Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence.Key Points• This report provides guidelines for MRI in endometriosis.• Minimal and optimal MRI acquisition protocols are provided.• Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.Electronic supplementary materialThe online version of this article (doi:10.1007/s00330-016-4673-z) contains supplementary material, which is available to authorized users.

• MRI is recommended for initial staging of endometrial cancer. • MR imaging protocol should be tailored based on the risk of lymph node metastases. • Myometrial invasion is best assessed using combined axial-oblique T2WI, DWI and contrast-enhanced imaging. • The mnemonic "Clinical and MRI Critical TEAM" summarizes key elements of the standardized report.

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In reproductive women, various physiologic conditions can cause morphologic changes of the ovary, resembling pathologic conditions. Benign ovarian diseases can also simulate malignancies. Magnetic resonance imaging (MRI) can play an important role in establishing accurate diagnosis. Functional cysts should not be confused with cystic neoplasms. Corpus luteum cysts typically have a thick wall and are occasionally hemorrhagic. Multicystic lesions that may mimic cystic neoplasms include hyperreactio luteinalis, ovarian hyperstimulation syndrome, and polycystic ovary syndrome. Recognition of clinical settings can help establish diagnosis. In endometrial cysts, MRI usually provides specific diagnosis; however, decidual change during pregnancy should not be confused with secondary neoplasm. Peritoneal inclusion cysts can be distinguished from cystic neoplasms by recognition of their characteristic configurations. Ovarian torsion and massive ovarian edema may mimic solid malignant tumors. Recognition of normal follicles and anatomic structures is useful in diagnosing these conditions. In pelvic inflammatory diseases, transfascial spread of the lesion should not be confused with invasive malignant tumors. Radiologic identification of abscess formation can be a diagnostic clue. Many benign tumors, including teratoma, Brenner tumor, and sex-cord stromal tumor, frequently show characteristic MRI features. Knowledge of MRI features of these conditions is essential in establishing accurate diagnosis and determining appropriate treatment.

Diffuse uterine enlargement is a common clinical finding. Because this abnormality can represent a physiologic manifestation, benign tumor, or malignancy, the diagnostic dilemma of a diffusely enlarged uterus can be challenging. Clinical findings can provide valuable information in regard to physiologic effects, pregnancy-related changes, and hormonal causes. Cytologic examination is essential for identification of cervical and endometrial malignancies. However, since preoperative histologic examination of myometrial lesions is not possible, preoperative distinction between benign and malignant conditions is frequently difficult. Imaging thus plays an important role in evaluation of myometrial lesions. In particular, magnetic resonance (MR) imaging allows specific diagnosis of several different lesions. Signal voids and prominent vessels at MR imaging are characteristic of vascular lesions. Adenomyosis and leiomyomas can be distinguished from other lesions with MR imaging, although a variety of unusual manifestations can be seen. MR imaging findings that allow distinction between leiomyoma and leiomyosarcoma have yet to be clearly established; however, invasion, hemorrhagic necrosis, or rapid growth is suggestive of malignancy. Endometrial stromal sarcoma tends to have distinct MR imaging features that allow differentiation from benign lesions.

Purpose:To demonstrate the feasibility of diffusion tensor imaging (DTI) of kidneys with respiratory triggering, and determine the optimal imaging parameters for fraction anisotropy (FA) maps. Materials and Methods:DTI of kidneys from 16 healthy volunteers was performed using a 1.5T scanner. Five different sequences with different parameters including respiration-triggered acquisition or multiple breath-holding, slice thicknesses of 3 or 5 mm, and different numbers of signal averaging and b values were compared. FA and apparent diffusion coefficients (ADCs) of the cortex and medulla were measured. Measurement error within the same and repeated examination was examined using within-individual standard deviation (Sw). Results:FAs of the renal cortex were lower than the medulla (mean value of a sequence ranging 0.148 -0.224, 0.433-0.476) and the ADCs of the cortex were higher than the medulla (2.26 -2.69 ϫ 10 Ϫ3 mm 2 /s, 1.77-2.19 ϫ 10 Ϫ3 mm 2 /s) in all sequences (P Ͻ 0.001). The renal cortexmedulla difference was the largest, with respiratory triggering including a 3-mm slice thickness, three signal averages,and a b-value ϭ 0, 200, or 400 s/mm 2 (P Ͻ 0.001). Sw tended to be smaller in the sequence with a b-value of 400 s/mm 2 . Conclusion: DTI of kidneys with respiratory triggering is feasible with excellent cortex-medulla differentiation.

Endometriosis is one of the most important causes of infertility; however the precise mechanism by which it affects female fertility is unclear. The objective of this study was to study the functional aspects of the uterus by evaluating uterine contractility in patients with endometrial cysts of the ovary. The study population was recruited from two institutes and consisted of 26 women (periovulatory (10), luteal (13), and menstrual phase (3); age range: 19-51 years) with untreated endometriosis; the control group consisted of 12 healthy women (age range: 22-41 years). Cine MR imaging obtained by a 1.5T magnet was visually evaluated at 12x faster than real speed, focusing on the presence of uterine peristalsis, the direction and frequency of peristalsis, and the presence of sustained uterine contractions. Uterine peristalsis was identifiable in 3/10, 3/13, and 3/3 of the endometriosis patients in each menstrual cycle, respectively, and in 11/12, 3/12, and 5/12 of their control subjects. Peristaltic detection rate and frequency were significantly less for the endometriosis group than for the controls in the periovulatory phase only (p<0.05). Sustained contractions were recognized in 19/36 control subjects and in 13/26 endometriosis patients, but the difference was not significant. Uterine peristalsis appears to be suppressed during the periovulatory phase in patients with endometriosis, which may have an adverse effect on sperm transport.