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Imaging modalities for the non-invasive diagnosis of endometriosis

  • Review
  • Diagnostic

Authors

  • Vicki Nisenblat,

    Corresponding author
    1. The University of Adelaide, Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, Adelaide, SA, Australia
    • Vicki Nisenblat, Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, The University of Adelaide, Level 6, Medical School North,, Frome Rd, Adelaide, SA, 5005, Australia. vnisenblat@gmail.com.

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  • Patrick MM Bossuyt,

    1. Academic Medical Center, University of Amsterdam, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam, Netherlands
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  • Cindy Farquhar,

    1. University of Auckland, Department of Obstetrics and Gynaecology, Auckland, New Zealand
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  • Neil Johnson,

    1. The University of Adelaide, Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, Adelaide, SA, Australia
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  • M Louise Hull

    1. The University of Adelaide, Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, Adelaide, SA, Australia
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Abstract

Background

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

Objectives

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.

• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.

Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

Search methods

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

Selection criteria

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

Data collection and analysis

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

Main results

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.

TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.

Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

Authors' conclusions

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

Plain language summary

Imaging tests for the non-invasive diagnosis of endometriosis

Review question

How accurate are imaging tests in detecting endometriosis? Can any imaging test be accurate enough to replace or reduce the need for surgery in the diagnosis of endometriosis?

Background

Women with endometriosis have endometrial tissue (the tissue that lines the womb and is shed during menstruation) growing outside the womb within the pelvis, causing chronic abdominal pain and difficulty conceiving. Currently, the only reliable way of diagnosing endometriosis is to perform laparoscopic surgery and visualise the endometrial deposits inside the abdomen. Because surgery is risky and expensive, imaging tests have been assessed for their ability to detect endometriosis non-invasively. An accurate imaging test could lead to the diagnosis of endometriosis without the need for surgery, or it could reduce the need for surgery, so only women who were most likely to have endometriosis would require it. Furthermore, if imaging tests could accurately predict the location of endometriotic lesions, surgeons would have the information they need to plan and improve their surgical approach. Other non-invasive ways of diagnosing endometriosis by using urine, blood and endometrial and combination tests have been evaluated in separate Cochrane reviews from this series.

Study characteristics

Evidence included in this review is current to April 2015. We included 49 studies involving 4807 participants. Thirteen studies evaluated pelvic endometriosis, 10 studies ovarian endometrioma, 15 studies deep endometriosis (endometriosis deeply situated in tissues in the pelvis) and 33 studies endometriosis at specific sites within the pelvic cavity. All studies included women of reproductive age who were undergoing diagnostic surgery because they had symptoms of endometriosis.

Key results

None of the imaging methods was accurate enough to provide this information on overall pelvic endometriosis. Transvaginal ultrasound identified ovarian endometriosis with enough accuracy to help surgeons determine whether surgery was needed, and magnetic resonance imaging (MRI) was sufficiently accurate to replace surgery in diagnosing endometrioma but was evaluated in only a small number of studies. Other imaging tests were assessed in small individual studies and could not be evaluated in a meaningful way. Transvaginal ultrasound could be used to locate more anatomical sites of deep endometriosis when compared with MRI, helping surgeons better plan an operative procedure. Endometriosis in the lower bowel appears to be relatively accurately identified by both transvaginal and transrectal ultrasound, by MRI and by multi-detector computerised tomography enema. New types of ultrasound and MRI show a lot of promise in detecting endometriosis but studies are too few to clearly show their diagnostic value.

Quality of the evidence

Generally the studies were of low methodological quality, and most imaging techniques were assessed by only a small number of studies. Differences between studies involved how they were run, groups of women studied, ways imaging tests were performed and how surgery was undertaken.

Future research

Additional high-quality research is needed to accurately evaluate the diagnostic potential of non-invasive imaging tests for endometriosis.

Резюме на простом языке

Методы визуализации для не-инвазивной диагностики эндометриоза

Вопрос обзора

Насколько точны методы медицинской визуализации для обнаружения эндометриоза? Может ли любой метод визуализации быть достаточно точным, чтобы заменить необходимость операции для диагностики эндометриоза?

Актуальность

У женщин с эндометриозом эндометриальные ткани (ткани, которые выстилают матку изнутри и выводятся при менструации) растут за пределы матки - в полость малого таза, и становятся причиной хронических абдоминальных болей (болей внизу живота), и проблем с зачатием. В настоящее время наиболее надёжным способом диагностики эндометриоза является проведение лапароскопической операции для визуального определения эндометриальных узлов в брюшной полости. В связи с тем, что операция является дорогостоящим и рискованным мероприятием, проводится оценка методов визуализации для не-инвазивного определения эндометриоза. Точный метод визуализации мог бы диагностировать эндометриоз без необходимости операции, или уменьшить необходимость в оперативном вмешательстве таким образом, что оно требовалось бы только тем женщинам, у которых наиболее высокая вероятность эндометриоза. Более того, если методы визуализации могли бы точно определять место эндометриоидных очагов, то хирурги располагали бы большей информацией для лучшего планирования оперативного подхода к лечению. Другими не-инвазивными методами диагностики эндометриоза являются исследования мочи, крови и эндометрия, а также комбинации тестов были оценены в отдельных Кокрейновских обзорах этой серии.

Характеристика исследований

Данные, включённые в этот обзор, актуальны по апрель 2015 года. Мы включили 49 исследований с участием 4807 женщин. 13 исследований рассматривали эндометриоз малого таза, 10 исследований рассматривали эндометриому яичника, 15 исследований - глубокий инфильтрирующий эндометриоз (эндометриоз, глубоко расположенный в тканях малого таза), и 33 исследования рассматривали эндометриоз в специфических зонах полости малого таза. Все исследования включали женщин детородного возраста, которым проводилась диагностическая операция в связи с симптомами эндометриоза.

Основные результаты

Ни один из методов визуализации не был достаточно точен для предоставления обобщённой информации об эндометриозе в полости малого таза. Трансвагинальное ультразвуковое исследование (УЗИ) определяло эндометриоз яичника с достаточной точностью, чтобы помочь хирургам выяснить необходимость операции. Магнитно-резонансная томография (МРТ) оказалась достаточно точна для замещения операции при диагностике эндометриомы, но эффективность этого метода оценивалась лишь в небольшом числе исследований. Иные методы визуализации оценивались в отдельных небольших исследованиях, но не могли быть значимо оценены. Трансвагинальное УЗИ находило большее число анатомических локусов с глубоким эндометриозом, в сравнении с МРТ, помогая хирургам лучше планировать оперативное вмешательство. Выяснилось, что эндометриоз нижних отделов толстой кишки можно относительно точно определить с помощью как трансвагинального, так и трансректального УЗИ, посредством МРТ или компьютерной томографией с множественными рядами детекторов и контрастной клизмой. Новые типы УЗИ и МРТ демонстрируют потенциал в определении эндометриоза, однако, существует ещё мало исследований для четкой демонстрации диагностической ценности этих методов.

Качество доказательств

Обычно исследования имели низкое методологическое качество, а большинство методов визуализации оценивались небольшим числом исследований. Различия между исследованиями включали различия в проведении исследований, группах женщин, методах визуализации и проведения операций.

Будущие исследования

Требуются дополнительные исследования высокого качества для оценки диагностического потенциала не-инвазивных методов визуализации для диагностики эндометриоза.

Заметки по переводу

Перевод: Гореликов Евгений Валентинович. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Казанский федеральный университет - аффилированный центр в Татарстане Северного Кокрейновского Центра. По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: lezign@gmail.com

Laički sažetak

Neinvazivna dijagnostika kao pretrage za endometriozu

Istraživačko pitanje

Koliko su pouzdane slikovne dijagnostičke pretrage u otkrivanju endometrioze? Mogu li slikovne dijagnostičke metode zamijeniti kirurške za dijagnozu endometrioze?

Dosadašnje spoznaje

Endometrioza je stanje kad se tkivo endometrija (tkivo unutrašnjosti maternice koje se ljušti menstruacijom) nalazi u trbušnoj šupljini izvan maternice te uzrokuje bolove u trbuhu i otežava postizanje trudnoće. Za sada je pouzdana metoda dijagostike laparoskopski zahvat i vizualni nalaz endometrija u trbušnoj šupljini. Kirurški zahvat ima određene rizike i skup je, te su ispitane mogućnosti slikovnih metoda kao neinvazivnih pretraga u dijagnostici endometrioze. Pouzdana slikovna metoda isključuje kirurški zahvat, ili smanjuje učestalost ovih zahvata kod sumnje na endometriozu. Slikovne metode također mogu odrediti lokaciju endometrioze, a što je važno pri kirurškom uklanjanju. Druge neinvazivne metode uključuju pretrage u krvi i mokraći, te su obrađene u zasebnom Cochrane sustavnom pregledu.

Značajke istraživanja

Dokazi prikazani u ovo sustavnom pregledu literature temelje se na podatcima objavljenim do travnja 2015. Uključili smo 49 studija s ukupno 4807 bolesnica. U 13 studija je istražena zdjelična endometrioza, u 10 endometrioza jajnika, u 15 duboka endometrioza (duboko u zdjeličnim tkivima) i 33 studije endometrioze na specifičnim mjestima zdjelice. Uključene su žene generativne dobi podvrgnute kirurškom zahvatu zbog simptoma endometrioze.

Ključni rezultati

Niti jedna slikovna metoda nije bila dovoljno točna za podatak o prisutnosti endometrioze u zdjelici. Transvaginalni ultrazvuk otkriva endometriozu jajnika sa dostatnom točnošću za procjenu potrebe kirurškog zahvata, a magnetska rezonanca (MRI, engl. magnetic resonance imaging) je dovoljno točna da isključi potrebu za dijagnostičkim kirurškim zahvatom, ali je ispitana u malom broju studija. Druge slikovne metode su ispitane u malim studijama i nisu prikladne za procjenu. Transvaginalni ultrazvuk je bolje primjenjiv za otkrivanje lokacija duboke endometrioze u usporedbi s magnetskom rezonancom pri planiranju kirurškog liječenja. Endometrioza u području stražnjeg crijeva može se pouzdano dijangosticirati transvaginalnim i transrektalnim ultrazvukom, magnetskom rezonancom i komjuteriziranom tomografijom uz klizmu. Nove vrste ultrazvuka i magnetske rezonance čine se obećavajuće u otkrivanju endometrioze, ali je premalo studija za procjenu njihove dijagnostičke vrijednosti.

Kvaliteta dokaza

Studije su općenito bile niske metodološke kvalitete i slikovne tehnike su ispitane u malom broju studija. Razlike između studija su se odnosile na provedbu, skupine uključenih žena, primjenu slikovnih metoda i kirurških zahvata.

Buduća istraživanja

Potrebna su dodatna kvalitetna istraživanja za pouzdanu procjenu mogućnosti neinvazivnih slikovnih metoda u dijagnostici endometrioze.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Vesna Kušec
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Laienverständliche Zusammenfassung

Bildgebungsverfahren zur nichtinvasiven Diagnose von Endometriose

Fragestellung

Wie genau sind Bildgebungsverfahren bei der Erkennung von Endometriose? Kann ein Bildgebungsverfahren genau genug sein, um einen chirurgischen Eingriff zur Diagnose von Endometriose zu ersetzen oder seine Notwendigkeit zu begrenzen?

Hintergrund

Bei Frauen mit Endometriose wächst Endometriumgewebe (das Gewebe, das die Gebärmutter auskleidet und während der Menstruation abgestoßen wird) außerhalb der Gebärmutter im Becken, was zu chronischen Bauchschmerzen und Schwierigkeiten bei der Empfängnis führt. Derzeit besteht die einzige zuverlässige Möglichkeit, eine Endometriose zu diagnostizieren, in der Durchführung eines laparoskopischen Eingriffs, um die Endometrioseherde im Bauchraum sichtbar zu machen. Da eine Operation immer mit Risiken verbunden und teuer ist, hat man Bildgebungsverfahren auf ihre Fähigkeit untersucht, Endometriose auf nichtinvasive Art zu erkennen. Ein genaues Bildgebungsverfahren könnte zur Diagnose von Endometriose ohne die Notwendigkeit eines chirurgischen Eingriffs führen oder könnte die Notwendigkeit eines solchen Eingriffs verringern, sodass nur Frauen mit der höchsten Wahrscheinlichkeit einer Endometriose ihn benötigen würden. Wenn Bildgebungsverfahren weiterhin genau vorhersagen könnten, an welchen Stellen sich endometrische Läsionen befinden, würde das Chirurgen die Informationen liefern, die sie bräuchten, um ihren Eingriff zu planen und zu verbessern. Andere nichtinvasive Möglichkeiten der Endometriose-Diagnose über Urin und Blut sowie die Untersuchung der Gebärmutterschleimhaut und Kombinationstests wurden in weiteren Cochrane Reviews dieser Reihe ausgewertet.

Studienmerkmale

Die Evidenz in diesem Review ist auf dem Stand vom April 2015. Wir schlossen 49 Studien mit 4807 Teilnehmerinnen ein. 13 Studien werteten Endometriose des Beckens aus, 10 Studien Endometrioseherde an den Eierstöcken, 15 Studien tief infiltrierende Endometriose (im Becken tief in Geweben auftretende Endometriose) und 33 Studien Endometriose an bestimmten Stellen im Beckenraum. Alle Studien wurden mit Frauen im gebärfähigen Alter durchgeführt, die sich einem diagnostischen Eingriff unterzogen, weil sie Symptome einer Endometriose zeigten.

Hauptergebnisse

Keins der Bildgebungsverfahren war genau genug, um diese Informationen zur allgemeinen Beckenendometriose zu liefern. Durch transvaginalen Ultraschall konnte Endometriose an den Eierstöcken mit ausreichender Genauigkeit erkannt werden, um die Chirurgen bei der Entscheidung zu unterstützen, ob ein Eingriff erforderlich ist, und die Magnetresonanztomografie (MRT) erwies sich als genau genug, um den chirurgischen Eingriff in der Diagnose von Endometrioseherden zu ersetzen, wurde jedoch nur in einer geringen Anzahl von Studien ausgewertet. Andere Bildgebungsverfahren wurden in kleinen Einzelstudien beurteilt und konnten nicht sinnvoll ausgewertet werden. Durch transvaginalen Ultraschall ließen sich im Vergleich zum MRT mehr anatomische Bereiche mit tief infiltrierender Endometriose aufspüren, wodurch die Chirurgen einen operativen Eingriff besser planen konnten. Endometriose im unteren Darmbereich lässt sich offenbar relativ genau sowohl durch transvaginalen als auch durch transrektalen Ultraschall, durch MRT und durch Multidetektor-CT mit Kontrastmitteleinlauf feststellen. Neue Arten von Ultraschall und MRT erscheinen vielversprechend für die Endometrioseerkennung, aber es gibt noch zu wenige Studien, um ihren diagnostischen Wert eindeutig zu belegen.

Qualität der Evidenz

Insgesamt waren die Studien von niedriger methodischer Qualität und die meisten Bildgebungsverfahren wurden nur in einer geringen Anzahl von Studien bewertet. Die Studien unterschieden sich beispielsweise in der Durchführung, den Gruppen untersuchter Frauen, der Durchführung der Bildgebung und der Durchführung der chirurgischen Eingriffe.

Zukünftige Forschungsarbeiten

Es sind zusätzliche hochwertige Forschungsarbeiten erforderlich, um das diagnostische Potenzial nichtinvasiver Bildgebungsverfahren bei Endometriose genau auszuwerten.

Anmerkungen zur Übersetzung

S. Schmidt-Wussow, freigegeben durch Cochrane Schweiz.

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