Imaging advances associated with better formation of ultrasounders and radiologists make it possible to improve the diagnosis of endometriosis. In an interview with Medscape, the PR PASASAL ROASSETRadiologist in Lyon and co-author of a report carried out under the aegis of the High Authority for Health, analyzes the interest and the place of ultrasound and MRI in the diagnosis of endometriosis.
Actualisation
A report led under the aegis of the High Authority of Health, has just updated the imagery part of the recommendations of the “management of endometriosis” of the National College of Obstetrician Gynecologists (CNGOF) of 2018. Indeed, there have since been advanced organizational advances thanks to the national strategy to combat endometriosis and regional and medical advances, in particular in technical changes, especially in MRI. A working group coordinated by the Pre Isabelle Thomassin-Naggara (Imaging service, Tenon Hospital, Paris) and Professor Pascal Rousset (deputy chief of the radiology service at the Lyon Sud University Hospital, president of the SIFEM, women’s imaging company) has therefore updated the place of imaging examinations, writing practical ultrasound sheets and MRI to help health professionals to take care of women suspectriose. Professor Pascal Rousset, specifies for Medscape, the place of the various imaging examinations for the diagnosis of endometriosis.
MEDSCAPE French edition: is there still in France a delay in the diagnosis of endometriosis?
PR PASASAL ROASTET: There is indeed in France, as elsewhere, always a delay in diagnosis, and this for several reasons. On the one hand, this delay can be linked to the lack of information or training of primary health care professionals or even specialists faced with extrapelvian events of endometriosis. On the other hand, imaging explorations can be falsely negative in ultrasound if the operator is not formed enough, similarly in MRI if the radiologist is not experienced. And above all, there are forms of endometriosis which are difficult to detect in imaging, in particular the lesions of isolated superficial endometriosis, without ovarian and/or deep involvement and which can concern 15 to 30 % of young women.
The first -line imaging technique is ultrasound given its lowest cost, its high availability and its little invasive character, the endovaginal route being the reference.
When should you offer imaging to a patient?
PR PASASAL ROASTET: Imaging should be proposed when the clinical diagnosis is suspected, in front of the combination of several symptoms, including the classics 5D: dysmenorrhea, deep dyspareunia, micual pain, defecation pain, chronic pelvic pain. Clinical examination is also able to evoke endometriosis.
Imaging aims to confirm the clinical diagnosis by relying on signs of certainty to avoid any overdiagnosis. It also makes it possible to make a cartography of the lesions. It also serves to eliminate differential diagnoses (other gynecological pathologies but also digestive or urinary pathologies). While knowing that a negative imaging does not eliminate the diagnosis of endometriosis, because it overlooks more than the lesions of superficial endometriosis.
We can consider having first -line ultrasounds and more advanced second -line ultrasounds by more experienced operators.
What is the most suitable first-line imaging?
PR PASASAL ROASTET: The first -line imaging technique is ultrasound given its lowest cost, its high availability and its little invasive character, the endovaginal route being the reference. On the other hand, it has a field of exploration of the pelvis more limited than MRI, it is however dependent operator and cannot be subject to a rereading in the event of 2nd opinion.
However, it allows the positive diagnosis of endometriosis in a certain number of cases, being particularly efficient to identify ovarian endometriosic cysts called endometrioms as well as certain lesions of deep endometriosis such as those located on the rectum or on the bladder. The other lesions of deep endometriosis, with regard to certain ligaments for example, are more inconstantly detected because they require a little more expertise. We can therefore consider having first -line ultrasounds and more advanced second -line ultrasounds by more experienced operators.
And when should you offer an MRI?
PR PASASAL ROASTET: MRI is the second -intention imaging technique, due to its higher cost, its slightest availability and the need for a dedicated protocol to ensure a good quality examination, especially in the event of rereading for 2nd reviews. It is proposed in the event of negative or dubious endovaginal ultrasound, in particular after a failure of medical treatment. It can be done immediately when the endovaginal ultrasound is unable (virginity, refusal of the examination, painful ultrasound requiring its judgment, etc.). It allows a complete exploration of the pelvis in particular of the lateral parts where the ureter which links the kidneys to the bladder but also the nerves are located. It has a very good sensitivity for the detection of lesions, the trap being the false positives with a risk of overdiagnosis.
As a pre-therapeutic, when a surgical management is discussed, it is recommended to make an MRI to ensure exhaustive mapping of the lesions and weep at best, in a multidisciplinary consultation meeting, the surgical indication. In the event of complex endometriosis, MRI will be particularly useful for anticipating surgical complexity, in particular with the DPEI score (new MRI classification of deep pelvic endometriosis) and most recently its free online application www.dpei-score.org.
Are imaging professionals always trained in this diagnostic ?
PR PASASAL ROASTET: For several years, and with recent acceleration thanks to the national strategy to combat endometriosis and the implementation of regional sectors, the level of training has increased significantly, accompanied by technological innovations in ultrasound and MRI and with the help of different learned societies. For example in radiology, the Sifem has set up e-learning with ultrasound, MRI routes and console workshops. It offers continuous medical training, especially during French Radiology Days or even during the annual SIFEM congress. There are also several training resources such as national endometriosis MOOC …
Today, do we have all the tools to diagnose endometriosis?
PR PASASAL ROASTET: It is quite possible that yes, especially with the technological innovation brought by the Endotest® developed by Ziwig, a salivary test which recognizes the signature of endometriosis from micro arns with diagnostic performance around 95 % in a population with a high prevalence of endometriosis. This test is currently evaluated as part of the Innovation Package by the Endobest Study with an inclusion of 2,500 patients. The Endotest® is indicated in the event of suspicion of endometriosis and imagery (ultrasound and MRI) negative or doubtful, to then allow an early diagnosis, the test results being available within ten days. The objective of this study is to assess the impact of this test on the medical decision, which integrates in a complementary manner in imaging.
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