{"paper_id":"ba501bdd-0b67-4ccd-ae18-884002c0349f","body_text":"CASE STUDY Open Access\n© The Author(s) 2025. Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International \nLicense, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate \ncredit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. \nYou do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party \nmaterial in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material \nis not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted \nuse, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p : /  / c r e a  t i v e c o  m m o n  s . o r g  / l i c e  n s \ne s / b  y - n c  - n d / 4 . 0 /.\nRosaria et al. Discover Medicine           (2025) 2:248 \nhttps://doi.org/10.1007/s44337-025-00429-z\n*Correspondence:\nValeria Fiaschetti\nvaleria.fiaschetti@uniroma2.it\n1U.O.C. Diagnostic Imaging, PTV \nPoliclinico “Tor Vergata” University, \nViale Oxford 81, Rome 00133, Italy\n2Department of Biomedicine and \nPrevention, University of Rome Tor \nVergata, Rome, Italy\n3U.O.C. Endocrinology and \nDiabetology, PTV Policlinico “Tor \nVergata” University, Viale Oxford 81, \nRome 00133, Italy\n4Department of Surgical Sciences, \nUnit of Obstetrics and Gynecology, \nUniversity of Rome Tor Vergata, \nRome, Italy\nLiterature update and MRI case collection \nof unusual localizations\nMeucci Rosaria1, Francesco Garaci2, Valeria Fiaschetti2*, Francesca Montesanto1, Flavia Rufi1, Mario Laudazi2,  \nColleen Patricia Ryan3, Consuelo Russo4 and Guglielmo Manenti2\n1 Introduction\nEndometriosis is a prevalent gynecologic pathology estimated to affect 10% of women \n[1] and is defined by the ectopic presence of endometrial tissue outside the uterine cav -\nity with consequent recurrent intralesional bleeding and resulting fibrosis. Feldman et \nal. discerned three forms of pelvic endometriosis: (a) superficial peritoneal lesions; (b) \novarian endometrioma; (c) deep infiltrating endometriosis (DIE), histologically identi -\nfied as a lesion that extends more than 5 mm into the sub- peritoneal space or involving \nthe walls of pelvic organs and ligaments [ 1]. Preeminent sites for endometriotic lesions \ninclude ovaries, pelvic peritoneum, uterosacral ligaments, and torus uterine [ 2]. Atypi-\ncal pelvic endometriosis localizations can occur in the cervix, vagina, round ligaments, \nureter, and nerves. Moreover, rare extra pelvic endometriosis implants can be localized \nin the upper abdomen, subphrenic fold or in the abdominal wall. While characteristic \nsymptoms comprise secondary dysmenorrhea and cyclic or persistent pelvic pain, the \ndiagnostic context is often non-specific, contributing to a notable diagnostic delay of up \nDiscover Medicine\nAbstract\nEndometriosis affects approximately 10% of women of reproductive age and is a \nsignificant cause of pelvic pain and infertility. It manifests in three patterns: superficial \nperitoneal lesions, ovarian endometriomas, and deep infiltrating endometriosis \n(DIE). Our aim is to remind radiologists of the possibility of atypical locations \nof pelvic and extrapelvic endometriosis and to illustrate their characteristics on \nmagnetic resonance imaging (MRI). The most common site of endometriosis is \nthe ovaries, followed by the pelvic peritoneum. Less common locations include \ndeep subperitoneal tissues, the gastrointestinal tract, the bladder, the thorax, \nand subcutaneous tissues. We present three rare clinical cases: diaphragmatic \nendometriosis, inguinal canal endometriosis, and a case of sciatic nerve infiltration. \nMRI provides important findings that help classify the disease and identify the extent \nof the lesion, thus facilitating appropriate diagnosis and treatment. Radiologists \nshould be familiar with the MRI findings of DIE in various anatomical sites to provide \ninformation that allows for adequate pre-surgical counseling.\n\n\nPage 2 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nto 10 years [1– 3]. Unusual sites of endometriosis may be associated with specific symp -\ntoms depending on different localizations [4].\nExtra pelvic compartments include right bowel structures (cecum, ileum, and appen -\ndix), sigmoid colon, lumbopelvic ureter, abdominal wall as well as umbilicus, and \nexternal part of inguinal canal [ 5], diaphragm and this paper explores three rare endo -\nmetriosis localizations, highlighting their Magnetic Resonance Imaging (MRI) and clini -\ncal features in cases involving the sciatic nerve, diaphragm, and abdominal wall.\n2  Non-invasive diagnosis of endometriosis\n2.1 The role of MRI and MRI features\nMRI is a useful noninvasive tool used to diagnose endometriosis because of the absence \nof ionizing radiation, multiplanar projections, and high contrast resolution with high \nsensitivity for detection of hemorrhagic lesions [6].\nAccording to European Society of Urogenital Radiology (ESUR), the paramount indi -\ncation for MRI lies in the examination of DIE. ESUR further advocates for MRI utili -\nzation in cases marked by positive clinical features but negative ultrasonography (US) \nresults, as well as in presurgical planning and as a second-line test when US proves \ninconclusive [ 2– 7]. MRI is essential in preoperative decision making, particularly in \ncases of extrapelvic disease where first line imaging by expert operators is not accurate \n[5]. Several papers demonstrated high agreement between imaging and surgical findings \n[8– 9]. This is also mentioned in the recent ESHRE guidelines [ 10], which highlight that \nsurgery is no longer the gold standard to diagnose endometriosis and MRI can be used \nfor consequent patient management.\nIn 2003–2005, SEF (Stiftung Endometriose-Forschung; Scientific Endometriosis Foun -\ndation) published the ENZIAN classification, which established a useful tool for DIE \nclassification focused also on MRI [ 11]. The latest revision of the ENZIAN score (2020) \nproposes a new comprehensive classification system, which includes anatomical location \nand size of the different forms of endometriotic lesions, presence of adhesions, and the \ndegree of involvement of adjacent organs [12].\nOn MRI, DIE manifests as hemorrhagic cysts or plaques, exhibiting hyperintensity in \nT1-weighted sequences, as well as solid or fibrous lesions characterized by low signal \nintensity on both T1- and T2-weighted images, indicative of an infiltrating behavior. \nHigh-resolution T1 and T2-weighted images are employed for meticulous evaluation, \nparticularly when lesions involve ligaments and the subperitoneal space (> 5 mm under \nperitoneal serosa). Discrimination between endometriotic tissue with hemorrhagic con -\ntent and fibrosis is achievable through MRI [3– 13].\nIn advanced stages, endometriosis is often associated with adhesions, appearing as \nspiculated bands of low to intermediate signal intensity on T1- and T2-weighted imag -\ning. These adhesions can obscure the interfaces between organs, leading to atypical \nimaging characteristics such as peritoneal space obliteration, fixed fluid accumulations, \nand distortion or displacement of nearby organs. To enhance visualization, axial, cor -\nonal, and sagittal planes are typically used, with oblique planes aligned to the affected \norgans providing additional information [2].\n\nPage 3 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \n2.2  MRI acquisition protocols\nAs described above endometriosis is a multifocal and systemic disease and MRI allows \ncomplete evaluation of every abdominal compartment, identifying and mapping all \ntypes of endometriosis lesions within a single study [5].\nRegarding technical recommendations, the application of fat saturation is advised for \nenhanced precision. Chemical frequency-selective fat saturation, targeting fat tissue, \nproves instrumental in accentuating distinctions among non-fat T1-weighted hyper -\nintense structures, thereby amplifying the visibility of minute hemorrhagic lesions \nassociated with endometriosis [ 2]. Recent ESUR guidelines do not provide specific rec -\nommendations regarding the timing of MRI in relation to the menstrual cycle [ 7]. At \nour institution, MRI was acquired with high field-strength (3 Tesla) systems, acquisition \nof axial, coronal and sagittal T2-weighted images and spin-echo or gradient-echo axial \nT1-weighted images obtained with or without fat suppression, with a slice thickness \nof 3 mm. In selected and atypical cases, axial T1-weighted images were obtained after \nintravenous administration of gadolinium-based contrast agent when deemed beneficial \nfor diagnosis. The usefulness of intravenous gadolinium injection to characterize endo -\nmetriosis is still under discussion. Incidentally, international recommendations assert \nthat the utilization of contrast agents typically does not contribute substantially to the \ninitial diagnostic information [14]. Nevertheless, it is deemed mandatory in cases where \nmalignant transformation of endometrioma is suspected, as highlighted by Schneider at \nal. [14]. MRI with vaginal opacification using sonographic gel is recognized as a viable \noption for evaluating DIE. Some papers recommended MRI with gel opacification of \nvagina for studying usual localization of DIE, particularly for the added value in evalu -\nation of recto-vaginal septum, utero-sacral ligaments and posterior vaginal fornix [ 15]. \nIt’s important to note that in our recent practice, we refrain from the practice of distend-\ning the vagina with sonographic gel [6].\n3 Unusual locations of extragenital endometriosis\nExtragenital endometriosis encompasses a spectrum of rare but clinically significant \nlesions that extend well beyond the pelvis, affecting organs and tissues such as the \nkidney, thoracic cavity, diaphragm, abdominal wall and groin [ 16– 28]. Although each \nlocation accounts for a small fraction of all endometriotic cases, their diverse presen -\ntations—including flank pain mimicking renal carcinoma, catamenial pneumothorax, \ncyclical chest or shoulder pain, and palpable masses in surgical scars—pose substantial \ndiagnostic and therapeutic challenges. Early recognition and accurate imaging assess -\nment (primarily with MRI) are therefore essential to distinguish these lesions from \nmalignancy, plan optimal surgical management and minimize morbidity.\nPatients with thoracic endometriosis (TE) usually present with the triad of pain, pneu -\nmothorax and haemoptysis [ 19]. While CT primarily serves to exclude other causes \nof pleural or parenchymal pathology, MRI more directly demonstrates endometrial \nimplants: small pleural or parenchymal nodules, haemothorax or haemorrhagic effu -\nsions appear hyperintense on T1- weighted fat -sat sequences and often enhance as \ndiscrete nodules or thickened pleural areas. MRI’s overall sensitivity for detecting dia -\nphragmatic and pleural disease approaches 83% [20, 51].\nDiaphragmatic endometriosis  (DE) refers to endometriotic implants encountered on \nthe visceral (abdominal) side of the diaphragm and it could be associated with TE. It is \n\nPage 4 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nrare and forms 0.67–4.7% of all endometriosis cases [ 21– 22, 52]. DE could cause symp -\ntoms like cyclic or noncyclic shoulder, arm, chest, or upper quadrant abdominal pain, \nbut it is most frequently diagnosed incidentally during laparoscopic surgery for coex -\nisting pelvic endometriosis. These foci are hyperintense on T1- weighted fat-sat images \nand demonstrate heterogeneous signal (“shading”) on T2; contrast-enhanced sequences \nreveal small enhancing nodules, aiding in differentiation from fibrotic or benign \nthickenings.\nRenal involvement in endometriosis is exceedingly rare—accounting for under 1% of \ncases—but can mimic malignancy with presentations of flank pain, haematuria and even \na palpable renal mass [ 16]. In case of symptoms, MRI is mandatory, to clarify the extent \nof the lesion and the depth of lesion invasion and to plan adequate surgical treatment \n[17– 18] Typical MRI features include cystic or mixed cystic-solid lesions that are mark -\nedly hyperintense on T1- weighted fat-saturated sequences (reflecting blood products), \nexhibit variable “shading” on T2- weighted images (due to chronic haemorrhage), and \nshow peripheral or septal enhancement after gadolinium administration.\nAbdominal wall endometriosis is divided into parietal and visceral endometriosis. Pari-\netal endometriosis lesions involve primary lesions on abdominal wall (often iatrogenic, \nas for scar endometriosis after caesarean section or umbilical endometriosis after lapa -\nroscopic surgery), groin and perineum [ 23– 24]. Visceral abdominal wall implants follow \nthe same signal characteristics but are located along peritoneal surfaces of omentum or \nbowel serosa. On MRI, these appear as well-circumscribed masses within subcutane -\nous fat or muscle. The frequency of abdominal wall endometriosis has been estimated to \nbe 0.04-5.5%, and symptoms could include a palpable mass (99%), cyclic pain (71%) and \ncyclic bleeding [25].\nUmbilical endometriosis can be categorized into two types: secondary umbilical endo -\nmetriosis, which is believed to arise from iatrogenic causes at the port site following \nlaparoscopic surgery, and primary umbilical endometriosis, which occurs spontaneously \nwithout any history of surgical procedures [ 25– 26]. Notably, primary umbilical endo -\nmetriosis is more commonly observed compared to the secondary form [ 27]. Imaging \ncannot reliably distinguish primary from secondary forms, so clinical history remains \ncrucial.\nInguinal endometriosis is a very unusual extrapelvic site for endometriosis (estimated \nincidence < 0.1% of cases) [ 28]. There is an increased right-sided predilection (~ 85% of \nreported cases) [ 29] likely due to the theory of menstrual blood reflux into the pelvic \ncavity [30]. It can present in various forms, such as cystic lesions within the hernia sac \nor the Nuck’s canal, as well as solid masses located in the extra-pelvic round ligament \nor subcutaneous tissue. Clinically, it is identified by the presence of a groin mass, which \nmay be associated with pain and periodic flare-ups or, alternatively, may be painless but \naccompanied by cyclical menstrual symptoms.\n4 Cases presentation\n4.1 Case 1: upper abdomen diaphragm localization\n4.1.1 Clinical case\nWe present a case of a 36-year-old woman with history of known fibrotic pelvic endo -\nmetriosis extended to the torus, uterosacral ligaments and round ligaments. Intestinal \nadhesions were also present. With the intention of achieving pregnancy, the patient \n\nPage 5 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nstopped estrogenic-progestin therapy. Few months after interrupting estrogenic-proges-\ntin therapy, the patient developed dysmenorrhea and pain radiating to the right shoulder \nduring the menstrual cycle. Physicians hypothesized disease recurrence and therefore \ndecided to perform an MRI exam extended to the upper abdomen. The suspicion of dia -\nphragmatic localization was accurate. Indeed, T1-weighted sequences revealed a focal \nhyperintensity in the right diaphragmatic pillar, adjacent to the seventh hepatic segment. \nThis finding raised suspicion of a deep endometriotic nodule, measuring approximately \n9 × 2 mm (Fig. 1). A diagnosis of fibrotic DIE with associated extra-pelvic endometriotic \nplaque in active phase was made.\n5 Discussion\nDE involving the full thickness of the diaphragm includes 1-1.5% of patients diagnosed \nwith endometriosis [ 31]. Preoperative diagnosis of DE poses various challenges due to \nthe significant proportion of asymptomatic patients, limited sensitivity of existing imag -\ning techniques, and lack of clinical suspicion [ 21]. Remarkably, as many as 70% of indi -\nviduals with DE exhibit no discernible symptoms [ 21]. This uncommon condition may \nremain asymptomatic and can be discovered incidentally [31].\nWhen symptomatic, DE is typically associated with chest pain (often pleuritic and pre-\ndominantly on the right side), dyspnea, epigastric discomfort, shoulder pain, and upper \nabdominal pain, which frequently occurs abruptly. The pain results from irritation of the \nsensory branches of the C3 and C5 nerve roots. Symptom severity depends on the depth \nand location of the lesions and is commonly linked to cyclical hormonal changes during \nthe menstrual cycle [31– 32].\nDE predominantly affects the right side, with lesions commonly located in the anterior \nor posterior diaphragm and in the area behind the liver. The higher prevalence in the \nsubphrenic region is explained by the retrograde menstruation theory, suggesting that \nrefluxed endometrial tissue becomes trapped by the falciform ligament near the right \nside of the diaphragm.\nMRI plays a crucial role in detecting these lesions, which are primarily visualized as \nhyperintense nodules on fat-suppressed T1-weighted sequences. According to Rousset \net al., MRI offers a sensitivity of 78–83% for identifying these abnormalities [ 33].\nThe authors suggest that a report of lesions of extrapelvic endometriosis should be \ncharacterized and described like pelvic localizations. Extrapelvic endometriosis nodules \ncan be defined based on shape and size:\n  • Foci: Thin and superficial, less than 1 cm.\n  • Nodules Solid: tri-dimensional, more than 1 cm.\n  • Plaques Fibrotic: bi-dimensional, more than 3 cm.\nSuperficially Isolated lesions usually measure less than 5  mm, without infiltration of \nmuscularis mucosa. Depth of invasion divides deep endometriosis from superficial: \nmore than 5  mm with infiltration of muscularis or full thickness with total diaphrag -\nmatic infiltration [ 21– 34]. Very often MRI alone is not sufficent and staging remains \nsurgical.\nThe management of diaphragmatic or suspected thoracic endometriosis often relies \non the patient’s medical history. For asymptomatic cases of DE, an expectant approach \nis strongly recommended as the most suitable treatment option compared to other \n\nPage 6 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \ninterventions [ 35]. For symptomatic individuals, surgical intervention is considered \neffective, particularly when hormonal therapies have not provided relief [36− 22].\nThe variables considered choosing the set therapy are patient age, future fertility \ndesire, symptomatic status, disease extension and location. In literature Smith et al. sug -\ngest surgery in symptomatic and infertile patients with failure of medical treatment [21].\nIn our case, the patient had a “focus” of deep DE, however without full thickness \ninfiltration of muscle. Our patient had minor symptoms with a low risk of developing \nFig. 1 Diaphragm localization; a-b: T1FS sequences coronal and axial plane of upper abdomen shows hyperin -\ntense linear area at the level of the right diaphragmatic pillar (diameter of approximately 9 millimeters); findings \ncompatible with active haemorrhagic endometriotic plaque\n \n\nPage 7 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \ncomplications, more over the plaque was single and small (< 1 cm). Our patient under -\nwent continuous hormonal progestin-based therapy, with consequent amenorrhea. \nAfter six months, the symptoms improved. Dysmenorrhea transitioned to amenorrhea \nand the irradiating pain to the shoulder almost completely disappeared.\n5.1 Case 2: posterior lateral compartment sciatic nerve localization\n5.1.1 Clinical case\nWe present a case of a 43-year-old woman, affected by DIE, who had a known history \nof ovarian endometriosis and complained of right sciatic pain, which was more evident \nduring the menstrual cycle. She underwent lumbo-sacral MRI which did not show sig -\nnificant spinal abnormalities, such as vertebral collapses or discal hernias. Due to the \ncatamenial progression of the symptoms the physician supposed an atypical localization \nof endometriosis, the patient underwent TVUS that showed bilateral endometriomas \nand a plaque of DIE in the posterior compartment. The lesions described at TVUS did \nnot fully explain the symptoms, so she also underwent a pelvic MRI to better evaluate all \npelvic compartments.\nThe MRI examination identified suspicious lesions at the right ischial foramen, within \nthe iliac obturator vascular-nervous bundle. It revealed a nodular region with spiculated \nmargins measuring 25  mm in diameter, exhibiting non-homogeneous intensity. This \nvariability was attributed to the presence of small hyperintense areas on T1-weighted \nimaging, indicative of haemorrhagic content (Fig. 2).\nThis finding, suggestive of an active DIE plaque, also appears to involve the root of \nthe ischial nerve. We concluded the MRI report describing a condition of endometriosis \nFig. 2 Sciatic nerve localization; a–b: axial T1FSw and T2w sequences, c: zoomed coronal T2w sequence highlight-\ning the suspicious nodule. MRI show an endometriotic plaque infiltrating the extra pelvic portion of the right ischi-\natic nerve, hyperintense on the T1w sequences and with very low T2 signal, compatible with active localization of \nextra-genital endometriosis in the lateral compartment\n \n\nPage 8 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \naffecting both intra-pelvic median and posterior compartment and extrapelvic lateral \ncompartment, involving the right sciatic nerve near the ipsilateral sciatic foramen.\nOur patient underwent surgical laparoscopic approach with excision of posterior DIE \nand nerve sparing surgery to remove the sciatic nodule. Histological findings confirmed \nsciatic nerve endometriosis. The symptoms resolved after surgical treatment and the \npatient started continuous progestin-based hormonal treatment to avoid disease relapse.\n6 Discussion\nThe sciatic nerve, the largest somatic nerve in the human body, was first linked to cycli -\ncal sciatica in a case reported by Head et al. in 1962 [ 37]. The exact mechanism behind \nthe sciatic localization of endometrial cells remains unclear. One theory suggests migra -\ntion of endometrial cells from pelvic endometriotic lesions, while other hypotheses pro -\npose mechanisms such as hematogenous spread, coelomic metaplasia, or embryonic cell \nremnants [37– 39]. Additionally, Possover et al. introduced a “neurologic hypothesis” in \n2007, describing a case of isolated sciatic nerve endometriosis with no detectable pelvic \nendometriotic lesions [40].\nThe most frequent site of sciatic nerve involvement in endometriosis is near the \ngreater sciatic foramen, with the right sciatic nerve being more commonly affected than \nthe left as seen in other reports [ 41, 54]. Cyclical bleeding into adjacent tissues leads to \ninflammation, fibrosis and scarring, which exacerbate nerve compression over time.\nThe diagnosis of sciatic nerve endometriosis is based on clinical symptoms and imag -\ning studies, with histopathological examination providing definitive confirmation. Key \nclinical indicators include sciatica that follows a cyclical pattern related to menstruation. \nAs the condition progresses, pain-free intervals shorten, and the pain becomes persis -\ntent, though it continues to worsen during menstruation.\nMRI is the preferred imaging modality for detecting sciatic endometriosis, offer -\ning a sensitivity of 90% and a specificity of 98% [ 42]. The appearance of endome -\ntriotic lesions varies with the stage of hemorrhage, typically showing high signal \nintensity on T1-weighted images and a combination of high and low signal intensities on \nT2-weighted images. Importantly, the absence of pelvic endometriosis does not rule out \nsciatic nerve involvement [43].\nSurgical treatment depends on the extent of the disease. If only the pelvic portion of \nthe sciatic nerve is affected, a skilled gynecologist can perform a laparoscopic or robotic \nprocedure [44]. When the extra-pelvic portion or both pelvic and extra-pelvic parts of \nthe nerve are involved, a trans-gluteal surgical approach is required. In such cases, a \nmultidisciplinary team comprising neurosurgeons and orthopedic specialists is essential \n[45].\nIn conclusion, sciatic nerve endometriosis should be considered in patients presenting \nwith sciatica exhibiting a cyclical pattern. MRI serves as the optimal imaging modality \nto support clinical diagnosis. Treatment requires the involvement of a multidisciplinary \nsurgical team with a thorough understanding of retroperitoneal neuroanatomy. The \nchoice of surgical approach, whether laparoscopic or trans-gluteal, should be carefully \nplanned prior to the procedure. Early diagnosis, timely intervention, and comprehen -\nsive post-operative physiotherapy can significantly enhance recovery outcomes for these \npatients.\n\nPage 9 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \n6.1  Case 3: abdominal wall and inguinal endometriosis\n6.1.1 Clinical case\nA 44-year-old patient presented with heavy menstrual periods. The patient had experi -\nenced two spontaneous pregnancies and deliveries and presented with a current medical \nhistory of systemic lupus erythematosus under treatment. At the first clinical evaluation, \nshe complained of dysmenorrhea (Visual Assessment Score, VAS 9), dyspareunia (VAS \n7), with no dyschezia or dysuria. She also complained of severe pain (VAS 10) in the \nright inguinal region during menstrual phase. She had never taken hormonal treatment.\nBecause of these invalidating symptoms, she underwent TVUS which showed a glo -\nbose uterus presenting fibromatosis and direct signs of adenomyosis. An hypoechoic \nnodule of 10 × 9 × 4 mm in size at the level of the torus uteri and an analogous nodule of \n15 × 8 × 9 mm in size in the posterior vaginal fornix were detected. Ovaries were normal. \nIn the right inguinal region, a painful hypoechoic nodule of 39 × 14  mm in size, with \nirregular margins, moderately vascularized at color-Doppler US, was observed.\nAll these findings led to the suspicion of pelvic DIE. The probability of an extra-pel -\nvic endometriosis, as inguinal endometriosis localization, was high and an indication to \ncarry out an MR exam was given. She was referred to dedicated genitourinary specialist \nradiologist. The MRI was performed with T1 fat saturation and T2 sequences in axial, \ncoronal and sagittal planes without contrast medium (Fig. 3). MRI showed an ovoid mass \nlocalized in the anterior abdominal wall which infiltrated the edge of the rectus abdomi -\nnis muscle and extended to the wall of right inguinal canal with probable involvement of \nthe pubic nerve as hypothesized from clinical symptoms. The MR images and features, \nin accordance with TVUS, were suggestive of endometrial glands ectopic localizations as \nglandular-cystic plaque.\nBased on the absence of previous surgery, clinical symptoms, US and MRI features, \nthe diagnostic hypothesis was Nuck’s canal endometriosis (Fig.  4). After diagnosis, the \npatient started a continuous progestin-based hormonal treatment for 12 months, induc -\ning amenorrhea, with improvement of dysmenorrhea but with persistence of dyspa -\nreunia and inguinal pain. Due to the persistence of symptoms the patient underwent \nlaparoscopy to remove DIE and groin incision to remove inguinal endometriosis.\nAt follow-up, symptoms were reduced (dysmenorrhea VAS 5, dyspareunia VAS 4, and \nabsent inguinal pain).\n7 Discussion\nEndometriosis of the inguinal region may involve inguinal hernia sac, Nuck’s canal, uter-\nine round ligament (RLU) and subcutaneous tissue [46– 47].\nInguinal endometriosis (from the labia majora to the abdominal wall) is a rare extra -\npelvic site for endometriosis, with incidence < 0.1% [48]. Incomplete obliteration of the \nNuck’s canal is known as a patent processus vaginalis and can result in either an inguinal \nhernia or a hydrocele in female children. It can provide a pathway for superficial ingui -\nnal endometriosis [ 49]. RLUs have an intrapelvic and an extrapelvic portion where the \nextrapelvic one is the distal part of the ligament in the Nuck’s canal [ 2]. Endometriosis \nfrom RLUs may advance through the inguinal ring into the inguinal canal, and this may \nbe an anatomical pathway for endometrial implants to the superficial inguinal soft tis -\nsues [50]. Symptoms of endometriosis of the intrapelvic portion of the RLUs are non -\nspecific, usually referred as pain localized in the lower abdomen [ 2]. Our patient had \n\nPage 10 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nsevere groin pain during menstrual cycle, associated with superficial swelling at the right \ninguinal level.\nOn sonographic imaging, our patient had a solid (hypoechoic) nodule, with irregu -\nlar margins, moderately vascularized on color doppler. Nevertheless, the sonographic \nappearance of inguinal endometriosis is not typical, varying between a predominantly \nFig. 3 Abdominal wall localization; a–b: T1FS- and T2FS -weighted axial sequences; c–d: T1FS- and T2-weighted \nsagittal sequences. MR images show an ovoid mass localized in the abdominis wall region which infiltrates the \nedge of the abdominis rectus muscle (a–b) and the anterior wall of inguinal canal (c–d). On T1-weighted sequenc-\nes (a, c) the lesion is isointense to the muscle. On T2-weighted sequences (c, d), the lesion displays areas of mixed \nhypointensity and hyperintensity, consistent with endometrial glands\n \n\nPage 11 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nsolid, a cystic or combined mass [ 50]. When extra-pelvic endometriosis is suspected, \nthe integration of US and MRI, like in our case, is the best approach in the diagnostic \nworkup [2, 5, 50]. Differential diagnosis includes abdominal wall masses, such as her -\nnias, lipomas, sebaceous cysts hematomas, and malignant tumors [ 2].\nOur patients underwent first-line medical treatment and subsequently surgery. As \nsuggested by Delkalitsis et al., while other treatment modalities like hormonal suppres -\nsive therapy remain to be evaluated, surgical treatment consists of excision of the mass \nfrom the Nuck’s canal and subcutaneous lesions is the better choice in case of severe \nsymptoms [50, 53].\n8  Conclusion\nThe most recent guidelines and reviews confirm the pivotal role of MRI both in the \npreoperative assessment and in the follow-up of extrapelvic localizations [ 55– 56]. The \ndiagnostic role of MRI in endometriosis is evolving, requiring radiologists to develop \na comprehensive understanding of various clinical and imaging manifestations in both \ntypical and atypical locations. This is particularly crucial when assessing patients sus -\npected of DIE. Radiologists must diligently explore, document, and stratify the disease \nacross a spectrum of locations in endometriosis patients. Accurate diagnosis holds para -\nmount significance for steering appropriate patient management. While laparoscopy \nremains the benchmark for endometriosis diagnosis, certain diagnostic challenges exist, \nsuch as the potential oversight of nodules concealed by adhesions and subperitoneal dis-\nease, highlighting the essential role of imaging.\nSuccessful treatment strategies encompass hormonal-based therapies including com -\nbined oral contraceptives (COC), progesterone agents, alongside lesion removal with \nradical surgery. In instances where surgery is indicated, MRI serves as a valuable tool, \nproviding a comprehensive roadmap. This facilitates effective presurgical counseling and \nguides the surgeon in the meticulous eradication of all endometriotic implants. The inte-\ngration of MRI into the diagnostic and therapeutic framework enhances precision and \ncontributes significantly to the overall management of endometriosis.\nFig. 4  Canal of Nuck localization. a–b: respectively T2-weighted axial and sagittal MR images show the same le -\nsion as Fig. 3 closely adherent to the right inguinal region suspicious for Nuck’s canal endometriosis\n \n\nPage 12 of 14\nRosaria et al. Discover Medicine           (2025) 2:248 \nAuthor contributions\nAll authors contributed equally to the work. The tasks were divided as follows: F.R, F.M and C.R wrote the main \nmanuscript text under the supervision of R.M and V.F, radiologists with over 10 years of experience in diagnostic imaging \nof the female pelvis.C.P .R. Conducted multiple ongoing reviews of the manuscript with particular attention to scientific \nterminology and English language.M.L prepared Figs. 1, 2, 3 and 4 and conducted multiple ongoing reviews and \nreviesed article layout and references F.G and G.M conducted the final review.\nFunding\nthe authors did not receive support from any organization for the submitted work.\nConflict of interest: the authors have no conflicts of interest to declare that are relevant to the content of this article.\nData availability\nAs per the Ministerial Decree of February 14, 1997, all MRI images of the reported cases will be stored in the digital \narchive of our polyclinic for 10 years.The clinical data collected will be gathered by the Research Center and processed \nthere. The Data Protection Officer for the healthcare company can be contacted upon reasonable request.Informed \nconsent was obtained from all individual participants included in the study. The informed consents will be archived in \nthe archive of our polyclinic as per Law No. 219 of December 22, 2017.\nDeclarations\nEthical approval and Consent to participate\nThe research was carried out following the guidelines of the institutional ethics committee. In particular, the need for \nethical approval was waived off by the ethical committee because our study is a case series and we iconographically \ndescribe images acquired during routine MRI examinations. The study was performed in accordance with the ethical \nstandards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. \nInformed consent was obtained from all individual participants included in the study.\nInformed consent\nThe patient(s), or their next of kin, or their legal representative(s) signed: - written informed consent in Italian for the \nperformance of contrast-enhanced MRI. - written informed consent in Italian to the use of images for research purposes \nand scientific description with written informed consent forms as approved by our ethical committee. The privacy of \nthe patient has been assured in all materials. Written informed consent forms from the patient(s) and/or their legal \nrepresentative(s)/guardian(s) are preserved in our department archive (U.O.C. Diagnostic Imaging, PTV Policlinico “Tor \nVergata” University, Viale Oxford 81, 00133, Rome, Italy).\nConsent to publish\nThe authors affirm that human research participants provided informed consent for publication.\nCompeting interests\nThe authors declare no competing interests. All procedures performed in studies involving human participants were in \naccordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration \nand its later amendments or comparable ethical standards.\nReceived: 6 December 2024 / Accepted: 12 July 2025\nReferences\n1. Feldman MK, VanBuren WM, Barnard H, Taffel MT, Kho RM. Systematic interpretation and structured reporting for pelvic \nmagnetic resonance imaging studies in patients with endometriosis: value added for improved patient care. Abdom \nRadiol (NY). 2020;45(6):1608–1622. https://doi.org/10.1007/s00261-019-02182-1. PMID: 31446452.\n2. Gui B, Valentini AL, Ninivaggi V, et al. 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