Comparison of 3D and 2D FSE T2-weighted MRI in the diagnosis of deep pelvic endometriosis: Preliminary results

doi:10.1016/j.crad.2012.05.014

Clinical Radiology

Volume 68, Issue 1, January 2013, Pages 47-54

https://doi.org/10.1016/j.crad.2012.05.014 Get rights and content

Aim

To evaluate image quality and diagnostic accuracy of two- (2D) and three-dimensional (3D) T2-weighted magnetic resonance imaging (MRI) for the evaluation of deep infiltrating endometriosis (DIE).

Materials and methods

One hundred and ten consecutive patients with suspicion of endometriosis were recruited at two institutions over a 5-month period. Twenty-three women underwent surgery, 18 had DIE at histology. Two readers independently evaluated 3D and 2D MRI for image quality and diagnosis of DIE. Descriptive analysis, chi-square test for categorical or nominal variables, McNemar test for comparison between 3D and 2D T2-weighted MRI, and weighted “statistics” for intra- and interobserver agreement were used for statistical analysis.

Results

Both readers found that 3D yielded significantly lower image quality than 2D MRI (p < 0.0001). Acquisition time for 3D was significantly shorter than 2D MRI (p < 0.01). 3D offered similar accuracy to diagnose DIE compared to 2D MRI. For all locations of endometriosis, a high or variable intra-observer agreement was observed for reader 1 and 2, respectively.

Conclusions

Despite a lower overall image quality, 3D provides significant time saving and similar accuracy than multiplanar 2D MRI in the diagnosis of specific DIE locations.

Introduction

Pelvic endometriosis is a frequent gynaecological disorder affecting 10–15% of women in reproductive years. Magnetic resonance imaging (MRI) has been demonstrated to be the best imaging technique to assess the various locations of endometriosis, especially those of deep infiltrating endometriosis (DIE).1, 2, 3, 4 Conventional MRI protocols for the diagnosis of pelvic endometriosis includes multiplanar two-dimensional (2D) fast spin-echo (FSE) T2-weighted MRI images in addition to T1-weighted MRI images with and without fat-suppression.1, 2 With this protocol, various studies have demonstrated that MRI is accurate in diagnosis of the extent of pelvic endometriosis with a variable accuracy ranging from 71–90.8%.2, 5, 6, 7, 8 Discrepancies among series could partly be explained by differences in study protocols (e.g., bowel preparation, administration of anti-peristaltic drugs, additional MRI sequences). In addition, Saba et al.⁹ underlined a variable interobserver agreement that mainly depended on different levels of reader expertise.

Recently, a new technique [three-dimensional (3D) coronal single-slab 3D FSE T2-weighted MRI (entitled “CUBE”)] using variable flip angle refocusing, auto-calibrating 2D accelerated parallel imaging, and nonlinear view ordering, has been introduced to produce high-resolution volumetric image datasets.¹⁰ Volumetric imaging enables reduction of the imaging time by using multiplanar reformations (MPRs). Previous studies have underlined the relevance of 3D T2-weighted MRI in bone, abdominal diseases, and prostate imaging.11, 12 Two recent reports have evaluated the contribution of such a 3D technique in comparison to 2D FSE T2-weighted MRI in the investigation of the female pelvis.13, 14 Both studies suggested that 3D T2 MRI provides superior image quality and improved 3D reconstructions in a shorter acquisition time and enables excellent visualization of pelvic anatomy in any plane.13, 14

The aim of the present study was to compare the overall image quality and diagnostic accuracy of 3D and 2D T2-weighted MRI sequences for the evaluation of DIE.

Section snippets

Patients

Institutional review board approval was obtained, and patients gave written informed consent. Between February 2010 and May 2010, 110 consecutive patients with a median age of 34 years (range 24–46 years), referred for pelvic MRI because of a clinical suspicion of endometriosis (e.g., dysmenorrhea, deep dyspareunia, dyschezia, dysuria, or infertility), were prospectively enrolled. The patients were recruited from two different radiological centres, providing 83 and 27 patients, respectively.

MRI technique

MRI

Surgical and pathological findings

Twenty-three of the 110 patients underwent surgery. Laparoscopy and laparotomy were performed in 20 (87%) and three (13%) of the 23 patients, respectively. All patients except three (87%) had histologically proven pelvic endometriosis. DIE was present in 18 (78.2%) of the 23 patients. Uterosacral ligaments, rectosigmoid colon, vaginal, and bladder endometriosis was detected in 17 (73.9%), 13 (56.5%), five (21.7%), and one (4.3%) of the 23 patients, respectively. Complete pouch of Douglas

Discussion

The present study demonstrates that despite a lower overall imaging quality, 3D CUBE offers similar accuracy to diagnose DIE compared to 2D FSE T2-weighted MRI. MRI evaluation of pelvic endometriosis is routinely performed with multiplanar sagittal, axial, and coronal 2D FSE T2-weighted sequences. These sequences are significantly longer to acquire compared to 3D CUBE, and on average are twice as long. This gain in acquisition time represents a major advantage of 3D CUBE yet at the expense of

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Abdom Imaging

(2010)

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What are the diagnostic performances of magnetic resonance imaging (MRI) scans when used to identify mild endometriosis of the uterosacral ligaments (USL)?
Monocentric retrospective study of patients who underwent a pelvic MRI followed by laparoscopy for determination of endometriosis between January 2016 and December 2020. Patients were included whether endometriosis of USL was suspected or not, but patients presenting large lesions that left no doubt as to their endometriotic nature on the MRI were excluded. Six criteria for the description of USL on MRI were studied to determine their diagnostic performances in predicting the presence of endometriosis on laparoscopy as follows: asymmetry, thickening, irregularity, straightness, the presence of a nodule or a hypersignal T1 spot.
Seventy-seven patients were included. Among the criteria, ‘asymmetry’ and ‘thickening’ had the highest sensitivities (0.69 [95% confidence interval 0.54–0.80] and 0.51 [0.40–0.63], respectively) but moderate specificities (0.52 [0.31–0.73] and 0.62 [0.50–0.72]). Conversely, ‘irregularity’, ‘nodule’, ‘straightness’ and ‘hypersignal T1 spot’ were associated with high specificities (0.81 [0.70–0.89], 0.96 [0.89–0.99], 0.95 [0.87–0.99] and 0.99 [0.93–1.00], respectively) but poor sensitivities (0.22 [0.14–0.33], 0.12 [0.06–0.21], 0.08 [0.03–0.16] and 0.08 [0.03–0.16], respectively). The presence of at least one criterion for the description of the USL was associated with good sensitivity (0.80 [0.66–0.89]) but poor specificity (0.35 [0.16–0.57]).
The results suggest that the identification of minimal changes in the normal appearance of USL should not automatically lead to a conclusion of mild endometriosis at this location.
dPEI classification: A new MR classification in endometriosis imaging
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L’endométriose pelvienne est une pathologie fréquente de la population féminine en âge de procréer, touchant 2 à 4 millions de femmes en France, pouvant entraîner une symptomatologie douloureuse potentiellement invalidante, et/ou des troubles de la fertilité primaires ou secondaires. La chirurgie de résection des lésions d’endométriose pelvienne profonde a démontré son utilité pour la réduction des douleurs et l’augmentation du taux de grossesse, mais peut être source de complications spécifiques, au premier rang desquelles on trouve la dysurie postopératoire. L’imagerie par résonance magnétique (IRM) est une technique de seconde intention dans le bilan diagnostique d’endométriose, après l’examen clinique et l’échographie endovaginale. Elle est la technique la plus sensible permettant une cartographie exhaustive des lésions d’endométriose profonde, notamment en identifiant les atteintes latérales et les atteintes digestives hautes. Elle est donc essentielle dans le bilan préopératoire de la maladie, ce d’autant plus qu’une nouvelle classification radiologique de l’endométriose pelvienne profonde en IRM a été publiée, en 2020, nommée Deep Pelvic Endometiosis Index (dPEI) qui permet, de façon reproductible, de prédire la survenue de complications postopératoires.
Pelvic endometriosis is a common pathology in the female population of childbearing age, which can lead to potentially disabling painful symptoms, and/or primary or secondary fertility disorders. The surgical removal of deep pelvic endometriosis lesions has been shown to be helpful in reducing pain and increasing the rate of pregnancy, but can cause specific complications, especially in lateral pelvic endometriosis. Imaging techniques, including magnetic resonance imaging (MRI), are useful in the preoperative workup of the disease. A new radiological classification of deep pelvic endometriosis on MRI was designed in 2019, named Deep Pelvic Endometiosis Index (dPEI), which reproducibly predicts the occurrence of postoperative complications, taking into account lateral pelvic endometriosis.
Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis
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To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis.
A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872).
Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28–79%), 99 % (95 % CI 98–100%), 54.5 (95 % CI 18.9–157.4), 0.46 (95 % CI 0.25 – 0.85) and 119 (95 % CI 24–577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23–82%), 99 % (96 % CI 97–100%), 48.8 (95 % CI 13.1–181.4), 0.47 (95 % CI 0.23 – 0.98), and 104 (95 % CI 15–711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool.
Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.
MRI of intestinal endometriosis
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Endometriosis is a common gynecological condition of unknown etiology, which mainly affects women of reproductive age. The commonest site of gastrointestinal endometriosis is the rectosigmoid colon. Involvement of the sigmoid, cecum, appendix, and small bowel are less common, but one third of rectosigmoid endometriosis is associated with right-sided extra-pelvic bowel endometriosis. Intestinal endometriosis represents one of the most severe forms of deep endometriosis (DE).
Magnetic resonance imaging (MRI) is recommended as a second-line technique in the preoperative workup of DE, especially for gastrointestinal endometriosis. An optimal MRI protocol is required for a complete mapping of endometriotic lesions. MRI could be used as a triage test in the diagnosis of rectosigmoid colon endometriosis. Magnetic resonance enterography should be additionally performed requiring a specific additional MRI protocol for the evaluation of multicentric intestinal endometriotic lesions.
Except other imaging techniques, the aim of this chapter is to expose indications for MRI, technical requirements, patient preparation, MRI protocols, and criteria for the diagnosis of intestinal endometriosis.
Posterior rectal pouch after large full-thickness disc excision of deep endometriosis infiltrating the low/mid rectum and relationship with digestive functional outcome
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Citation Excerpt :
As mentioned above, even if all patients had rectal opacification with 180 cc of US gel, the PRP volume could be reduced if gel spread to the sigmoid instead of distending the PRP. PRP volume was estimated using volume-rendering reconstruction on a T2-weighted 3D sequence [20]. However, the PRP aspect can be seen well on sagittal T2-weighted sequence, and the measurement of its volume has no impact on patient management.
The aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms.
Single center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence.
Eighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = −0.24, 95%CI -0.51−0.69, p = 0.44).
Large disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.
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Comparison of 3D and 2D FSE T2-weighted MRI in the diagnosis of deep pelvic endometriosis: Preliminary results

Aim

Materials and methods

Results

Conclusions

Introduction

Section snippets

Patients

MRI technique

Surgical and pathological findings

Discussion

Fertil Steril

Int J Gynaecol Obstet

Gynecol Obstet Fertil

Obstet Gynecol

Fertil Steril

Magnetic resonance imaging characteristics of deep endometriosis

Hum Reprod

Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease

Radiology

Posterior cul-de-sac obliteration associated with endometriosis: MR imaging evaluation

Radiology

Endometriosis: contribution of 3.0-T pelvic MR imaging in preoperative assessment—initial results

Radiology

Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis

Hum Reprod

Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography

Abdom Imaging