The utility of diffusion-weighted magnetic resonance imaging in differentiation of endometriomas from hemorrhagic ovarian cysts

doi:10.1016/j.clinimag.2015.05.003

Clinical Imaging

Volume 39, Issue 5, September–October 2015, Pages 830-833

https://doi.org/10.1016/j.clinimag.2015.05.003 Get rights and content

Abstract

The aim was to determine the utility of diffusion-weighted magnetic resonance imaging (DW MRI) and apparent diffusion coefficient (ADC) measurements in differentiation of endometrioma and hemorrhagic ovarian cyst. A total of 24 female patients who underwent pelvic MRI with an initial diagnosis of ovarian cyst were included in the study. The final diagnosis was endometrioma in 12 patients and hemorrhagic ovarian cyst in 12 patients. We observed significantly lower ADC values in endometriomas compared with hemorrhagic ovarian cysts in all b values. DW MRI with quantitative ADC measurements can be used for differentiation of endometrioma from hemorrhagic ovarian cysts.

Introduction

Adnexa are anatomic regions between pelvic walls and uterine cornus. A mass in this region generally originates from ovaries, and many of them can mimic each other with similar imaging findings. Differentiation of endometrioma from hemorrhagic ovarian cyst can be challenging among ovarian pathologies. Endometriosis may contribute to pelvic pain and infertility. It was shown that patients with endometriosis have an increased risk of developing clear cell and endometrioid epithelial ovarian cancer [1]. Therefore, it becomes important to differentiate endometrioma that have coexistence with endometriosis from hemorrhagic ovarian cyst that spontaneously resolves with no associated malignancy risk.

The role of magnetic resonance imaging (MRI) in evaluation of pelvic gynecologic pathologies increased in recent years [2]. Despite the usefulness of ultrasonography in characterization of adnexal masses, MRI is a superior imaging method with an accuracy rate over 90%, and it is generally used as a problem solver [2]. It was reported that MRI limits additional expense and invasive diagnostic and surgical applications and has advantages in terms of cost-effectiveness contrary to general belief [3].

Diffusion-weighted (DW) MRI is a new technique that shows the molecular diffusion difference which is also known as Brownian motion. On DW MRI, image contrast is affected by Brownian motion of water molecules and gives information about microscopic level [4], [5], [6]. DW MRI also gives quantitative biophysical parameter of the water called apparent diffusion coefficient (ADC) [7], [8]. By the way, DW imaging gives both qualitative and quantitative information that can be useful in differentiation of different lesions from each other. This is also an advantageous method which can be performed in a single breath hold period and without contrast administration. This technique was first described for early diagnosis of acute ischemic stroke in neuroradiology [9]. The usage of DW MRI in abdominal organs was also improved in conjuction with the development of fast MRI sequences such as echo-planar imaging.

In the present study, we aimed to determine the utility of DW MRI and ADC measurements in differentiation of endometrioma from hemorrhagic ovarian cyst.

Section snippets

Material and methods

A total of 24 female patients who were referred to our department for pelvic MRI with a suspected gynecologic mass between October 2007 and October 2008 were included in this study. All patients gave written informed consent for MRI examination. This study was approved by our institutional review board. From the study patients, 6 were operated and 18 were followed up. According to the histopathologic evaluation and follow-up results, the final diagnosis was endometrioma for 12 lesions and

Results

A total of 24 female patients with ovarian lesions were included in this study. The final diagnosis was made according to the histopathologic evaluation (n= 6) or follow-up results (n= 18), which are based on follow-up ultrasound examinations. The diagnosis of five patients was endometrioma and one patient was hemorrhagic ovarian cyst according to the histopathologic evaluation. Other patients with endometrioma were treated with drugs. Lesions were divided into two groups: endometriomas (n= 12)

Discussion

Endometriomas and hemorrhagic ovarian cysts are common ovarian pathologies, and differentiation of one from the other can be challenging. Endometriosis is the presence of endometrial gland and stroma outside the uterine cavity or myometrium [10], and the prevalence of it is approximately 5%–10% [11]. Endometriosis is a frequent cause of dysmenorrhea, pelvic pain, and infertility. The prevalence of endometriosis in the presence of infertility is about 20%, and there are varying degrees of

Conclusions

DW MRI is a noninvasive, fast, and effective diagnostic tool that does not require contrast material and gives quantitative information about the lesion. DW MRI with quantitative ADC measurements can be used for differentiation of endometrioma from hemorrhagic ovarian cysts.

Acknowledgments

None of the authors have relevant conflict of interest.

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Overview of pelvic MRI for endometriosis in France
2024, Imagerie de la Femme
En 2017, la Société européenne de radiologie urogénitale (European Society of Urogenital Radiology, ESUR) et la Haute Autorité de santé (HAS) ont émis des recommandations sur le protocole optimal d’IRM et les critères pour le diagnostic de l’endométriose pelvienne. Il n’existe pas, à ce jour, d’étude évaluant les pratiques radiologiques en France pour le dépistage et le diagnostic de l’endométriose. Nous avons mené une enquête d’évaluation des pratiques professionnelles sous l’égide de la Société d’imagerie de la femme (Sifem) afin d’évaluer : (i) le type de préparation réalisée dans le cadre d’une IRM pour le dépistage, le diagnostic ou le suivi d’une endométriose ; (ii) le type de séquences réalisées ; et (iii) l’utilisation d’un compte rendu type et les informations mentionnées par les radiologues.
Il s’agit d’une enquête nationale réalisée sous la forme d’une évaluation des pratiques professionnelles, au moyen d’un questionnaire de 46 questions.
En tout, 180 radiologues ont répondu à l’étude. La majorité des répondants était spécialisés en endométriose (n = 124, soit 69 %) et réalisait au moins une IRM pelvienne hebdomadaire pour explorer une suspicion d’endométriose (n = 154, soit 86 %). Seuls 101 radiologues (56 %) avaient connaissance des recommandations du protocole d’IRM de l’ESUR et 49 % utilisaient un compte rendu standardisé. Une préparation digestive était prescrite par 76 % (n = 137) et une réplétion vésicale étaient demandées par 55 % (n = 100) des radiologues répondant à l’étude. Les répondants réalisaient un balisage vaginal dans 59 % des cas (n = 106) et un balisage rectal dans 32 % (n = 57) des cas. Les antipéristaltiques étaient administrés pour 83 % (n = 150) des radiologues. Tous les radiologues réalisaient des séquences T2 et T1 sans et avec suppression du signal de la graisse. Seize pour cent (n = 28) des radiologues effectuaient des séquences de type HASTE ou SSFSE pour évaluer le péristaltisme utérin. Une séquence T1 tardive après injection de gadolinium était réalisée dans 10 % des cas (n = 18).
Cette étude a permis de décrire à l’échelle nationale les pratiques des radiologues en IRM en France pour le diagnostic de l’endométriose. Elles retrouvent certaines disparités entre les recommandations de l’ESUR ainsi que celle de l’HAS et la pratique quotidienne, notamment la réplétion vésicale et la réalisation de séquences de péristaltisme utérin, mais elle atteste aussi que les radiologues appliquent progressivement ces recommandations sur certains points tels que la préparation digestive des patientes.
In 2017, the European Society of Urogenital Radiology (ESUR) and the French National Authority for Health (HAS) issued recommendations on the optimal MRI protocol and criteria for the diagnosis of pelvic endometriosis. To date, there has been no study evaluating radiological practices in France for screening and diagnosing endometriosis. We conducted a survey to evaluate professional practices recommended by the Société d’imagerie de la femme (Sifem) in order to assess: (i) the type of preparation performed as part of an MRI scan for the screening, diagnosis or follow-up of endometriosis; (ii) the type of sequences performed; and (iii) the use of a standard report and the information mentioned by radiologists.
This was a national survey carried out in the form of a professional practice assessment with a 46 questions questionnaire.
A total of 180 radiologists responded to the study. The majority of radiologists were specialised in endometriosis (n = 124; 69%) and performed at least one pelvic MRI on a weekly basis for suspected endometriosis (n = 154; 86%). Only 101 radiologists (56%) were aware of the ESUR MRI protocol recommendations and 49% used a standardised report. Digestive preparation was prescribed by 76% (n = 137) and bladder repletion was requested by 55% (n = 100) of radiologists responding to the study. Vaginal opacification was performed in 59% of cases (n = 106) and rectal opacification in 32% (n = 57) of cases. Antiperistalsis medication was administered in 83% (n = 150) of radiologists. All radiologists performed T2 and T1 sequences with and without fat suppression. Sixteen percent (n = 28) of the radiologists performed uterine HASTE or SSFSE type sequences to assess uterine peristalsis. An axial T1 sequence after gadolinium injection was performed in 10% of cases (n = 18).
This study provided a nationwide description of the practices of MRI radiologists in France in the context of MRI diagnosis of endometriosis. It revealed certain disparities between the ESUR and HAS recommendations and day-to-day practice, particularly with regards to bladder repletion and uterine peristalsis sequences, but also showed that radiologists are gradually applying these recommendations on certain points, such as digestive preparation of patients.
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Citation Excerpt :
However, distinguishing between the 2 entities on conventional MR imaging can be challenging at times given the overlapping imaging characteristics of blood products, and it has been suggested that using apparent diffusion coefficient (ADC) values would be helpful in making that distinction. In their study of 25 women, Balaban and colleagues34 observed that endometriomas had significantly lower ADC values compared with hemorrhagic cysts, with a higher sensitivity and specificity at b 1000. Hemorrhagic cysts are thought to be the result of bleeding into corpus luteum cysts.
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Original ArticleThe utility of diffusion-weighted magnetic resonance imaging in differentiation of endometriomas from hemorrhagic ovarian cysts

Abstract

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Acknowledgments

Fertil Steril

Obstet Gynecol Clin North Am

The relation between endometriosis and ovarian cancer—a review

Acta Obstet Gynecol Scand

Characterization of adnexial masses with MRI

AJR Am J Roentgenol

Cancer statistics, 2007

CA Cancer J Clin

Diffusion MR imaging: clinical applications

AJR Am J Roentgenol

Advances in the early detection of ovarian carcinoma

J Reprod Med

Lung carcinoma: diffusion-weighted MR imaging-preliminary evaluation with apparent diffusion coefficient

Radiology

Original Article
The utility of diffusion-weighted magnetic resonance imaging in differentiation of endometriomas from hemorrhagic ovarian cysts