Beware of Deep Infiltrating Endometriosis - MRI Multi-Compartment Seeding, a Series of Cases

Genital / Reproductive system female, Pelvis, Urinary Tract / Bladder, MR, Imaging sequences, Education and training, Obstruction / Occlusion, Pelvic floor dysfunction Authors: E. C. Gavrila, L. Stanciulescu, H. Roman DOI: 10.26044/ecr2026/C-18642 Learning objectives The aim of this educational exhibit is to: Review the MRI definition and key imaging characteristics of deep infiltrating endometriosis (DIE). Illustrate MRI features of DIE in pelvic and extra-pelvic compartments that are frequently underdiagnosed and carry major prognostic implications. Emphasize the value of symptom-oriented MRI interpretation for accurate lesion localization and optimized preoperative planning.

Endometriosis is a chronic inflammatory disease characterized by ectopic endometrial-like tissue, affecting up to 10% of women of reproductive age. Deep infiltrating endometriosis (DIE) represents the most severe form, defined by infiltration exceeding 5 mm beneath the peritoneal surface.DIE is a compartment-based disease that may involve pelvic and extra-pelvic structures, including the bowel, urinary tract, pelvic nerves, and diaphragm. Symptoms are often disproportionate to lesion size and may be misleading or non-specific.Accurate preoperative mapping is crucial, as missed lesions may lead to persistent symptoms, incomplete... Findings and procedure details MRI Technique and General Imaging PrinciplesMRI enables multiplanar evaluation with excellent soft-tissue contrast, allowing detection of both direct and indirect signs of DIE.A standardized pelvic MRI protocol should include: High-resolution T2-weighted sequences in axial, sagittal, and oblique or coronal planes Axial and sagittal T1-weighted images, with and without fat suppression Diffusion-weighted imaging (DWI) (optional) Coronal and oblique planes are particularly valuable for assessing structures with oblique or cranio-caudal courses, such as pelvic nerves and diaphragmatic insertions.Routine gadolinium administration is not required but may be useful...

Deep infiltrating endometriosis is a complex, compartment-based disease in which MRI plays a pivotal role beyond lesion detection. Correlating symptom patterns with anatomical compartments and recognizing indirect imaging signs enables accurate disease mapping, prognostic assessment, and optimized surgical planning. A systematic, symptom-oriented MRI approach across pelvic and extra-pelvic compartments is essential to improve patient outcomes. Personal information and conflict of interest E. C. Gavrila: Nothing to disclose L. Stanciulescu: Nothing to disclose H. Roman: Nothing to disclose

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