RPS 507 - Non-malignant pathology of the female pelvis: insights and imaging approaches

Author Block: N. Bogveradze, A. Santonocito, J. Heine, T. Helbich, P. A. Baltzer, R. Wenzl, P. Clauser; Vienna/AT
Purpose: Diaphragmatic endometriosis (DE) is rare, with limited data on its frequency and management. The deep Pelvic Endometriosis Index (dPEI) and #Enzian classification systems improve pelvis magnetic resonance imaging (MRI) accuracy for diagnosing endometriosis by stratifying disease severity. Our study aimed to assess the prevalence of DE and its correlation with disease severity and associated clinical symptoms.
Methods or Background: In this IRB-approved retrospective study, consecutive abdominal MRIs performed for endometriosis (2018-2022) were reviewed by three radiologists in consensus. Positive cases of diaphragmatic endometriosis were defined by consensus among readers or available histology. Pelvic disease severity was assessed using dPEI and #Enzian scores, classifying endometriosis as mild (score ≤2), moderate (scores 3-4), or severe (scores ≥5). Descriptive statistics were used to analyze the relationship between pelvic disease severity, diaphragmatic involvement, and symptoms.
Results or Findings: DE was detected in 16/108 patients (14.8%). Among 92 patients with clinical data, 7/92 (7.6%) showed upper abdominal symptoms, with DE confirmed in 4/7 (57.1%). No imaging correlates were identified for three symptomatic patients. Based on dPEI, 2/92 asymptomatic patients had moderate disease (2.2%), while symptomatic patients, 17/92 had mild (18.5%), 36/92 moderate (39.1%), and 37/92 severe (40.2%) disease. Among 16 DE patients by dPEI, 2/16 (12.5%) had mild, 7/16 (43.8%) moderate, and 7/16 (43.8%) severe disease. According to #Enzian, 2/92 asymptomatic patients had severe disease (2.2%), while in symptomatic patients, 8/92 had mild (8.7%), 11/92 moderate (12.0%), and 71/92 severe (77.2%). By #Enzian, of the 16 DE patients, none had mild, 2/16 (12.5%) had moderate, and 14/16 (87.5%) had severe disease.
Conclusion: DE detected on MRI was associated with symptoms in 25% of the cases. The presence of diaphragmatic endometriosis is associated with more severe pelvic disease in both scoring systems.
Limitations: Retrospective
Funding for this study: N/A
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Number: 2057/2017

Author Block: A. Durur Karakaya, H. Özen Atalay, V. Samadli, U. Kalkan; Istanbul/TR
Purpose: The aims of this study are to evaluate the correlation between the types/dominant side of the adenomyosis and the location of deep infiltrating endometriosis (DIE) implants, as well as the relationship between the type of adenomyosis and the presence of endometrioma.
Methods or Background: We retrospectively evaluated 311 patients with adenomyosis on MRI examinations between January 2022 and September 2024. The poor quality MRI examination and patients without DIE were excluded from the study, and the final evaluation was performed with 50 patients with adenomyosis and accompanying DIE. Adenomyosis was classified into 3 based on the type as focal, diffuse, cystic; and based on the dominant side in the uterus as anterior, posterior, no dominance. DIE implants were also categorized based on the location as anterior, posterior, or involvement of both compartments. Additionally, the presence and size of endometrioma were evaluated. Statistical significance was examined by chi-square tests (p < 0.05).
Results or Findings: The median patient age was 39 years. A statistically significant correlation was found between adenomyosis dominant side and DIE implant location (p = 0.019). Adenomyosis with no dominant side or diffuse adenomyosis was not significantly associated with effecting of both compartments by DIE implants (p = 0.275 and p = 0.102, respectively). The correlation between adenomyosis type and endometrioma presence (p = 0.390) or size >40 mm (p = 0.687) was not statistically significant.
Conclusion: To our knowledge, this is the first study evaluating the correlation between the dominant side of adenomyosis and DIE implant location. Previous studies indicated the relationship between the adenomyosis dominant side's and symptom severity, pregnancy loss. Our findings emphasize the need for further investigation into this subject.
Limitations: The limitations are the small sample size and retrospective nature.
Funding for this study: Not applicable
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Koc University Biomedical Research Ethics Committee, Istanbul/Turkey

Author Block: I. Thomassin-Naggara¹, M. Dolciami², L. Chamie³, A. Guerra⁴, N. Bharwani⁵, S. Freeman⁶, P. Rousset⁷, L. Manganaro²; ¹Paris/FR, ²Rome/IT, ³São Paulo/BR, ⁴Lisbon/PT, ⁵Surbiton/UK, ⁶Cambridge/UK, ⁷Lyon/FR
Purpose: The ESUR Research Committee appointed two chairs to supervise the development of the updated guidelines.
Methods or Background: These guidelines are recommendations developed by the European Society of Urogenital Radiology (ESUR). A targeted literature search was performed to discover recent evidence concerning the imaging of endometriosis. The guidelines were formulated after careful consideration of the available literature by a group of international experts.
The panel included 20 experts from 10 different countries, including 14 European centers and one non-European institution. The methodology was based on DELPHI process. Each item was classified as follows: “RECOMMENDED” (if agreement ≥ 80%); “OPTIONAL” (if agreement ≥ 70 % but < 80 %); or “NOT RECOMMENDED” (if consensus was not reached, with < 70 % agreement). The survey was composed of three parts: 1) Indications, 2) MR protocol and lexicon 3) classification/reporting.
Results or Findings: Regarding indications, MRI is recommended when TVUS is inconclusive in diagnosing endometriosis or negative, in a symptomatic patient, before surgery or interventional procedure or after surgical treatment if symptoms persist. Regarding reporting, MR classification is recommended, especially radiological score (dPEI). “Patient centered care” is a key dimension of quality care. Good communication with patients, as well as among the healthcare team, has the potential to improve care coordination, enhance safety and outcomes, increase patient satisfaction, and reduce healthcare costs. Standardized MR report and drawing are crucial for improving communication with patients and surgeons.
Conclusion: In conclusion, the ESUR consensus on endometriosis emphasizes the importance of standardized reporting and MR classifications to enhance communication between radiologists and the multidisciplinary team, as well as between radiologists and their patients. This is crucial in managing a disease where optimized communication is essential for providing patient-centered and value-based care
Limitations: Consensus paper
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable

Author Block: I. Thomassin-Naggara¹, M. Dolciami², L. Chamie³, A. Guerra⁴, S. Freeman⁵, N. Bharwani⁶, P. Rousset⁷, L. Manganaro²; ¹Paris/FR, ²Rome/IT, ³São Paulo/BR, ⁴Lisbon/PT, ⁵Cambridge/UK, ⁶Surbiton/UK, ⁷Lyon/FR
Purpose: The ESUR Research Committee appointed two chairs to supervise the development of the updated guidelines
Methods or Background: The panel included 20 experts from 10 different countries
Results or Findings: Pre imaging fasting, the use of antiperistalsic agents, a moderately filled bladder and bowel preparation before MRI are highly recommended. Vaginal and rectal opacification should be considered as an option. MR protocol must include multiplanar T2W and T1W sequence and a sequence that visualizes the kidneys. Superficial endometriosis should be described on T1FS as high signal intensity foci on the peritoneal surface. Endometriomas or implants should be described regarding multiplicity, signal intensity, central or peripheral location and bilaterality. MR evaluation of deep pelvic endometriosis should be performed using a compartmental division defining two horizontal and vertical lines. A bladder nodule should be accurately described according to location measured and the distance to ureteric orifice provided. Uterosacral ligament (USL) of ≤3mm is normal. A USL must be considered as abnormal if a nodule or spiculation is visible in at least two planes or if a bright T1W spot is detected. A posterior vaginal wall or pouch of Douglas nodule should be described and measured. The term rectovaginal septum must be accurately used for sub peritoneal nodules. External adenomyosis should be described according to location and size. The description of a rectosigmoid nodule includes location, number of nodules, longitudinal extent, distance to the anal verge, and wall thickening. The lateral compartment includes the anterior distal round ligament, mediolateral parametrium and posterolateral parametrium. Abdominal wall nodules, ileocaecal junction and appendiceal nodules, as well as sigmoid nodules, must be systematically described.
Conclusion: This lecture will present the 10 ESUR statement regarding MR Endometriosis protocol and lexicon
Limitations: Consensus
Funding for this study: Nond
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable

Author Block: Y. Qi, Z. Zhao, X. Gao, P. Zhang, H. Xue, Y. He, L. Zhu; Beijing/CN
Purpose: To assess MRI features in accessory cavitated uterine mass (ACUM) and cystic adenomyosis by evaluating lesion and uterine morphology.
Methods or Background: The study included 16 ACUM patients (mean age 25.8 years) and 14 cystic adenomyosis patients (mean age 35.5 years) with surgically and pathologically confirmed diagnoses. Pre-treatment pelvic MRI scans were performed, assessing lesion location, size, shape, cystic cavity, peripheral myometrial thickness, and uterine structure.
Results or Findings: Patients presented with symptoms like dysmenorrhea and abdominal pain. Lesions appeared as layered structures with T2 hypointensity peripherally and T1 hyperintensity centrally. ACUM lesions were typically single and located at the fundal lateral wall, while cystic adenomyosis lesions varied in location, 5 adenomyosis lesions were irregular. ACUM patients had lesions ranging from 22mm to 45mm, with a central cystic cavity diameter of 7mm to 36mm and peripheral myometrial thickness of 5mm to 10mm. Fifteen ACUM cases showed a concentric ring structure and the junctional zone was not significantly thickened. Cystic adenomyosis lesions ranging from 20mm to 64mm, with a cystic cavity diameter of 4mm to 60mm and peripheral myometrial thickness of 2mm to 34mm. 5 cases showing uneven peripheral myometrium, only 1 case showing a concentric ring structure. 8 cases showing thickening junctional zone and 8 cases showing adenomyosis or fibroid presence, and 7 patients with ovarian or tubal endometriosis.
Conclusion: MRI is valuable for diagnosing ACUM and cystic adenomyosis. ACUM patients are younger, with single, concentric lesions at the fundal lateral wall, rarely showing junctional zone thickening or adenomyosis-like changes. Cystic adenomyosis is suggested by lesions on the posterior wall, irregular shapes, large size, uneven shape, junctional zone thickening, deep endometriosis, and fibroids.
Limitations: ACUM and cystic adenomyosis are rare diseases, such the number of cases are limited.
Funding for this study: National High Level Hospital Clinical Research Funding, 2022-PUMCH-B-069
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Peking Union Medical College Hospital Ethics committee.

Author Block: A. P. Hemingway, K. M. Wourms, S. Sudderuddin, E. Kashef; London/UK
Purpose: Hysterosalpingography (HSG) represents the mainstay of the imaging evaluation of the patency of fallopian tubes in the investigation of subfertility. An apparent association of improved conception following HSG has been recognised since the early 1900’s. An randomised controlled trial (RCT )published in 2017 established a significant difference between OSCM and WSCM with ongoing pregnancies in 39.7% following OSCM and 29.1% following WSCM .The purpose of this study was to determine if these results could be replicated in routine clinical practice.
Methods or Background: Imaging and medical records relating to 667 consecutive HSGs performed between January 2020 and December 2021 were reviewed. For both WSCM and OSCM data was analysed with respect to age, primary of secondary sub-fertility, normal or abnormal HSGs, number of pregnancies, mode of conception and pregnancy outcome.
Results or Findings: Records relating to 667 women were reviewed, 76 lost to follow-up. 591 records, 498 following WSCM, 93 following OSCM were analysed.
A total of 354 conceptions were recorded, 291 (58.4%) following WSCM, 63 (67.7%) following OSCM. Spontaneous conceptions accounted for 160 of the WSCM (32.1%) pregnancies and 38 (40.9%) of the OSCM pregnancies. Time to conception was faster in the OSCM group and the pregnancy outcomes were similar in both groups. There were no observed differences in pregnancy rates following assisted reproduction in the two groups.
Conclusion: This retrospective study is in accordance with published RCTs and meta analyses that an HSG with WSCM or OSCM is advantageous in increasing the chances of spontaneous conception and that OSCM has a significant advantage over WSCM.
Limitations: This is a retrospective study. The OSCM group is smaller than the WSCM group. The study period and analysis is being extended to encompass HSGs undertaken in 2022 and 2023
Funding for this study: No external funding. HSGs standard of care. Retrospective data collection
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This retrospective study was approved IRAS Number 254621

Author Block: A. Santonocito, N. Bogveradze, J. Heine, T. H. Helbich, P. A. Baltzer, R. Wenzl, P. Clauser; Vienna/AT
Purpose: The deep pelvic endometriosis index (dPEI) and #Enzian classifications have been introduced to facilitate reporting endometriosis patients. While studies show good inter-reader agreement with #Enzian, limited data exist for dPEI. This study aimed to assess the inter-reader agreement of both classifications.
Methods or Background: In this retrospective, monocentric, IRB-approved study the pelvic MRIs performed in consecutive patients for suspected endometriosis from February 2018 to November 2023 were evaluated. Two readers (R1, dedicated radiologist, 5 years of experience; R2, general radiologist, 2 years of experience) independently assessed the presence of lesions using dPEI and #Enzian classifications. The extent of disease was then categorized as mild (score ≤2), moderate (3-4), or severe (≥5). Inter-reader agreement was evaluated by using Cohen’s Kappa.
Results or Findings: A total of 108 patients (mean age 32.7 ±7.1 years; range 21-50 years old) were included in this study. Using dPEI, R1 classified 22 (20.4%) patients with mild, 43 (39.8%) moderate, and 43 (39.8%) severe disease; while R2 classified 28 (25.9%) patients with mild, 43 (39.8%) moderate, and 37 (34.3%) severe disease. The inter-reader agreement for dPEI was k=0.47 (p<0.001). Using #Enzian, R1 classified 10 (9.3%) patients as mild, 12 (11.1%) as moderate, and 86 (79.6%) as severe disease; while R2 classified 21 (19.4%) patients as mild, 34 (31.5%) moderate, and 53 (49.1%) severe disease. The inter-reader agreement for #Enzian was k=0.31 (p<0.001).
Conclusion: Inter-reader agreement was moderate for dPEI and fair for #Enzian. This evidence suggests that dPEI, as a radiologically based classification, could be easier to use by non-specialist radiologists. However, a dedicated training is essential to improve inter-reader agreement in the evaluation of endometriosis.
Limitations: Retrospective study; lacking of assessment of histology
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Number: 2057/2017