Closing the communication loop between gynecological surgeons, diagnostic imaging experts and pathologists in endometriosis: building bridges between specialties

In endometriosis, it is becoming increasingly clear how important imaging is to advancing the potential to provide an accurate non-invasive diagnosis1, 2, understanding severity preoperatively3, triaging patients to an appropriately trained surgeon4 and guiding surgical decisions to optimize outcome and mitigate complications. Advancing endometriosis research has required a closed, two-way communication loop between surgeons and diagnostic imaging experts (sonographers, sonologists, technicians, radiologists) or, in some instances, a built-in communication loop when the sonologist and surgeon are the same person. Similarly, to ensure progress in our molecular knowledge of endometriosis5, which has major implications for our understanding of etiology, progression, recurrence and malignant transformation6, 7, relationships between surgeons and pathologists have been essential. However, in most clinical settings, there is generally only one-way communication with little or no feedback communication from surgeons to diagnostic imaging experts regarding surgical findings. There may be some element of two-way communication between surgeons and pathologists, but this is usually in the form of a few written words on a pathology requisition and the returned pathology report. There is often no communication between diagnostic imaging experts and pathologists. Our current siloed model of practice forfeits many opportunities for learning, quality assurance and research. Conversely, in oncology, multidisciplinary team meetings including surgeons, diagnostic imaging experts and pathologists, are a well-established practice8, 9. One guaranteed method to overcome the gaps in endometriosis care is to optimize two-way communication between gynecological surgeons and the other main gatekeepers to diagnosing endometriosis: diagnostic imaging experts and pathologists. Endometriosis is a prevalent disease10 but, even so, its diagnosis is estimated to be delayed by 8–12 years11-13. The gold standard for diagnosing endometriosis is still widely considered to be surgery to inspect the abdominopelvic cavity, biopsy and obtaining histological confirmation of suspected lesions14-16. However, the need for histological confirmation is becoming a matter of debate17-20. While surgeons have demonstrated high accuracy and interobserver agreement at surgery, visually recognized endometriotic lesions are not always histologically confirmed21. On the other hand, microscopic endometriosis can be detected in biopsies of visually normal peritoneum from women without evidence of endometriosis22-24. Since it is not recommended to excise normal-appearing peritoneum, it is only when a surgeon sees an area of abnormality that a biopsy or excision is done. As such, it is our impression that direct visualization at surgery is the prioritized diagnostic method at present. In expert hands, pelvic ultrasound and other imaging modalities can be used to directly visualize endometriosis non-invasively. It is increasingly accepted that non-invasive imaging is accurate in diagnosing ovarian and deep endometriosis16. Recently, it has been proposed that superficial endometriosis is also directly visible using ultrasound25. However, expert ultrasound is not readily available outside of endometriosis centers of excellence26 and, when it is available, there is variation in the approach, nomenclature and reporting. There has been significant movement to overcome these limitations by the International Deep Endometriosis Analysis (IDEA) group, who assembled a consensus opinion statement to unify an approach and standardize terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis27. The vast majority of members of the IDEA group are gynecological sonologists with experience in clinical gynecology. To disperse this knowledge to general sonographers and radiologists, immense knowledge-translation efforts are necessary. Even with increased awareness, there still comes the limitation of the learning curve for those without intimate understanding of surgical anatomy and pathophysiology28. In North America, most gynecological scans are performed by sonographers and interpreted by radiologists without any surgical experience. For us, as both advanced gynecological surgeons and gynecological sonologists, it was the back-and-forth between surgery and ultrasound that enhanced our learning curve and subsequently led to ongoing improvements in our understanding of endometriosis, both surgically and sonographically. As such, one possible strategy to consider implementing to achieve the goal of far-reaching education is for gynecological surgeons to send the diagnostic imaging team a copy of the operative and histopathology reports. In many settings, these reports are already sent to the referring general practitioner or family physician, so the effort to add additional recipients should be negligible. Standardized operative report templates with diagrams could be useful29 to close the communication loop between diagnostic imaging experts and gynecological surgeons. While research on providing feedback to diagnostic imaging experts is scarce, one study noted that radiologists found feedback following mammography useful, particularly when contextualized with other radiologists' performance data geographically and with clear benchmarks30. However, we must acknowledge that a radiology–surgery or radiology–pathology correlation would be time-consuming for the diagnostic imaging team based on the typical practice volumes and variety31. Fortunately, this is being addressed by a team that is developing and studying a tool that automatically provides radiologists with pathology results related to the imaging examinations they interpreted, which has been found to be a valuable opportunity for radiologists across different experience levels to learn, increase their skill and improve patient care32. This tool allows radiologists to mark the results as concordant or discordant with their imaging report. In the field of endometriosis, developing tools that could automatically provide feedback on histopathology outcomes could not only help diagnostic imaging experts to increase their accuracy in the diagnosis of endometriosis, but also encourage a movement to a gold-standard non-invasive diagnosis of endometriosis, without the need to conduct a laparoscopy. Moreover, this endeavor could help refine our evaluation of ovarian masses in general. Not uncommonly, endometriomas are described as ‘complex’ (a now outdated term requiring replacement with more specific language33), leading to a journey to ‘rule out cancer’. Though rare compared to the prevalence of an endometrioma, ovarian cancer will occasionally be identified. A closed feedback loop between pathologists and diagnostic imaging experts could advance this area of work, as demonstrated by the significant contribution to the literature by the International Ovarian Tumor Analysis (IOTA) group34, 35. In general, closed-loop two-way communication amongst specialists is an area that could advance endometriosis care, particularly as it pertains to the diagnosis of this enigmatic condition. This concept should be considered in a prospective feasibility study to evaluate the utility of feedback tools amongst gynecological surgeons, diagnostic imaging experts and pathologists. We hypothesize that several positive consequences may come from this change in our medical culture: (1) improvement in the quality of gynecological imaging; (2) reduced costs to the healthcare system36; (3) better patient outcomes (for example, efficacy of surgery and reduction in the complication rate); (4) enhanced professional relationships between gynecological surgeons, diagnostic imaging experts and pathologists; and (5) new research and technology opportunities. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.