MR Imaging of Endometriosis: Ten Imaging Pearls

TLDR

Endometriosis, defined by ectopic endometrial tissue outside the uterus, affects up to 10 % of premenopausal women and can present with pelvic pain, infertility, and imaging findings such as restricted diffusion in endometriomas, dilated fallopian tubes, and potential ovarian malignancy indicators that require confirmation. The study aims to provide radiologists with practical MR imaging pearls to recognize and differentiate endometriosis from other pelvic lesions. The authors recommend using T1‑weighted fat‑suppressed sequences for all pelvic MR exams, and they describe deep infiltrating endometriosis as poorly defined, T2‑hypointense lesions with subcentimeter T2‑hyperintense foci that can aid diagnosis. © RSNA, 2012.

Abstract

Endometriosis, which is defined as the presence of ectopic endometrial glands and stroma outside the uterus, is a common cause of pelvic pain and infertility, affecting as many as 10% of premenopausal women. Because its effects may be devastating, radiologists should be familiar with the various imaging manifestations of the disease, especially those that allow its differentiation from other pelvic lesions. The "pearls" offered here are observations culled from the authors' experience with the use of magnetic resonance (MR) imaging for the detection and characterization of pelvic endometriosis. First, the inclusion of T1-weighted fat-suppressed sequences is recommended for all MR examinations of the female pelvis because such sequences facilitate the detection of small endometriomas and aid in their differentiation from mature cystic teratomas. Second, it must be remembered that benign endometriomas, like many pelvic malignancies, may exhibit restricted diffusion. Although women with endometriosis are at risk for developing clear cell and endometrioid epithelial ovarian cancers (ie, endometriosis-associated ovarian cancers), imaging findings such as enhancing mural nodules should be confirmed before a diagnosis of ovarian malignancy is offered. The presence of a dilated fallopian tube, especially one containing hemorrhagic content, is often associated with pelvic endometriosis. Deep (solid infiltrating) endometriosis can involve the pelvic ligaments, anterior rectosigmoid colon, bladder, uterus, and cul-de-sac, as well as surgical scars; the lesions often have poorly defined margins and T2 signal hypointensity as a result of fibrosis. The presence of subcentimeter foci with T2 hyperintensity representing ectopic endometrial glands within these infiltrating fibrotic masses may help establish the diagnosis. © RSNA, 2012