{"paper_id":"65f55f98-7321-4b19-a013-beb55304627e","body_text":"Abstract\nPurpose\nProposal of a systematic approach to assess Deep infiltrating endometriosis (DIE) through pelvic Magnetic resonance imaging (MRI) using the Enzian classification and examination of inter-rater agreement.\nMethods\nThree radiologists reviewed 23 MRI of patients with pelvic DIE at one tertiary referral center retrospectively and independently. Inclusion criteria were intraoperative confirmation of DIE and MR imaging according to ESUR (European Society of Urogenital Radiology) guidelines. Assessment of the anatomical pelvic compartments was performed using a manual based on the Enzian classification with step-by-step instructions using recommended planes and sequences presented here. Interrater agreement was measured using kappa statistics.\nResults\nAccording to the intraoperative site lesions in 53 anatomical compartments were present. Interrater agreement was best for compartments A (0.255) and FB (0.642). For FI (0.204) and B (0.146) it was slight, there was poor agreement for C (− 0.263), FA (− 0.022), and FO (− 0.030), respectively, and as for FU, no ureter infiltration was described.\nConclusion\nMRI as a noninvasive diagnostic tool offers essential advantages regarding classification and therapy planning for patients with DIE. However, its assessment is difficult and a more systematic approach is needed. Our proposed manual based on the Enzian classification is reproducible and could support radiologists and gynecologists.\nSimilar content being viewed by others\nAvailability of data and materials\nData are available upon reasonable request.\nReferences\nGiudice LC, Kao LC (2004) Endometriosis. Lancet 364(9447):1789–1799. https://doi.org/10.1016/S0140-6736(04)17403-5 (PubMed PMID: 15541453)\nBuck Louis GM, Hediger ML, Peterson CM, Croughan M, Sundaram R, Stanford J et al (2011) Incidence of endometriosis by study population and diagnostic method: the ENDO study. Fertil Steril 96(2):360–365. https://doi.org/10.1016/j.fertnstert.2011.05.087 ((PubMed PMID: 21719000; PubMed Central PMCID: PMCPMC3143230))\nHadfield R, Mardon H, Barlow D, Kennedy S (1996) Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod 11(4):878–880 (PubMed PMID: 8671344)\nNnoaham KE, Hummelshoj L, Webster P, d’Hooghe T, de Cicco NF, de Cicco NC et al (2011) Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 96(2):366–73.e8. https://doi.org/10.1016/j.fertnstert.2011.05.090 ((PubMed PMID: 21718982; PubMed Central PMCID: PMCPMC3679489))\nNisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2:CD009591. https://doi.org/10.1002/14651858.CD009591.pub2 ((PubMed PMID: 26919512))\nDunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B et al (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod 29(3):400–412. https://doi.org/10.1093/humrep/det457 ((Epub 2014/01/15, PubMed PMID: 24435778))\nDi Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi MR (2015) Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur J Radiol 84(4):568–574. https://doi.org/10.1016/j.ejrad.2014.12.017 (PubMed PMID: 25604906)\nBurla L, Scheiner D, Samartzis EP, Seidel S, Eberhard M, Fink D et al (2019) The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 300(1):109–116. https://doi.org/10.1007/s00404-019-05157-1 ((Epub 2019/04/12, PubMed PMID: 30980276))\nTuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW, Wustlich M et al (2005) ENZIAN-score, a classification of deep infiltrating endometriosis. Zentralbl Gynakol 127(5):275–281. https://doi.org/10.1055/s-2005-836904 (PubMed PMID: 16195969)\nRogers PA, Adamson GD, Al-Jefout M, Becker CM, D’Hooghe TM, Dunselman GA et al (2017) Research Priorities for Endometriosis. Reprod Sci 24(2):202–226. https://doi.org/10.1177/1933719116654991 ((Epub 2016/09/27, PubMed PMID: 27368878))\nBazot M, Bharwani N, Huchon C, Kinkel K, Cunha TM, Guerra A et al (2017) European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 27(7):2765–2775. https://doi.org/10.1007/s00330-016-4673-z ((Epub 2016/12/05, PubMed PMID: 27921160; PubMed Central PMCID: PMCPMC5486785))\nSchneider C, Oehmke F, Tinneberg HR, Krombach GA (2016) MRI technique for the preoperative evaluation of deep infiltrating endometriosis: current status and protocol recommendation. Clin Radiol 71(3):179–194. https://doi.org/10.1016/j.crad.2015.09.014 ((Epub 2015/12/17, PubMed PMID: 26703119))\nBhayana A, Ghasi RG (2019) MRI evaluation of pelvis in Mayer-Rokitansky-Kuster-Hauser syndrome: interobserver agreement for surgically relevant structures. Br J Radiol. 92(1097):20190045. https://doi.org/10.1259/bjr.20190045 ((Epub 2019/03/15, PubMed PMID: 30864823; PubMed Central PMCID: PMCPMC6580901))\nMori K, Saida T, Hoshiai S, Shibuya Y, Obata-Yasuoka M, Ishiguro T et al (2020) High prevalence of intrapelvic parasitic arteries in patients with placenta accreta spectrum: a case-control study using unenhanced magnetic resonance angiography. Clin Imaging 63:50–56. https://doi.org/10.1016/j.clinimag.2020.02.013 ((Epub 2020/02/27, PubMed PMID: 32143124))\nBalcacer P, Cooper KA, Huber S, Spektor M, Pahade JK, Israel GM (2018) Magnetic resonance imaging features of endometrial polyps: frequency of occurrence and interobserver reliability. J Comput Assist Tomogr 42(5):721–726. https://doi.org/10.1097/RCT.0000000000000765 (PubMed PMID: 29901509)\nJaramillo-Cardoso A, Shenoy-Bhangle A, Garces-Descovich A, Glickman J, King L, Mortele KJ (2019) Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise. Abdom Radiol. https://doi.org/10.1007/s00261-019-02199-6 ((Epub 2019/08/29, PubMed PMID: 31468155))\nThomassin-Naggara I, Lamrabet S, Crestani A, Bekhouche A, Wahab CA, Kermarrec E et al (2020) Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management. Hum Reprod. https://doi.org/10.1093/humrep/deaa103 ((Epub 2020/07/03, PubMed PMID: 32619220))\nHolland TK, Hoo WL, Mavrelos D, Saridogan E, Cutner A, Jurkovic D (2013) Reproducibility of assessment of severity of pelvic endometriosis using transvaginal ultrasound. Ultrasound Obstet Gynecol 41(2):210–215. https://doi.org/10.1002/uog.11216 (PubMed PMID: 22745055)\nTammaa A, Fritzer N, Lozano P, Krell A, Salzer H, Salama M et al (2015) Interobserver agreement and accuracy of non-invasive diagnosis of endometriosis by transvaginal sonography. Ultrasound Obstet Gynecol 46(6):737–740. https://doi.org/10.1002/uog.14843 (PubMed PMID: 25766661)\nBean E, Chaggar P, Thanatsis N, Dooley W, Bottomley C, Jurkovic D (2020) Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions. Hum Reprod Open. 2020(2):hoaa001. https://doi.org/10.1093/hropen/hoaa001 ((Epub 2020/03/06, PubMed PMID: 32161818; PubMed Central PMCID: PMCPMC7060019))\nPiessens S, Healey M, Maher P, Tsaltas J, Rombauts L (2014) Can anyone screen for deep infiltrating endometriosis with transvaginal ultrasound? Aust N Z J Obstet Gynaecol 54(5):462–468. https://doi.org/10.1111/ajo.12242 (PubMed PMID: 25287563)\nGuerriero S, Pascual MA, Ajossa S, Rodriguez I, Zajicek M, Rolla M et al (2019) Learning curve for ultrasonographic diagnosis of deep infiltrating endometriosis using structured offline training program. Ultrasound Obstet Gynecol 54(2):262–269. https://doi.org/10.1002/uog.20176 (PubMed PMID: 30426587)\nTammaa A, Fritzer N, Strunk G, Krell A, Salzer H, Hudelist G (2014) Learning curve for the detection of pouch of Douglas obliteration and deep infiltrating endometriosis of the rectum. Hum Reprod 29(6):1199–1204. https://doi.org/10.1093/humrep/deu078 ((Epub 2014/04/28, PubMed PMID: 24777849))\nFraser MA, Agarwal S, Chen I, Singh SS (2015) Routine vs. expert-guided transvaginal ultrasound in the diagnosis of endometriosis: a retrospective review. Abdom Imaging 40(3):587–594. https://doi.org/10.1007/s00261-014-0243-5 ((PubMed PMID: 25236953; PubMed Central PMCID: PMCPMC4325192))\nSaba L, Guerriero S, Sulis R, Pilloni M, Ajossa S, Melis G et al (2011) Learning curve in the detection of ovarian and deep endometriosis by using Magnetic Resonance: comparison with surgical results. Eur J Radiol 79(2):237–244. https://doi.org/10.1016/j.ejrad.2010.01.019 ((Epub 2010/02/19, PubMed PMID: 20171820))\nFunding\nNo funding was received.\nAuthor information\nAuthors and Affiliations\nContributions\nLB: data collection, manuscript writing/editing. DS: data analysis, critically revision. AMH and AM: examining radiologist, critically revision. DF: protocol/project development, critically revision. AB: examining radiologist, critically revision, protocol/project development, supervision. PI: manuscript writing/editing, protocol/project development, supervision.\nCorresponding author\nEthics declarations\nConflict of interest\nAuthor Laurin Burla declares that he has no conflict of interest. Author David Scheiner declares that he has no conflict of interest. Author Andreas M Hötker declares that he has no conflict of interest. Author Andreas Meier declares that he has no conflict of interest. Author Daniel Fink declares that he has no conflict of interest. Author Andreas Boss declares that he has no conflict of interest. Author Patrick Imesch declares that he has no conflict of interest.\nEthical approval\nAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved prior to its initiation by the cantonal ethics committee of Zurich (2016-00613).\nInformed consent\nInformed consent was obtained from all individual participants included in the study.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nRights and permissions\nAbout this article\nCite this article\nBurla, L., Scheiner, D., Hötker, A.M. et al. Structured manual for MRI assessment of deep infiltrating endometriosis using the ENZIAN classification. Arch Gynecol Obstet 303, 751–757 (2021). https://doi.org/10.1007/s00404-020-05892-w\nReceived:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s00404-020-05892-w","source_license":"CC0","license_restricted":false}