Tatnai L. Burnett

Background Rectosigmoid endometriosis (RSE) presents with a diverse array of MRI findings that impact surgical planning. No standardized reporting and data system has been established for RSE. Purpose We propose a novel MRI scoring system designed to predict the likelihood of muscularis propria (MP) involvement in RSE, which would, in turn, influence surgical planning. Materials and methods The records of patients with bowel endometriosis treated surgically from May 2018 to June 2022 were retrieved. Surgery was classified as partial thickness discoid, full thickness discoid, or segmental resection. Each pre-treatment MRI was scored based on the mutual agreement of two abdominal radiologists (reference score). The MRI score was defined as (1) score 0: no evidence of RSE, (2) score 1: minimal tethering involving the serosal surface without MP involvement, (3) score 2: intermediate soft tissue thickening involving the rectosigmoid colon with indeterminate MP involvement, or (4) score 3: definite mushroom cap sign or definite MP involvement. In the reader study, two radiologists independently scored each exam. The area under the curve (AUC) was evaluated for predicting the need for segmental or full thickness discoid resection. Results The cohort consisted of 95 patients (median age: 36 years); 16, 14, 30, and 35 patients had MRI score 0, 1, 2, and 3, respectively. Patients with MRI scores 3 and 2 underwent partial thickness discoid (6% vs. 50%), full thickness discoid (6% vs. 17%), and segmental resection (89% vs. 33%), respectively. All patients with MRI scores 1 or 0 either underwent partial thickness discoid resection or did not undergo rectosigmoid surgery. The AUCs were 92.2%, 84.5% and 93.9% for MRI scores of the reference, reader 1, and 2, respectively. Conclusion Our MRI scoring system based on suspected depth of bowel invasion showed good diagnostic performance to predict the type of surgical intervention needed.

Endometriosis is a multifocal disease of pelvis affecting mostly reproductive age women. It can involve genital and extra genital organs. The gastrointestinal tract including rectum and sigmoid colon is the most affected extragenital site. Bowel involvement can change the surgery from simple shaving to resection based on depth of invasion and disease distribution. Benefit of ultrasound for bowel endometriosis, especially for rectum and rectosigmoid colon have been reported, however MRI directed ultrasound, particularly for the lesions which demonstrate indeterminate depth of wall invasion and multifocal bowel involvement hasn’t been reported. Here we present a case of rectosigmoid endometriosis evaluated with preoperative MRI directed ultrasound, which provided better visualization of muscularis propria invasion of the bowel and multifocal lesions.

Background and purpose Endometriosis affects 5–10% of women of reproductive age. Despite its prevalence, diagnosing endometriosis through imaging remains challenging. Advances in deep learning (DL) are revolutionizing the diagnosis and management of complex medical conditions. This study aims to evaluate DL tools in enhancing the accuracy of multi-sequence MRI-based detection of endometriosis. Method We gathered a patient cohort from our institutional database, composed of patients with pathologically confirmed endometriosis from 2015 to 2024. We created an age-matched control group that underwent a similar MR protocol without an endometriosis diagnosis. We used sagittal fat-saturated T1-weighted (T1W FS) pre- and post-contrast and T2-weighted (T2W) MRIs. Our dataset was split at the patient level, allocating 12.5% for testing and conducting seven-fold cross-validation on the remainder. Seven abdominal radiologists with experience in endometriosis MRI and complex surgical planning and one women’s imaging fellow with specific training in endometriosis MRI reviewed a random selection of images and documented their endometriosis detection. Results 395 and 356 patients were included in the case and control groups respectively. The final 3D-DenseNet-121 classifier model demonstrated robust performance. Our findings indicated the most accurate predictions were obtained using T2W, T1W FS pre-, and post-contrast images. Using an ensemble technique on the test set resulted in an F1 Score of 0.881, AUROCC of 0.911, sensitivity of 0.976, and specificity of 0.720. Radiologists achieved 84.48% and 87.93% sensitivity without and with AI assistance in detecting endometriosis. The agreement among radiologists in predicting labels for endometriosis was measured as a Fleiss’ kappa of 0.5718 without AI assistance and 0.6839 with AI assistance. Conclusion This study introduced the first DL model to use multi-sequence MRI on a large cohort, showing results equivalent to human detection by trained readers in identifying endometriosis.

Endometriosis is the presence of hormonally sensitive endometrium-like tissue outside the uterus. It is a common condition, affecting 10% of reproductive-age people assigned as female at birth. Although usually occurring in the pelvis, it can rarely involve the thoracic cavity and diaphragm which is termed thoracic endometriosis. Thoracic endometriosis syndrome (TES) refers to four well-recognized clinical entities: catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, and lung nodules. However, TES presentation can also be nonspecific, even absent. Optimal management is multidisciplinary, as it depends on patient presentation and lesion characteristics. While initial imaging of thoracic symptoms is with chest radiography and computerized tomography, these modalities have inferior soft tissue contrast resolution and tissue characterization compared to magnetic resonance imaging (MRI), especially for the detection of both hematic and cystic endometriotic implants. Therefore, a dedicated MRI protocol is essential for diagnosing thoracic endometriosis and aiding surgical planning. Considering the dome-shaped morphology of the diaphragm, sagittal and coronal projections can improve visualization of tiny endometriotic plaques or deposits that are inconspicuous on the axial plane. Breath-hold and respiratory-triggered or navigated techniques are critical for mitigating motion artifacts. T1-weighted fat-suppressed sequences are important for identifying intrinsic T1 hyperintensity and blood products associated with endometriotic lesions. T2-weighted fat-suppressed sequences increase sensitivity for cystic or vesicular tissue. Diffusion-weighted and postcontrast imaging can help diagnose alternative causes of symptomology, including malignancy.

The spectrum of abnormalities associated with endometriosis necessitates a pattern-based, systematic approach that includes diagnosis with dedicated US and MRI protocols to optimize treatment outcomes and effectively communicate with patients and referring physicians.

The Society of Radiologists in Ultrasound expert consensus provides recommendations for augmenting routine pelvic US examinations through additional maneuvers and imaging to improve diagnosis of deep endometriosis.

Objective: To determine if gastrointestinal (GI) symptoms can predict deep endometriosis (DE) of the posterior pelvic compartment on magnetic resonance imaging (MRI). Methods: Patients with suspected endometriosis undergoing endometriosis protocol MRI at an academic center between 9/1/2015 and 7/31/2018 were identified. Presenting GI symptoms were collected via a standardized survey instrument prospectively at initial presentation. MRI and interdisciplinary conference notes were reviewed to identify posterior compartment DE (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DE were evaluated. Results: A total of 104 patients met inclusion criteria, and 89 (85.6%) presented with at least one GI symptom. Posterior compartment DE was identified on MRI in 47 patients (45.2%). The GI symptom that most strongly predicted DE was a bowel movement resulting in pain relief (OR 3.36, 95% CI 1.31–8.61, p = 0.012), with sensitivity, specificity, positive and negative predictive values 0.42, 0.82, 0.67, and 0.63, respectively. Other GI symptoms such as nausea, vomiting, rectal bleeding, change in frequency of bowel movements, and pain exacerbation by bowel movements did not significantly correlate to having DE. Of the 15 patients with no GI symptoms, 5 were found to have posterior compartment DE. Conclusion: In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than three times the odds of having DE of the posterior compartment on MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DE.

Introduction: Adenomyoma and leiomyoma are benign uterine lesions commonly encountered by gynecologic surgeons. While often confused with one another, these clinical entities may present with different symptomatology and imaging findings. Pelvic MRI is a key tool to distinguish these two lesions. Although both are amenable to laparoscopic resection, differences in surgical approach are required.¹ Methods: In this video, two separate cases are presented to illustrate the clinical factors and surgical principles. Patient and lesion characteristics at time of presentation are compared. Technical considerations for laparoscopic adenomyomectomy are compared with laparoscopic myomectomy. Results: Adenomyomas are characterized by a focus of endometrial glands and stroma, most commonly within the myometrium of the uterus. Symptoms may include heavy menstrual bleeding and pelvic pain as well as potential impact on fertility. Blood products associated with adenomyoma present as T2 hypointensity with corresponding T1 hyperintensity on pelvic MRI.^2,3 In contrast, leiomyomas are benign smooth muscle tumors that may present with heavy menstrual bleeding or bulk-type symptoms with an impact on fertility that is dependent on size and location. On pelvic MRI, leiomyoma typically appears as T2 hypointense lesions without corresponding T1 hyperintensity.^4,5 Laparoscopic resection is a possible treatment option for both lesion types,^2–5 however, alterations in surgical technique are required. Although both uterine lesions are amenable to laparoscopic resection, the surgical approach differs with significant differences in the surgical planes around the pathology, the tissue characteristics of the pathology itself, and the potential increased difficulty of reapproximation of the adenomyoma resection bed.¹ Conclusion: Careful assessment of clinical presentation and pelvic MRI findings may help differentiate adenomyoma and leiomyoma, which is important for both patient counseling and surgical planning. No competing financial interests exist. Patient Consent: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Prior presentation: This study was previously presented as a video poster at the 2021 Annual Scientific Meeting of the Society of Gynecologic Surgeons in June 2021. Runtime of video: 6 mins 43 secs