Imaging Biomarkers of Endometriosis: Potential Role in Disease Stratification and Monitoring

Background: Endometriosis is a kind of a chronic inflammatory pathology, which is characterized by the ectopic endometrial-like tissue, which leads to pelvic pain, dysmenorrhea, and infertility. Even though laparoscopy remains the diagnostic gold standard, the role of imaging modalities cannot be underrated in non-invasive disease detection, mapping of diseases, surgery planning and longitudinal follow-up. The recent experience with transvaginal ultrasound (TVS), magnetic resonance imaging (MRI) and sonovaginography (SVG) has expanded the range of imaging biomarkers to accurately characterize lesions and stratify diseases. Methods: A systemic review was performed , including the research published between January 2006 and June 2024 and accessed via PubMed and open databases. Qualified studies published on the diagnostic quality of imaging tests compared with those of surgery or histopathology. The results of sensitivity and specificity were obtained and a meta-analysis of anatomically similar sites through random-effects was done. Quality of the study was evaluated using QUADAS-2 tool. Results: Quantitative synthesis involved the use of sixteen studies and qualitative synthesis involved thirty studies. TVS was very sensitive in identifying ovarian endometriomas and rectosigmoid lesion as MRI was better able to identify uterosacral ligament, bladder and posterior compartment disease. SVG significantly increased the ability to visualize the pathology of the rectovaginal septum. Organizational systems of reporting, including the Enzian classification, enhanced the consistency of the diagnosis. New radiomic and artificial intelligence technologies showed a promising accuracy in discriminating lesion phenotypes. Conclusion: TVS remains the first-line imaging modality, with MRI serving as a complementary tool for deep and complex disease. SVG enhances posterior compartment detection.The integration of standardized practices and novel quantitative imaging biomarkers has the potential to improve the stratification and monitoring of the disease and, thus, promote individualized treatment modalities.