Interactive Transcript
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.
© 2024 MRI Online. All Rights Reserved.