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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Wendolyn Van Buren for a lecture entitled Imaging Evaluation

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of an Endometriosis.

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Dr. Van Buren is a board certified radiologist associate

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professor and chair

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of the gynecological imaging section at the Mayo Clinic in

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Rochester, Minnesota,

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with a dedicated interest in endometriosis.

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She's the course director

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for the International Endometriosis Imaging Congress

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and a founding course director

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for the Mayo Clinic Gynecological and Breast Imaging course.

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Dr. Van Buren also co-founded the disease focus panel on

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endometriosis for the SAR

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and is an active author publishing in high impact journals.

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Additionally, her ongoing work has been highlighted at a

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variety of national and international radiology, gynecology

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and pelvic pain conferences.

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At the end of her lecture, please join her in a q

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and a session where she will address questions you may

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have on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture, Dr.

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Van Buren. Please take it from here.

1:21

Okay, wonderful. Good. Alright, well, there you go.

1:24

So, I mean, um, just to go to show you,

1:27

there's a learning curve always, uh, whether it's PowerPoint

1:30

or endometriosis imaging.

1:31

So you are in the right place today, um,

1:33

to get some of that learning.

1:34

And so, you know, this is a topic

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that I'm very passionate about

1:38

and interact with in my daily life in some way

1:40

or another, um, whether it's clinical work

1:42

or education like this or, or research.

1:45

So, um, we're gonna talk about both ultrasound and Mr.

1:48

So we'll get started here.

1:53

As is mentioned, I have a few disclosures here,

1:54

mainly pertaining to lecturing and, uh, and conferences.

1:58

Um, nothing, no off label usage

2:00

will be discussed in this lecture.

2:02

So we're gonna discuss both ultrasound and MRI

2:04

and the management of endometriosis.

2:05

Take a look at the disease spectrum

2:07

and then take a look at some cases.

2:08

We'll touch on some technical aspects too,

2:10

to help you if you're onboarding, uh,

2:12

imaging into your program.

2:14

So, let's talk a little bit about endometriosis.

2:16

You probably are aware of it,

2:17

particularly if you hear it at this lecture today,

2:20

but it's a chronic benign,

2:22

estrogen dependent inflammatory chronic

2:24

gynecological disorder.

2:25

So we speak about it mainly in the female pelvis,

2:27

but really it's a chronic systemic disorder.

2:30

Think of that, um, you know,

2:32

when you're keeping in mind endometriosis,

2:34

and we look at these cases

2:35

and all the body parts that may be involved, it's defined

2:38

by endometrial glands

2:39

and s stroma located outside the uterus.

2:41

So a lot of times we focus so much

2:43

of our imaging on the uterus and ovaries,

2:45

but I want you to broaden that perspective

2:46

and we're gonna look at some of those common disease sites.

2:49

It's a common contributor

2:50

to chronic pelvic pain dyspareunia,

2:52

and is actually one of the leading causes of infertility.

2:55

We know that we have a 10 year diagnostic delay on average,

2:58

which is a really daunting number.

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I think the more we improve our diagnostic standards

3:02

with imaging, we're, we're helping to reduce that.

3:05

Um, but it does impact what we know to be at least 10%

3:08

of reproductive age women

3:09

and possibly more as we, um, have better diagnostic tools.

3:13

So what are some of the common locations?

3:14

This is really a distribution

3:16

of the pelvis you're seeing it at in a sagittal

3:18

oblique orientation.

3:20

So really I want you to focus on all

3:21

of the peritoneal surfaces.

3:23

So we've got the organs,

3:24

but what's, what's the covering of the organs,

3:26

generally speaking is peritoneum

3:28

and we're gonna look for implants

3:29

and disease that starts on those surfaces.

3:32

So with regards to the histologic classification,

3:35

it does impact our radiology interpretation,

3:37

and we kind of think of it in three separate phenotypes, uh,

3:41

with regards to superficial disease, which are very,

3:43

very tiny deposits.

3:44

Think of them like salt

3:46

and pepper, um, on the peritoneal surface.

3:48

Then ovarian endometriosis,

3:49

which are our classic hemorrhagic cystic lesions, of course.

3:51

And then deep endometriosis, which historically was defined

3:55

as greater than five millimeters of peroneal invasion.

3:58

However, depending on the literature you're reading,

4:00

that can now be variable.

4:01

And oftentimes that's a surgical diagnosis observed

4:04

by the surgeon at the time

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of operating rather than a true histologic diagnosis.

4:10

So starting with ultrasound,

4:12

superficial endometriosis deposits are really not routinely

4:15

seen on any of our imaging modalities on mr.

4:18

If they're hemorrhagic, we have an opportunity

4:19

to observe them and then even less commonly are they seen on

4:22

ultrasound, and it suffers for both sensitivity

4:25

and specificity in that regard.

4:26

So this is really a true laparoscopic diagnosis.

4:30

Ultrasound is a great job ov ovarian endometriomas.

4:33

We can take a look at some of their sensitivity

4:35

and specificity, which we'll go over several times.

4:38

Historically, they have diffuse low level internal echoes,

4:40

but as we focus more on endometriosis, you'll see that

4:43

by the time you have an ovarian endometrioma,

4:45

particularly if over three centimeters, you're starting

4:48

to have more complex disease.

4:49

And this is a whole pelvis disease,

4:51

not just an ovary disease.

4:53

Um, and most often the disease starts on

4:55

the uterosacral ligaments.

4:56

So you're going to have other sites of disease.

4:58

If you have an ovarian endometrium.

5:00

It is a marker of disease severity, actually.

5:02

So they can have a variety of appearances as you see here,

5:05

but they should have no internal blood flow.

5:07

So what is that location?

5:09

So the posterior compartment

5:10

of the pelvis is really like the area

5:12

where we see it most commonly.

5:14

So retro cervical space

5:15

and uterosacral ligaments,

5:16

which are bilateral paired structures,

5:18

which insert near the cervix or utero cervical junction.

5:21

So 93% of disease occurs there,

5:24

and then the GI tract within

5:25

that subset is a smaller percentage.

5:28

Um, but you can see here the uterosacral ligaments are

5:30

involved in about 69% of patients, um, in this publication.

5:34

Um, that's a very large cohort.

5:36

So we'll go through and you'll see lots of cases.

5:38

The ultrasound probe here is directed in the

5:40

posterior vaginal fornix.

5:41

So we can see here in this diagram the anterior fornix

5:44

and the posterior fornix.

5:45

Most commonly we see ultrasound scanning being performed

5:48

inferior to the cervix or the anterior co um, fornix.

5:51

So you'll start to look at these cases too,

5:52

and it'll draw it to your attention, um,

5:54

where the ultrasound probe is positioned

5:56

because it really, really does change

5:57

our perspective on things.

6:00

And these are some common locations of our disease implants.

6:03

So why ultrasound for deep endometriosis?

6:05

Well, if you're thinking maybe MR is the best tool

6:08

that we have, they're really complimentary modalities

6:10

and ultrasound has a superior resolution compared to RI.

6:14

So if you're looking for very small deposits

6:16

or depth of bowel invasion in the layers of the bowel wall

6:19

and ultrasound, um,

6:20

they can be more accurately assessed given the proper

6:23

technical parameters as well.

6:24

And then ultrasound also allows for dynamic assessment, um,

6:27

structural mobility, and of course the tenderness

6:29

assessment, um, as you are with the patient.

6:32

So what are practice standards

6:34

and what is the role of sonography?

6:36

And I'm gonna speak specifically here to the, um,

6:38

clinical environment in the United States

6:40

because this is variable, uh, depending on the country

6:43

that is performing the ultrasound

6:44

and what their practices are.

6:45

So what we generally have is routine pelvic ultrasound

6:48

that's stenographer performed, the uterus

6:50

and ovaries are well assessed with transvaginal ultrasound,

6:52

and then we have dedicated MRI protocols

6:55

for endometriosis disease mapping.

6:57

Now, those also may not be implemented

6:59

yet at your institution,

7:00

but that is something that is possible.

7:02

So what do we really need?

7:04

So the SRU put together a consensus on endometriosis imaging

7:07

for ultrasound assessment, and that we need more

7:10

advanced diagnostic ultrasound for disease mapping.

7:13

And as well, we need clinicians

7:14

and patients to understand the strengths

7:15

and limitations of our imaging modalities

7:18

and then all these protocols that we're talking about.

7:21

So just to give you an overview

7:22

and not to have it be too daunting,

7:23

I'm gonna show a few different charts here.

7:26

So this first one was the consensus, um, put forth by, uh,

7:30

SRU, and this is published in the Journal of Radiology.

7:33

And you can find here, you know, sort of the definitions

7:35

of the various exams.

7:36

So our routine pelvic ultrasound, what's being suggested

7:39

by the augmented exam, which is just as few simple maneuvers

7:42

that are really high yield for common sites

7:44

of disease detection, advanced endometriosis imaging,

7:48

and then how we're categorizing our imaging characteristics.

7:51

So whether they're direct observations, something

7:53

that you're seeing, a precise manifestation

7:55

of the disease itself

7:57

or an indirect finding

7:58

where when we have this morphologic change in the pelvis,

8:02

I want you to start recognizing the orientation

8:04

of the uterus, the ovaries, the bowel,

8:05

and how it's a really common presentation.

8:08

And we all know that radiologists are great

8:10

at pattern recognition.

8:11

So that's what we're gonna really drive home today in our

8:13

lecture, is pattern recognition of endometriosis.

8:16

So then when we're taking a look at the, um,

8:18

the routine exams of who should, um,

8:20

have this augmented exam, um,

8:22

with the additional maneuvers for endometriosis.

8:24

So essentially anyone who has symptoms

8:27

or history of endometriosis or infertility

8:29

or suspected clinical, uh,

8:31

endometriosis would receive these additional maneuvers.

8:34

Perhaps once uh, there is more data,

8:36

this could be extrapolated to an asymptomatic population.

8:41

Um, so one of the key hallmark maneuvers, part

8:43

of this is the sliding sign.

8:45

And the sliding sign may be

8:47

performed in a few different ways.

8:48

And this schematic is taken directly from the paper

8:50

and it shows you, depending on the orientation of the uterus

8:53

and what might be technically possible in the individual

8:56

to assess predominantly the posterior

8:58

compartment sliding sign.

9:00

Really the sliding sign is a dynamic maneuver

9:02

looking for mobility.

9:03

So you could perform an anterior sliding sign,

9:05

a bundle sliding sign,

9:07

but really looking in the high yield place in the retro

9:09

cervical space is where we're gonna focus.

9:12

So this here is a sliding sign in the posterior fornix.

9:16

So this is the posterior fornix of the vagina.

9:18

You can see as the probe is moved anteriorly

9:20

and posteriorly, you can see

9:22

that there's a potential space there

9:23

that the ultrasound probe moves into, and the bowel

9:26

and the uterus are all moving together.

9:28

They should slide independent of one another

9:31

with a sliding motion.

9:33

So this may be performed with a back

9:34

and forth motion of the ultrasound probe

9:36

or slight fundal pressure upon the

9:38

uterus, or a little bit of both.

9:39

Of course, we always wanna be mindful

9:41

to counsel the patients before performing the maneuvers so

9:43

that they are, um, aware of this

9:45

and if there's any tenderness to, um, to inform us of that

9:49

so that we can alter what we're doing.

9:52

Also included would be a posterior longitudinal sweep.

9:55

So here we can see a retroflexed uterus

9:57

and as well, we wanna keep our eyes into the retro cervical

10:00

space and notice that there is potential disease there.

10:03

We'll also wanna take a look in, um,

10:05

the transverse plane doing a sweep.

10:08

In this orientation, we can assess for the position

10:11

of the ovaries in the uterus.

10:12

So we see already there's retro positioned

10:14

ovaries here in a large ovarian endometrium,

10:16

and we see this retro cervical disease really

10:18

nicely as we're passing through.

10:21

So that might have gone by a little bit quickly,

10:24

but it's just to give you an overview

10:26

of those technical parameters

10:27

and we'll look at more cases in detail.

10:30

And we really wanna be mindful of direct observations,

10:32

which are direct manifestations,

10:34

ovarian endometrium, deep implant.

10:37

And then we wanna be thinking of the indirect observations.

10:39

So was there a kissing or retro positioned ovary was

10:42

the uterus and retro flexion.

10:44

Um, these are things that we want to be thinking of

10:47

as we're looking at both our ultrasound

10:48

and then also our mr.

10:52

The reporting of these is dependent on what you see and

10:55

and how confident we are in our diagnosis.

10:57

The point of the augmented pelvic ultrasound is

10:59

to triage patients to a more thorough diagnostic evaluation.

11:03

So if you have a positive exam, in all likelihood,

11:06

it means you have one category A or direct observation,

11:09

or at least two indirect observations.

11:12

If you start to have, you know, one indirect observation,

11:15

the likelihood of confidence that you have

11:17

for endometriosis is gonna be a lit bit lower.

11:20

But the point is not to be a perfect

11:22

diagnostician with this exam.

11:23

The point of this exam is to capture as many patients

11:26

as possible who need to have a diagnostic quality exam.

11:29

And that includes an a PU zero category if you're unable

11:33

to perform the maneuvers,

11:34

if it's technically inadequate in any way.

11:37

Um, and even in if there are no manifestations,

11:40

if the patient is symptomatic,

11:42

that still would warrant further evaluation.

11:44

So we wanna make sure that no one is lost in this pipeline.

11:48

So then let's move on

11:49

to deep pelvic endometriosis ultrasound at expert

11:52

level for disease mapping.

11:54

This is a very different exam.

11:55

Um, if you take a look at, um, the idea consensus

11:59

or other groups who've published on this, oftentimes

12:01

it's a fully comprehensive exam,

12:03

transabdominal, transvaginal.

12:05

It may include upper imaging of the kidneys,

12:07

the urinary bladder, and as well often as performed

12:09

with bowel preparation, which I'm a big fan of

12:12

for this level of exam.

12:14

Here's our bowel preparation.

12:15

Um, if you're looking to do that, we'll see some examples.

12:18

And definitely if you're gonna be looking at depth

12:20

of bowel invasion, I strongly recommend, um,

12:22

that the bowel is prepped without the bowel gas.

12:25

There. You can see everything better in the pelvis.

12:28

So let's take a look at some cases.

12:30

We're gonna start with the MR here.

12:31

In this 28-year-old, she has bilateral ovarian endometriomas

12:34

and a kissing configuration.

12:36

The bowel is retracted and pulled in centrally,

12:39

and there is thickening there of the bowel.

12:42

Now this is a pretty obvious case,

12:44

but I'm gonna show you sometimes there are cases

12:46

where it's questionable, and when it's compressed

12:47

between those ovaries, it can be really challenging to see.

12:51

So here we go. This is a T one weighted imaging

12:54

with fat saturation.

12:55

We see those light bulb, bright ovarian endometriomas,

12:57

but the bulk of the deep disease is between them.

13:00

So it's the uterosacral ligaments, the TAUs utes, the bowel.

13:04

And let's take a look on our ultrasound, what we see.

13:06

So this is an MR directed ultrasound, which is an exam

13:09

that we developed here,

13:11

and we published a technical

13:12

paper on it if you're interested.

13:14

So it includes bowel preparation

13:16

and a targeted ultrasound evaluation

13:17

with specific questions generated from your MRI.

13:20

So here's that last case.

13:21

And we see a beautiful mushroom cap bowel invasive lesion

13:24

into the rectus sigmoid colon.

13:27

Here's another example that was sent

13:28

for Mr Direct and ultrasound.

13:29

It was a young female who'd had hysterectomy.

13:32

So I often tell our residents, if you have a young patient

13:34

that's been to hysterectomy,

13:35

that usually means even if you don't have the history,

13:38

chronic pelvic pain, bleeding, uh, bloating,

13:41

some significant symptom, it's not normal to have, um,

13:44

you know, someone go for a surgery

13:46

unless there's been significant symptoms.

13:48

And oftentimes the hysterectomy is what's been done,

13:51

even though that's, we know by virtue of the definition

13:54

of the disease, it occurs outside the uterus.

13:56

So what's left behind all the disease.

13:58

So we see here that there actually is residual disease here

14:01

on the cuff, and we can see that

14:03

with a slightly different echo texture than the vaginal

14:05

cuff, which at MR was difficult to differentiate.

14:08

Here's another example of bowel preparation.

14:10

You'll notice that this is a really nicely prepped case.

14:12

There's no bowel gas to distract you,

14:14

and you can see an additional very small lesion, you know,

14:17

along here on the rectal sigmoid colon.

14:19

So depending on the orientation of the bowel

14:21

or the size of the lesion, um, it is possible

14:23

that the ultrasound can be beneficial

14:25

for detecting additional lesions.

14:27

Here's an example of superficial disease.

14:29

So the MR did not demonstrate any thickening or lesions.

14:33

And with the, um, benefit of speaking to the patient,

14:36

assessing for focal pain, having some free fluid helps us

14:40

with the identification

14:41

of this area here along the rectosigmoid, um, colon.

14:45

However, you know, the sensitivity

14:47

and specificity with this finding is going to be quite low,

14:50

and she was having surgery planned regardless.

14:53

So, you know, you know,

14:55

where would I put my diagnostic confidence in this?

14:57

We'll be very careful when we see something like this

14:59

that we don't wanna overstate, um,

15:01

our confidence in detection.

15:04

Here's an example of a 41-year-old with chronic pelvic pain

15:06

and also an absence sliding sign.

15:09

Uh, we see that there's a huge ovarian endometrioma.

15:12

The ovarian or the uterine configuration is retroflexed.

15:15

And we can see too that there's an implant involving

15:17

the TAUs utes.

15:19

Now sometimes the scope of disease, you know,

15:21

when looking at things that are really small

15:22

and within the, the scope of the ultrasound probe, um,

15:25

we can have a good assessment.

15:26

And just to have you notice

15:27

that this is in the anterior fornix of the, of the vagina,

15:31

um, but the scope of disease,

15:33

and we know that this is already advanced disease severity

15:36

with deep disease invading the tors utes

15:38

and myometrium obliterating the posterior cul-de-sac,

15:41

we're gonna start to want an MR to be sure

15:43

that we're capturing all these disease sites properly.

15:46

So that's our transition to MRI. So why have an M mri?

15:50

Well, to further characterize an ultrasound finding

15:52

or one of the augmented pelvic ultrasound recommendations,

15:55

um, from your ultrasounds, uh, confirmation

15:58

of disease in the setting of a negative ultrasound.

16:01

We do have increased sensitivity with m mark impaired

16:03

to ultrasound, and we'll show some data

16:05

with regards to that later.

16:07

It can also really help with preoperative planning

16:09

and a dedicated protocol.

16:10

MR is excellent at identifying most disease sites,

16:13

including extra pelvic imaging,

16:14

including the liver and small bowel.

16:17

So let's touch on some protocol considerations,

16:19

because this really matters without a properly set up

16:21

protocol, the rest of it is going

16:23

to be a bit of a wash for you.

16:24

You're not going to be able to see these things.

16:26

So this is an outside mr,

16:27

and you can see here that there's a lot of motion.

16:30

So either breathing, um,

16:31

and bowel peristalsis,

16:33

those are the two that are gonna get you.

16:34

Um, and there's a large mushroom cap bowel invasive lesion

16:37

there once you have a proper protocol.

16:39

So these two images here were required, um, you know, with,

16:43

uh, anti peristaltic agent, whether you use, um, glucagon

16:48

or basca pan in your country.

16:49

These are possibilities that are most common.

16:52

And, uh, we can see here there's vaginal

16:54

gel pacifying the vagina.

16:56

I like that it supports the uterus in the cervix.

16:58

It also allows us to assess the depth

16:59

of invasion of the vaginal wall.

17:01

And we can see here these hemorrhagic tracts invading the

17:04

cervix, which is an important characteristic when we are

17:07

assessing for fertility preservation as often.

17:09

These are very young patients, um,

17:11

to see if tra colectomy is possible.

17:13

So we generally speaking, need about a centimeter

17:15

of upper cervix, um, in order to perform tra colectomy and,

17:19

and fertility preservation.

17:20

Unfortunately, in this case, we see almost the entirety

17:23

of the whole cervix, um, is involved by endometriosis

17:26

with hemorrhagic tracts invading almost the full

17:29

thickness of the stroma.

17:31

So what are the considerations for your protocol direct you

17:34

to the Society of Abdominal Radiology recommendations?

17:37

This is our consensus on this.

17:39

Um, it's within the journal of, um,

17:41

abdominal radiology published in 2020.

17:43

But just to focus on some of the high points,

17:45

we wanna do T two weighted imaging in three planes, whether

17:48

or not you acquire that, um,

17:50

through iso volumetric scanning plus an additional one,

17:53

you are gonna have better soft tissue characterization in,

17:56

um, your more conventional T twos.

17:58

You want T one weighted imaging

18:00

with fat saturation in at least two planes.

18:02

The sagittal plane is critical if the sagittal plane is not

18:04

there, the exam is a no go for me,

18:07

because you need to be able to see the cul-de-sacs.

18:09

They're the most common areas for disease.

18:12

Um, and that is absolutely essential.

18:14

We want our diffusion weighted imaging as well

18:15

because endometriosis associated malignancies

18:18

and frankly malignant endo are assessed best with

18:21

that plus contrast, which is my next teaching point.

18:24

And we wanna do subtraction imaging as

18:26

with the intrinsically high T one signal without

18:29

subtraction, you really can't detect this.

18:31

So we'll take a look

18:32

through examples of that later on as well.

18:35

We also wanna be mindful of thoracic endometriosis.

18:38

Um, so, you know, this is something

18:40

that really you could add on a few additional sequences,

18:43

but I would strongly advocate if it's something

18:45

that you're looking to thoroughly evaluate if the patient's

18:47

truly symptomatic or going to surgery,

18:49

you want a dedicated protocol for this,

18:51

and that might actually include the

18:52

entirety of the pleura as well.

18:54

Um, so here we can see those small T one

18:56

hyperintense implant here.

18:58

We wanna be mindful of both the coronal

19:00

and sagittal planes in addition to axial,

19:02

because we know these small lesions in the contour

19:05

of the diaphragm, um, and the shape of the organs there.

19:08

Really, we need to have, um, our, um, orientation

19:11

for our MR protocols set up appropriately.

19:14

So you can see here, we just published this in,

19:16

in abdominal radiology, um, in September of 2025.

19:19

And this demonstrates for, you know,

19:21

several different vendors what the parameters would be

19:24

for your thoracic protocol.

19:28

And then finally, MR is not a standalone tool

19:31

that functions best in isolated environment.

19:34

No, no, it does not.

19:35

It works best when we communicate with each other

19:38

and, uh, use interdisciplinary conferences.

19:40

So this is a way that we have shown in the past,

19:43

and we published on this in 2020,

19:45

that we had almost a 20% change in patient management

19:47

based on these discussions.

19:49

So reviewing the clinical history, discussing the MRI,

19:52

the outcomes and and desires, uh, for the patient.

19:54

Perhaps their chronic pain patient

19:56

that wants a complete resection, perhaps they're looking

19:59

to preserve fertility.

20:00

Are there any features that are suggestive

20:02

of borderline or malignancy changes?

20:05

Um, is there wall ablation consideration?

20:07

We'll look through all these cases

20:08

and see how these conversations really dictate, um,

20:12

the planning that goes on.

20:14

Here's a suggestion of a template.

20:16

Now this has came from our more recent state

20:19

of the art paper in the Journal of Radiology.

20:21

I really strongly encourage you to go there.

20:22

There's a lot of supplemental information in cases there

20:25

as well, including our expert consensus, um, on Mr.

20:28

Interpretation. You can see that survey

20:30

and all the considerations that go into it

20:32

because there's a lot of subtlety and nuance with Mr.

20:35

Interpretation. It's not cut and dry, right?

20:37

If it was, um, you know, we wouldn't have

20:39

to be talking about it today

20:41

because really there's a lot of different sensitivities

20:43

and specificities for each disease site and location,

20:46

and there are many different

20:47

variables that contribute to that.

20:49

So, you know, this is really just the anatomic overview

20:51

of the places that you wanna be mindful of,

20:53

but there are so many other variables to be mindful of

20:56

as well, including the phenotypes we mentioned earlier, um,

20:59

and, uh, malignancy.

21:02

So why is it challenging to identify and why does it matter?

21:06

We, it's a disease of pattern recognition,

21:08

so we can get this, this is possible.

21:10

Um, but a lot of patients go from multiple surgeries.

21:13

Uh, imaging was only first recommended, um,

21:16

in European guidelines in 2022.

21:18

This is shocking, right?

21:19

So this is why we've been lacking in uniformity.

21:21

It's only within recent years

21:23

that we even have the recommendation to include imaging.

21:26

And it was generally speaking, absent from formal education.

21:29

And it's still really a ity of education at the level of,

21:32

of, of medical school with regards

21:33

to endometriosis in general and imaging specifically.

21:36

So most people do not understand the role of imaging,

21:39

the complexity of the disease as it pertains to imaging

21:43

and our strengths and weaknesses.

21:44

So this is where this confidence

21:46

and disease identification becomes part of

21:48

that understanding and also our role in communicating

21:52

and then how it interplays with the management.

21:54

So let's go through a spectrum

21:55

of findings on Mr kissing ovaries

21:57

while described its surgery.

21:59

This is when the ovaries are posteriorly

22:01

positioned in a butting one another.

22:03

Um, they're usually connected by deep endometriosis.

22:06

So while we say the ovaries are kissing

22:08

and they usually have ovarian

22:09

endometriosis, they don't have to.

22:11

And what really is going on there is, is the deep disease.

22:14

And that's often bilateral uterosacral disease.

22:16

They converge on the posterior uterus at the tus utes

22:20

and result in this fibrotic tethering.

22:22

Um, and so we see here

22:23

that we have also kissing ovaries on MRI.

22:26

You can also observe this configuration on ct.

22:29

So just start looking, that's one of the patterns.

22:31

It should just be a knee jerk reflection.

22:33

Oh, there's kissing ovaries.

22:34

That's probably a endometriosis.

22:35

It's probably advanced stage, the shading

22:39

of the ovarian endometrium.

22:40

So they're light bulb bright with varying degrees

22:42

of shading related to the chronicity of the blood products.

22:45

There you can also see fluid, fluid layers.

22:48

I've seen endometriomas bleed into themselves

22:50

and have a swirling appearance.

22:51

The T two dark spot sign can increase, um, your specificity

22:55

for end endometrioma.

22:56

They may have a thickened T two dark, um, hemosiderin wall.

23:00

So there's a number of variables that can help you.

23:02

So we don't wanna just take a look

23:03

and memorize the signal characteristics

23:05

of a ovarian endometrioma.

23:07

We wanna take a look at the positioning,

23:08

the pelvic architecture

23:09

and things that tell us that there's a more chronic process

23:11

occurring when we take a look at the data with respect

23:15

to ultrasound versus MR for endometriomas.

23:18

And this is from a recent, um, systematic review

23:20

that we published in a JR.

23:22

You know, it's really interesting

23:23

because in general MR has a greater sensitivity.

23:27

But when we take a look at endometriomas,

23:29

we take a look at the data

23:30

and MR actually doesn't perform very well.

23:33

Now why is that?

23:34

That is because that reflects more practice patterns.

23:38

So a lot of the literature in ultrasound is taken from

23:41

perhaps even solo practitioner,

23:43

physician derived ultrasounds and expert clinics.

23:46

And the MR could be general MRI all comers.

23:51

In general, there was not the same level of expertise.

23:55

So that's something that we can't forget about, is

23:57

that we're not just looking at one

23:58

modality versus the other.

23:59

Um, in terms of these parameters,

24:01

we're taking a look at the experience, the expertise,

24:04

the education, and the patient population.

24:07

So then moving on to deep implants, that's something

24:10

that's really important to learn.

24:11

So I think for the longest time even,

24:13

I thought all I'd seen were cases of, um,

24:16

ovarian endometriomas.

24:17

But really, you know, once your eyes start to be opened up

24:19

to deep implants

24:20

and fibrotic disease, you're going

24:22

to start seeing it everywhere.

24:24

And all the time, especially if you're using an appropriate

24:27

protocol, which is gonna have a smaller field of view,

24:29

you can't be doing a full field of view pelvis mr.

24:31

And expect to see the types

24:32

of implants that we're talking about.

24:33

You need to start doing smaller field of view imaging.

24:36

If you're not already, these may have T one hyperintense

24:39

implants on them, but a lot of times

24:41

with hormonal management, including hormonal IUDs

24:44

and OCPs, we tend

24:45

to lose the hemorrhagic glandular components

24:47

and they may just look T one and T two dark.

24:51

So let's talk about the performance of MR versus ultrasound

24:54

for deep endometriosis.

24:55

So we kind of touched on the endometriomas,

24:57

which frankly both modalities do a great job of.

25:01

Um, you know, when we take a look at deep disease,

25:04

of course, MRI, because it has a larger field of view,

25:07

is going to have a much higher sensitivity than ultrasound.

25:09

And this study here was taken from an expert

25:11

environment for both modalities.

25:13

The specificity is roughly the same, perhaps slightly better

25:16

for ultrasound because as we saw, we're able

25:18

to see those layers of the bowel wall

25:20

and the exact depth of invasion, um, of the rectum.

25:24

Now in our paper, when we did our systematic review,

25:26

taking a look at all comer studies,

25:28

not just the expert ones, it's really variable.

25:31

You know, if you take a look at it

25:32

via its different compartments.

25:33

So we tend to talk about anterior, middle

25:35

and posterior compartments,

25:36

even though in endometriosis we've got a lot of distortion

25:39

of fibrosis that can change the organs of origin, uh,

25:41

from one compartment to another.

25:43

But generally speaking, MR tends

25:44

to do much better for anterior compartment.

25:46

Middle compartment is highly variable in the studies all

25:49

over the map, which again, should tell you something about,

25:52

um, expertise and experience rather than something

25:54

that's truly related to the modality

25:56

or perhaps it's their protocols.

25:58

And then the posterior compartment, we see

26:00

that there's generally quite good performance, um,

26:02

if there's dedicated protocols with ultrasound, um,

26:05

being more effective for rectal disease assessment.

26:10

So the best modality to use is the one

26:13

where you have the most expertise.

26:14

And the best case scenario is to have both

26:16

and have expertise in both.

26:18

So let's take a look at some MR cases focusing

26:20

on the posterior compartment.

26:22

The uterosacral ligaments are these thin

26:23

paired bilateral structures.

26:25

They're generally speaking less than

26:26

three millimeters in thickness.

26:28

Imagine a very smooth, thin sharpie line.

26:30

And then if it starts to have T two dark nodularity

26:33

or thickening, then you can start to think

26:35

that perhaps there might be endometriosis.

26:37

Now on your sagittal T one weighted imaging

26:39

with fat saturation, now you'll know why

26:41

I'm telling you this is essential.

26:43

Um, you can see that there's associated signal

26:45

intensity abnormality with it.

26:46

This is gonna be very confident diagnosis

26:49

of endometriosis implants.

26:51

These might even be superficial. They're so small.

26:53

And if you are taking a look at adolescents,

26:55

this is oftentimes how it presents in earlier mild disease.

26:59

Don't be thinking that you're looking at the ovaries

27:01

and ruling out endometriosis.

27:02

This is definitely where your eyes need to be directed.

27:05

Posterior compartment can also involve the

27:07

rectal vaginal septum.

27:08

I think this is one of the more common areas that's missed,

27:11

even if it is quite a broad area of disease such as this.

27:14

And why is that? Well, oftentimes there's no vaginal gel,

27:17

so it's hard to see the vaginal invasion component of it,

27:20

and it's off midline.

27:21

So it's directed towards oftentimes the lateral

27:24

posterolateral pelvis.

27:25

It might be isolated. There might not be any ovarian

27:27

disease or disease elsewhere.

27:29

Um, and so, you know, it's quite common to have,

27:32

have this very low lateral disease, um, not be recognized.

27:36

So keep your eyes open for that spot.

27:39

Um, next we're gonna go through a couple

27:40

of bowel disease cases.

27:41

So the mushroom cap lesion is essentially almost

27:44

pathognomonic for deep disease.

27:47

So let me clarify with the bowel

27:48

what deep disease means there.

27:49

We wanna speak to the muscularis

27:51

propria invasion specifically.

27:53

So when I'm talking about the mushroom cap sign,

27:55

it has about a 95%, um, uh, specificity

28:00

for muscular propria invasion.

28:02

So when you see that, you can be pretty confident.

28:04

And now why is that important?

28:05

Because those patients, if they have one lesion,

28:08

three centimeters or less,

28:09

and less than 50% circumference are candidates

28:12

for a surgical resection called a discoid resection,

28:15

which essentially takes out

28:16

that lateral aspect of the bowel.

28:18

Now, if it's larger than three centimeters,

28:21

more than 50% circumference

28:22

or multifocals, such as this case,

28:24

we wanna send the patients to a, a segmental resection.

28:27

And so this patient here went to low anterior resection

28:30

for multifocal deep endometriosis.

28:33

Why is the imaging important?

28:35

So, you know, you may have heard perhaps in the past that,

28:38

um, that this was a surgical diagnosis, which is great

28:41

for peritoneal disease

28:42

as we saw those small superficial implants.

28:45

But it's a problem for the deep disease, right?

28:47

Because when you have a disease like this that's hallmarked

28:50

by adhesions and fibrosis,

28:52

architectural changes in the pelvis, you are not going

28:55

to see the depth of invasion of the organs.

28:56

You may not even know that an organ is invaded.

28:59

This requires a lot of surgical dissection, a ton

29:02

of expertise and effort, a lot of planning.

29:05

Um, and so we see here, you know, that this is a case, um,

29:08

you know, initially when you see this completely obliterated

29:12

cul-de-sac and all of these dense fibrotic adhesions

29:14

and what that can look like after dissection.

29:17

So here's another example, a very different look to it.

29:20

So oftentimes the deep disease in the posterior compartment

29:23

is more solid or fibrotic disease,

29:25

and it may have some cystic or glandular components.

29:28

Um, however, occasionally such as this case, we can see one

29:32

that's predominantly cystic.

29:34

So a lot of inflammation in the rectum.

29:36

It's actually invading the TAUs utes

29:38

and we have bilateral kissing ovaries.

29:41

So interestingly, this, um, patient decided

29:43

to trial an IUD placement

29:45

and had resolution of her cyclic pain and rectal filling.

29:48

So, you know, not everyone elects to go to surgery,

29:51

even though they may have advanced endometriosis.

29:54

A lot of times medical management will be attempted and, um,

29:58

and, and may be sufficient depending on the individual case.

30:02

However, as an imager, of course, um, definitely advocate

30:06

for surveillance imaging.

30:07

And that's something we can get to when we look

30:09

through our malignancy cases because

30:11

although we don't know who is going

30:12

to potentially be at risk

30:13

or progress to malignancy, that's still an unknown for us.

30:17

And even though a small percentage, um, perhaps, you know,

30:20

unless newly symptomatic, we do need

30:22

to have an interval follow up.

30:24

Here's another example of two mushroom cap lesions.

30:26

So we see, um, those two lesions here

30:29

behind the rectal vaginal septum area,

30:31

and then another one behind the tors utes.

30:33

So we see those two there.

30:34

They oftentimes have delayed hypo enhancement

30:37

as fibrotic lesions.

30:38

So on our post contrast image here, you know,

30:41

you can see them, but don't be looking for something

30:43

that's gonna be avidly enhancing like a carcinoid or a gist

30:47

or a neuroendocrine tumor.

30:48

No, not even at close to that.

30:51

In fact, it might be hypo enhancing

30:53

with respect to the bowel wall.

30:54

So you know, if the, the enhancement is a useful tool, um,

30:59

to confirm it when you're looking for the distribution.

31:03

It's a useful tool when you're looking for malignancy,

31:05

if it's enhancing abnormally with early arterial enhancement

31:08

or other differentials.

31:10

Um, and we can see here on the ultrasound there's a mushroom

31:12

cap lesion kind of identified on the ultrasound.

31:14

This is, again, scanning through the anterior fornix.

31:17

If perhaps they'd had scanning via the posterior fornix,

31:20

maybe they would've seen the additional

31:22

mushroom cap lesion behind the vagina.

31:24

But, you know, if this was an SRU consensus exam,

31:27

you're just doing your regular routine pelvic ultrasound,

31:30

you see this lesion, they go to mr.

31:32

They can have the full disease mapping, um, performed

31:35

for them, or advanced level ultrasound would

31:37

be possible if available.

31:39

Here's another example.

31:40

And you know, this is an unfortunate

31:42

combination of variables.

31:44

This patient had already been for surgery, um,

31:47

for left ectomy, for large ovarian endometrium,

31:49

but we see a very long segment of sigmoid disease,

31:52

which is residual here,

31:54

and the left uterosacral ligament, um, is pulled into it.

31:57

This is really common. So, you know,

31:59

while I can't say specifically

32:00

'cause I don't watch on MRI everyone's pelvis daily,

32:04

I would say that most disease starts on the uterosacral

32:07

ligaments and then eventually with time

32:08

and disease severity,

32:10

it becomes encompassed into the regional bowel.

32:12

So if you have advanced disease on your uterosacral

32:14

ligaments and you're doing ultrasound mr you wanna be

32:17

scanning out to this region, bowel disease can happen

32:20

independent of that process as well.

32:21

So we don't wanna use that as, um, you know, as our,

32:25

as our only detection or search pattern,

32:28

but we certainly wanna be mindful of that.

32:30

Um, and so that's certainly, you know,

32:33

requiring a second surgery here

32:34

after, you know, dedicated imaging is necessary.

32:37

And it also goes to show, you know, one

32:39

of the reasons why we wanna do appropriate imaging prior

32:42

to surgery is so we can avoid the circumstances, um,

32:45

of having repeat surgeries, which are quite numerous.

32:49

Sometimes let's look at some anterior compartment cases.

32:52

This is a very large obvious case

32:55

of bladder invasive endometriosis.

32:57

So they may have some small T two

32:59

or T one hyperintense cystic spaces in them,

33:01

and they generally speaking, you know, are, um,

33:04

a submucosal process.

33:06

So they may be missed a cystoscopy.

33:08

And likewise for the bowel,

33:09

it's a submucosal process coming from the outside in.

33:13

So these luminal evaluations,

33:15

if you have a question about the presence

33:18

or absence of it to recommend luminal based evaluation

33:22

is not something that's going to rule out the lesion.

33:24

It could theoretically rule it in if they see it,

33:26

but it's definitely not gonna rule it out.

33:28

So, so, you know, it's, it's not really appropriate

33:30

to send someone for colonoscopy.

33:32

If you have a question about a bowel invasive

33:34

endometriosis lesion.

33:37

Canal of neck is another, um, area

33:38

where we can have endometriosis implants, again,

33:41

notice the normal, um, right ovary close to the CCO

33:45

C-section scar pain.

33:47

So this is a slightly different pathophysiology for

33:49

to our understanding of course.

33:51

So oftentimes it's

33:52

after people have had either, um, laparoscopic surgery

33:55

with port sites or more commonly C-section,

33:58

and there can be scar related endometriosis implants.

34:01

So of course it makes sense if the endometrium has been open

34:04

for the purposes of a c-section that a few cells could,

34:07

could land there

34:09

and then behave like endometriosis in the wall.

34:11

How is it different from other places?

34:13

Well, the signal characteristics are variable.

34:15

They can present like masses or they can be infiltrative.

34:19

Um, they may have glandular foci,

34:21

but they may not, they may be predominantly fibrotic.

34:23

They enhance early and avidly.

34:25

So unlike most fibrotic implants elsewhere,

34:27

these overlap with desmoid.

34:29

Um, so oftentimes they do require biopsy.

34:32

We've published on the possibility of doing, um,

34:34

anterior abdominal wall cryoablation,

34:36

and this is actually status post cryoablation now.

34:39

And we can see some peripheral enhancement on subtraction

34:41

imaging of the cavity,

34:42

but a relative hypo enhancement, uh, centrally

34:46

malignant degeneration.

34:47

This is a topic that I think is extremely important.

34:50

We're gonna look at a few um, cases,

34:52

but you know, I, I have a whole talk

34:54

that I give separately on this, um,

34:56

because it's something that I think really requires a lot

34:58

of additional education for us and understanding

35:01

and is our role as radiologists to really, um,

35:03

push forward the association

35:05

between endometriosis and malignancy.

35:09

So here's an example of a 44-year-old female

35:11

who had pelvic pain

35:13

and we see a bi lobe cystic mass with neural nodularity.

35:16

It demonstrates enhancement.

35:18

Um, you know, this is not really an eye test with regards

35:22

to malignancy.

35:23

We do know that, um, you know, could present it in this way.

35:28

So what makes this case interesting

35:30

and I'll have you reference our postmenopausal paper

35:32

and radiographics if you're interested in looking at

35:34

more malignancy cases.

35:35

There's um, there's several in there.

35:37

And of course this can occur at any age.

35:39

It does not have to happen just postmenopausally.

35:42

Um, but you'll see here ovarian endometriomas,

35:44

if we have the advantage of imaging, um, previous imaging,

35:47

we can see that oftentimes they increase in size,

35:50

they can lose their T two shading

35:51

and they can lose their extent

35:52

of T one hyperintensity, such as the case here.

35:55

So you can see the mass now, um, on the left hand side

35:58

of the screen, which does not have the same T one

36:01

hyperintensity compared to the year prior.

36:03

And then as well with the subtraction imaging,

36:05

how nicely we can see that enhancing nodule, um, within

36:09

what would've otherwise been a T one hyperintense cyst.

36:13

So really use that, um, to your advantage.

36:17

Here's an example of, uh, bowel invasive endometriosis

36:21

that was actually malignancy.

36:23

These cases are really tough.

36:25

So my would encourage you to, um,

36:27

to be really astute when you're reading your rectal cancer

36:30

cases because not just your endometriosis imaging cases.

36:34

So when you're doing your endo imaging cases,

36:36

you wanna be sure that when you're looking for your bowel

36:37

and invasive disease, and like 99% of the time they're going

36:41

to be benign, they're gonna be T two dark, um,

36:44

they're gonna show, you know, hypo enhancement

36:46

or perhaps, you know, mild delayed enhancement.

36:48

They're not gonna show significant restricted diffusion.

36:52

Um, and they should not really have any mucosal invasion.

36:55

So it's pretty rare, although it can occur in benign endo,

36:58

it's more rare for it to have mucosal invasion.

37:01

So, you know, oftentimes it's bland endometriosis.

37:04

When do we start to become worried about malignant

37:07

bowel endometriosis?

37:08

This case was actually, um, an individual

37:11

who was sent from colonoscopy

37:13

with biopsy proven adenocarcinoma.

37:15

And this is a staging rectal cancer, Mr.

37:17

And we used to use rectal contrast at that time.

37:20

And the person reading the exam reached out

37:23

and said, you know, Wendy, doesn't this look like, uh,

37:26

that those bowel endometriosis cases of yours?

37:29

And sure enough, yeah, it has the mushroom cap

37:31

configuration, but it has some differences, right?

37:33

We see here it's in her enhancing very early in

37:36

arterial phase enhancement.

37:38

So very early in avid enhancement,

37:40

it already has mucosal invasion.

37:42

We can see these frank, um, ulcerating, um,

37:45

patterns on our colonoscopy and our EUS.

37:48

So really the thing to do here is

37:51

to pursue additional stains.

37:52

So if you think there's a chance your case might have

37:54

endometriosis associated malignancy, um, you know,

37:57

you can request PAX eight and ERP

37:59

or positivity for staining to start going down that path.

38:02

And I'm sure the smart pathologist,

38:04

if there's any listening, can add extra stains.

38:07

But I think those are the first ones you wanna have.

38:09

So, um, you can have, uh, you know,

38:12

the configuration of endometriosis.

38:14

You might have the presence of endometriosis elsewhere in

38:16

the pelvis, or it could be a case like this

38:18

where it's isolated bowel endometriosis.

38:20

Um, and you know, this isn't just the first case I've seen,

38:23

it's, I've seen now several of them.

38:25

So it's something to keep on your radar.

38:29

Sciatic nerve and pelvic sidewall.

38:30

Again, another area to be mindful of.

38:32

Oftentimes low lateral, um, the patient distribution

38:36

of pain, um, may be in keeping with end, uh, maybe with,

38:40

you know, for the nerve distribution, but perhaps not

38:43

because we do have a disconnect

38:45

that's somewhat unfortunate for us as imagers.

38:47

'cause if we always had the pain correspond to the area, um,

38:51

and even clinically, wouldn't

38:52

that be just the ideal circumstance?

38:54

We'd know exactly where to look exactly what to do.

38:56

However, there is variability in the symptom presentation

38:59

from asymptomatic all the way to severely symptomatic.

39:02

And then the organ of origin

39:04

with which the pain is associated may be different.

39:07

So that probably has to do with central sensitization

39:10

or communication of nerve fibers, ENT

39:13

and afferent back to the spinal cord.

39:14

So something to be protective us.

39:16

Um, as a human species, if your bladder is injured,

39:20

maybe your bowel hurts, you know, so this is kind of one

39:22

of those things, um, that,

39:24

that could in theory be protective.

39:26

But I'm getting off topic a little bit.

39:28

We're gonna talk specifically about sciatic nerve pain here.

39:31

And we can see here this T two dark spiculated area in the

39:34

rectal vaginal space with, um,

39:36

fibrosis extending towards the sciatic notch

39:39

with a few hyperintense glandular foci we see here.

39:42

Some of them may have T one hyperintense foci within them,

39:45

and then some enhancement directed

39:46

towards the sciatic nerve.

39:47

But no frank invasion of the nerve itself.

39:50

So if you're curious about that, there is a paper, um,

39:53

in radiograph that we published on that.

39:55

Um, and that shows a number of different cases

39:58

and how to read the different pelvic nerves, what type

40:01

of imaging protocols you need, the field of view.

40:03

And sometimes we see distribution of disease

40:06

of endometriosis and not the nerve itself,

40:09

but we know by virtue of the geography

40:12

that the nerve is involved.

40:15

And so that patient was severely symptomatic.

40:17

We know she presented with disease, um,

40:19

in her the sciatic nerve distribution.

40:21

This is another patient, 40 years old, um,

40:24

who had mild pain.

40:26

And, um, we take a look here at much more severe disease.

40:30

So rectal invasion, vaginal invasion, um,

40:33

and frank, you know, cystic

40:34

and fibrotic disease extending out to the sciatic nausea,

40:36

frankly invading the sciatic nerve.

40:39

But she had mild pain and really did not want any treatment.

40:41

So we were aware of the disease, we knew the severity, um,

40:46

you know, monitoring this.

40:47

Um, but with stable and mild symptoms

40:50

and not wanting surgery, knowing

40:51

that these surgeries can be quite complex.

40:53

Um, this was elected for, uh, surveillance.

40:58

Next we're gonna move to diaphragm and plural disease.

41:00

We'll take a few cases here.

41:02

So a lot of these you can reference in our paper

41:05

and abdominal radiology, um,

41:07

if you're curious to learn more about them.

41:08

So it's just to sort of, um,

41:11

to really show you a few examples about how, um, thoracic

41:15

or diaphragm disease can be variable in its presentation.

41:18

Um, if you haven't seen it before, it can be subtle.

41:20

It can be dramatic. So this is a subtle case.

41:23

Oftentimes they can be punctate deposits or small plaques.

41:27

A lot of times by the time you look at the operative image,

41:29

there may be implants observed at surgery

41:32

that are much more, more multiple than

41:34

what you've seen on your imaging.

41:35

And, and you can go back and try to find them.

41:37

But you know, I think you'd be hard pressed to find.

41:39

Sometimes it will look like it's completely involving

41:42

the entirety of the diaphragm.

41:44

But if you have one and you're confident about it,

41:46

you can definitely suggest it.

41:48

Here's another case, of course, not an eye test.

41:50

We have hemorrhagic implants along the, um,

41:53

the liver capsule here.

41:55

And we wanna do of course, subtraction imaging again,

41:58

to be sure there's no solid components.

41:59

I have seen implants that are solid in the liver from

42:03

around the capsule and have a figo,

42:06

one malignancy associated with them.

42:07

Now that's only been one case and it has been a long time.

42:10

Um, but it's another reason why we wanna be sure

42:13

that there's not something else going on there.

42:15

This could have a differential,

42:16

it's a large lesion and it's hemorrhagic.

42:20

Here's another example. The history, of course, is going to,

42:23

um, really be a hallmark, um,

42:25

for this differential diagnosis, um, of endometriosis.

42:28

So we see that there doesn't really have much

42:31

for T two hyperintensity, which generally we see

42:33

because of the cystic or glandular parts,

42:35

but it's also quite large.

42:36

It doesn't have any intrinsic T one hyperintense signal.

42:39

Um, but the patient does have pelvic pain

42:41

and catal, pneumo thoes,

42:43

and of course she had, um, endometriosis.

42:48

Here's another example

42:49

with cyclic right upper quadrant discomfort

42:51

and pneumothoraces, we see very linear

42:54

and punctate T one hyperintensity with an eye of faith.

42:57

I'll ask you to believe me on that one.

42:59

Um, and this is T two dark as well.

43:00

And then you can see here the treatment, um,

43:02

mechanical pleurodesis with scratch pad

43:04

and argon beam, um, coagulation.

43:07

So they did diaphragmatic endometriosis, um, lesion excision

43:10

and a primary repair.

43:11

So these can be quite complicated surgeries.

43:13

Sometimes the pleural ones can be tricky depending on the

43:17

visceral and parietal pleural and the location

43:19

and the timing of the cycle.

43:21

And in general, we don't time people's scans to their cycle.

43:23

Sometimes it can be unknown, right?

43:25

So, um, it, it is certainly a challenge.

43:29

Ureteric and postoperative complications are also another

43:32

area where MR does a good job of assessment.

43:34

These are tricky cases.

43:36

Um, so in general,

43:38

ureteric endometriosis is an extension of ome disease.

43:41

So of course we know the peroneum comes out from the sides

43:44

of the cervix like this.

43:45

Um, and then the ureters course nearby.

43:47

And if there's the fibrotic disease, um,

43:50

that is involved enough,

43:52

it can actually involve the ureters resulting in hydro

43:54

necrosis, um, and silent death of the kidney.

43:57

So we wanna be very mindful of patients

43:59

who have ureteric endometriosis.

44:02

Um, disease above the pelvic rim can be uncommon.

44:05

However, of course I'm gonna show you a case of that.

44:07

So this is really from a ct, um,

44:09

a screening CT colono, uh, colonography.

44:12

And you can see that, um, you know

44:14

that there is fibrotic disease around the ureter.

44:16

We see a T two hypo intense asymmetric

44:19

rim around that ureter.

44:21

So you know, this is a 68-year-old female.

44:23

She was asymptomatic, it was an incidental finding.

44:27

Um, but the pathology is really kind of where that came in.

44:30

'cause of course, endometriosis is not gonna be our first

44:32

consideration, um, in this demographic.

44:35

Let's take a look at another case.

44:37

A 38-year-old female with gross hematuria.

44:39

This is a much more common location

44:41

for ureteric involvement in the pelvis related

44:43

to peral disease.

44:44

She'd already had a left cell pinga ectomy

44:47

and reimplantation of that left ureter.

44:49

Um, but you can still see that the distal ureters in place,

44:52

it's still hypot intense.

44:53

It's still involved by endometriosis.

44:56

So why does she still have her gross hematuria though?

44:59

So when we take a look at this, we see that there is,

45:02

you know, maybe some of the characteristics of

45:03

what we've looked at in ovarian endometriomas.

45:05

There's a T two hypo intense rim.

45:07

There's fluid, fluid layers,

45:08

but it doesn't have a lot of intrinsic T

45:10

one hyperintense signal.

45:11

And when we give contrast, we see it enhances at the same,

45:15

um, time and to the same extent as the regional arteries.

45:18

So, you know, this is again, another one

45:21

of the reasons why we like to give intravenous contrast.

45:23

Why is that? Because we're not, we're not just looking

45:26

for, you know, malignancy.

45:27

We're looking for assessment of everything in the pelvis,

45:30

other pathologies that need evaluation and vessels

45:33

and postoperative complications such as this, which could be

45:36

otherwise, um, potentially catastrophic, especially if, um,

45:39

going to surgical intervention without this knowledge.

45:41

So we see here a pseudo aneurysm arising from a branch

45:44

of the internal, um, iliac artery

45:47

enhancing in every modality that we could throw at it.

45:50

And then the patient went to embolization.

45:52

We can see here the pseudo aneurysm

45:54

and that was effectively coiled

45:55

and the patient's symptoms improved.

45:57

So again, this is a really complex disease, uh, that can be

46:02

multifaceted in terms of its presentation, its phenotypes,

46:05

its imaging phenotypes, its risk profiles,

46:08

the patient population and where they're at in life

46:10

and what, um, you know, are they,

46:12

they're having fertility considerations still in

46:15

family planning is very important.

46:17

Um, so we have to be really mindful as imagers to

46:19

to know the context of

46:21

of the patient when we are taking a look at their imaging.

46:24

But we also need to be really thorough

46:26

and comprehensive, um, in our evaluation.

46:29

So this is again, just one of the final slides to share

46:31

with you showing deep endometriosis involving the ureter,

46:34

frankly invading the ovary, the vagina.

46:37

You know, you can get really involved in certain disease

46:40

sites, um, when you're reading your scans

46:42

and it's important to not have that satisfaction of search.

46:45

And you can see here just a very small tiny mushroom cap

46:49

lesion in the lateral rectum, you know, very tricky.

46:52

So I find even for myself, I've been doing this

46:54

for over 10 years now and, and looked at so many cases,

46:57

but, uh, always this disease will keep you interested

47:01

because even though there are reproducible patterns,

47:04

the kissing ovaries, the retroflex, the prometrium, the

47:09

uterosacral ligaments going into the bowel, um, you know,

47:12

all of the patterns that I showed you were just

47:13

some of the most common ones.

47:15

But there are always surprises.

47:17

There are always new sites of disease.

47:18

So you have to always keep looking, um,

47:20

because you never know, uh, you know,

47:22

what could be the culprit for something

47:24

that's left behind a surgery.

47:25

And, and so it's really, it's very interesting work.

47:28

I think that it makes, makes a tremendous

47:29

impact, uh, for patient care.

47:31

And when there are good protocols and

47:33

and communication, whether that's through reporting

47:36

or interdisciplinary work, I think that um,

47:38

you have a chance to make a real impact in people's lives.

47:41

So in summary, we talked about a complex spectrum

47:43

of disease, the histology, um,

47:46

and how we use that histology in our protocols to use, uh,

47:50

to make them to our advantage

47:51

and do our reporting appropriately.

47:54

We wanna look for both hemorrhagic and fibrotic implants

47:56

and coexisting, um, imaging features of both of those.

47:59

We wanna look at pelvic and extra pelvic locations,

48:02

understanding that, um, you know, advanced

48:06

and more severe disease in the pelvis might be more at risk

48:09

for disease up by the diaphragm or pleura.

48:11

So really co uh, co-managing that situation with regards

48:14

to the imaging using dedicated ultrasound.

48:17

And MR protocols are excellent at pelvic disease detection,

48:20

but what we've learned from taking a look at some

48:22

of the data is really has to do

48:23

with the protocols that you're using.

48:26

Um, your experience, your expertise,

48:28

and a little bit of patient population.

48:30

So I really encourage, um, if you're not doing it already,

48:33

to embark on a program that is interdisciplinary

48:36

because when you have the feedback about

48:38

what you're reporting and doing the rad path,

48:41

surgical correlation is essential to that.

48:43

Um, MR is the modality of choice for the upper abdomen,

48:46

the nerves, the lateral compartment, so all of those nerves

48:49

and pelvic sidewall structures, the liver and diaphragm

48:52

and extra ovarian malignant degeneration.

48:54

So ultrasound can take a good look as we know via RADS

48:57

and other tools to take a look at the ovaries.

48:59

But malignant degeneration can occur in any

49:01

site of endometriosis.

49:03

And we also wanna be, um, thinking more of CT

49:07

and MR for postoperative complications with of course, um,

49:10

Mr providing us a little bit more detail there.

49:12

Um, with respect to the endometriosis

49:14

and then interdisciplinary conference again, I'll say

49:16

that over and over, uh, is really invaluable.

49:21

So if you have any questions, I'll take a look.

49:23

I'll look at the questions here

49:24

that you've submitted in the chat for now.

49:25

But if there's any additional ones that come forward,

49:27

please feel free to reach out to me.

49:29

Um, you know, or you know, email or social media.

49:32

And then as well if you're interested

49:34

to learn more about endometriosis,

49:35

we have a whole two day meeting

49:36

through the International Endometriosis

49:38

Congress with two tracks.

49:40

So that's intended for ultrasound or primary care

49:42

or introductory to endo imaging

49:44

and another one that's more advanced

49:46

that goes into all these topics with a lot more depth.

49:48

So I would love to have all of you there and learning more

49:52

and um, I'm thrilled to have you here today. So

49:56

Dr. Van Buren, thank

49:57

you so much for

49:57

that awesome lecture. Appreciate that.

50:00

You're welcome. We are gonna open the floor

50:02

to some questions and if you're able to pop open that q

50:06

and a box, we have quite a few in there.

50:09

Oh right, yes. I see. Okay, fabulous.

50:12

So I'm gonna read through those quickly.

50:15

Um, alright, so this is the first one from you.

50:21

There's the other box at the bottom of your zoom screen.

50:24

It's got the little chat bubble with a question mark in it.

50:26

It's called q and a. Oh sure. Okay, perfect. Thank you.

50:29

That's better. Alright, excellent.

50:32

Um, so yeah, so that,

50:37

you know, cultural sensitivity is one

50:39

of the questions um, to deal with.

50:41

So I'll read this out loud here.

50:43

Ino vaginal ultrasound is accurate,

50:45

but in Africa it's contraindicated

50:47

for non sexually active women and girls.

50:50

Um, for the transvaginal approach,

50:51

what approach do you recommend?

50:53

Um, and this is a question from Uganda.

50:55

Thank you for that question

50:56

because in really, um, with respect to endometriosis,

50:59

there are so many different countries and cultural practices

51:03

and that exist for a variety of reasons.

51:05

They may be religious, they may be socioeconomic,

51:07

they may be geographical.

51:09

Um, so, you know, it does give a somewhat of a limitation,

51:13

um, in this age group, you know,

51:15

and it can depend a little bit.

51:17

So transabdominal ultrasound I think is probably gonna be

51:20

the resource that's most available that will

51:23

perhaps take a look at the ovaries

51:25

to see if there's ovarian endometriomas

51:27

and you could take a look to see if there is any

51:29

of the architectural changes in the pelvis

51:31

that could suggest it.

51:32

Um, so these are generally though going to be young women.

51:35

They are most likely going to have disease

51:38

behind the uterus at the uterus acral ligaments,

51:41

and it's going to be mild disease.

51:42

So that's gonna be very challenging to see

51:44

with transabdominal ultrasound.

51:46

But you know, I think an MR is usually the study

51:49

that would be the most effective,

51:51

but I'm guessing with that is gonna be a resource

51:52

that's gonna have very limited availability.

51:55

So in that context, unfortunately I don't have a great

51:57

answer, uh, for what would be best.

51:59

But I think a transabdominal ultrasound could take a look at

52:02

least for severe disease manifestations.

52:05

Um, and then other than that, perhaps, um, you know,

52:08

we'll have to keep working on additional, uh, technical

52:11

or, you know, biochemical markers

52:13

for, for disease detection.

52:16

All right. Uh, is spontaneous regression of MR.

52:19

Visible endometriosis

52:20

that can round ligament possible no

52:21

treatment in the patient history?

52:24

Well, that's an interesting question.

52:25

People ask me all the time about, um,

52:29

about medical management and regression

52:32

and also to, I would say that the,

52:34

the round ligament is a little bit questionable.

52:37

So depends what you have.

52:38

If you have T one hyperintense foci of endometriosis

52:43

and you've seen those resolve with nothing,

52:45

um, that would be unusual.

52:47

If you have just thickening of the round ligament,

52:50

this could be positional or related to contraction

52:53

because of its relationship to the groin.

52:56

Um, and uterine positioning and even uterine peristalsis.

52:59

I think that that could be something

53:00

that could be a transient finding.

53:02

So, uh, round ligament, um, endometriosis

53:06

or thought to be endometriosis based on thickening on T two

53:09

alone, I think would be a very, um, low specificity finding

53:13

and could give the appearance of regression.

53:15

I would look for other disease sites in the pelvis too.

53:17

If you have isolated disease in that location.

53:19

That's T two thickening only.

53:21

I would say that's like a very low sensitivity

53:24

and specificity for endometriosis.

53:26

So just to be cautious on the initial interpretation,

53:28

um, with that finding.

53:31

Now, can endometriosis regress?

53:33

I would say, you know,

53:34

that's without any medical therapy, very unlikely.

53:37

Usually with the hormonal treatments we can see

53:39

to some extent either stability

53:41

or possibly regression of the hemorrhagic

53:44

or, um, cystic glandular components,

53:46

but the fibrotic part of the disease will remain so.

53:50

Um, so no,

53:51

I've never seen an endometriosis lesion completely

53:53

disappear to that point.

53:55

Um, now if it was very early just cystic superficial disease

53:58

that we happen to catch, uh, could it resolve?

54:02

Maybe, you know, I mean it's possible.

54:04

I'm not, I never say never in medicine

54:06

because nothing is a hundred percent.

54:08

Could some small macrophage have come in there

54:10

and like digested that little tiny foci of T one.

54:12

I'm not gonna say no to that,

54:13

but I will say it's very, very uncommon.

54:16

Um, alright, so hopefully that answers that question.

54:19

Um, are there evidence-based recommendations

54:22

regarding the optimal timing within the menstrual cycle

54:25

for imaging studies, disease mapping, pre-ops?

54:28

Um, no. So we do not time it to the menstrual cycle.

54:32

Most people do not. It's very difficult for us

54:34

to be able to do that.

54:35

A lot of people are uncertain of their cycle,

54:37

so no, we do not do that.

54:40

Um, so

54:45

lemme just sit over here.

54:46

Are there evidence-based recommendations

54:47

regarding the off oh, that, okay, that one's done.

54:50

Uh, do I include T one weighted 3D FSC in their MR protocol?

54:55

Uh, no, we do not. That doesn't mean

54:58

that you can't try that.

55:00

That seems like it could be

55:01

something that could work for you.

55:03

We, you know, a lot of times too,

55:04

when you have your protocols, um, you know,

55:06

whether you decide to do something in 3D

55:09

or you know, basically 2D in three planes, for example,

55:13

there's trade-offs with every decision that you make.

55:15

So there's advantages from a timing standpoint,

55:18

you're gonna lose some soft tissue characterization,

55:20

but you might get some, um, you know,

55:22

obviously some smaller, you know, thickness

55:24

of slices in that circumstance.

55:26

But a lot of times it has to do with

55:27

what your eye is tuned into as well.

55:29

So it's like you've been practicing

55:30

for a long time in one way

55:31

or another, it's probably gonna be

55:32

the way that you are best at it.

55:34

So keeping that in mind too.

55:36

So if you're gonna change things in your protocol, this is

55:38

for, you know, for anyone change.

55:40

Maybe once you have a fundamental protocol, of course

55:43

that's comprehensive for you.

55:44

If you're gonna change things and try out different new

55:47

sequences, maybe try one variable at a time.

55:49

Um, as, as you may wanna test it

55:51

against your preexisting one.

55:52

You could run them both, um, in, um, in unison too.

55:56

Good question. I said, yeah, follow up question, Mr.

55:59

Often not accessible ultrasound is more available.

56:02

Yes, I figured that that was the case.

56:04

Um, again, from Uganda there, I, I had a feeling that I was,

56:07

so unfortunately transabdominal ultrasound

56:10

is really the only, um, available imaging tool then

56:13

and is gonna be significantly limited

56:15

except for severe disease.

56:18

Uh, is delayed contrast enhancements helpful

56:21

for d as it's fibrotic?

56:22

Yes, so we do, um, you know, um,

56:26

multiple post contrast sequences we wanna look for early,

56:29

you know, middle and late enhancements.

56:31

So I think it is helpful.

56:33

You know, also too, what's what's helpful is as

56:35

for fibrotic diseases, just your T ones pre contrast.

56:38

So another technical aspect there is to maybe run those

56:41

before your contrast bolus

56:42

because sometimes you can have a little bit

56:44

of contrast enhancement

56:45

and that's really can be a confounder.

56:47

Um, it's problematic 'cause we know if we see

56:49

that really nice T one hyper intense tiny little focus, um,

56:53

that we, it really increases our specificity.

56:55

So again, yes, T ones before contrast bolus is great.

56:59

Um, what is the relationship with the uterosacral ligament

57:03

and the mes rectal fascia?

57:05

That is a question that also a lot of people love to ask

57:08

because they say, is this not the same thing?

57:10

And so they can sometimes run, you know,

57:12

together at a certain point

57:13

and they become opposed to one another

57:15

and the dissection is a potential space.

57:17

So, you know, it can be difficult,

57:19

but you're not gonna see the, the mear rectal, um,

57:23

fascia come up to the, uh,

57:25

to the TAUs Utes behind the cervix, right?

57:27

So those are more lateral structures.

57:29

Um, so, but there is a certain point there

57:31

where they may be abutting one another very close proximity.

57:34

Um, but when we're looking at the proximal portion,

57:36

the uterosacral are quite different.

57:38

And then just to be mindful, of course,

57:40

when a patient has a hysterectomy,

57:42

those are uterosacral ligaments which are extremely thin,

57:45

generally speaking, unless involved

57:46

by endometriosis are reattached to the cuff

57:49

because they're dispensary, right?

57:51

If you didn't have your uterosacral ligaments,

57:52

you'd have like major prolapse issues.

57:54

So again, don't think that they're absent,

57:57

they should still be there after the

57:58

patient's had hysterectomy.

58:01

Uh, can you share the patient prep please?

58:03

The protocol, the sequences?

58:05

Um, yeah, those are will be in the papers that I referenced,

58:09

um, and they were in the talk.

58:11

So I would say if you're able to reference the papers,

58:15

that is probably the best way to do that.

58:18

Um, but maybe I can figure out here too, if there's a way

58:22

for me to share those with you after.

58:24

What's the average time for

58:25

endometriosis to become malignant?

58:27

Uh, and in those cases that become the average time.

58:30

So it's interesting, you know,

58:31

in our postmenopausal paper we have, we have our cases

58:35

of malignant endometriosis in that patient population.

58:38

So it's probably by phenotypic.

58:41

And there's one, so we know

58:42

that there's an increased risk per year

58:44

of malignant transformation.

58:45

Like, you know, we quote like 1% chance per year.

58:48

But then there are also cases that I see in young patients

58:51

and they're quite aggressive and early

58:53

and they, I'm not sure what the timeframe is

58:55

that they've had their endometriosis,

58:57

but it can't possibly be that long, right?

58:58

Based on their age. So there will be ones

59:01

that perhaps are the result of, you know,

59:02

chronic inflammation and chronic processes

59:04

and others that are perhaps, um, you know,

59:08

an underlying genetic

59:10

or other variable that has predisposed them to malignancy.

59:14

And, and really those might coincide sometimes,

59:18

but they definitely create somewhat of, um, yeah,

59:21

a bi phenotypic presentation.

59:22

So you can't really say that, you know,

59:25

age is the only predictor of malignancy.

59:27

The problem is is that the numbers are in general low,

59:30

so it's hard to know and attribute that risk.

59:33

And also too, since we don't know what our diagnosis is

59:35

of endometriosis, truly in the background population,

59:37

that also makes it challenging.

59:39

Um, so anyway, very good question

59:41

and I think probably more to come

59:43

as more research comes forward.

59:45

Do you perform sliding sign in a

59:47

post hysterectomy ultrasound?

59:48

Do you focus mainly on the rectal

59:50

sigmoid and vaginal cough areas?

59:51

That's a great question. I mean,

59:53

I don't think we generally do that

59:54

because, uh, you need to have

59:58

the ability to, you know, to have something that's mobile

60:01

and the vaginal cuff in general is not extremely mobile.

60:04

So there's, with the uterus,

60:06

you can apply the fundal pressure and have it move.

60:08

Um, the vaginal cuff is generally somewhat fixed.

60:11

Now that said, if you have a way to assess mobility

60:13

and the structure that you're looking at, certainly and,

60:16

and you find that helpful, I, uh, I think

60:20

that you could certainly use that,

60:21

but it's not the conventional sliding sign in, in the manner

60:25

that we know it, uh, to be described.

60:28

Alright. What are the unmet imaging needs

60:30

from an MR perspective?

60:31

Sorry, it was addressed. The unmet needs. Wow, okay.

60:34

Yeah, that's a huge question.

60:35

So, I mean, I think the unmet needs are, are many, you know,

60:38

if I get to have my wishlist right now, um, we need to have

60:42

endometriosis imaging organized like breast imaging.

60:45

And I felt like this for a long time

60:47

that it should be done in this kind of context

60:49

where we have, if the resources are available.

60:52

Again, I always use it with that caveat

60:54

because everyone's practice

60:55

environments are gonna be different.

60:57

So I'm gonna speak specifically

60:58

to the United States right now.

61:00

Um, but you know, something like the SRU consensus

61:03

or a tool that is used effectively, um, to triage patients

61:08

with perhaps the possibility of endometriosis on imaging

61:11

to then narrow their pathway to higher levels

61:15

of diagnostic imaging.

61:16

So either MR or ultrasound, if it were

61:18

to become more readily available in our country,

61:20

but globally available is gonna be more so as the mr.

61:23

And then we need to have, you know,

61:25

a more standardized system built around that, um, with,

61:29

with some models of, um, of minimum standards

61:33

that are necessary so that people understand

61:36

that if they're having a pelvic MR for endometriosis,

61:39

is it the appropriate, you know, protocol

61:40

and technical parameters at least at minimum,

61:42

that have been performed?

61:44

Um, and is the reporting

61:45

and expertise of the individual also acceptable?

61:48

So, you know, I think that's something that we take care of

61:51

through birads, through training,

61:53

through reading of mammograms.

61:55

And then we have an ul um, radiologist driven practice

61:58

with regards to the diagnostic evaluation.

62:01

And then when they go to see their surgeon

62:02

or breast clinic referring clinician,

62:05

they have their whole understanding

62:06

of the disease presentation.

62:09

I think that, that we could really benefit from similar

62:11

technical and,

62:12

and interpretation standards, um, for endometriosis.

62:17

That's the, that's the dream. All right.

62:21

So do you recommend the use of any classification like NZN

62:23

or severity staging?

62:26

You know, I think that, again, it's best

62:28

to use us as radiologists.

62:30

We're fundamentally communicating with our surgeons, right?

62:32

So you need to know who your audience is.

62:34

So understanding all the disease sites is really important

62:38

and, um, we wanna be mindful of all the anatomy

62:40

and the descriptors and the things

62:41

that change surgical evaluation.

62:43

But if your surgeons are not using NZN for interpretation

62:46

or planning their surgeries off of it, it's not going

62:48

to be helpful for you to go through that effort.

62:50

Um, however, if your clinical practice

62:52

environment does, that's great.

62:54

So, you know, I think I would just have a conversation

62:57

with your referring clinicians

62:58

and find out how they would like

63:00

to have things best communicated.

63:01

Is that a report template?

63:03

You know, it can, it can be variable

63:04

and I'll say that, you know,

63:06

report template can be very effective for teaching

63:08

and, um, if people are new to endometriosis imaging, um,

63:13

or an experienced expert,

63:14

but also too, I think there is room depending on disease

63:17

severity because it's a trans spatial process at this stage.

63:21

For me, sometimes when I'm looking at a really severe

63:24

disease, I'm not gonna talk about it in 300 different

63:27

anatomic sites and distributions because it's trans spatial.

63:30

And I'm gonna talk more about the distribution of disease

63:32

and what all it encompasses as opposed

63:35

to each anatomic landmark

63:36

and artificially dividing the disease into small morsels

63:40

that doesn't, you know, so there's like a,

63:42

there's a certain place where there's um, you know,

63:45

there's a balance in what you're doing

63:46

and there's different ways of reporting effectively.

63:50

So again, communication is key and,

63:52

and if you don't know who your audience is, um,

63:55

then you can default by using something

63:58

that's a society recommendation, for example.

64:00

Um, and what you think the, um,

64:02

general practice environment would, would be using.

64:05

Good question. Alright, let's see,

64:09

we've got some more.

64:11

Uh, do you recommend trans peroneal ultrasound

64:14

for better evaluation of the rectal vaginal septum?

64:18

I mean, I personally have not done that.

64:21

We, through transvaginal ultrasound can do a pretty good

64:25

directed view with the ultrasound probe, like even,

64:27

you know, through probe insertion from the anus through

64:30

to the vaginal fores.

64:32

So, um, you know, it's an interesting thought.

64:37

I think it would be somewhat limited if you have good cases

64:40

and good utilization of that though,

64:41

and are comfortable doing it, I would say that's wonderful.

64:44

You know, the more ways you have of taking a look at

64:48

for endometriosis disease sites, I think that

64:50

that's great because it's a challenge.

64:52

Um, and you may have other limitations that, that, you know,

64:55

perhaps like, uh, let's say pelvic pain,

64:57

if there's severe dyspareunia, um,

65:00

if it's really advanced disease,

65:01

maybe the transvaginal ultrasound's

65:03

not going to be tolerated, right?

65:04

So it's good to have things like a

65:06

transparent peral ultrasound.

65:08

Um, if you have experience with

65:09

that, that could be effective.

65:11

I'm guessing probably like a three

65:12

or four D um, might be the best in that circumstance.

65:17

Do we use IV contrast in all cases?

65:19

Yes, we definitely use IV contrast in all cases.

65:22

Um, our society, uh, of abdominal radiology has put

65:25

that in their consensus, um, recommendations

65:28

and as well then the expert panel in the journal

65:30

of radiology was also our recommendations.

65:32

Now why is that? So I've talked about some of the reasons,

65:35

um, you know,

65:37

but we really for a few, for a few things.

65:41

So I know that it's not typically the practice in Europe

65:44

or Australia or some other countries

65:46

to give intravenous contrast.

65:48

Now if you're in a practice environment where you're able

65:50

to, um, check your cases

65:54

while the patients are on the scanner

65:56

and make a decision in real time, uh,

65:58

that can be one option.

66:00

Now the other option is if you have callbacks

66:04

and that are easy to do, so patients

66:05

that are in your community

66:07

and they can easily come back

66:08

for intravenous contrast if needed.

66:10

So I think those could be two environments that are common

66:14

and, and, and could be the case.

66:16

Now with respect to, again, I'll speak to the United States,

66:20

we have a very broad geographic, um, distribution

66:24

and a lot of times people may travel

66:26

even from other countries.

66:27

And this ability to have people coming back, especially

66:30

with, um, the practicality aspect.

66:33

So if they're traveling or even working

66:35

or have a family, um, whatever the variables might be

66:38

that take their time, um, it's difficult to organize, um,

66:42

something of that nature,

66:43

especially if there's a high volume

66:44

of patients now also too, because we just don't know.

66:48

We have patients being scanned at night,

66:49

morning, evening, weekends.

66:51

Um, you know, what is gonna be like the timeframe of,

66:54

of identifying these types of things

66:57

and our spectrum of disease pathology.

66:59

So, you know, it's not just endometriosis.

67:01

Anyone who reads endometriosis knows

67:03

that you're gonna see a whole lot

67:04

of other things in the female pelvis, for sure.

67:06

You're gonna have some fibroids.

67:08

How are you gonna characterize your

67:09

fibroids without contrast?

67:10

It's a very important part of our malignancy assessment

67:13

and risk assessment for fibroids, um,

67:16

polyps in the endometrium, again,

67:18

you wanna be looking for that.

67:20

Plus any other malignancy

67:21

that requires characterization also requires contrast.

67:24

So I think, um, you know,

67:26

we're looking at a holistic approach to the pelvis,

67:28

not just endometriosis, um, specific decision making.

67:32

So it's, it's for both practice patterns and,

67:34

and comprehensive disease reporting, um, that, you know,

67:38

we've made this decision.

67:40

And then do I know of about good European conference on

67:42

endometriosis imaging?

67:44

So, you know, I know there's a couple of good,

67:47

um, resources.

67:48

So the European Society, um, of your general radiology.

67:52

So ESUR, uh, has great recommendations

67:55

and guidelines for the European environment.

67:57

And I think their upcoming meeting

67:59

in September, I'll be there.

68:00

There's gonna be some endometriosis sessions

68:02

I'm really looking forward to.

68:03

Um, as well,

68:05

the European Endometriosis League does workshops

68:08

and seminars, and I know

68:09

that they have some terrific resources as well.

68:12

And then on, depending on the environment, I, I know

68:15

that other people, um,

68:17

a good friend and colleague of mine, Dr.

68:18

Suzanne Johnson in the UK runs, um, workshops and,

68:22

and seminars for endometriosis ultrasound evaluation.

68:25

Um, so depending on, you know, the country you're located

68:27

and you know, where you're able to travel

68:29

or access, I would seek out maybe perhaps someone, um,

68:33

regional to who might have an, uh,

68:34

expertise and interest in this area.

68:38

Wow. You got through a lot of questions, Dr.

68:40

Van Bier, and thank you so much.

68:42

You're welcome. I talk quickly, so you know, it's

68:46

You knocked, you knocked 'em all out. Yeah,

68:48

Right. Thank

68:49

You so much for the lecture and for staying on a little

68:51

after noon and um,

68:53

No, you're welcome. Thanks

68:54

everyone for being here.

68:55

Yeah, for sure. Thank you for having me.

68:58

Absolutely. Thank you. And yeah, thank you so much

69:00

for everyone else for participating in this noon conference

69:02

and asking such great questions.

69:04

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69:06

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69:16

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69:18

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69:24

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69:28

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