Myra Kay Feldman

US is a valuable tool for assessing ovarian and adnexal lesions but is an operator-dependent modality, and it is crucial to optimize US technique to enhance O-RADS accuracy for reliable characterization and malignancy risk assessment.

The interpretation of gynecologic pelvic MRI benefits from tailored MRI protocols, radiologists' knowledge of normal female pelvic anatomy, and a step-by-step approach focusing on lesion origin, lesion tissue composition, and solid tissue morphology, with findings presented in a structured report.

Endometriosis is a common condition primarily impacting women of childbearing age. Despite increasing awareness that endometriosis can be diagnosed non-invasively with the correct imaging techniques, there exists a significant delay in diagnosis, to the tune of 5–10 years. This gap can be narrowed by understanding that this is a disease that lends itself to pattern recognition, and learning to recognize the characteristic patterns on any imaging study will allow earlier diagnosis and prevent long-term complications that can occur with progressive, untreated endometriosis. The disease is often multifocal and thus can present with a wide array of nonspecific symptoms. When clinical findings do not suggest endometriosis, patients often undergo non-targeted imaging, such as chest, abdominal, or pelvic computed tomography (CT); Magnetic Resonance imaging (MRI) studies optimized for neurologic or musculoskeletal indications; or ultrasound (US) exams performed for palpable masses or nonspecific abdominal pain. Familiarity with endometriosis’s characteristic patterns across organ systems and how it can masquerade as other diseases helps radiologists broaden their differential to include endometriosis, even on studies not originally aimed at its detection. This review article will describe those imaging findings of endometriosis affecting various organ systems that mimic other pathologies and will enable the reader to pause and question whether endometriosis should be included in the differential. Graphical abstract

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 gynecologic disorder characterized by endometrial-like tissue in ectopic locations, outside of the uterine cavity. In the adolescent population, the diagnosis of endometriosis is often overlooked as a cause of pelvic pain because of limited awareness by both patients and providers and a tendency to undervalue the complaints of pain by both families and caregivers. Although historically diagnosed by laparoscopy, there has been a shift in recent years towards imaging diagnosis. Transvaginal ultrasound is considered the first-line imaging technique for endometriosis in the adult population; however, this minimally invasive procedure is commonly avoided in adolescents, with MRI often used instead. Here, we discuss the clinical presentation and imaging considerations and treatment options involved in adolescents with suspected endometriosis. Graphical abstract

Adenomyosis is a common, estrogen-dependent condition where endometrial tissue grows within the myometrium, often accompanied by smooth muscle hypertrophy. Initially thought to represent a condition primarily seen in multiparas with menorrhagia, and dysmenorrhea, adenomyosis is now increasingly recognized in younger patients and those with infertility and subfertility. As a result, conservative treatments aimed at preserving the uterus and improving reproductive outcomes have gained attention to treat adenomyosis. While research has largely focused on managing abnormal uterine bleeding and dysmenorrhea, there is limited evidence on the treatment of infertility associated with adenomyosis, particularly in terms of imaging follow-up. This paper reviews the emerging literature, highlighting key imaging findings before and after uterus-preserving treatments for adenomyosis, to better inform management and decision-making. Graphical Abstract

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.

Imaging findings of postmenopausal endometriosis reflect the low-estrogen state and show a predominance of fibrosis and adhesions and occasional cystic or glandular components, with malignant transformation of ovarian endometriomas as the most common endometriosis-related neoplasm.

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.