Three‐dimensional ultrasonographic characteristics of endometriomata

• DOI: 10.1002/uog.5380
• Publication Date: 2008-05-27T10:46:43Z
• Authors: N. Raine‐Fenning; K. Jayaprakasan; S. Deb
• Keywords: Etiology; Pelvic inflammatory disease

Endometriosis is a common condition, affecting somewhere between 5% and 60% of women reproductive age approximately 2 million in the UK. The exact prevalence difficult to ascertain varies according diagnostic criteria used populations studied, varying from 50% without symptoms, 40 with dysmenorrhea, 20 30% subfertility1, 2. etiology unknown, but disease characterized by objective demonstration endometrial-like tissue outside uterus. condition seen predominantly age, it occurs all ethnic social groups. Whilst extrapelvic can occur, endometriosis typically affects pelvic organs peritoneum. Disease severity assessed semi-quantitatively at laparoscopy or laparotomy scored American Society for Reproductive Medicine3, poor predictor patient's symptoms many cases. extent considerably; may involve small areas peritoneum alone, be associated significant fibrosis, adhesions nodular infiltration, different individuals same symptoms1. ovary involved only superficially contain cyst lined known as an 'endometrioma'. Endometriotic cysts have always been controversial entity. There no consensus pathological processes which define their development management terms timing, type effects surgery. Opinion divided whether these arise progressive invagination endometriotic deposits on ovarian cortex4, 5, metaplasia epithelial inclusions ovary5, 6 because secondary involvement functional process7. theory accepted most, there agreement endometrial cells are superficial implants they derived through metaplastic transformation normal cortical tissue. supported histological studies, consistently show that pseudocysts, real plane cleavage endometrial-type stroma cortex, containing obliterated, mostly endometrial-gland, lining8. walls endometrioma initially thin, subsequently become fibrotic thickened, give irregular external border. Endometriomata small, 81% measuring 30 59 mm diameter9, although reach 15–20 cm diameter. Is isolated peritoneal endometriosis? Many found evidence disease, pathophysiological mechanisms determine how expressed remain unclear. Women thought reduced fertility, surgical treatment improve fecundity those minimal mild disease10. Just fertility any effect probably relates anatomical distortion immobilization adhesion formation organ infiltration and/or change environment one less favorable fertilization embryo implantation. clear, definitive impaired. However, intervention often recommended when measures more than 3–4 diameter11 so, unsurprisingly, endometriomata represent most frequently reported subtype following operative excision cysts12. Preoperative detection therefore important, ultrasound investigative tool choice Conventional two-dimensional has established role adnexal masses differentiation pattern recognition characteristic morphological patterns13. Most studies use transvaginal rather transabdominal ultrasound, this approach allows closer approximation probe higher frequencies, provide better resolution. should supplemented with, ideally preceded by, assessment, ensures high mass not missed. commonly described features include thickness wall, presence nodules hyperechoic foci wall within body cyst, focal acoustic impedance, regional bright echoes lines dots. These characteristics subjectively benign important diagnosis endometriomata. consistent ultrasonographic feature diffuse, low-level 82–95% cases14, 15. referred 'chocolate cysts', term first Sampson 192116, reflecting color texture material contain. This gives 'ground glass' appearance readily evident due consistency and, while absence finding does exclude endometrioma, significantly decrease its likelihood (negative ratio, 0.1)17. thick-walled, findings changes outlined above. Wall nodularity 20% It distinguish papillation, closely malignancy. Doppler assessment nodule reveals absent flow nodule, whilst malignancy, reduce likelihood. multilocular, reliable sign, both unilocular multilocular non-endometriotic relatively common9. Endometriomata, therefore, wide range manifestations, appearing simple cystic structure occasionally complex solid elements. So, just useful cysts? Some17 suggest highly accurate, positive predictive value 96.4% false-positive rate 3.8%. figures reflect opinion observer expertise surgery, truly reflective standard clinical practice. Other investigators14 demonstrate predicted nature confirmed histologically 64–89% cases, proving hemorrhagic (Table 1). A systematic review Moore et al.18 concluded was effective confirm moderate accuracy (positive 7.6–29.8; negative 0.1–0.4), 95% CIs were wide. summary descriptions given Table 1. discrepancy results could relate study designs, poorly designed exaggerating size18, might inadequate sampling pathologist, who miss lining otherwise capsule, shown that, (10–98%) internal surface covered lining19. We feel, however, likely reason performance research group, inappropriate diagnosis. misdiagnoses difficulty differentiating endometriotic, dermoid hemorraghic cysts. Hemorrhagic also said echoes, fibrinous strands retracting clots, suggestive recent resolving hemorrhage, respectively, cyst. cysts, variety appearances, dependent stage evolution clot, lacelike reticular intracystic clot typical (Figures 1 2)20. 8% endometriomata, specific. In contrast, teratomas impedance association dots, (Figure 3). An neoplastic if acute especially multilocularity present14. series images showing heterogeneous patterns degrees fibrin becomes organized. chronologically older compared Figure 1, single well-organized clot. (benign teratoma), help differentiate cysts: elements causing thickening, shadowing Rokitansky's protuberance (a), thick, borders (b) semi-cystic, semi-solid (c), dots fluid hair (d). what done sensitivity specificity masses? steady, improvement software hardware accompanies industrial drive behind our speciality providing us image quality, alone allow revise simply confident Education training will play key role, good work International Ovarian Tumor Analysis (IOTA) Group experienced perform multiple regression models neural networks. comes down recognition, efforts aimed obtaining best possible standardizing display ensure maximum amount information assessment. Three-dimensional facilitates such potential advantages over conventional ultrasound. improves spatial orientation displays manipulated modified area object interest. data generally multiplanar display, where together two orthogonal 4). Any selected rotated scrolled through. adjustment equal simultaneous movement other planes, affording user virtual real-time information. slices planes tomographic imaging (TUI). TUI fewer distances each other, appropriate individual. particularly large masses, analysis whole adnexum image; clearly demonstrates distinct differences homogeneity three-dimensional endometrioma. three images, provides reader information, rendered view (lower right image) shown. larger mass. pathologies coexist, difference them apparent considered. dataset viewed rendering. uses algorithms volume ('voxels') characteristics, defined echogenicity. shows classic apparent, thickened capsule echodense number antral follicles distributed around periphery larger, dominant follicle developing lower aspect. image, speckle reduction enhance contrast interfaces 7). characteristics: smooth (SRI). Two shown; had SRI applied borders, making apparent. Rendering formats. 'glass rendering' option vascular gray-scale allowing appreciation relationship two. tree separate entity subtraction immediate impression vessel distribution branching. technique 8. well perfused vessels appear short course, variation diameter, surrounds uniform manner; we refer 'bird's nest' appearance. reconstruction article overview current base obtainable modern machines brief insight into hope presented others enthusiasm ideas future work.