E2372. Dive Into Deep Infiltrating Endometriosis
  1. Madhura Desai; Mayo Clinic Florida
  2. Neema Patel; Mayo Clinic Florida
  3. Sadhna Nandwana; Emory School of Medicine
  4. Kelly Cox; Mayo Clinic Florida
Endometriosis is a common, benign, inflammatory disease related to endometrial glands and stroma outside the endometrial cavity. These ectopic glands and tissue can bleed and breakdown, triggering chronic inflammation and fibrosis. Symptoms (most commonly including chronic pain, infertility, dysmenorrhea, and dyspareunia) can range in severity and are related to disease phenotype and anatomic location. The most severe phenotype is deep infiltrating endometriosis (DIE), which has been historically diagnosed with laparoscopic exploration and biopsy. However, a move to presumptive diagnosis based on clinical symptoms, physical findings, and high-quality imaging offers a non-invasive, lower risk management pathway with a shorter treatment delay. In patients who fail conservative therapy, dedicated imaging can help guide surgical planning for definitive diagnosis and treatment. The purpose of this exhibit is to familiarize imagers with optimal MRI technique for detection of DIE and characteristic MRI findings of DIE that can establish diagnosis and direct management.

Educational Goals / Teaching Points
After reviewing this exhibit, the reader will appreciate the essential sequences of a dedicated endometriosis MRI pelvis protocol, recognize endometriosis phenotypes and associated imaging findings, particularly those of the DIE phenotype, and review pelvic compartmental anatomy to understand common sites of DIE and enhance detection.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
DIE is the most severe endometriosis phenotype, defined by endometriotic lesions invading more than 5 mm deep to the peritoneum. Pelvic DIE can distort and tether pelvic anatomy and invade adjacent organs (most often bowel, vagina, and bladder). High quality, multiplanar, small field of view T2 weighted imaging without fat suppression is preferred for the detection of the T2 hypointense lesions which are the hallmark of DIE. A structured search by anatomic compartment provides a sensitive and efficient search pattern for the often-subtle lesions of DIE. MRI demonstrates utility in preoperative planning where it may detect DIE lesions in laparoscopic blind spots including those hidden by adhesions, in atypical locations, or in the subperitoneal space.

High-quality pelvis imaging plays a key role in the multidisciplinary diagnosis and management of DIE. This education exhibits aims to increase the reader’s familiarity with MRI of DIE to enable more accurate reporting and diagnosis, which in turn can facilitate patient counseling, and enable successful medical therapy or definitive surgical resection.