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Endometriosis: common and rare radiological presentations Learning objectives

Poster · March 2019

DOI: 10.26044/ecr2019/C-0444

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Endometriosis: common and rare radiological presentations

Poster No.: C-0444

Congress: ECR 2019
Type: Educational Exhibit
Authors: 1 2 2
N. M. Saloum , A. Alrashid , M. Abdelhafeez , S. Ibrahim , A.
2

2 2 1 2
Kambal , A. E. Mahfouz ; Doha, Doha/QA, Doha/QA
Keywords: Pathology, Education, MR, Genital / Reproductive system female
DOI: 10.26044/ecr2019/C-0444

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Page 1 of 16
Learning objectives

The aim is to describe the common and rare radiological findings of ovarian and extra-
ovarian endometriomas.

Page 2 of 16
Background

Endometriosis is a chronic disorder predominantly affecting women of childbearing age. It

is defined as presence of ectopic endometrial glands and stroma outside the uterus. This
condition manifests in as many as 10% of premenopausal woman and is an important
cause of chronic pelvic pain and infertility. Several hypotheses have been proposed
to explain the pathogenesis of endometriosis, but the most widely accepted theory is
metastatic implantation of endometrial tissue from retrograde menstruation.

Endometriosis can involve almost any body part with a notary exception, the spleen.
However, endometriosis most commonly involves the ovaries and pelvic peritoneum
followed by GI system and urinary system in order of frequency.

Distribution and types of endometriosis:

Common lesions

Ovaries:

-Endometrial cyst (endometrioma).

Pelvic peritoneum:

Peritoneal implants are subdivided into superficial and deep.

Superficial implants are the implants in the covering of the uterus, tubes, uterine ligament,
anterior and posterior cul-de-sacs, rectosegmoid, and bladder.

Deep infiltration is defined as the presence of endometrial tissue at least 5 mm beneath

the peritoneal surface lead to invasion of the sub-peritoneal space.

Sub peritoneal Space:

-Anterior with involvement of the bladder.

-Posterior with involvement of the torus, utero-sacral ligaments, posterior vaginal fornix,
rectovaginal septum, and anterior wall of rectosegmoid junction. -Lateral involvement of
the ureters (Extrinsic).

Peritoneal cavity:

-Adhesions.

Other GI tract locations:

Page 3 of 16
-Lower rectum and sigmoid.

Less common lesions

Intratubal implants

Peritoneal endometriotic psudocyst

Other GI tract locations: appendix, caecum, small bowl, and transverse colon.

Cutaneous: scars, umbilicus, and inguinal region.

Rare lesions

Diaphragm

Thoracic cavity: Pleura and lung.

Other urinary tract locations: Kidneys and ureters.

Other GI tract locations:Gall bladder, liver, and pancreas.

Nervous system: CNS and peripheral nerves.

Lymphatic system: Pelvic lymph nodes.

The gold standard for diagnosis of endometriosis is by laparoscopy and histopathology.

However, imaging plays an important role in preoperative disease depiction and mapping.
Transvaginal US should be carried out as first line imaging when investigating cases of
infertility and pelvic pain and for evaluation of the ovaries. MRI is excellent for determining
extent of deep pelvic involvement and depiction of extensive pelvic adhesions and
ureteral involvement.

Rectal endoscopic sonography with high-frequency probes (7.5 - 12 MHz) has been
recommended for the detection of rectal, rectovaginal, uterosacral or recto sigmoid
endometriosis, but it has poor penetration.

Computed tomography (CT) usually is not very helpful in the diagnosis of endometriosis.

This poster reviews the different sites of involvement in endometriosis and discusses
radiological appearances with emphasis on MRI.

Page 4 of 16
Findings and procedure details

On ultrasound, ovarian endometriomas appear homogeneous, hypoechoic cyst with

diffuse low-level echoes, commonly termed 'ground glass'. Endometrioma can be multi-
locular and have thin or even thick septations.

The close proximity of both ovaries is known as "kissing ovaries" which is caused by
adhesions and is considered a sign of pelvic endometriosis.

The MRI standard protocol which is mostly used is, T2-weighted fast spin echo sequence,
T1- weighted fast spin echo sequence, and T1-weighted fast spin echo fat saturation
sequence. The T1-weighted fat saturated technique plays an important role in the small
lesions (less than 1 cm) and helps in differentiation between hemorrhagic and lipid
component of the lesions, so it plays role in differentiation of endometriomas from dermoid
cysts and the increased detection of small implants. The injection of (Gadolinium) as
contrast medium doesn't have any advantage over the non-contrast MRI except if
malignant lesions are suspected.

MRI findings of endometrioma are, ovarian cystic mass with high signal intensity on T1-
weighted images and low signal intensity on T2-weighted images. The cause of this is
repeated hemorrhage which result in high protein and iron concentration which is called
"shading phenomena". Benign endometriomas show restricted diffusion.

MR imaging features that are suggestive of malignant transformation of an endometrioma

is the development of enhancing mural nodules.

Multiple T1-hyperintense adnexal cysts are specific for endometrioma.

Hematosalpinx should be considered specific for pelvic endometriosis and appears of

T1-weighted hyper intensity within a dilated fallopian tube.

MRI findings of endometriosis either pelvic or extra pelvic depend on the contents of these
implants which is mainly include degraded blood products and protein, and the signal
intensity varies according to the stage of the hemorrhage. The acute hemorrhage is of
low signal intensity (dark) on the T1-weighted images and T-weighted images, while the
lesions containing chronic degraded blood products like methemoglobin gives high signal
intensity (bright) on T1-weighted images and low signal intensity (dark) on T2 weighted
images.

Page 5 of 16
Images for this section:

Fig. 1: Ovarian Endometrioma (ULTRASOUND PELVIS)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 6 of 16
Fig. 2: Ovarian Endometrioma (MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 7 of 16
Fig. 3: Right Hematosalpinx (MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 8 of 16
Fig. 4: Deep pelvic and vesical endometriosis (MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 9 of 16
Fig. 5: Peritoneal and subcutaneous endometriosis (MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 10 of 16
Fig. 6: Abdominal wall endometriosis (Ultrasound and MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 11 of 16
Fig. 7: Vulvar endometriosis (MRI perineum)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 12 of 16
Fig. 8: Cystadenocarcinoma arising in endometrioma (MRI pelvis)

© Radiology, Corporation, Hamad medical hospital - Doha/QA

Page 13 of 16
Conclusion

Although laparoscopy continues to be the gold standard for the diagnosis of

endometriosis, MRI is increasingly being used, especially to evaluate deep disease, with
high sensitivity and specificity. Ultrasound is predominantly used to evaluate the ovaries
and to assess the pelvis in the workup for pelvic pain or infertility.

Page 14 of 16
Personal information

Dr Nehal Mohamed Saloum.

Clinical Fellow, Diagnostic Imaging.

Hamad Medical Corporation, Doha, Qatar.

Email: nsaloum@hamad.qa.

Page 15 of 16
 References

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4. Chamié LP, et al. Findings of pelvic endometriosis at transvaginal US, MR imaging,

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5. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010;

116:223-236.

6. S.Nehal, Q.Samra, I.Sulafa and A.Amal. A Rare Case Report of Endometriosis in an

Episiotomy Scar without Anal Sphincter Involvement. EC GYNAECOLOGY, 2018.

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Secondary Mullerian system 2013; Chapter 17.

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9. Bazot M., et al. "Deep pelvic endometriosis: MR imaging for diagnosis and prediction
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preoperative assessment of deeply infltrating endometriosis. Int J Gynaecol Obstet
2009;106; 198-201.

11. Gonçalves MO, et al. Transvaginal ultrasound for diagnosis of deeply infltrating
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