Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists’ understanding of this disease. Similar content being viewed by others

As-Sanie S, Black R, Giudice LC, Gray Valbrun T, Gupta J, Jones B, Laufer MR, Milspaw AT, Missmer SA, Norman A, Taylor RN, Wallace K, Williams Z, Yong PJ, Nebel RA (2019) Assessing research gaps and unmet needs in endometriosis. Am J Obstet Gynecol. https://doi.org/10.1016/j.ajog.2019.02.033 Ballard K, Lowton K, Wright J (2006) What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis. Fertil Steril 86 (5):1296-1301. https://doi.org/10.1016/j.fertnstert.2006.04.054 Nnoaham KE, Hummelshoj L, Webster P, d’Hooghe T, de Cicco Nardone F, de Cicco Nardone C, Jenkinson C, Kennedy SH, Zondervan KT, World Endometriosis Research Foundation Global Study of Women’s Health c (2011) Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 96 (2):366-373 e368. https://doi.org/10.1016/j.fertnstert.2011.05.090 Patel BG, Lenk EE, Lebovic DI, Shu Y, Yu J, Taylor RN (2018) Pathogenesis of endometriosis: Interaction between Endocrine and inflammatory pathways. Best practice & research Clinical obstetrics & gynaecology 50:50-60. https://doi.org/10.1016/j.bpobgyn.2018.01.006 Siegelman ES, Oliver ER (2012) MR imaging of endometriosis: ten imaging pearls. Radiographics 32 (6):1675-1691. https://doi.org/10.1148/rg.326125518 Hsu AL, Khachikyan I, Stratton P (2010) Invasive and noninvasive methods for the diagnosis of endometriosis. Clin Obstet Gynecol 53 (2):413-419. https://doi.org/10.1097/grf.0b013e3181db7ce8 Khan Z, Zanfagnin V, El-Nashar SA, Famuyide AO, Daftary GS, Hopkins MR (2017) Risk Factors, Clinical Presentation, and Outcomes for Abdominal Wall Endometriosis. Journal of minimally invasive gynecology 24 (3):478-484. https://doi.org/10.1016/j.jmig.2017.01.005 Chamie LP, Ribeiro D, Tiferes DA, Macedo Neto AC, Serafini PC (2018) Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings. Radiographics 38 (1):309-328. https://doi.org/10.1148/rg.2018170093 Chowdary P, Stone K, Ma T, Readman E, McIlwaine K, Druitt M, Ellett L, Cameron M, Maher P (2019) Multicentre retrospective study to assess diagnostic accuracy of ultrasound for superficial endometriosis-Are we any closer? Aust N Z J Obstet Gynaecol 59 (2):279-284. https://doi.org/10.1111/ajo.12911 Medeiros LR, Rosa MI, Silva BR, Reis ME, Simon CS, Dondossola ER, da Cunha Filho JS (2015) Accuracy of magnetic resonance in deeply infiltrating endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet 291 (3):611-621. https://doi.org/10.1007/s00404-014-3470-7 Rousset P, Gregory J, Rousset-Jablonski C, Hugon-Rodin J, Regnard JF, Chapron C, Coste J, Golfier F, Revel MP (2016) MR diagnosis of diaphragmatic endometriosis. Eur Radiol 26 (11):3968-3977. https://doi.org/10.1007/s00330-016-4226-5 Sandre A, Philip CA, De-Saint-Hilaire P, Maissiat E, Bailly F, Cortet M, Dubernard G (2019) Comparison of three-dimensional rectosonography, rectal endoscopic sonography and magnetic resonance imaging performances in the diagnosis of rectosigmoid endometriosis. Eur J Obstet Gynecol Reprod Biol 240:288-292. https://doi.org/10.1016/j.ejogrb.2019.07.008 Hernandez Gutierrez A, Spagnolo E, Hidalgo P, Lopez A, Zapardiel I, Rodriguez R (2019) Magnetic resonance imaging versus transvaginal ultrasound for complete survey of the pelvic compartments among patients with deep infiltrating endometriosis. Int JGynaecol Obstet 146 (3):380-385. https://doi.org/10.1002/ijgo.12894 Zhang Y, Xiao X, Xu F, Lin Q, Xu J, Du B (2019) Evaluation of Uterosacral Ligament Involvement in Deep Endometriosis by Transvaginal Ultrasonography. Front Pharmacol 10:374. https://doi.org/10.3389/fphar.2019.00374 Di Paola V, Manfredi R, Castelli F, Negrelli R, Mehrabi S, Pozzi Mucelli R (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 Bartlett DJ, Burkett BJ, Burnett TL, Sheedy SP, Fletcher JG, VanBuren WM (2019) Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis. Abdom Radiol (NY). https://doi.org/10.1007/s00261-019-02124-x Kinkel K, Frei KA, Balleyguier C, Chapron C (2006) Diagnosis of endometriosis with imaging: a review. Eur Radiol 16 (2):285-298. https://doi.org/10.1007/s00330-005-2882-y Schneider 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 Coutinho A, Jr., Bittencourt LK, Pires CE, Junqueira F, Lima CM, Coutinho E, Domingues MA, Domingues RC, Marchiori E (2011) MR imaging in deep pelvic endometriosis: a pictorial essay. Radiographics 31 (2):549-567. https://doi.org/10.1148/rg.312105144 Rolla E (2019) Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Res 8. https://doi.org/10.12688/f1000research.14817.1 Togashi K, Nishimura K, Kimura I, Tsuda Y, Yamashita K, Shibata T, Nakano Y, Konishi J, Konishi I, Mori T (1991) Endometrial cysts: diagnosis with MR imaging. Radiology 180 (1):73-78. https://doi.org/10.1148/radiology.180.1.2052726 Woodward PJ, Sohaey R, Mezzetti TP, Jr. (2001) Endometriosis: radiologic-pathologic correlation. Radiographics 21 (1):193-216; questionnaire 288-194. https://doi.org/10.1148/radiographics.21.1.g01ja14193 Rehmer JM, Flyckt RL, Goodman LR, Falcone T (2019) Management of Endometriomas. Obstet Gynecol Surv 74 (4):232-240. https://doi.org/10.1097/ogx.0000000000000660 Foti PV, Ognibene N, Spadola S, Caltabiano R, Farina R, Palmucci S, Milone P, Ettorre GC (2016) Non-neoplastic diseases of the fallopian tube: MR imaging with emphasis on diffusion-weighted imaging. Insights into imaging 7 (3):311-327. https://doi.org/10.1007/s13244-016-0484-7 Kim MY, Rha SE, Oh SN, Jung SE, Lee YJ, Kim YS, Byun JY, Lee A, Kim MR (2009) MR Imaging findings of hydrosalpinx: a comprehensive review. Radiographics 29 (2):495-507. https://doi.org/10.1148/rg.292085070 Gougoutas CA, Siegelman ES, Hunt J, Outwater EK (2000) Pelvic endometriosis: various manifestations and MR imaging findings. AJR Am J Roentgenol 175 (2):353-358. https://doi.org/10.2214/ajr.175.2.1750353 Stratton P, Winkel C, Premkumar A, Chow C, Wilson J, Hearns-Stokes R, Heo S, Merino M, Nieman LK (2003) Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathologic examination for the detection of endometriosis. Fertil Steril 79 (5):1078-1085. https://doi.org/10.1016/s0015-0282(03)00155-9 Darvishzadeh A, McEachern W, Lee TK, Bhosale P, Shirkhoda A, Menias C, Lall C (2016) Deep pelvic endometriosis: a radiologist’s guide to key imaging features with clinical and histopathologic review. Abdom Radiol (NY) 41 (12):2380-2400. https://doi.org/10.1007/s00261-016-0956-8 Del Frate C, Girometti R, Pittino M, Del Frate G, Bazzocchi M, Zuiani C (2006) Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. Radiographics 26 (6):1705-1718. https://doi.org/10.1148/rg.266065048 Bis KG, Vrachliotis TG, Agrawal R, Shetty AN, Maximovich A, Hricak H (1997) Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls. Radiographics 17 (3):639-655. https://doi.org/10.1148/radiographics.17.3.9153703 Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, Mueller MD (2005) “Kissing ovaries”: a sonographic sign of moderate to severe endometriosis. Fertil Steril 83 (1):143-147. https://doi.org/10.1016/j.fertnstert.2004.05.094 Nezhat C, Li A, Falik R, Copeland D, Razavi G, Shakib A, Mihailide C, Bamford H, DiFrancesco L, Tazuke S, Ghanouni P, Rivas H, Nezhat A, Nezhat C, Nezhat F (2018) Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol 218 (6):549-562. https://doi.org/10.1016/j.ajog.2017.09.023 Yoon JH, Choi D, Jang KT, Kim CK, Kim H, Lee SJ, Chun HK, Lee WY, Yun SH (2010) Deep rectosigmoid endometriosis: “mushroom cap” sign on T2-weighted MR imaging. Abdom Imaging 35 (6):726-731. https://doi.org/10.1007/s00261-010-9643-3 Barra F, Scala C, Biscaldi E, Vellone VG, Ceccaroni M, Terrone C, Ferrero S (2018) Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. Hum Reprod Update 24 (6):710-730. https://doi.org/10.1093/humupd/dmy027 Kruger K, Gilly L, Niedobitek-Kreuter G, Mpinou L, Ebert AD (2014) Bladder endometriosis: characterization by magnetic resonance imaging and the value of documenting ureteral involvement. Eur J Obstet Gynecol Reprod Biol 176:39-43. https://doi.org/10.1016/j.ejogrb.2014.02.019 Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Vigano P, Vercellini P (2017) Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. Eur Urol 71 (5):790-807. https://doi.org/10.1016/j.eururo.2016.12.015 Villa G, Mabrouk M, Guerrini M, Mignemi G, Montanari G, Fabbri E, Venturoli S, Seracchioli R (2007) Relationship between site and size of bladder endometriotic nodules and severity of dysuria. Journal of minimally invasive gynecology 14 (5):628-632. https://doi.org/10.1016/j.jmig.2007.04.015 Marcellin L, Santulli P, Bortolato S, Morin C, Millischer AE, Borghese B, Chapron C (2018) Anterior Focal Adenomyosis and Bladder Deep Infiltrating Endometriosis: Is There a Link? Journal of minimally invasive gynecology 25 (5):896-901. https://doi.org/10.1016/j.jmig.2018.02.002 Nezhat C, Paka C, Gomaa M, Schipper E (2012) Silent loss of kidney seconary to ureteral endometriosis. JSLS 16 (3):451-455. https://doi.org/10.4293/108680812x13462882736213 Balleyguier C, Roupret M, Nguyen T, Kinkel K, Helenon O, Chapron C (2004) Ureteral endometriosis: the role of magnetic resonance imaging. J Am Assoc Gynecol Laparosc 11 (4):530-536 Charatsi D, Koukoura O, Ntavela IG, Chintziou F, Gkorila G, Tsagkoulis M, Mikos T, Pistofidis G, Hajiioannou J, Daponte A (2018) Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis. Advances in medicine 2018:3461209. https://doi.org/10.1155/2018/3461209 Ghafoor S, Lakhman Y, Park KJ, Petkovska I (2019) Polypoid endometriosis: a mimic of malignancy. Abdom Radiol (NY). https://doi.org/10.1007/s00261-019-02143-8 Parker RL, Dadmanesh F, Young RH, Clement PB (2004) Polypoid endometriosis: a clinicopathologic analysis of 24 cases and a review of the literature. Am J Surg Pathol 28 (3):285-297 Kozawa E, Inoue K, Iwasa N, Fujiwara K, Yasuda M, Tanaka J, Kimura F (2012) MR imaging of polypoid endometriosis of the ovary. Magnetic resonance in medical sciences : MRMS : an official journal of Japan Society of Magnetic Resonance in Medicine 11 (3):201-204. https://doi.org/10.2463/mrms.11.201 Flyckt R, Lyden S, Roma A, Falcone T (2011) Post-menopausal endometriosis with inferior vena cava invasion requiring surgical management. Hum Reprod 26 (10):2709-2712. https://doi.org/10.1093/humrep/der260 Takeuchi M, Matsuzaki K, Furumoto H, Nishitani H (2008) Case report: A case of polypoid endometriosis: MR pathological correlation. Br J Radiol 81 (964):e118-119. https://doi.org/10.1259/bjr/23847518 Siquara De Sousa AC, Capek S, Amrami KK, Spinner RJ (2015) Neural involvement in endometriosis: Review of anatomic distribution and mechanisms. Clin Anat 28 (8):1029-1038. https://doi.org/10.1002/ca.22617 Foti PV, Farina R, Palmucci S, Vizzini IAA, Libertini N, Coronella M, Spadola S, Caltabiano R, Iraci M, Basile A, Milone P, Cianci A, Ettorre GC (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging 9 (2):149-172. https://doi.org/10.1007/s13244-017-0591-0 Ceccaroni M, Clarizia R, Alboni C, Ruffo G, Bruni F, Roviglione G, Scioscia M, Peters I, De Placido G, Minelli L (2010) Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique. Surg Radiol Anat 32 (6):601-604. https://doi.org/10.1007/s00276-010-0624-6 Jaramillo-Cardoso A, Balcacer P, Garces-Descovich A, Beker K, Roth E, Glickman J, Mortele KJ (2018) Multimodality imaging and clinicopathologic assessment of abdominal wall endometriosis: knocking down the enigma. Abdom Radiol (NY). https://doi.org/10.1007/s00261-018-1666-1 Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M (2008) Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg 196 (2):207-212. https://doi.org/10.1016/j.amjsurg.2007.07.035 Marras S, Pluchino N, Petignat P, Wenger JM, Ris F, Buchs NC, Dubuisson J (2019) Abdominal wall endometriosis: An 11-year retrospective observational cohort study. Eur J Obstet Gynecol Reprod Biol X 4:100096. https://doi.org/10.1016/j.eurox.2019.100096 Gidwaney R, Badler RL, Yam BL, Hines JJ, Alexeeva V, Donovan V, Katz DS (2012) Endometriosis of abdominal and pelvic wall scars: multimodality imaging findings, pathologic correlation, and radiologic mimics. Radiographics 32 (7):2031-2043. https://doi.org/10.1148/rg.327125024 Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, Beygui RE (2009) Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy. Journal of minimally invasive gynecology 16 (5):573-580. https://doi.org/10.1016/j.jmig.2009.06.012 Machairiotis N, Stylianaki A, Dryllis G, Zarogoulidis P, Kouroutou P, Tsiamis N, Katsikogiannis N, Sarika E, Courcoutsakis N, Tsiouda T, Gschwendtner A, Zarogoulidis K, Sakkas L, Baliaka A, Machairiotis C (2013) Extrapelvic endometriosis: a rare entity or an under diagnosed condition? Diagnostic pathology 8:194. https://doi.org/10.1186/1746-1596-8-194 Nezhat C, Lindheim SR, Backhus L, Vu M, Vang N, Nezhat A, Nezhat C (2019) Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management. JSLS 23 (3). https://doi.org/10.4293/jsls.2019.00029 Davis AC, Goldberg JM (2017) Extrapelvic Endometriosis. Semin Reprod Med 35 (1):98-101. https://doi.org/10.1055/s-0036-1597122 Liu K, Zhang W, Liu S, Dong B, Liu Y (2015) Hepatic endometriosis: a rare case and review of the literature. Eur J Med Res 20:48. https://doi.org/10.1186/s40001-015-0137-1 Keramidaris D, Gourgiotis S, Koutela A, Mpairamidis E, Oikonomou C, Villias C, Rigas A (2018) Rare Case of Hepatic Endometriosis as an Incidental Finding: Difficult Diagnosis of a Diagnostic Dilemma. Annals of hepatology 17 (5):884-887. https://doi.org/10.5604/01.3001.0012.3173 Sherif AM, Musa ER, Kedar R, Fu L (2016) Subcapsular hepatic endometriosis: case report and review of the literature. Radiology case reports 11 (4):303-308. https://doi.org/10.1016/j.radcr.2016.08.004 Yamamoto R, Konagaya K, Iijima H, Kashiwagi H, Hashimoto M, Shindo A, Sasaki Y, Yamamoto K, Nakagawa M, Suno Y, Abe T, Takaki M, Suda K, Watanabe K (2019) A Rare Case of Pancreatic Endometrial Cyst and Review of the Literature. Intern Med 58 (8):1097-1101. https://doi.org/10.2169/internalmedicine.1702-18 Plodeck V, Sommer U, Baretton GB, Aust DE, Laniado M, Hoffmann RT, Platzek I (2016) A rare case of pancreatic endometriosis in a postmenopausal woman and review of the literature. Acta Radiol Open 5 (9):2058460116669385. https://doi.org/10.1177/2058460116669385 Mederos MA, Villafane N, Dhingra S, Farinas C, McElhany A, Fisher WE, Van Buren Ii G (2017) Pancreatic endometrial cyst mimics mucinous cystic neoplasm of the pancreas. World journal of gastroenterology 23 (6):1113-1118. https://doi.org/10.3748/wjg.v23.i6.1113 Takeuchi M, Matsuzaki K, Uehara H, Nishitani H (2006) Malignant transformation of pelvic endometriosis: MR imaging findings and pathologic correlation. Radiographics 26 (2):407-417. https://doi.org/10.1148/rg.262055041 Tsuruga T, Hirata T, Akiyama I, Matsumoto Y, Oda K, Fujii T, Osuga Y (2019) Mixed endometrioid and clear cell carcinoma arising from laparoscopic trocar site endometriosis. J Obstet Gynaecol Res 45 (8):1613-1618. https://doi.org/10.1111/jog.14014 Robinson KA, Menias CO, Chen L, Schiappacasse G, Shaaban AM, Caserta MP, Elsayes KM, VanBuren WM, Bolan CW (2019) Understanding malignant transformation of endometriosis: imaging features with pathologic correlation. Abdom Radiol (NY). https://doi.org/10.1007/s00261-019-01914-7 Tanaka YO, Yoshizako T, Nishida M, Yamaguchi M, Sugimura K, Itai Y (2000) Ovarian carcinoma in patients with endometriosis: MR imaging findings. AJR Am J Roentgenol 175 (5):1423-1430. https://doi.org/10.2214/ajr.175.5.1751423 Author information Authors and Affiliations Corresponding author Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions About this article Cite this article Mason, B.R., Chatterjee, D., Menias, C.O. et al. Encyclopedia of endometriosis: a pictorial rad-path review. Abdom Radiol 45, 1587–1607 (2020). https://doi.org/10.1007/s00261-019-02381-w Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00261-019-02381-w