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Endometriosis – Introduction

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0:01

Okay, so now we'll talk about endometriosis.

0:04

Again, this is a very common

0:06

disease that we may see.

0:09

when we're imaging our pelvic patients.

0:11

So I'm going to spend quite a bit of

0:13

time just talking about the disease

0:15

process and the imaging appearances.

0:17

So firstly, what is endometriosis?

0:20

Well, endometriosis is when there is endometrial

0:25

tissue that's located outside the uterus.

0:28

So it's abnormal placement

0:30

of endometrial tissue.

0:31

And this is quite a common disease.

0:33

It can affect up to 10 percent

0:36

of reproductive-aged women.

0:37

And the typical locations

0:40

of endometriosis are here.

0:42

Some of them are on the slide,

0:43

but usually the ovaries tend to be

0:46

involved, but there can be deposits of

0:48

endometriosis all throughout the pelvis.

0:50

So the uterine ligaments, the cul-de-sac,

0:52

the peritoneum, fallopian tubes, retrosigmoid

0:55

colon, and this makes it quite challenging.

0:59

sometimes to diagnose because the deposits can

1:02

be quite small and plaque-like in appearance.

1:05

So as radiologists, it's important to be aware

1:08

of these locations that are kind of atypical,

1:11

but also very important for us to be aware of.

1:14

So, I like to think about the rule

1:16

of tens with endometriosis as well.

1:19

So we know that up to 10 percent of

1:21

women can be affected, but routine pelvic

1:24

ultrasound accurately diagnoses endometriosis

1:28

in only about 10 percent of cases.

1:31

So if you think about that,

1:32

that's actually quite significant.

1:34

So, if a patient comes to your clinic or

1:36

your hospital with possible endometriosis

1:39

and you do a pelvic ultrasound, in 90 percent

1:42

of cases, we're missing the endometriosis.

1:45

So that's where MRI can really play

1:47

a significant role, even higher than

1:50

laparoscopy, as we'll learn shortly.

1:53

Endometriosis, as we now know, is often

1:56

under-recognized and under-treated, and

1:59

some patients have a very protracted

2:02

course and delayed diagnosis.

2:04

The average time to diagnosis is seven years.

2:07

So you can imagine if you're suffering with

2:09

those symptoms for seven years, that's a long

2:11

time to be going through without a diagnosis.

2:14

We still don't really know what the

2:16

pathogenesis of endometriosis is.

2:18

There are several theories out there

2:21

from retrograde menstruation to peritoneal

2:25

metaplasia to transformation of stem cells.

2:28

And we haven't really landed on the

2:30

exact cause, but unfortunately these poor

2:33

patients often undergo repeated imaging

2:35

studies, sometimes with no solid diagnosis.

2:39

And laparoscopy is often used for

2:43

diagnosis and for treatment as well.

2:45

And it's considered the gold

2:46

standard, but it also, unfortunately,

2:49

frequently underestimates the disease.

2:52

And there is a high false negative

2:53

rate for laparoscopy as well.

2:55

And that's partially due to the fact that

2:58

the laparoscopist can be blinded by the presence

3:02

of adhesions and scarring, which prevents

3:05

them from looking behind the uterus and into

3:07

the posterior compartment of the pelvis.

3:10

So deep deposits can be invisible to

3:12

the laparoscopist, and that's kind of

3:14

referred to as the iceberg phenomenon.

3:17

So you might see one tiny little

3:19

deposit, but you're not able to see

3:21

deep to that in the OR, but luckily MRI

3:24

does have a role to play there because

3:26

we can visualize those structures.

3:29

So what should we be

3:30

looking for as radiologists?

3:32

Well, we know that the ultrasound

3:34

diagnosis of an endometrioma alone is

3:37

really not enough because many patients

3:39

may not have any ovarian involvement.

3:42

So we can maximize our yield on

3:44

ultrasound by up to 80 percent by

3:47

looking for other manifestations.

3:48

So that includes deep infiltrating disease

3:51

of the bowel, deposits that might be present

3:54

in the retro-cervical space, adjacent to

3:57

the vagina, the bladder, and the ureter.

4:00

And another feature that we can look

4:01

for is frozen cul-de-sac, which is

4:03

important for surgical planning.

4:05

And I'll talk about that in just a moment.

4:07

There's lots of peritoneal

4:08

signs that we can also look for.

4:10

And if we're not aware of these,

4:12

obviously, we're going to miss them.

4:14

So you don't know what you don't know, right?

4:16

So.

4:17

As long as we're aware of these

4:18

peritoneal signs, we can start to look

4:21

for them both on ultrasound and MRI.

4:23

And some of those include filmy

4:25

adhesions and kissing ovaries.

4:28

So this is from abdominal imaging and just

4:30

looks at the different types of endometriotic

4:32

lesions on routine transvaginal ultrasound

4:36

and expert-guided transvaginal ultrasound.

4:38

So what is expert-guided ultrasound?

4:40

Well, it's an ultrasound that's

4:42

done in a dynamic way by an

4:44

expert in gynecologic imaging.

4:46

So many of us might be reporting pelvic

4:49

ultrasounds once they've already been completed

4:51

and the patient is no longer available.

4:54

But these expert-guided ultrasounds actually

4:57

are done by the radiologist on site in the

5:00

room using some of the dynamic maneuvers like

5:03

compression and different positions, et cetera.

5:05

So you can see how the detection of

5:09

abnormalities really increases when

5:11

the expert-guided approach is used.

5:14

So all radiologists really should be

5:15

aware of these manifestations, even if

5:17

you're not able to offer the service

5:19

of an expert doing the ultrasound.

Report

Faculty

Zahra Kassam, MD, FRCPC

Associate Professor of Medical Imaging, Division Head of Body Imaging

Western University

Tags

Uterus

Ultrasound

Pelvic Wall and Floor

Ovaries

Non-infectious Inflammatory

Neoplastic

MRI

Idiopathic

Gynecologic (GYN)

CT

Body

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