Atypical Sites of Deeply Infiltrative Endometriosis: Clinical Characteristics and Imaging Findings

Abstract

Endometriosis is defined as the presence of endometrial tissue that is located outside the uterine cavity and associated with fibrosis and inflammatory reaction. It is a polymorphic and multifocal disease with no known cure or preventive mechanisms. Patients may be asymptomatic or may experience chronic pelvic pain, dysmenorrhea, dyspareunia, or infertility. The pelvic cavity is the most common location for endometriotic implants, which usually affect the retrocervical space, ovaries, vagina, rectosigmoid colon, bladder dome, and round ligaments. Atypical endometriosis is rare and difficult to diagnose. The most common atypical locations are the gastrointestinal tract, urinary tract, lung, umbilicus, inguinal area, breast, and pelvic nerves, as well as abdominal surgical scars. Gastrointestinal lesions are the most common extragenital manifestation, and the diaphragm is the most frequent extrapelvic site. The catamenial nature of the symptoms (occurring between 24 hours before and 72 hours after the onset of menstruation) may help suggest the diagnosis, but imaging by specialists is fundamental to evaluation. Depending on the area affected, radiography, ultrasonography, thin-section computed tomography, or magnetic resonance imaging can be used to assess suspected lesions. Because isolated extragenital endometriosis is rare, concomitant evaluation of the pelvic cavity is mandatory. Surgical excision is the only therapeutic option for definitive treatment, and comprehensive disease mapping is necessary to avoid residual disease. The authors review atypical locations for endometriosis and emphasize the most appropriate imaging protocols for investigation of various clinical manifestations. Online supplemental material is available for this article. RSNA, 2018.

Laparoscopic excision of round ligament endometrioma

“…Doppler US will show a hypoechoic mass with no flow, and MR can be more accurate demonstrating old haemorrhagic content in the cyst 1. Round ligament endometriosis is rarely found isolated and usually can be often neglected while performing surgery for deep infiltrating endometriosis (DIE) 2 3.…”

The importance of extragenital endometriosis for surgeons

“…Based on the results of preoperative anamnesis, physical examination and ultrasound imaging, EE was diagnosed correctly in more than twothirds of our patients. Suture granulomas, abscesses, hernia, hematomas and desmoid tumours should be considered in the differential diagnosis, and additional imaging methods should be carried out in certain cases (2) . In addition, if the clinician does not suspect this rare condition in the differential diagnosis and does not warn the pathologist, making a histopathological diagnosis might be problematic.…”

“…Endometriosis affects 6%-10% of women in their reproductive age (1) . Extragenital or extrapelvic endometriosis is located outside the genital tract and is detected in 8.9% of endometriosis cases (2) . Extragenital endometriosis (EE) can be detected in scar tissue in several different areas such as eyes, lungs, umbilicus, bile ducts, liver, skin and abdominal wall (3) .…”

“…These masses cause problems in making a differential diagnosis as they could be mistaken for abscess, lipoma, lymphadenopathy, suture granuloma, foreign body or benign or malignant tumours (2,5) . This study describes the characteristics of patients who were treated in our general surgery clinic for EE.…”

MRT der Endometriose und Adenomyose

“…B. mit einem katamenialen Pneumothorax bei Einblutungen in den Pleuraraum. Prädilektionsstellen der weitaus häufigeren pelvinen Endometriose sind im kleinen Becken [24]:…”