Deep pelvic endometriosis: MR imaging with laparoscopic and histologic correlation Poster No.: C-0372 Congress: ECR 2012 Type: Scientific Exhibit Authors: S. Gispert; Barcelona/ES DOI: 10.1594/ecr2012/C-0372 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 31
Purpose Deep pelvic endometriosis is defined as subperitoneal infiltration of the endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina or bladder. Accurate preoperative assessment of deep pelvic endometriosis is required for planning complete surgical excision, but such assessment is difficult with physical examination, ultrasound, even with exploratory laparoscopy. Despite some limitations, magnetic resonance (MR) imaging is able to directly demonstrate deep pelvic endometriosis. The purpose of this retrospective study was to evaluate the accuracy of MR for the preoperative diagnosis and local staging of deep pelvic endometriosis by comparing results with those of laparoscopy. Page 2 of 31
Methods and Materials Among a large group of patients referred in our institution to MR study for pelvic endometriosis, we selected 18 patients with histologically confirmed deep pelvic endometriosis. We retrospectively evaluated those studies performed between January 2006 and October 2008 (overall duration 34 months) and compared with the laparoscopic results. The age of the patients ranged from 24 to 47 years (mean age 32). All patients underwent transvaginal ultrasound, MR, and laparoscopy. We also reviewed: - clinical symptoms - surgical history - performance of other imaging studies: Ultrasound: - transvaginal - abdominal - endorectal Rectosigmoidoscopy Cistoscopy An interval of 1-3 months between MR examination and laparoscopic surgery was observed. All dissected lesions were examined histologically for the presence of endometrial tissue. Magnetic Resonance technique Page 3 of 31
All examinations were performed on a 1.5-T MR imaging system with a pelvic-phasedarray coil. No special patient's preparation (for instance, cleaning enema, fasting, or muscle relaxant agent) was used. Our protocol included: - T2-weighted sequences (TR/TE: 4400/95, slice thickness: 4 mm, 0.8 mm gap, matrix size: 512*512) in 3 perpendicular planes and sagittal and coronal oblique planes depending on the axis of the uterus. - an axial T1-weighted image (TR/TE: 536/20, slice thickness: 6 mm, 1.8 mm gap, matrix size: 384*512) and with fat suppression (TR/TE: 680/12, slice thickness: 4 mm, 0.8 mm gap, matrix size: 256*256). - a sagital T1-weighted image with fat suppression (TR/TE: 668/11, slice thickness: 4 mm, 0.8 mm gap, matrix size: 256*256). - an axial T2-weighted image with fat suppression (TR/TE: 4510/68, slice thickness: 4 mm, 0.8 mm gap, matrix size: 256*256). We administrated intravenous contrast medium (gadolinium) in 1 patient in order to characterize a bladder mass. The administration of intravenous contrast medium was reserved for selected patients only when it was necessary to demonstrate the possible neoplastic nature of a solid component detected within the mass. Image analysis We evaluated the next parameters of the deep implants: - presence and number (single or multiple) - anatomical location rectovaginal septum pouch of Douglas uterosacral ligament large ligament deep anterior compartment Page 4 of 31
» vesicouterine fold» bladder - morphology nodule laminar or plaque-like lesion fibrotic obliteration of the pouch of Douglas adhesions - signal intensity hyperintense in T1-w and hyperintense in T2-w images hyperintense in T1-w and hyporintense in T2-w images isointense in T1-w and hypointense in T2-w images ANATOMICAL LOCATION: 1. RECTOVAGINAL SEPTUM The rectovaginal septum is the subperitoneal fascial layer between the vagina and the lower part of the rectum. Endometriosis of the rectovaginal septum was classified according to the Koninckx types (Fig. 1 on page 8): - Type I corresponds to rectovaginal septum lesions (Fig. 2 on page 8). - Type II corresponds to posterior wall forniceal lesions (the most frequent type, Fig. 3 on page 9). - Type III is described as hourglass-shaped lesions and is due to posterior extension of a posterior forniceal lesion toward the anterior rectal muscularis (Fig. 4 on page 10). They require bowel resection. Page 5 of 31
2. UTEROSACRAL LIGAMENT An involvement of the uterosacral ligaments was defined as an asymmetric nodular hypointense or hyperintense thickening of the proximal portion of the ligament with regular or stellate margins (Fig. 5 on page 11). 3. DEEP ANTERIOR COMPARTMENT An involvement of the deep anterior compartment was diagnosed when there was a mass at the level of the vesicouterine pouch which can disrupt off the muscular layer the bladder wall with potentially a protrusion into the lumen (Fig. 6 on page 12, Fig. 7 on page 13). MORPHOLOGY: There were several morphologies: nodules (Fig. 8 on page 14), laminar or plaquelike (Fig. 9 on page 15), fibrosis in the pouch of Douglas (Fig. 10 on page 16) and adhesions (Fig. 11 on page 17). Direct signs of adhesions correspond to spiculated low-signal-intensity faint strands converging toward the intestinal wall. Indirect signs of adhesions include: - anterior rectal triangular attraction - angulation of intestinal loops toward the uterosacral ligaments - an elevated or stretched posterior vaginal fornix superior to the level of the uterine isthmus - a posterior displacement of the uterus and the ovaries with medial position ASSOCIATED FINDINGS: We also recorded other associated findings as: - Uterus position ante#exion Page 6 of 31
retro#exion - Adenomyosis diffuse focal - Endometriomas (Fig. 12 on page 18) - Hidrosalpinx-hematosalpinx - Uterine congenital malformations Page 7 of 31
Images for this section: Fig. 1 Radiographics Page 8 of 31
Fig. 2 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 9 of 31
Fig. 3 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 10 of 31
Fig. 4 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 11 of 31
Fig. 5 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 12 of 31
Fig. 6 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 13 of 31
Fig. 7 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 14 of 31
Fig. 8 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 15 of 31
Fig. 9 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 16 of 31
Fig. 10 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 17 of 31
Fig. 11 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 18 of 31
Fig. 12 Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 19 of 31
Results The most frequent clinical symptom was pain. The patients also reported: - dysmenorrhoea (12/18) - tenesmus and/or pain on defaecation (7/18) - sterility (6/18) - chronic pelvic pain (5/18) - dyspareunia (5/18) - dysuria (2/18) Regarding previous surgical procedures some patient underwent: - adhesiolysis for previous adherences (4/18) - bilateral ovarian cystectomy for endometriomas (3/18) - ovariectomy and salpinguectomy for endometriosis (1/18) - subtotal histerectomy for adenomyosis (1/18) - appendicectomy (1/18) - cervical uterine conization (1/18) All the patients were evaluated by transvaginal ultrasound. An abdominal ultrasound was performed in 2 patients for study of a bladder mass and a palpable nodule in the abdominal wall, respectively. 1 patient underwent endorectal ultrasound and it showed deep endometriosis in the rectovaginal septum. The ultrasound detected: Page 20 of 31
- endometriomas (15/18) - leiomyomas (4/18) - hidrosalpinx (2/18) / tubaric endometrioma (1/18) - retrouterine implants (2/18) - bladder endometriosis (1/18) - nodule in the rectus abdominis muscle (1/18) - no abnormality (1/18) Rectosigmoidoscopy was performed in 5/18 patients before surgery: - negative for endometriosis (3 cases) - adhesions (1 case) - extrinsic compression of the sigma (1 case) Cistoscopy was performed in 2/18 patients before surgery: - negative for endometriosis (1 case) - endometriotic bladder mass (1 case) MR RESULTS MR examination showed the presence of endometriotic lesions in 17/18 patients. In one case the MR study was performed to find residual implants or recurrence of an endometriotic lesion in the rectus abdominis muscle after its excision, with a negative result of the follow-up. Overall it demonstrated 20 lesions with the following anatomical distribution and signal intensity (Fig. 13 on page 25), and morphology (Fig. 14 on page 25). Of the 20 deep implants, in 3 patients they appeared as single (in the rectovaginal septum), and in the remaining patients they were multiple. Page 21 of 31
Other associated findings to deep endometriosis diagnosed by MR were: - endometriomas (11/18) - diffuse adenomyosis (6/18) - focal adenomyosis (1/18) - leiomyomas (6/18) - anteflexed uterus (13/18) - retroflexed uterus (5/18) - tubaric endometriosis (2/18) - uterine malformation (bicornuate uterus) (1/18) Overall the laparoscopy demonstrated 22 deep endometriotic lesions with the following anatomical distribution (Fig. 15 on page 26). Comparing the 22 deep implants detected by laparoscopy with the 20 deep implants detected by MR, it means 90% of correct diagnosis. The implants of the rectovaginal septum were classified by MR according to Koninckx types as: - Type II (7/8) - Type I (1/8) DATA ANALYSIS After being analysed separately, MR imaging findings in the 18 patients were compared with the results of laparoscopy in order to define the number of correct diagnoses (true positives and true negatives), underestimated lesions (false negatives) and overestimated lesions (false positives) (Fig. 16 on page 27). Among the 20 deep implants detected by MR, the total number of lesions in the same anatomical site diagnosed with MR and confirmed by surgery was 17 (true positives). Page 22 of 31
MR misdiagnosed 5 lesions (false negatives). The number of lesions identified by MR but not confirmed by laparoscopy (false positives) was 3. SURGICAL RESULTS The surgical procedures performed were: - adhesiolysis (7/18) - ovarian cystectomy (6/18) - annexectomy (5/18) - total excision of the nodules of the rectovaginal septum (4/18) - hysterectomy (4/18) - salpinguectomy (2/18) - segmental bowel resection (2/18) - partial rectovaginal septum resection (1/18) - myomectomy (1/18) - partial bladder resection (1/18) - total excision of a nodule of the abdominal wall (1/18) PATHOLOGICAL RESULTS All patients had endometrial tissue composed of glands and stroma at the histopathologic examination of the resected subperitoneal lesions. 2 patients underwent segmental bowel resection due to adhered implants to the intestinal wall. The implants had invasion of : - serosal and muscular layer (1 case) Page 23 of 31
- serosal, muscular layer and submucosa (1 case) They were located respectively at the next sites: - rectosigmoid junction (1 case) - rectum (1 case) Page 24 of 31
Images for this section: Fig. 13: Table 1. Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 25 of 31
Fig. 14: Table 2. Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 26 of 31
Fig. 15: Table 3. Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 27 of 31
Fig. 16: Table 4. Department of Clinical Radiology, Hospital Vall d' Hebron - Unitat RM - Barcelona/ES Page 28 of 31
Conclusion MR imaging is a useful modality as an adjunct to physical examination and transvaginal and transrectal sonography in evaluation of patients with deep infiltrating endometriosis. MR imaging demonstrates high accuracy (90% of success) in the detection of deep implants as well as their extension. All the information offered by MR imaging is useful in planning the best treatment, surgical or medical, for the disease. Therefore, in our opinion, MR imaging may be recommended in preoperative assessment of patients with deep pelvic endometriosis. MR imaging is a noninvasive procedure able to characterize endometriotic lesions, extraperitoneal sites of involvement, contents of a pelvic mass, or lesions hidden by adherences. MR imaging is a necessary tool as a complement of exploratory and therapeutic laparoscopy. Page 29 of 31
References 1. 2. 3. 4. 5. C. Del Frate, R. Girometti, M. Pittino, G. Del Frate, M. Bazzocchi, C. Zuiani. Deep Retroperitoneal Pelvic Endometriosis: MR Imaging Appearance with Laparoscopic Correlation. RadioGraphics 2006;26:1705-1718. Bazot M, Darai E, Hourani R. et al. Radiology 2004 Aug;232(2):379-89.Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Chapron C, Fauconnier A, Vieira M, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003; 18:157-161. Zanardi R, Del Frate C, Zuiani C, Del Frate G, Bazzocchi M. Staging of pelvic endometriosis using magnetic resonance imaging compared with the laparoscopic classification of the American Fertility Society: a prospective study. Radiol Med (Torino) 2003;105:326-338. Zanardi R, Del Frate C, Zuiani C, Del Frate G, Bazzocchi M. Staging of pelvic endometriosis based on MRI findings versus laparoscopic classification according to the American Fertility Society. Abdom Imaging 2003;28(5):733-742. Page 30 of 31
Personal Information Dr. Susana Gispert Herrero Magnetic Resonance Unit - IDI, Vall d' Hebron Hospital (Barcelona,Spain) email: susanagispert@gmail.com Page 31 of 31