{"paper_id":"62af7f20-0228-477a-8c33-a1d344cb1a0b","body_text":"Abstract\nDiaphragmatic endometriosis (DiaE) is a frequently underdiagnosed manifestation of deep endometriosis (DE), typically occurring in patients with advanced pelvic disease. Accurate preoperative detection remains challenging, as standard laparoscopy may overlook posterior diaphragmatic lesions due to their subhepatic location. In this context, magnetic resonance imaging (MRI) plays a central role by enabling lesion detection, precise mapping, and comprehensive assessment of disease extent. This review synthesizes diaphragmatic anatomy, pathophysiology, and clinical presentation, delivering a practical framework for MRI evaluation. We propose an abbreviated diaphragm-focused MRI protocol, acquired within an abdominal field of view in conjunction with standard pelvic MRI. This combined approach emphasizes high-resolution fat-suppressed T1-weighted sequences to detect hemorrhagic lesions, alongside a systematic evaluation of non-hemorrhagic features on fat-suppressed T2-weighted images, allowing simultaneous assessment of the pelvis and abdominal extrapelvic sites. Finally, we provide a structured reporting template designed to improve radiologist-surgeon communication. Combining a targeted imaging protocol with standardized anatomic reporting enhances preoperative planning, reduces intraoperative uncertainty, and facilitates complete disease excision, potentially reducing the need for repeat surgical interventions. The proposed abbreviated diaphragm-focused MRI protocol and structured reporting template represent the central practical contributions of this review.\nSimilar content being viewed by others\nData availability\nNo datasets were generated or analysed during the current study.\nAbbreviations\n- DE:\n-\nDeep endometriosis\n- DiaE:\n-\nDiaphragmatic endometriosis\n- TES:\n-\nThoracic endometriosis syndrome\n- T1W:\n-\nT1-weighted\n- T2W:\n-\nT2-weighted\n- DWI:\n-\nDiffusion-weighted imaging\n- FS:\n-\nFat-suppressed\nReferences\nNaem A, Roman H, Martin DC, Krentel H. A bird-eye view of diaphragmatic endometriosis: current practices and future perspectives. Front Med (Lausanne). 2024 Nov 15;11:1505399. https://doi.org/10.3389/fmed.2024.1505399\nNaem A, Andrikos A, Constantin AS, Khamou M, Andrikos D, Laganà AS, et al. Diaphragmatic endometriosis-A single-center retrospective analysis of the patients’ demographics, symptomatology, and long-term treatment outcomes. 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T.S.R. provided the intraoperative surgical images. F.A.F.F. worked with an illustration artist to create Figs. 1, 3, and 5. J.J.S. prepared Figs. 2, 4, and 6, reviewed all figures and illustrations, and drafted the figure legends. F.A.F.F. and A.C.C.B.S. conceptualized the MRI protocol recommendation table, with critical review by J.J.S. and L.P.C. F.A.F.F. created the surgical anatomy table, with contributions from C.A.S. and review by J.J.S. Sectional writing contributions included: I.P.F. (Introduction), A.L.D.M. (Anatomy), L.C.B. (Structured Reporting Template), and M.A.P.O., T.S.R., and C.A.S. (Surgical Considerations and Treatment). A.C.C.B.S., L.P.C., J.J.S., and F.A.F.F. curated the literature and references. All authors critically reviewed and approved the final manuscript.\nCorresponding authors\nEthics declarations\nConflict of interest\nThe authors declare no competing interests.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary Information\nBelow is the link to the electronic supplementary material.\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nJabbur Stern, J., Ferreira Francisco, F., di Mango, A. et al. Diaphragmatic endometriosis: a practical radiologic guide to diagnosis, mapping, and multidisciplinary surgical planning. Abdom Radiol (2026). https://doi.org/10.1007/s00261-026-05616-9\nReceived:\nRevised:\nAccepted:\nPublished:\nVersion of record:\nDOI: https://doi.org/10.1007/s00261-026-05616-9","source_license":"CC0","license_restricted":false}