Fertility in patients with untreated rectosigmoid endometriosis.

RESEARCH QUESTION: Several studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery. DESIGN: A retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded. RESULTS: During the median length of follow-up of 31 months (range 13-63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8-35.6%) with a median time required to conceive of 10 months (range 2-34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1-45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed. CONCLUSIONS: At median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.

Other imaging techniques: Double-contrast barium enema, endoscopic ultrasonography, multidetector CT enema, and computed tomography colonoscopy.

Double-contrast barium enema (DCBE), transrectal endoscopic ultrasonography (REU), multidetector computerized tomography enema (MDCT-e), and computed tomography colonoscopy (CTC) have been successfully used for the diagnosis of bowel endometriosis. DCBE provides a complete overview of the entire colon and allows detecting cecal nodules. The accuracy of DCBE is operator dependent and, thus, it may have low specificity. It does not allow identifying the cause of the mass effect. DCBE requires the administration of barium and exposure to radiation. REU precisely estimates the distance between the rectosigmoid nodule and the anal verge. However, it allows investigating only the distal part of rectosigmoid, it misses anterior pelvic lesions, and it has poor sensitivity for the diagnosis of endometriomas. MDCT-e is accurate and reproducible in diagnosing intestinal endometriosis and in assessing its characteristics: the largest diameter of the nodule, the distance between the distal part of the nodule and the anal verge, and depth of infiltration of endometriosis in the intestinal wall. MDCT-e requires the administration of iodinated contrast medium (CM) and the exposure to radiations. CTC has good performance in the diagnosis of rectosigmoid endometriosis. It allows estimating the degree of intestinal stenosis CTC, and the distance between the intestinal endometriotic nodule and the anal verge. It requires exposure to radiations, and it may require the administration of an iodinated CM.

Evaluation of novel coronavirus disease (COVID-19) using quantitative lung CT and clinical data: prediction of short-term outcome.

BACKGROUND: Computed tomography (CT) enables quantification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, helping in outcome prediction. METHODS: From 1 to 22 March 2020, patients with pneumonia symptoms, positive lung CT scan, and confirmed SARS-CoV-2 on reverse transcription-polymerase chain reaction (RT-PCR) were consecutively enrolled. Clinical data was collected. Outcome was defined as favourable or adverse (i.e., need for mechanical ventilation or death) and registered over a period of 10 days following CT. Volume of disease (VoD) on CT was calculated semi-automatically. Multiple linear regression was used to predict VoD by clinical/laboratory data. To predict outcome, important features were selected using a priori analysis and subsequently used to train 4 different models. RESULTS: A total of 106 consecutive patients were enrolled (median age 63.5 years, range 26-95 years; 41/106 women, 38.7%). Median duration of symptoms and C-reactive protein (CRP) was 5 days (range 1-30) and 4.94 mg/L (range 0.1-28.3), respectively. Median VoD was 249.5 cm3 (range 9.9-1505) and was predicted by lymphocyte percentage (p = 0.008) and CRP (p < 0.001). Important variables for outcome prediction included CRP (area under the curve [AUC] 0.77), VoD (AUC 0.75), age (AUC 0.72), lymphocyte percentage (AUC 0.70), coronary calcification (AUC 0.68), and presence of comorbidities (AUC 0.66). Support vector machine had the best performance in outcome prediction, yielding an AUC of 0.92. CONCLUSIONS: Measuring the VoD using a simple CT post-processing tool estimates SARS-CoV-2 burden. CT and clinical data together enable accurate prediction of short-term clinical outcome.

Magnetic Resonance Rectal Enema Versus Computed Tomographic Colonography in the Diagnosis of Rectosigmoid Endometriosis.

OBJECTIVES: Rectosigmoid involvement by endometriosis causes intestinal symptoms such as constipation, diarrhea, and dyschezia. A precise diagnosis about the presence, location, and extent of bowel implants is required to plan the most appropriate treatment. The aim of the study was to compare the accuracy of magnetic resonance with distension of the rectosigmoid (MR-e) with computed colonography (CTC) for diagnosing rectosigmoid endometriosis. METHODS: This study was based on the retrospective analysis of a prospectively collected database of patients with suspicion of rectosigmoid endometriosis who underwent both MR-e and CTC, and subsequently were treated by laparoscopy. The findings of imaging techniques were compared with surgical and histological results. RESULTS: Of 90 women included in the study, 44 (48.9%) had rectosigmoid nodules and underwent bowel surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of rectosigmoid endometriosis were 88.6%, 93.5%, 92.9%, 89.6%, and 91.1% for CTC, and 93.2%, 97.9%, 97.6%, 93.8%, and 95.6% for MR-e. There was no significant difference in the accuracy of both radiologic examinations for diagnosing rectosigmoid endometriosis (P = 0.344). However, MR-e was more accurate than CTC in estimating the largest diameter of the main rectosigmoid nodule (P < 0.001). The pain perceived by the patients was significantly lower during MR-e than during CTC (P < 0.001). CONCLUSIONS: MR-e and CTC have similar diagnostic performance for the diagnosis of rectosigmoid involvement of endometriosis. However, MR-e is more accurate in the estimation of the largest diameter of main rectosigmoid nodule and more tolerated than CTC.

A Prospective Study Comparing Three-Dimensional Rectal Water Contrast Transvaginal Ultrasonography and Computed Tomographic Colonography in the Diagnosis of Rectosigmoid Endometriosis.

(1) Objectives: In patients with symptoms suggestive of rectosigmoid endometriosis, imaging techniques are required to confirm the presence and establish the extent of the disease. The objective of the current study was to compare the performance of three-dimensional rectal water contrast transvaginal ultrasonography (3D-RWC-TVS) and computed tomographic colonography (CTC) in predicting the presence and characteristics of rectosigmoid endometriosis. (2) Methods: This prospective study included patients with suspicion of rectosigmoid endometriosis who underwent both 3D-RWC-TVS and CTC and subsequently were surgically treated. The findings of imaging techniques were compared with surgical and histological results. (3) Results: Out of 68 women included in the study, 37 (48.9; 95% C.I. 38.2-59.7%) had rectosigmoid nodules and underwent bowel surgery. There was no significant difference in the accuracy of 3D-RWC-TVS and CTC in diagnosing the presence of rectosigmoid endometriotic nodules (p = 0.118), although CTC was more precise in diagnosing endometriosis located in the sigmoid (p = 0.016). 3D-RWC-TVS and CTC had similar precision in estimating the largest diameter of the main endometriotic nodule (p = 0.099) and, in patients undergoing segmental resection, the degree of the stenosis of the bowel lumen (p = 0.293). CTC was more accurate in estimating the distance between the lower margin of the intestinal nodule and the anal verge (p = 0.030) but was less tolerated than 3D-RWC-TVS (p < 0.001). (4) Conclusion: This was the first study comparing the performance of 3D-RWC-TVS and CTC in the diagnosis of rectosigmoid endometriosis. Both techniques allowed for the evaluation of the profile of the bowel lumen in a pseudoendoscopic fashion and had a similar performance for the diagnosis of rectosigmoid endometriosis, although CTC was more accurate in diagnosing and characterizing sigmoid nodules.

Magnetic Resonance Enema in Rectosigmoid Endometriosis.

Intestinal endometriosis occurs in 4% to 37% of women with deep endometriosis (DE). Noninvasive diagnosis of presence and characteristics of rectosigmoid endometriosis permits the best counseling of patients and ensures best therapeutic planning. Magnetic resonance enema (MR-e) is accurate in diagnosing DE. After colon cleansing, rectal distention and opacification improves the performance of MR-e in diagnosing rectosigmoid endometriosis. MR imaging cannot optimally assess the depth of penetration of endometriosis in the intestinal wall. There is a need for multicentric studies with a larger sample size to evaluate reproducibility of MR-e in diagnosis of rectosigmoid endometriosis for less experienced radiologists.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility.

BACKGROUND: The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined. OBJECTIVE AND RATIONALE: The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE. SEARCH METHODS: A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review. OUTCOMES: The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE. WIDER IMPLICATIONS: In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Spontaneous fertility after expectant or surgical management of rectovaginal endometriosis in women with or without ovarian endometrioma: a retrospective analysis.

OBJECTIVE: To investigate spontaneous pregnancy rate (SPRs) of women with rectovaginal endometriosis (RV) with/without ovarian endometrioma (OMA) and treated with the use of expectant or surgical management. DESIGN: Retrospective study. SETTING: University hospital. PATIENT(S): The study included patients with RV with or without OMA who tried to conceive spontaneously for 1 year either without undergoing surgery (group E; n = 284) or after surgery (group S; n = 221). The study population was further divided into four subgroups: women with RV without OMA who directly tried to conceive (group eRV; n = 121) or tried to conceive after surgery (group sRV; n = 96), and women with RV with OMA who directly tried to conceive (group eOMA; n = 163) or tried to conceive after surgery (group sOMA; n = 125). INTERVENTIONS(S): Expectant or surgical management. MAIN OUTCOME MEASURE(S): Crude and cumulative SPRs. RESULT(S): At 1 year, crude and cumulative SPRs were lower in group E (17.3% and 23.8%, respectively) than in group S (35.7% and 39.5%). Similarly, crude and cumulative SPRs were lower in group eRV (24.8% and 30.6%) than in group sRV (42.7% and 45.7%, respectively) and in group eOMA (11.7% and 18.0%) than group sOMA (30.4% and 34.5%). At 1 year, crude and cumulative SPRs were higher in group eRV (24.8% and 30.6%) than in group eOMA (11.7% and 18.0%), and in group sRV (42.7% and 45.7%) than in group sOMA (30.4% and 34.5%). CONCLUSION(S): Crude and cumulative SPRs are lower in women treated with the use of expectant rather than surgical management. The presence of OMAs decreases SPRs independently from the treatment modality adopted.

Efficacy and acceptability of long-term norethindrone acetate for the treatment of rectovaginal endometriosis.

OBJECTIVE: To study the efficacy of long-term treatment with norethindrone acetate (NETA) in patients with rectovaginal endometriosis. STUDY DESIGN: This retrospective cohort study included 103 women with pain symptoms caused by rectovaginal endometriosis. Patients received NETA alone (2.5mg/day up to 5mg/day) for 5 years. Primary outcome was the degree of satisfaction with treatment after 5 years of progestin therapy. Secondary outcomes were the assessment of any variation in pain symptoms and the volumetric assessment of the disease by magnetic resonance imaging (MRI). RESULTS: Sixty-one women completed the 5-year follow-up (61/103, 59.2%) with 16 women withdrawing because of adverse effects (38.1%). Overall, 68.8% (42/61) of the women who completed the study were satisfied or very satisfied of this long term NETA treatment. This represents a 40.8% (42/103) of the patients enrolled. Intensity of chronic pelvic pain and deep dyspareunia significantly decreased during treatment (p<0.001 versus baseline at 1 and 5year). Dyschezia improved after 1-year respect to baseline (p=0.008) but remained stable between first and second year (p=0.409). At the end of 5 years treatment, a radiological partial response was observed in 33 patients (55.9%, n 33/59); a stable disease in 19 patients (32.2%, n 19/59). Seven women (7/59, 11.9%) displayed a volumetric increase of rectovaginal endometriosis under NETA treatment. CONCLUSION: Five-year therapy with NETA is safe and well tolerated by women with rectovaginal endometriosis. Due to its low cost and good pharmacological profile, it represents a good candidate for long-term treatment in this setting.

Association of Biomarkers with Serious Cardiac Adverse Events during Abiraterone Acetate Treatment in Castration Resistant Prostate Cancer.

BACKGROUND: Abiraterone acetate is an effective drug for castration-resistant prostate cancer, but cardiac serious adverse events (SAEs) may occur. We studied their association with N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T (TnT) during abiraterone therapy. PATIENTS AND METHODS: In a single institution, 17 patients were treated with abiraterone acetate 1 g daily with concomitant prednisone and then switched to dexametasone plus canrenone. Blood samples for PSA, NT-proBNP, and TnT were obtained at baseline and after 1, 3, and 6 months. RESULTS: Five patients (29.4%) experienced G3 to 4 cardiac SAEs after a median of 13 weeks (range, 9-32), including pulmonary edema, heart failure, acute coronary syndrome, sinus bradycardia with syncope, and pulmonary edema. At baseline, 4 weeks, and 3 months, median NT-proBNP and TnT levels were higher in patients with subsequent cardiac SAEs (P= .03 and P= .04 for NT-proBNP and TnT at 3 months, respectively). After switching to dexametasone and introducing canrenone, no additional cardiac SAEs were noted. Overall response rate was 67%. CONCLUSIONS: Our study suggests a higher than expected risk of cardiac SAEs during abiraterone treatment which may well be due to the small sample size and the unrestricted entry criteria. However, baseline and frequent NT-proBNP and TnT monitoring predicted a higher risk for cardiac SAE. Larger studies should confirm our findings.

MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences.

INTRODUCTION: Although some studies proved the role of STIR sequences in the evaluation of perianal fistulas in Crohn's Disease (CD), contrast medium is still injected in many institutions since there is not a validated reference MR protocol. Our purpose was to evaluate the role of the STIR sequence in the detection and characterization of perianal fistulae comparing it to the post-contrast T1 sequence and correlating it with rectal examination under anesthesia. MATERIALS AND METHODS: We retrospectively reviewed all clinical records of 31 CD patients, suspected of having perianal fistulas, who had been submitted to an MR study before and after contrast medium injection and surgical exploration under anesthesia within the same month. Perianal fistulas were classified according to the Parks' criteria. Finally, comparison between STIR and post-contrast T1-weighted fat saturated sequences was done. RESULTS: 29 fistulas were detected in 25 patients who underwent an MR study. There was no significant difference between MR imaging and exploration under anesthesia. For the detection of perianal fistulas of any type, there was a perfect statistical agreement between gadolinium-enhanced and STIR sequences (kappa value = 1). CONCLUSION: STIR sequences represent a valid alternative to the T1-weighted sequences acquired after the injection of contrast medium, allowing the identification of the primary fistula, any secondary ramification, and complications of the disease.

The Italian consensus to virtual colonoscopy.

OBJECTIVES: To produce an informed consent for CT colonography (CTC), to be diffused by the Italian Society of Radiology, aimed to make patients and referring physicians aware of CTC examination protocol, advantages and disadvantages, limits and potential related risks. MATERIALS AND METHODS: Delphi method was used to create a consensus among experts on an informed consent for CTC. The overall agreement among different consulted specialists was evaluated and ranked using the Cronbach's correlation coefficient (α) at two time points: after the first and the second 'round' of consultation. RESULTS: The Cronbach index was 0.84 at the end of the first round and 0.93 at the end of the second round. The number of disagreements dropped from an overall of 11-5, from the first to the second round. CONCLUSIONS: The experts were able to produce an informed consent for CTC, hoping that this may be the beginning of a process focused on implementation of quality standards in CTC.

Value of fused 18F-Choline-PET/MRI to evaluate prostate cancer relapse in patients showing biochemical recurrence after EBRT: preliminary results.

PURPOSE: We compared the accuracy of (18)F-Choline-PET/MRI with that of multiparametric MRI (mMRI), (18)F-Choline-PET/CT, (18)F-Fluoride-PET/CT, and contrast-enhanced CT (CeCT) in detecting relapse in patients with suspected relapse of prostate cancer (PC) after external beam radiotherapy (EBRT). We assessed the association between standard uptake value (SUV) and apparent diffusion coefficient (ADC). METHODS: We evaluated 21 patients with biochemical relapse after EBRT. Patients underwent (18)F-Choline-PET/contrast-enhanced (Ce)CT, (18)F-Fluoride-PET/CT, and mMRI. Imaging coregistration of PET and mMRI was performed. RESULTS: (18)F-Choline-PET/MRI was positive in 18/21 patients, with a detection rate (DR) of 86%. DRs of (18)F-Choline-PET/CT, CeCT, and mMRI were 76%, 43%, and 81%, respectively. In terms of DR the only significant difference was between (18)F-Choline-PET/MRI and CeCT. On lesion-based analysis, the accuracy of (18)F-Choline-PET/MRI, (18)F-Choline-PET/CT, CeCT, and mMRI was 99%, 95%, 70%, and 85%, respectively. Accuracy, sensitivity, and NPV of (18)F-Choline-PET/MRI were significantly higher than those of both mMRI and CeCT. On whole-body assessment of bone metastases, the sensitivity of (18)F-Choline-PET/CT and (18)F-Fluoride-PET/CT was significantly higher than that of CeCT. Regarding local and lymph node relapse, we found a significant inverse correlation between ADC and SUV-max. CONCLUSION: (18)F-Choline-PET/MRI is a promising technique in detecting PC relapse.

Advantages of percutaneous abdominal biopsy under PET-CT/ultrasound fusion imaging guidance: a pictorial essay.

Positron emission tomography (PET) is a functional imaging technique that can investigate the metabolic characteristics of tissues. Currently, PET images are acquired and co-registered with a computed tomography (CT) scan (PET-CT), which is employed for correction of attenuation and anatomical localization. In spite of the high negative predictive value of PET, false-positive results may occur; indeed, Fluorine 18 ((18)F)-fluorodeoxyglucose ((18)F-FDG) uptake is not specific to cancer. As (18)F-FDG uptake may also be seen in non-malignant infectious or inflammatory processes, FDG-avid lesions may necessitate biopsy to confirm or rule out malignancy. However, some PET-positive lesions may have little or no correlative ultrasound (US) and/or CT findings (i.e., low conspicuity on morphological imaging). Since it is not possible to perform biopsy under PET guidance alone, owing to intrinsic technical limitations, PET information has to be integrated into a CT- or US-guided biopsy procedure (multimodal US/PET-CT fusion imaging). The purpose of this pictorial essay is to describe the technique of multimodal imaging fusion between real-time US and PET/CT, and to provide an overview of the clinical settings in which this multimodal integration may be useful in guiding biopsy procedures in PET-positive abdominal lesions.

Multidetector computerized tomography enema versus magnetic resonance enema in the diagnosis of rectosigmoid endometriosis.

PURPOSE: To compare the accuracy of multidetector computerized tomography enema (MDCT-e) and magnetic resonance enema (MRI-e) in determining the presence of sigmoid and rectal endometriotic nodules. MATERIALS AND METHODS: 260 women (32.6 ± 4.3 years) with symptoms suggestive of rectosigmoid endometriosis underwent MDCT-e and MRI-e prior to laparoscopy. After retrograde colonic distention and injection of intravenous contrast medium, patients were scanned on a 64-row MDCT scanner. MRI-e was performed on a 1.5T magnet using an 8 channels phased array coil; intestinal distention was achieved by introducing in the rectum 250-300 ml of ultrasonographic gel diluted with saline solution. Radiological findings were compared with surgical and histological results. RESULTS: 176 women had rectosigmoid endometriosis at surgery. There was no significant difference in the accuracy of MDCT-e (98.5%) and MRI-e (96.9%) in the diagnosis of sigmoid and rectal endometriosis (p=0.248). The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of MDCT-e and MRI-e were respectively 98.3%, 98.8%, 99.4%, 96.5%, 81.59, 0.02 and 97.2%, 96.4%, 98.3%, 94.1%, 26.89, 0.03. CONCLUSIONS: Both MDCT-e and MRI-e are accurate in the diagnosis of rectal and sigmoid endometriosis.

Diagnostic value of real-time elastography in the assessment of hepatic fibrosis in patients with liver iron overload.

OBJECTIVE: The objective of our prospective monocentric work was to determine the diagnostic value of real-time elastography (RTE) in the assessment of liver fibrosis in patients with iron overload, using transient elastography (TE) as reference standard. METHODS: Sixty-seven consecutive patients with MRI detectable iron overload (T2*<6.3 ms) were enrolled. TE and RTE were performed on the same day as MRI. Elastograms were acquired by an experienced operator and analyzed by calculating the elastic ratio between perihepatic soft tissues and liver parenchyma. An elliptical ROI of 1cm(2) (Z1) was positioned in the liver parenchyma and a smaller elliptical ROI of 2mm(2) (Z2) was positioned in a homogeneously soft (red) region of the diaphragm, which was considered as internal control to calculate the elastic ratio Z2/Z1. RESULTS: Seven patients were excluded because of invalid TE or RTE examinations. The remaining 60 patients were 57% males and 43% females (mean age: 42 [21-76] years), including 37 homozygous-ß-thalassemics, 13 patients with ß-thalassemia intermedia, 6 with primary hemochromatosis, and 4 with myelodysplastic syndrome. Increasing elastic ratios were significantly correlated with increasing TE values (r=0.645, 95% CI 0.468-0.772, P<0.0001). The mean elastic ratios for each METAVIR group were as follows: F0/1 = 1.9 ± 0.4; F2 = 2.2 ± 0.4; F3 = 2.9 ± 0.5; F4 = 3.2 ± 0.4. The diagnostic accuracy of RTE for F ≥ 2 evaluated by AUC-ROC analysis was 0.798 (95% CI 0.674-0.890). The diagnostic accuracy of RTE for F ≥ 3 was 0.909 (95% CI 0.806-0.968). At a cut-off ≥ 2.75, RTE showed a sensitivity of 70% (95% CI 45.7-88.1) and a specificity of 97.5% (95% CI 86.8-99.9). CONCLUSIONS: In patients with MRI-detectable liver iron-overload RTE allows to discriminate between F0/1-F2 and F3-F4 with a reasonable diagnostic accuracy.