MR Imaging of Endometriosis: A

Guide to Evaluation and Reporting

Endometriosis cases

dr.Refni Muslim SpRad

PIT PDSRI ke-15
25 Februari 2021
 INTRODUCTION
ENDOMETRIOSIS :
• Chronic gynaecological condition ➔ women of reproductive age ➔ pelvic pain and
infertility.
• Uterine adenomyosis ➔ benign condition ➔ presence of endometrial glands and stroma
within the myometrium.
• Ectopic endometrial glands and stroma outside the uterus → ovarian endometriomas,
peritoneal implants, deep pelvic endometriosis
• Aetiology : unknown
• Pathogenesis : complex, multifactorial and still debated.
• Prevalence :
• 10% in women of reproductive age,
• 20–50% with infertility
• nearly 90% with chronic pelvic pain
(1) Marc Bazot, M.D.a,b and Emile Daraï, M.D., Ph.D ; Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis, Fertility and Sterility® Vol. 109,
No. 3, March 2018 0015-0282.
(2) Pietro Valerio Foti, et al; Endometriosis: clinical features, MR imaging findings and pathologic correlation ; Insights into Imaging (2018) 9:149–172
 INTRODUCTION
ENDOMETRIOSIS :
• locations:
• Primary : pelvic
• Extra pelvis : rarely
• Diagnosis ➔ clinical history, invasive and non-invasive techniques and imaging
• Definitive diagnosis : laparoscopy with histological confirmation.
• MRI → treatment planning. MRI is as a second-line technique after ultrasound.
• The MRI appearance of endometriotic lesions is variable and depends on the quantity and
age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation
and fibrosis

(1) Marc Bazot, M.D.a,b and Emile Daraï, M.D., Ph.D ; Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis, Fertility and Sterility® Vol. 109, No. 3, March 2018 0015-0282.
(2) Pietro Valerio Foti, et al; Endometriosis: clinical features, MR imaging findings and pathologic correlation ; Insights into Imaging (2018) 9:149–172
ANATOMY OF WOMEN PELVIC
VASCULARIZATION OF REPRODUCTIVE TRACT
NORMAL SCIATIC NERVE

• Formed by the L4–S3 nerve roots

• The nerve exits the greater sciatic foramen

Petchprapa CN, Rosenberg ZN, Sconfienza LM et al. MR Imaging of Entrapment Neuropathies of The Lower Extremity. 2010. Radiographics, 30:4
ETIOLOGY

Metastases
a. Retrograde
menstruation.
b. Lymphatic spread
c. Hematogenous spread
Metaplastic
d. Coelomic metaplasia
Induction → Combination

Woodward PJ, et al, Endometriosis: Radiologic-Pathologic Correlation1 RadioGraphics 2001; 21:193–216

 Endometriosis Locations

Regular margin → ovarium

Irregular spiculated → Deep Infiltrating Endometriosis
Luciana Pardini Chamié et al, Findings of Pelvic Endometriosis at Transvaginal US, MR Imaging, and Laparoscopy RadioGraphics 2011; 31:E77–E10
 Diagnostic Modality

• ULTRASOUND
• MRI
• LAPARASCOPIC DIAGNOSTIC
 Magnetic Resonance Imaging
(MRI)
Advantage :
• Non invasive
• High spatial resolution that allows multiplanar evaluation
• Good tissue characterization
• Without the use of ionizing radiation
• Highly accurate ➔ infiltrating extraperitoneal endometriosis,
Identification of lesions that are hidden by adhesions and the evaluation
of subperitoneal lesion extension

Luciana Pardini Chamié et al, Findings of Pelvic Endometriosis at Transvaginal US, MR Imaging, and Laparoscopy RadioGraphics 2011; 31:E77–E10
Bazot M, Darai E. Role of transvaginal sonoghraphy and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and Sterility..2018. 109:3.
 MRI PROCEDURE
• MRI 1,5 Tesla.
• Fasting 6 hour before
• Hold pee 1 hour before :
• Oral laxatif (5 mg bisacodyl )
• Not be performed during the menstruation period if
possible

Luciana Pardini Chamié et al, Findings of Pelvic Endometriosis at Transvaginal US, MR Imaging, and Laparoscopy RadioGraphics 2011; 31:E77–E10
Bazot M, Darai E. Role of transvaginal sonoghraphy and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and Sterility..2018. 109:3.
 MRI PROCEDURE
• 10 mg butylescopolamine intra vena, for reduced peristaltic,
if there no contra indication.
• 50 - 60 ml ultrasonography gel → intra vagina → distension
vagina fornix.
• Gel or saline → rectum → constipastion, hematoscezia or
pain bowel movements
• Intra Vena Gadolinium chelate : not necessary, if just
endometriosis.

Luciana Pardini Chamié et al, Findings of Pelvic Endometriosis at Transvaginal US, MR Imaging, and Laparoscopy RadioGraphics 2011; 31:E77–E10
 MRI SEQUENCE
• T1WI : hiperintens lesion➔ components of the bleeding.
• T1WI FAT SUPPRESSI → sensitif for detection bloody foci
• T2WI fast spin-echo images → for evaluation fibrotic lesion, espesially
at ligament ,retroservix space and perivesical resesus
• T1WI dan T2WI, for diagnosis endometrioma, → shading effect
• MRI urografi , coronal T2WI → if suspect ureter involvement.

Luciana Pardini Chamié et al, Findings of Pelvic Endometriosis at Transvaginal US, MR Imaging, and Laparoscopy RadioGraphics 2011; 31:E77–E10
SAGITAL AND AXIAL SECTION
CORONAL OBLIQ LAX AND SAX
WITH AND WITHOUT GEL
INTRAVAGINAL GEL CONTRAST IS VERY IMPORTANT FOR
FORNIX ENDOMETRIOSIS

BLAST

SERVIX

VAGINA

POSTERIOR
VAGINA
FORNIX
RECTUM

RECTUM
Intravaginal gel pre MRI Examination is not
expensive, well tolerated and improve MRI
diagnostic imaging for benign or malignant
lesion

Brown MA, et al. AJR 2005; 185;1221-1227

Increase accuracy from 70% to 95%
NORMAL PELVIC MRI : UTERUS AND SERVIX
NORMAL OVARIUM MRI
NORMAL SALPHING MRI

LONG 10-12 CM
DIAMETER 1-4MM

Synonym :
• Endocervical gland cyst
• Retension cyst of the servix
• Tunnel clusters
NABOTHIAN CYST
Definition :
• Mucinous endocervical gland cyst : obstruction by overgrowth
of squamous epithelium at their neck.
• Tunnel clusters : specific type of nabothian cyst characterized
by complex multicystic dilatasion of endocervical glands
NORMAL SACROUTERINA LIGAMENT MRI
FROM THE UTERUS TO THE ANTERIOR ASPECT OF THE SACRUM

RIGHT AND LEFT SACRO UTERINA

LIGAMENT
 NORMAL SCIATIC NERVE MRI
Formed by the L4–S3 nerve roots
The nerve exits the greater sciatic foramen

Figure 1. Normal anatomy of the sciatic nerve. (a) Axial T1- weighted MR image (repetition time msec/ echo time msec =
553/12) shows the fascicular composition of the sciatic nerve (arrow). (b) Coronal T1-weighted MR image (713/25) shows the
abundant perifascicular fat of the sciatic nerve (arrows).
 NORMAL BLAST, VAGINA AND RECTUM MRI

BLAST

BLAST
ADENOMYOSIS

VAGINA

VAGINA RECTUM
RECTUM
STAGING
Lee SY, Koo YJ, Lee DH. Classification of Endometriosis. 2020. Yeungnam University Journal of Medicine
 The summarized resulting point scores are
classified into four grades of severity:
• Stage I (minimal) 1–5 points;
• Stage II (mild) 6–15 points;
• Stage III (moderate) 16–40 points;
• Stage IV (severe) >40 points.

Lee SY, Koo YJ, Lee DH. Classification of Endometriosis. 2020. Yeungnam University Journal of Medicine
 ENDOMETRIOSIS
• INTERNAL ENDOMETRIOSIS ➔ UTERINE
• EXTERNAL ENDOMETRIOSIS
 LOCATIONS
Anterior Compartment: Media Compartement : Posterior Compartement :
• Vesicouterine • Uterine • Rectovagina Puoch
Puoch
• Ovarium • Retroservix area
• Vesicovagina
Septum • Fallopian Tube • Sacrouterina Ligament
• Bladder • Posterior Fornix
• Urether vagina
• Rectovagina Septum
• Rectosigmoid
 MEDIA COMPARTMENT
INTERNAL ADENOMYOSIS UTERINE
JUNCTIONAL ZONE
• T2-weighted imaging → Zonal anatomy of the uterus
The JZ (inner low signal area), separates the central
endometrium (high signal intensity) from the outer
myometrium (intermediate signal)
• JZ during menstruation → Pseudo-thickening
• MRI evaluation of internal adenomyosis → not performed
during the menstruation period.
• Adenomyosis Uterine indirect criteria :
• JZ max ≥ 12 mm
• Ratio max > 40%

Bazot M, Darai E. Role of transvaginal sonoghraphy and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and Sterility..2018. 109:3
• Main direct criteria on MRI → tiny myometrial cysts related to islets of dilated ectopic endometrium
• High-intensity myometrial foci ≤ 3 mm, most common in the inner myometrium → high signal on T2WI and a low
signal on T1WI
• Detected in only about half of the cases on T2 . This low sensitivity (50%) is mainly due to the limited spatial resolution.
• Cystic adenomyoma (≥ 1 cm ) is characterized by its predominant hemorrhage content
• T1WI → Homogeneously high signal intensity.
• T2-weighted MRI is variable reflecting hemorrhage in different stages of organization. In addition, fluid-fluid level and low signal
rim on T2 are sometimes present .

Bazot M, Darai E. Role of transvaginal sonoghraphy and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and Sterility..2018. 109:3
 CLASSIFICATION OF ADENOMYOSIS

(1) Marc Bazot, M.D.a,b and Emile Daraï, M.D., Ph.D ; Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis, Fertility and Sterility®
Vol. 109, No. 3, March 2018 0015-0282.
 INTERNAL ADENOMYOSIS
FOKAL ADENOMYOSIS

Localized intramyometrial
with or without buldging JZ
 INTERNAL ADENOMYOSIS
SUPERFICIAL ADENOMYOSIS

Disseminated subendometrial
without buldging JZ
(symmetric or asymmetric)
 INTERNAL
ADENOMYOSIS
DIFFUSE ASIMETRIC Disseminated intramyometrial
with buldging JZ (asymmetric)
INTERNAL ADENOMYOSIS
DIFFUSES ADENOMYOSIS
SIMETRIC

Disseminated intramyometrial
with buldging JZ (symmetric)
 Intramural Solid Adenomyoma

ADENOMYOMA

Myometrial lesion with

tiny cyst component
(haemorrhagic or not)
 Adenomyoma VS Myoma

Intramural adenomyoma
myoma

adenomyoma

adenomyoma
Subserosa
myoma
 INTRAMURAL CYSTIC ADENOMYOMA

CYSTIC ADENOMYOMA
ADENOMYOMA

ADENOMYOSIS

Myometrial lesion with

haemorrhagic cystic cavity

CYSTIC ADENOMYOMA
 ADENOMYOMA

SUBMUCOSAL ADENOMYOMA

Ill defined myometrial lesion with

tiny cystic component and
intracavity protrusion
Submucosal Adenomyoma

SOLID
INTRAMURAL
ADENOMYOMA
 Subserosal Adenomyoma

ADENOMYOMA

Subserous myometrial
lesion with tiny cystic
component
Posterior External Adenomyosis
Subserosal posterior myometrial mass assosciated with posterior
deep endometriosis
 Anterior External Adenomyosis
Subserosal anterior myometrial mass assosciated with anterior deep
endometriosis
 MEDIA COMPARTMENT
OVARIAN ENDOMETRIOSIS
• Endometrioma or Chocolate cyst
• Unilateral, bilateral, multiple
• Hyperintense ➔ T1WI
• Shading ➔ T2WI ➔ contain methemoglobin, protein and Fe
ENDOMETRIOMA BILATERAL
KISSING ENDOMETRIOMA
 KISSING
ENDOMETRIOMA
KISSING ENDOMETRIOMA WITH ADHESION

SPIKULASI
MEDIA COMPARTMENT
FALLOPIAN TUBE
ENDOMETRIOSIS
HYDROSALPHING WITH NORMAL UTERUS
HYDROSALPHING ENDOMETROSIS
HYDROSALPHING
ENDOMETROSIS
 ANTERIOR COMPARTMENT
BLADDER AND URETHER ENDOMETRIOSIS
ANTERIOR COMPARTMENT
VESICOTERINE POUCH
BLADDER DIE
BLADDER DIE
DIE : left urether -> intrinsic lesion (20-25%)
• Unilateral (80%)
• Bilateral (15-20%)
 RIGHT
URETHER DIE
intrinsic lesion
RIGHT URETHER
DIE:
and extrinsic lesion
(75-80%)
 ANTERIOR COMPARTMENT
CYSTIC ADENOMYOMA INFEROANTERIOR VESICOVAGINA
SEPTUM
POSTERIOR COMPARTMENT
POSTERIOR FORNIX VAGINA
DIE AT POSTERIOR FORNIX VAGINA

BULI
• dI
VAGINA

RECTUM
DIE Posterior Vaginal Fornix And Extend
To Anterior Rectal Wall
POSTERIOR COMPARTMENT
RECTOVAGINA SEPTUM
DIE BEHIND THE POSTERIOR VAGINAL FORNIX
POSTERIOR COMPARTMENT
RECTOSIGMOID
DIE RECTUM
Die rectum and bilateral Endometrioma
DIE RECTUM
DIE RECTUM
INVADE
MUSCULARIS
LAYER
NO DEFECT ON
SUBMUCOSA LAYER
DIE RECTUM
INVADE
SUBMUCOUS
LAYER
DIE SIGMOID

SIGMOID

RECTUM
POSTERIOR COMPARTMENT
SACROUTERINE LIGAMENT
RIGHT SACROUTERINA LIGAMENT DIE
DIE AT LEFT SACROUTERINE LIGAMENT AND RECTUM (INDIAN HEAD)
DIE AT RIGHT SACROUTERINE LIGAMENT
ENDOMETRIOSIS WITH
ADHESION
ADHESION OF SUBSEROSA ADENOMYOSIS
WITH RIGHT ENDOMETRIOMA

ENDOMETRIOMA
ENDOMETRIOSIS WITH
ADHESION
ENDOMETRIOSIS WITH ADHESION
ENDOMETRIOSIS WITH ADHESION

SPIKULASI
ENDOMETRIOSIS WITH ADHESION
VASCULAR OBLITERATION
SCIATIC NERVE ENDOMETRIOSIS

Petchprapa C et al. MR Imaging of Entrapment Neuropathies of The Lower Extremity. 2015. Radioghraphics. 30:4
MALIGNANT TRANSFORMATION
ENDOMETRIOSIS
 MALIGNANT TRANSFORMATION ENDOMETRIOSIS
• 0.5%–1% ➔ complicated by malignancy
• Most common endometriosis-associated histological types ➔ endometrioid
adenocarcinoma and clear cell adenocarcinoma.
• Prevalence of ovarian cancers among women with endometriosis is higher than that
in the general population
• Radiologists play a key role in recognizing the malignant transformation of ovarian
and extraovarian endometriosis
• Solid mural nodules in endometriotic cyst➔ unenhanced and contrast-enhanced
T1-weighted imaging.
• Restriction Diffusion weighted imaging ➔ characterize indeterminate masses in the
female pelvis as potentially malignant

Nezhat C, Vu M,Vang N et al. Endometriosis Malignant Transformation Review: Rhabdomyosarcoma Arising From an Endometrioma.2019.JSLS. 23(4): e2019
McDermont S, Oei T, Iyer V, Lee S. MR Imaging of Malignancies Arising in Endometriomas and Extraovarian Endometriosis.2012.RSNA 32:3
MALIGNANT TRANSFORMATION ENDOMETRIOMA
 MALIGNANT TRANSFORMATION ENDOMETRYOMA

CLEAR CELL
CARCINOMA OVARIUM
PA
Well differentiated endometrioid
carcinoma uterine and endometrioid Left Endometriod
carcinoma ovarial bilateral carcinoma ovarial
(synchronous )

Endometrioid
carcinoma uterine
 MALINGNANT TRANSFOMATION LEFT OVARIAL

PA : ENDOMETRIOID
CARCINOMA LEFT OVARIAL
 Extra Pelvis Endometriosis

• Abdominal Wall Endometriosis (Parietal Endometriosis)

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis.2020. Reproductive Medicine Biology, 19:323-333
 Abdominal Wall Endometriosis
• 0.04 – 5.5 %
• Secondary incision (80%)
• Spontaneous lesion (20%)
• Umbilicus
• Groin
• Typical symptoms ➔ painful mass in the abdominal wall during
menstruation
• MRI ➔ presence of blood components within the abdominal wall
mass is suggestive of endometriosis

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis.2020. Reproductive Medicine Biology, 19:323-333
 Abdominal Wall Endometriosis ( 0.04 – 5.5 % )
Secondary incision (80%)
• Scar endometriosis
• Malignant transformation ➔ very poor prognosis ➔ clear cell (66.7% & endometrioid carcinoma
(14.6%) ➔ multifaktorial ( genetic, imunologic, environment factor)

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis.2020. Reproductive Medicine Biology, 19:323-333
 UMBILICAL ENDOMETRIOSIS
• Primary (66%) ➔ migrating through blood / lymphatic vessel
• Secondary (history of trocar insertion)➔ Iatrogenic ➔ endometrial cell / endometriosis cell
implanted by direct contact

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis2020. Reproductive Medicine Biology, 19:323-333
Adenomyosis , endometrioma with umbilical endometriosis

Die umbilicus

endometrioma

adenomyosis
 • Very rare
DIE INGUINAL BILATERAL 23YO
• Right > left
• Types
• Cystic ➔ Hernia Sac &Nuck’s Canal
• Solid ➔ Round ligaments & subcutaneous tissue

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis2020. Reproductive Medicine Biology, 19:323-333
 DIE INGUINAL BILATERAL

Two types of inguinal endometriosis:

• Cystic ➔ Hernia Sac &Nuck’s Canal
• Solid ➔ Round ligaments &
subcutaneous tissue
Read arrowheads denote inguinal
endometriosis.
A. T2W ➔ cystic lesion, B. FatSat T1W ➔
hyperintense nodule in the wall of cystic
lesion
C. T2W ➔ solid (iso intense with muscle), D.
FatSat T1W ➔ hyperintese nodule

Hirata T, Koga K, OsugaY. Extra Pelvic Endometriosis2020. Reproductive Medicine Biology, 19:323-333
 CONCLUSION

• MR imaging to help diagnose and plan surgical strategy is critical in the management of
the disease.

• Preoperative detection of all endometriotic lesions is recommended to choose the

surgical approach and to plan a multidisciplinary team work

• This multidisciplinary approach including radiologists, gynaecologists, urologists,

gastrointestinal surgeons, and (in selected cases) neurosurgeons, is recommended to
improve diagnostic imaging accuracy and patients’ outcome, and to reduce postoperative
complication rates
TERIMA KASIH