ESUR consensus MRI for endometriosis: indications, reporting, and classifications

Abstract

Objective: To propose an update of ESUR endometriosis guidelines to reflect advances in MRI indications, reporting, and classifications.

Methods: The ESUR Research Committee appointed two chairs (I.T.N., L.M.) to supervise the development of the updated guidelines. Following literature research, a survey was delivered to 20 experts in gynecological imaging from 10 countries. Two rounds of surveys were conducted to obtain a consensus according to a Delphi process method. In this article, the results regarding MR indication, the use of standardized reports, and classifications are presented RESULTS: Magnetic resonance imaging (MRI) is recommended when transvaginal ultrasonography is inconclusive in diagnosing endometriosis or negative, in a symptomatic patient, before surgery or interventional procedure, or after surgical treatment if symptoms persist. ESUR panelists consider the roles of an MR classification: to improve communication between radiologist and surgeon (100%, 20/20) and between the radiologist and the patient (45%, 9/20), to predict operating time if surgery is planned (70%, 14/20), to predict the length of hospital stay after surgery (40%, 8/20), and to predict postoperative complications (70%, 14/20). ESUR panelists strongly agree that using an MR classification is useful (19/20, 95%), especially the radiological score, deep-pelvic endometriosis index (dPEI). Among the ESUR expert group, 9/20 experts (45%) used or agreed to use drawings in their report to improve communication with patients.

Conclusion: Standardized MR reporting is crucial and should include the use of MR classification. Drawings are considered an option, knowing that communication with the patient and surgeon is of paramount importance.

Key points: Question ESUR's endometriosis guidelines were last published in 2017; an update is provided to reflect advances in MRI indications, reporting, and classifications. Findings MRI is advised for inconclusive/negative transvaginal ultrasound in symptomatic patients, before surgery, or post-treatment if symptoms persist. A structured report enhances communication with surgeons and patients. Clinical relevance A standardized report based on a compartmental analysis of the location of endometriotic nodules, with optional drawings, is essential for comprehensive mapping and optimal communication with both patient and surgeon.

Keywords: Consensus; Endometriosis, Pelvis; Magnetic resonance imaging.

Fig. 1

dPEI MR classification. dPEI classification is based on a division of the pelvis into 9 compartments and the description of one extrapelvic compartment. One point was allocated per compartment where any DPE lesion was detected, and an additional point was allocated when an endometriotic lesion involved the pelvic wall in the lateral compartment. One point could be added if a location was found in the vagina or in the trigone (defined as the lower part of bladder base), or if ureteral dilatation was observed [27]. The extent of the disease was defined as follows: mild disease (score ≤ 2); moderate disease (scores 3 and 4), and severe disease (score ≥ 5). Modified from Rousset P, Florin M, Bharwani N et al (2023) Deep-pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group. Diagn Interv Imaging. 104:95–112 Copyright © 2023

Fig. 2

Endometriosis in a 36-year-old woman with deep dyspareunia and chronic constipation. a Sagittal T2-weighted image shows a retrocervical nodule (white straight arrow) involving posterior vaginal wall associated with obliteration of the pouch-of-Douglas (*) (mediocentral compartment) and rectal infiltration (curved arrow) (posterocentral compartment). Another nodule affecting the rectosigmoid colon is noted (black straight arrow). b, c Axial (b) and coronal (c) T2-weighted MR images show bilateral mediolateral parametrial extension (area inside the dashed line in (b) and straight arrows in (c), inferring involvement of the inferior hypogastric plexus. Bowel involvement is also noted (straight arrow in b and curved arrow in c). Thus, this patient is quoted with a dPEI score of 5 (severe disease) with 4 compartments affected (mediocentral, posterocentral, right mediolateral, left mediolateral)

Fig. 3

Endometriosis in a 39-year-old woman with deep dyspareunia, chronic constipation, and weak urinary flow. a Axial T2-weighted MR image shows a retractile fibrotic mass (straight arrows) involving the torus uterinus, uterosacral ligaments, pouch-of-Douglas (mediocentral compartment), and rectum (curved arrow) (posterocentral compartment), with bilateral mediolateral (dark arrow) and posterolateral parametrium (white arrow). Bilateral involvement of the inferior hypogastric plexus, hypogastric nerves (white arrows), and splanchnic roots is also noted. b Coronal T2-weighted MR image shows the parametrial extension of the lesions (arrows). Thus, this patient is quoted with a dPEI score of 6 (severe disease) with 6 compartments affected (mediocentral, posterocentral, right and left mediolateral, right and left posterolateral)

Fig. 4

Importance of drawings for improving communication