The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis

Laurin Burla, David Scheiner, Scheiner D, Samartzis EP, Eleftherios Pierre Samartzis, Seidel S, Stefan Seidel, Markus Eberhard, Eberhard M, Fink D, Daniel Fink, Andreas Boss, Boss A, Patrick Imesch, Imesch P
Archives of gynecology and obstetrics · 2019 · vol. 300(1) , pp. 109–116 · doi:10.1007/s00404-019-05157-1 · PMID:30980276 · W2935869923
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This study compared preoperative MRI with intraoperative findings using the ENZIAN score in 63 deep infiltrating endometriosis patients, showing good correlation but highlighting the need for standardized MRI protocols.

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This retrospective two-center study evaluated whether preoperative pelvic MRI findings, classified using the ENZIAN score, matched intraoperative findings in 63 patients with deep infiltrating endometriosis who had surgery between 2012 and 2016 and had preoperative pelvic MRI plus intraoperative/bioptic confirmation. MRI accuracy was assessed by comparing ENZIAN score-based MRI results with surgical findings and by analyzing the diagnostic value of different MRI sequences using a Likert scale. The study reported high sensitivity and negative predictive values for several lesion locations (e.g., vaginal/rectovaginal space, rectum/sigmoid colon, bladder), while performance varied by compartment, including uterine myometrium and uterosacral ligaments; additionally, T2 axial and sagittal sequences combined with a T1 sequence were considered diagnostically sufficient. The authors explicitly note that sequence variations created considerable difficulty and poorer comparability, motivating MRI protocol standardization to improve diagnostic validity; This paper is centrally about endometriosis — it focuses on using the ENZIAN score to classify deep infiltrating endometriosis from preoperative MRI and compare it with intraoperative findings.

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Abstract

PurposeComparison of preoperative magnetic resonance imaging (MRI) with intraoperative findings in patients with deep infiltrating endometriosis (DIE) by means of the ENZIAN score.MethodsThis retrospective two-center study includes 63 patients with deep infiltrating endometriosis, who underwent surgery between 2012 and 2016 at both the University Hospital of Zurich and the Cantonal Hospital of Schaffhausen. Inclusion criteria were a preoperative pelvic MRI and intraoperative or bioptic confirmation of DIE. The preoperative MRI findings were compared with the intraoperative results by means of the ENZIAN score. Furthermore, the various MRI sequences were analyzed for their diagnostic value based on a Likert scale.ResultsSensitivity and negative predictive values of MRI confirmed by surgery were 95.2% and 91.7% (lesions in the vaginal/rectovaginal space), 78.4% and 56% (uterosacral ligaments), 91.4% and 89.7% (rectum/sigmoid colon), 57.1% and 94.1% (myometrium), 85.7% and 98.3% (bladder), and 73.3% and 92.2% (intestine), respectively. T2 axial and sagittal MRI sequences in combination with a T1 sequence were diagnostically sufficient.ConclusionsThe MRI-based ENZIAN score correlates well with the intraoperative findings, enabling a better planning of the surgical procedure for patients and physicians. However, considerable difficulty and a poorer comparability result from the variations in sequences used in the detection of this multifaceted disease. Therefore, a standardization of MRI protocols used in the detection of DIE will be a crucial step towards increased diagnostic validity and the ENZIAN score may be used as an anatomical land map and valuable communication tool between radiologists and gynecologists.
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Abstract

Purpose Comparison of preoperative magnetic resonance imaging (MRI) with intraoperative findings in patients with deep infiltrating endometriosis (DIE) by means of the ENZIAN score.

Methods

This retrospective two-center study includes 63 patients with deep infiltrating endometriosis, who underwent surgery between 2012 and 2016 at both the University Hospital of Zurich and the Cantonal Hospital of Schaffhausen. Inclusion criteria were a preoperative pelvic MRI and intraoperative or bioptic confirmation of DIE. The preoperative MRI findings were compared with the intraoperative results by means of the ENZIAN score. Furthermore, the various MRI sequences were analyzed for their diagnostic value based on a Likert scale.

Results

Sensitivity and negative predictive values of MRI confirmed by surgery were 95.2% and 91.7% (lesions in the vaginal/rectovaginal space), 78.4% and 56% (uterosacral ligaments), 91.4% and 89.7% (rectum/sigmoid colon), 57.1% and 94.1% (myometrium), 85.7% and 98.3% (bladder), and 73.3% and 92.2% (intestine), respectively. T2 axial and sagittal MRI sequences in combination with a T1 sequence were diagnostically sufficient.

Conclusions

The MRI-based ENZIAN score correlates well with the intraoperative findings, enabling a better planning of the surgical procedure for patients and physicians. However, considerable difficulty and a poorer comparability result from the variations in sequences used in the detection of this multifaceted disease. Therefore, a standardization of MRI protocols used in the detection of DIE will be a crucial step towards increased diagnostic validity and the ENZIAN score may be used as an anatomical land map and valuable communication tool between radiologists and gynecologists. Similar content being viewed by others

References

Giudice LC, Kao LC (2004) Endometriosis. Lancet. 364(9447):1789–1799. https://doi.org/10.1016/S0140-6736(04)17403-5 Burney RO, Giudice LC (2012) Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 98(3):511–519. https://doi.org/10.1016/j.fertnstert.2012.06.029 Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D'Hooghe T (2009) High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril. 92(1):68–74. https://doi.org/10.1016/j.fertnstert.2008.04.056 Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C 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 Chapron C, Dubuisson JB, Pansini V, Vieira M, Fauconnier A, Barakat H et al (2002) Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis. J Am Assoc Gynecol Laparosc 9(2):115–119. Gauche Cazalis C, Koskas M, Martin B, Palazzo L, Madelenat P, Yazbeck C (2012) Preoperative imaging of deeply infiltrating endometriosis. In: Transvaginal sonography, rectal endoscopic sonography and magnetic resonance imaging. Gynecol Obstet Fertil 40(11), 634–641. https://doi.org/10.1016/j.gyobfe.2012.09.014 Fraser 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 Piessens 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 Nisenblat 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 Bazot M, Bharwani N, Huchon C, Kinkel K, Cunha TM, Guerra A et al (2016) European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 1:1. https://doi.org/10.1007/s00330-016-4673-z Custódio Silva MP, Trovó de Marqui AB (1997) Revised American Society for Reproductive Medicine classification of endometriosis 1996. Fertil Steril 67(5):817–821 Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS et al (2017) World endometriosis society consensus on the classification of endometriosis. Hum Reprod 32(2):315–324. https://doi.org/10.1093/humrep/dew293 Haas D, Wurm P, Shamiyeh A, Shebl O, Chvatal R, Oppelt P (2013) Efficacy of the revised Enzian classification: a retrospective analysis: Does the revised Enzian classification solve the problem of duplicate classification in rASRM and Enzian? Arch Gynecol Obstet. 287(5):941–945. https://doi.org/10.1007/s00404-012-2647-1 Tuttlies 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 Haas D, Shebl O, Shamiyeh A, Oppelt P (2013) The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Acta Obstet Gynecol Scand. 92(1):3–7. https://doi.org/10.1111/aogs.12026 Chamié LP, Blasbalg R, Gonçalves MO, Carvalho FM, Abrão MS, de Oliveira IS (2009) Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis. Int J Gynaecol Obstet. 106(3):198–201. https://doi.org/10.1016/j.ijgo.2009.04.013 Ito TE, Abi Khalil ED, Taffel M, Moawad GN (2017) Magnetic resonance imaging correlation to intraoperative findings of deeply infiltrative endometriosis. Fertil Steril. 107(2):e11–e12. https://doi.org/10.1016/j.fertnstert.2016.10.024 Saba L, Sulcis R, Melis GB, Ibba G, Alcazar JL, Piga M et al (2014) Diagnostic confidence analysis in the magnetic resonance imaging of ovarian and deep endometriosis: comparison with surgical results. Eur Radiol. 24(2):335–343. https://doi.org/10.1007/s00330-013-3013-9 Haas D, Chvatal R, Habelsberger A, Schimetta W, Wayand W, Shamiyeh A et al (2013) Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification. Eur J Obstet Gynecol Reprod Biol. 166(1):99–103. https://doi.org/10.1016/j.ejogrb.2012.10.012 Foti PV, Farina R, Palmucci S, Vizzini IAA, Libertini N, Coronella M et al (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights Imaging. 9(2):149–172. https://doi.org/10.1007/s13244-017-0591-0 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 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 Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C (2008) MR imaging features of deep pelvic endometriosis: correlation with laparoscopy. J Radiol. 89(11 Pt 1):1745–1754 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 Zanardi R, Del Frate C, Zuiani C, Bazzocchi M (2003) Staging of pelvic endometriosis based on MRI findings versus laparoscopic classification according to the American Fertility Society. Abdom Imaging. 28(5):733–742 Woodward PJ, Sohaey R, Mezzetti TP (2001) Endometriosis: radiologic-pathologic correlation. Radiographics. 21(1):193–216. https://doi.org/10.1148/radiographics.21.1.g01ja14193

Acknowledgements

The authors thank Burkhardt Seifert for statistical consulting. Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest The author Laurin Burla declares that he has no conflict of interest. The author David Scheiner declares that he has no conflict of interest. The author Eleftherios Pierre Samartzis declares that he has no conflict of interest. The author Stefan Seidel declares that he has no conflict of interest. The author Markus Eberhard declares that he has no conflict of interest. The author Daniel Fink declares that he has no conflict of interest. The author Andreas Boss declares that he has no conflict of interest. The author Patrick Imesch declares that he has no conflict of interest. Ethical approval All the 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). Informed consent Informed consent was obtained from all individual participants included in the study. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material Below is the link to the electronic supplementary material. Rights and permissions About this article Cite this article Burla, L., Scheiner, D., Samartzis, E.P. et al. The ENZIAN score as a preoperative MRI-based classification instrument for deep infiltrating endometriosis. Arch Gynecol Obstet 300, 109–116 (2019). https://doi.org/10.1007/s00404-019-05157-1 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00404-019-05157-1

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endometriosisdie_deep_infiltrating

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Endometriosis Endometriosis Magnetic Resonance Imaging Adult Endometriosis Endometriosis Female Humans Magnetic Resonance Imaging Preoperative Care Retrospective Studies

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