER slide-76

77 Just to to let you know your work is appreciated! 2017 MFMER slide-77

Endometriosis - MRI findings with anatomic-pathologic correlation

Endometriosis - MRI findings with anatomic-pathologic correlation Poster No.: C-2551 Congress: ECR 2015 Type: Educational Exhibit Authors: E. Matos, A. T. Almeida, A. Sanches; Vila Nova de Gaia/PT Keywords: