 We again have the international edition of our MRA teaching course, so on 16th and 17th of November and 9th and 10th of November, 2024. And finally, we have this ono bars 2025, which is to be held in Jan. Just a quick word or quick highlights about our MRA teaching course, which is to be held in April from the 5th to 7th. This will be in Mumbai at Hotel C Princes and we have planned several interesting sessions for you like the MR Mania quiz, which received really good response during our last conference. We have exciting prizes for the winners. And we also have a multidisciplinary meet where our radio ortho and patho teams will be discussing bone tumor related topics. And also we have radiology sprints where we have 10 to 15 minutes important exam oriented topic sessions. We also have prizes for the best paper and poster entries. So please do go ahead and send. So registrations for all these programs are open. I'll be sharing the links in the chat box. So moving on to the session for today. It's my pleasure to introduce Dr. Gayatri Hershey. She's a consultant radiologist at Nanavati Max Super Speciality Hospital and her interests are in body imaging. So she will be discussing an article on endometriosis, clinical features and MR imaging findings along with the enzyme classification. Thanks Gayatri for joining us and you can take over now. Thank you Gauri. And can I share my theory? Yes, please. Good morning everyone. I'm Dr. Gayatri and first and foremost I would like to thank Indian radiologist for giving me this opportunity to present the journal. And now without further ado, I will start with my article. So here overview of the today's lecture will be basic terminologies from rad assist, which I thought will be useful for you. Then followed by endometriosis, the article which we are going to discuss endometriosis, clinical features, MR imaging findings and pathologic correlation. Then how the newer enzyme classification we can apply while doing our cases and few of the cases where we can apply this enzyme and how we can do that. This is the rad assist article where they have described some terminologies. Article name is MRI of endometriosis. So we will quickly go through few terminologies which we are not, we are well versed but we want to just quick review of that. So this is the superficial endometriosis implant, which is called as SIE, which is less than five millimeter of peritoneal invasion. In the MR, these are the implants which are even hyper intense for along the serosa of the cervix. And these are not well seen on T2 weighted images. These superficial endometriotic implants actually burden estimate underestimated by the MRI. Most of the times we miss these legions on MR. Next is deep infiltrating endometriosis that is more than five millimeter of peritoneal invasion. There are two morphologic subtypes of this, where you can first is the active glandular morphology. In this image where the T2 axial image is showing T2 hyper intense area which is, these are T2 hyper intense cysts and these are T1 hyper intense corresponding to that. So these are mainly the hemorrhagic glandular or cystic tissue predominates. These are mean T1 hyper intense and T2 hyper intense or they can be T1 hyper intense and T2 hyper intense cysts. Next is deep infiltrating endometriosis are the type chronic stromal fibrotic morphology. Smooth muscle hypertrophy and fibrosis predominates here. This is the lesion which is T2 hyper intense. It is also T1 hyper intense and it has these linear scars, steel age shaped scars. This may cause tethering or obliteration of spaces and fibrotic scarring across a peritoneal or retroperitoneal space bringing adjacent organ into fixed contact with one another. Then next is endometriomas which we are familiar with. These are homogenously T1 hyper intense and heterogenously T2 hyper intense ovarian or para ovarian lesions and they show shading sign. Why this happen? Because there is multiple stages of blood within this cyst and they form the layering but not exactly the level but however there can be multi-locular appearance, angled margins, fluid-fluid levels and internal restricted diffusion in few cases. Next is T2 dark spot sign. This is quite specific sign. We can confidently say this is a endometrioma where you will see this T2 hyper intense dot of blood which is T1 hyper intense that is called T2 dark spot sign. This is a case of kissing ovary. These are T2-weighted images. These two are ovaries which are medialized and flushed with the uterine serosa. So there is medialization, tethering of the para ovarian deep endometriotic implants. In coming to hemorrhagic cyst, it is important to differentiate endometriomas from hemorrhagic cyst because we can actually avoid the surgical intervention in these cases. So here you can see these strands or mesh like network in the hemorrhagic cyst and it is T1 hyper intense. Moving to the compartments. Anterior compartment contains, this is the anterior compartment. It contains pre-vicycle space, urinary bladder, round ligament, distilirator and vesico uterine, vesico cervical and vesico vaginal space. Moving forward to the middle compartment. This is the middle compartment which contains uterus cervix vagina as well as fallopian tubes, broad ligaments and ovaries. Now in the posterior compartment, you will see recto uterine space, recto cervical space going down and further down it is recto vaginal space, utero sacral ligaments, recto sigmoid colon which is the important structure here and last is the pre-sacral space but that is also important. Now we will move to the journal article that is endometriosis, clinical features, MR imaging findings and pathologic correlation. I chose this article as it actually explains all the MR findings very clearly which is pretty basic but we need to know these things and this is by Pietro Valerio for me. What they describe in the abstract is objectives of this article are illustration of the magnetic resonance imaging features of endometriosis. Endometriosis is a chronic gynecological condition affecting women of reproductive age and cause pelvic pain and infertility. That is the most common feature, pelvic pain and infertility. When these features, if patient is saying then you have to look for the endometriosis. Growth of functional endometrial glands are outside the endometrial canal. Three different manifestations are there that is the ovarian endometriomas, peritoneal implants and deep pelvic endometriosis. We are more familiar with ovarian endometriomas that is the chocolate cyst but we need to understand more in detail about the deep pelvic endometriosis. Peritoneal implants, MRI is not that sensitive but we can detect these. The primary location is pelvis. Extrapelvic endometriosis is also there but it is rare. The definitive diagnosis based on laparoscopy and histological confirmation. MR appearances are variable and depends on quantity, age of hemorrhage and amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. So coming to the introduction, as I mentioned it is a multifocal gynecologic disease and it is mainly characterized by growth of functional ectopic endometrial glands and stroma outside the uterus. Approximately 10% of the women of free productive age are having endometriosis, 20 to 50% of the women with infertility because of this disease and nearly 90% women with chronic pelvic pain. Coming to the manifestations of endometriosis, what are the clinical features, what are the location and based on location and clinical features, what are the MR differentials. Most common mentioned is recto-survival region, uterosecral ligament area. If deposits they are around 69 to around 69%. What happens is the dysperiunia and non-specific pelvic pain can happen and followed by ovaries which are having non-specific pain ovaries are involved, then what are the differentials, they are dermoid, hemorrhage exist, clear cell or endometrioid cell tumors. So we have to see these differentials when we are looking for endometriomas that whether there is any abnormal enhancement or we are not just calling hemorrhage exist as a endometrioma or dermoid when we will do fat-sat even. We can definitely differentiate between the endometrioma and dermoid. Then comes the recto-signoid that is vagina where 14% pre-balance and symptoms are dysmenorrhea, dysperiunia and post-virtual spotting. They can be, we can miss, they can mimic like cervical or vaginal carcinomas but these are more T2 hypo-intense. So we have to see the T2 characteristic and T1 and T2 hyper-intense force are within. Then comes the recto-signoid colon that is 9.9 to 37%. Here the cyclical pain, cyclical rectal bleeding can be there. So if patient is suggesting cyclical pain and cyclical rectal bleeding then you have to see whether there is rectal involvement in a case of endometriosis. What are the differentials? They are colorectal cancer, metastatic implants and then other legions, other locations are bladder and ureter. Ureter is least common but it is most important they can have surgical complications if ureteric involvement we miss and we didn't tell our surgeon. So coming to the protocol what they have mentioned and what preparation they are doing in the study in this particular article. They ask for fasting for 4 to 6 hours, boil preparation include enema, moderate repletion of the bladder because overfilled bladder can cause detrusal contraction and obliteration of the adjacent dresses and comprising the identification of small nodules. And if the bladder is empty then it prevents optimal visualization of the ureter. So both way it is problematic. So moderate repletion of the bladder is required. Rectal opacification is performed before examination with the enema. What we are doing is fasting around 2 to 4 hours, boil preparation is not that mandatory and if required rectal gel we can insert that gives good result. Protocol what they use is axial T2, sagittal T2 and oblique coronal T2. The plane of as uterus can be retroverted we need to understand the plane of our study and according to that we can take our oblique coronal or oblique axial. They mention about T2 star imaging that is the GRE imaging but that is optional what they also mention then axial diffusion and post contrast lava that is in sagittal plane. They even asked for 3 different planes to look for the peritoneal implants but we can get in the sagittal plane also what we are doing at our hospital is sagittal lava post contrast study we get good result for surface deposits in the plane fat set even what we get here. Then moving to the next set T2 embedded images without fat separation that is the best sequence for detecting pelvic endometriosis in particular for evaluation of fibrotic legions. Then comes the other sequence which is most important here is the fat suppress T when T 3D gradient eco lava that is in G. This pulse sequence improves the sensitivity of MRI in detection of smaller legions because we can see other legions on T2 and the other sequences but the smaller even hyper intense peritoneal implants or the serosal implants will be missed in this cases because sometimes they are not having T2 correlate. So here this lava sequence helps us in that case and then followed by dynamic post contrast study that gives us idea that there is no nodular enhancement to differentiate it from the malignancy. Even though it is less common endometrioma having malignant transformation but we need to look carefully for that because these cases are coming for like follow up for longer time and as T1 hyper intensity is there we can misdiagnose this. So carefully look at the post contrast subtracted images for nodular enhancement in these cases because T1 is already hyper intense. Then comes the fat containing legion that is like dermoid teratomas we can rule out these legions with the fat set lava images. Then as I said post contrast study that is enhancing neural nodules detection with adenic cell masses and in their experience the major benefit of intravenous gadolinium is ureter visualization. So they can we can actually depict the anatomical relationship of ureters with the endometriotic cyst or implants in the which is very important information for surgeon while doing their cases. As injury to the ureter is most common urologic complication of pelvic surgery with an incidence that ranges from 1 to 10% most cases related to gynecologic procedures. So here they have given the example of post contrast even delayed images where first is the axial even fat set image and the second is coronal image. You can see the relation of ureter with the uterus and with the endometrioma on the left side. So this is the right side ureter this white dot and this arrowed one is the left ureter in relation to left endometrioma posteriorly. These neat images are giving more clear idea and this is another case where these are the endometriomas which are even hyper intense. And this is the ureter insertion disc ureter position and this is the left side endometrioma. So on the right side ureter is medially and on the left side ureter is on the lateral aspect of the legion. Types of endometriotic legions so mean different types of endometriotic legions in ovaries are endometrial ovariances as we already saw. Small superficial peritoneal implants adhesions deep infiltrating endometriosis like solid deep legions involving round ligament, parametrium, retro cervical region, ureter sacral regions. This is another example 40 year old female with dysmenorrhea and who underwent two previous surgical interventions. This is the sagittal tituated image, coronal titu and axial tituated image. You can see this is uterus and this is the rectosigmoid junction which is the loss of fat plane in between these two. And this speculated legion with strands arranged in confluent angle with loss of cleavage what they mention among the anterior surface of the sigmoid. And posterior uterine cirrhosa and along with this there are bilateral endometriomas. This is these are like chocolates is sharing sign is positive. They are medial lights kissing ovary sign is positive. So these are indirect signs and they predict the severity of the disease process. These are those angular margins. This is another case 43 year old female with speculated hypo intense strands between the anterior surface of sigmoid. Rectosigmoid region and posterior uterine cirrhosa with angular of rectosigmoid colon. So colon is angulated anteriorly. Here also you can see this case and this is the deposit and strands which are T2 hypo intense. So moving forward what are the features of these adhesions how they look. Tethering of the pelvic structures and loss of corresponding cleavage plane without applicable nodular legions may be another imaging finding suggesting adhesion. Extensive adhesions may distort pelvic anatomy and compartmentalize the pelvis and obliterate the pouch of Douglas. So if you see the obliteration of the pouch of Douglas recto uterine space then think about first these adhesions. Posterior displacement of uterus that's why you normally see retroverted retro flexed uterus in endometriosis. Then angulation of rectosigmoid colon, bowel loops, elevation of posterior vaginal phonics, loculated fluid collections and hydrosalpenes. These are indirect signs of adhesions. Free fluid in the pelvis on empty peak life position not in the cul-de-sac. That is another indirect sign of adhesion. If you see routine cases you will not see the fluid in the anti-declared position it will be in the cul-de-sac. So on MR how is the intensity? There is intermediate signal intensity on T1 weighted images and low signal intensity on T2 weighted images. Therefore T2 images solid endometriotic legions appears hypo intense nodular structures with irregular stelaid margins due to fibrous tissue. So when you are describing your endometriotic deposit you can use these terms irregular, stelaid margins, angular margins, these one instead of mentioning ill-defined. In certain cases deep endometriotic legions may also occur as a irregular and hypo intense soft tissue nodular thickening on T2 weighted images and it occurs when the disease involves uterus sacral or vaginal or rectal bone. And within the solid endometriotic masses how you will differentiate them with the metastatic deposit? So one thing is patients will have most of the time will have other endometriotic deposits. They will be more T2 hypo intense rather than T1 hypo intense. Then they are having hyper intense focal on T2 weighted images and may be seen presenting dilated ectopic endometrial glands. Indirect signs of adhesions in 36 year old women with bilateral endometrium mass. These are these endometrium mass on both sides with shading sign. They are medialized and fluid in the anti-declared position due to presence of adhesions and bilateral endometrium mass. Next is deep infiltrating endometriosis in 34 year old women where you will this is a T1 weighted image and there is infiltrating muscular layer of anterior rectal wall. The legion displays homogeneous intermediate signal intensity due to fibrous tissue and smooth muscles. This is another case of deep pelvic endometriosis in 48 year old women with T1 fat side images suggestive of infiltrating muscular layer of anterior rectal wall. Within the legion hyper intense foci are seen and on T2 weighted image it is T2 hyper intense with T2 hyper intense foci within. So these T2 hyper intense cystic foci inside the legion are dilated ectopic endometrial glands. Moving forward bladder involvement. Here is the case of 35 year old women with dysuria, hematuria and urinary incontinence during menses. These are the images where you are seeing a speculated legion along the posterior wall of urinary bladder and within the utero vesicle uterine space. This is a T1 weighted Lava image where you can see multiple T1 hyper intense foci. This is the legion and on delayed post contrast images you can see these urators bilaterally. So they are depicting the position of the urators also in this case. Another case with the uratoral endometriosis. If you see these deposits in a case of endometriosis and bilateral hydrouretronephrosis then think about endometriotic deposits. These can have T1 hyper intense foci as we already mentioned. They can have enhancement on post contrast study. So it is important to find out these legions. Uratoral endometriosis may be defined as in any situation where the endometriosis or surrounding associated fibrosis causes compression or distortion of normal uratoral anatomy. Even when hydrouretronephrosis is not yet present. MR is the best imaging technique for uratoral evaluation on T2 weighted MR images. Uratoral implants appear as a solid nodules with speculated margins same thing showing low signal intensity that envelop the urator causing dilatation of urator upstream. So moving to the endometriomas with which we are very familiar. These are the endometriomas on both sides medialized as I already said and they are having adhesions with shading sign even hyper intense. All these signs are present kissing ovaries sign. So in ovaries there are peritoneal implants confined to ovarian surface are often tinned to underdiagnosed at imaging. You do their small size less than 5 millimeter they are called micro intra ovarian. Then there is another term micro intra ovarian endometriomas. They are small in size less than 1 centimeter implants within the ovaries. But we can actually depict them on T2 and as well as even fat side images rather than even images. Recently published meta-analysis they are saying that MR for diagnosis of endometriosis where 95 to 91 around sensitivity is 95% and specificity is 91% respectively. The differential diagnosis of endometriomas include legions with high signal intensity on even weighted images like dermoid, mucinus, stume, cystic neoplasms. They can also have even hyper intensity and then hemorrhagic masses. So these are the differentials for them. Fat saturation, fat side even weighted images are helpful to rule out fat containing legions such as dermoids. As I already mentioned and in mucinus legions, hyper intensity on even weighted images is there but the signal intensity is lower than that of the blood. So that you need to see. Hence it is most challenging and differential diagnosis is with other hemorrhagic masses. To differentiate endometriomas from functional hemorrhagic cyst it is important in order to prevent unnecessary surgical intervention. So here comes our role of differentiating the endometriomas from hemorrhagic cyst. Other possibility as I already mentioned endometrioid and clear cell tumors associated with endometriosis. That is why we are giving contrast looking for the nodularity, thick septations, enhancing solid components which are suggesting malignancy. Then next is uterine cirrhosa, round ligaments, broad ligaments and fallopian tube involvement. Here is the round ligament involvement where this is the location of round ligament on both side. This lady already undergone surgery for endometrioma removal and here you can see the nodularity in the round ligament on both sides. Going up to canal of knuckle. Here is the nodularity. Routinely you will not see this thick round ligament. And on fat side even weighted images there is subtle even hyper intensity within this that represent hemorrhagic component. Moving to the next case hematosulpins in a 46 year old female with endometriosis. For these regions we describe them as a tubo ovarian regions. And how you are differentiating it from normal endometriomas? These are those partial septations within. Those are also called as plicae along the tubal wall. These are the septae which are partial not complete. So this is not the multi-locular cyst. It is a complex tubo ovarian region with shading sign. So this represents endometrioma along with hematosulpins. And these are adhered to the uterine wall. Already patient is having endometriosis. Posterior wall is thickened. There is loss of junctional zone and myometrium interface. In MRI round ligament can be identified as a thin structures with hyper intense fibrous signal on even weighted images. And these extends from the uterine haunts to the pelvic side wall. Passing anteriorly to the external iliac vessels. They have intra as well as extra pelvic portion. So it is important to know the location of round ligament. If you can identify round ligament, you can comment on that. It later being distal part of the ligament of canal of nuk. Then involved in endometriosis round ligament appear thickened, nodular, shorted and irregular. It is similar to the other endometriotic deposits. It is T1, T2, hyper intense. There can be T1, fat sat, hyper intensity within these lesions. What you have to see is asymmetry of the morphology of the ligament. There can be both ligaments are involved but you have to see always asymmetry. Whether there is symmetry and if there is a symmetry then look for other things. And those intra-aluminal implants determine the cystic haemorrhage thus causing hematosalpins. At MR imaging hematosalpins appear as a torches enlarge tubular adenic cell structure filled with haemorrhage fluid. Endoluminal content shows high signal intensity on even fat sat images and intermediate signal intensity with or without internal fluid flow levels on T2 added images. So, these are dilated fallopian tube is suggestive of hyper intensity within the dilated fallopian tube is suggestive of endometriosis. So, rarely hematosalpins can be associated with other pathologic conditions such as tubal torsion, tubal ectopic pregnancy and malignancy. So, you have to carefully look at it. Here is the other case of recto-survival involvement. This is uterus which is retroverted. If you are not able to see the space this recto-survival space in between the rectum and cervix it is all gone. And what you are seeing is a ill-defined legion which is infiltrating the cervix as well as anterior wall of rectum. This is another case with the similar features but advanced involving the serosa, the space and involvement of the muscularis micoza of the rectum. Few even hyper intense foci are seen within that suggestive of endometriotic deposit. At the same time you are able to see the endometriotic cyst on the left side with the shading sign and even hyper intensity. Here is another case of, can you just put in the chart box about what is the structure? So, this is a uterosecral ligament. You can see this one. This is a thickened uterosecral ligament with few even hyper intense foci within. This is involvement of the uterosecral ligament with multiple DI legions. Deep endometriotic legions of a retro-survival area frequently appear as a ill-defined infiltrating tissue which is hyper intense on t2-reted images and extending from the posterior uterine serosa to the uterocervical region. Some ligens may contain appendent glandular component and little fibrotic reaction the showing high signal intensity on p-ven-reted images and variable signal intensity on t2-reted images. Small cystic areas, hyper intense on t2-reted images may also be seen and solid glandular component enhances after intravenous administration of contrast material. You have to carefully look at these areas to differentiate it from the metastatic deposits. MRI for the diagnosis of endometriosis of pouch of Douglas, the sensitivity is 89% and specificity is 94%. Differentials of retro-survival legions include peritoneal metastasis as I already mentioned for intraperitoneal malignancies. Then gastrointestinal and ovarian neoplasms. You can differentiate slight difference but it is important. Peritoneal metastasis usually show intermediate to high signal intensity on t2-reted images and primary cancer site as the primary cancer site and high signal intensity on diffusion. As well as it will have a cytosumeral mass in the abdominal cavity. On the other hand, solid endometriosis show low signal intensity on t2-reted images and uterosexual ligaments are most frequent location of deep endometriosis. Bilateral uterosexual ligament is often associated with posterior deep endometriotic locations. This is a case of right uterosexual ligament involvement where you can see the speculated deposit. These are those angular margins, speculations and t2-hypo intense legions along the uterosexual ligament on the right side. On the left side you are not able to see any legions. This is another case with the recto vaginal space. So we are moving down from the recto cervical region to recto vaginal region. It is quite difficult to depict the legion here but even lava images are depicting this legion very nicely. You can see those even hyper intense focal within the vaginal fornex. For vagina and posterior vaginal fornex endometriosis MR sensitivity is 82% as well as specificity also 82%. Differential diagnosis includes epithelial neoplasms arising from uterine cervix or vaginal one. Diffusion may be useful in this setting demonstrating no restricted diffusion within the endometriotic mass. If you see the vaginal or cervical legions they exhibit diffusion restriction. So always look at your diffusion. Now you can put answering the chart box. What are the other names for this particular legion? Any particular shape or name for this? So here is a legion which is in the uterocervical region with obliteration of the space T2-hyper intense with T2-hypo intense with T2-hyper intense FOSAT and at the same time few T1-hyper intense FOSAT within. It involves the muscularis layer of the sigmoid as well as serozyl surface. As they have given the enema it is nicely depicted. So enema plays a role. We can even give rectal jail in these cases. This legion is called mushroom or fan shaped legion. It is infiltrating the muscular layer of the anterior rectal wall. It is very important to mention about these legions because these legions will actually play important role in deciding the surgeries. Whether to do shaving or whether to do rectal segmental resection those are important in this case. So coming to the rectosigmoid colon involvement. Among the bowel segments the rectosigmoid is most commonly involved in the mitraosis. Followed by Bermie form appendix, terminal ileum, seachem, descending colon in order of frequency. Anatomically rectosigmoid wall is characterized by four intraparitoneal layers that is the seroza, outer longitudinal muscularis, inner circular muscularis and then mucosa. So it is important for us to involve mention about whether there is serozyl involvement or whether there is muscularis or mucosal involvement in the rectum, these deep endometrotic deposits. The implants generally involve the serozyl surface. Most of the time when we are looking at the adhesions they are just at the serozyl involving the serozyl up to 1 to 3 mm. But they may invade underlying muscular and submucosa layers. At this point even you are not doing your routinely rectal gel administration in these patients. If you see these type of lesions then definitely after doing whole MR you can actually give around 100 ml of ultrasound gel into the rectum and you can see these lesions very beautifully. Typically endometrotic lesions infiltrating the anterior rectal wall have characteristic fan shape or mushroom shaped configuration or pyramidal shape with the base adhering to the rectal wall. So base is, if you see here, the base is along the anterior rectal wall and apex is towards the cervix. So that is important thing and if we see the metastatic deposits or the rectum malignancies, the apex will be towards the rectum and the lesion will start from the rectum towards the cervix or any other space. So that is one of the differential point to confidently say about these rectal endometrotic deposits rather than metastatic deposits. And again T1-T2-hypo intense with T1-hyper intense foci. What is important here is adhesion, stricture, bowel obstruction may be representing complication of intestinal endometriosis. Surgical procedure depends on the lesion sense that is important. That is why we need to mention about the size of the serosil involvement or the mucosil involvement. Degree of infiltration, muscularis invasion that is important. Percentage of circumference involvement. So how, what is the circumferential involvement of the rectum mucosa by the endometrotic deposit? Number and location of intestinal lesions. Now we are saying about the rectus sigmoid but there can be some other intestinal lesions like iliac or appendix or within the colon but they are very rare. And if you are describing about your rectal lesions describe them how much is the distance from an alverge. What they have mentioned here is differential, a different laparoscopic bowel resection techniques depending on degree of invasion. So here is the laparoscopic rectus sigmoid shaving resection. If the legion is less than 1 centimeter removal of the legion only followed by primary suture. Then mucosil skin that is removal of both muscular layers followed by interrupted sutures, plaques located on the anterior rectus sigmoid wall. We need to mention about the muscular layer involvement. Rectus sigmoid discoid resection, full thickness resection of anterior bowel wall followed by two layer sutures. And that is single legion less than 3 centimeter involving less than one third of the circumference. Laparoscopic rectus sigmoid segmental resection that is bowel resection followed by end to end anastomosis with sparing of mesentric nerves. Multiple or bigger legions determining the bowel distortion. I think now you realize why it is important to inform about the rectal involvement. Diffusion also plays important role in differentiating between the carcinoma. Diffusion will be there will be restriction restricted diffusion in the because of cellularity in the malignancies. However, here there will be no diffusion restriction and the legions are more T2 hypointense where the legions are more iso intense on T2. These are few extra pelvic locations of endometriotic deposits. These are better seen on they have done sagittal T2 and axial coronal. All these planes T2 weighted images which are non and other is fat set T1 weighted images which are actually depicting these legions very beautifully. So, even when you are performing and having doubt that there can be some deposit in the peritoneum or in the abdomen. You can perform one sequence that is this coronal lava that will also suffice to give you the location or you can identify the endometriotic deposit in this case. This is a case where the patient is having cyclical sciatica, sciatic pain. Can you see can you identify the legions and what is the pathology? So, here is the extra pelvic sciatic nerve endometriosis in a 31 year old women women who has been suffering from cyclical sciatica for around 2 years. And what you are seeing is here the symmetry plays a role. You have to look for the symmetry. See on the contralateral side there is no legion. If you see on the right side there is a T2 hyper intense legion which is involving the sciatic nerve. Even your T2 plays very very important role and then the other followed by that. First and most important thing is to locate the legion. We are not very used to see these regions but if you are thinking of endometriosis look for all possible extra pelvic areas at the same time. Look at the abdominal wall. Look for the nerves. Trace them in your axial images. If you are not very sure then as we said peritoneum on tibian fat sat lava image. You don't have to do all the sequences in all the planes. You can choose these sequences and minimize your time. Other indirect sign here to locate this sciatic nerve involvement is asymmetrical atrophy of the right obturated internal muscle. That is giving you a clue. This is sciatic nerve on the left side and this is the thickened T2 hyper intense nodular areas within on the right side sciatic nerve. So in conclusion they have mentioned that endometriosis is a chronic condition affecting women during the reproductive lifespan. Diagnosis of endometriosis must take into account clinical symptoms, physical examination, laboratory test and different imaging techniques. Only one single imaging or your physical examination or clinical symptoms will not give a clue. It will give a clue but it will not give a diagnosis. So you have to see in all these things in total. Since pelvic anatomy is complex it may vary with distortion by invasion of endometriosis. So look for the symmetry as I said. Radiologists must be aware of both normal and deranged anatomy. Ideal purpose of surgery is therapeutic and effective intervention based on careful preoperative evaluation. From this point of view the role of MR imaging to help diagnose and plan the surgical strategy. It is very important in cases of rectal legions because the whole plan of action will change whatever diagnosis or involvement we are giving. Then the involvement of the urators we need to inform them. So always look at the urators when you are looking for the other legions. And the clue is hydronephrosis. If you are doing just pelvis look at the sagittal images carefully. You will see hydronephrosis of hydrourator and hydronephrosis in these images. Preoperative detection of all endometriotic legions is recommended to choose the surgical approach. As I already said to plan a multi-disciplinary teamwork. Even they have to call for the neurologist gastrointestinal surgeons and neurosurgeons in few of the cases. And that reduce the postoperative complication rate. So in conclusion what we understood from this is history discussion with the referral doctor what they want. Then correct protocol choosing the correct protocol. If you are not taking correct plan that will also not give you the idea of involvement of the rectum or the other organs. If required rectal or vaginal gel administration. And administration of the anti peristaltic agents like glucagon or buscopen to reduce the movement of the bowel. And knowing the pelvic anatomy very well. That gives you the idea how to go for this endometriosis imaging. So I conclude this article here and a quick overview for the next article. That is MRI of endometriosis in correlation with NZN classification. Its applicability and structural reports. Nowadays gynecologist ask for NZN classification when we are reporting. Actually it is a good thing that it is having the universal acceptability for the reporting. So in abstract what they have mentioned is NZN is published in 2021. And it proposes a new comprehensive classification system of endometriosis. Combining a complete staging of deep infiltrative endometriosis with evaluation of peritoneal ovarian tubal localizations. And presence of adenomyosis. This article addresses the applicability of NZN classification primarily based on surgical findings. To the MRI evaluation of endometriosis. So that is this will help them for the surgery. It is for there is surgical NZN. It is based on ultrasound and then based on MRI. So what we are using is MRI based NZN. So that mentions NZNM. Overall there is significant matching between the MR features and NZN classification criteria. And two different perspective of endometriosis mapping with different goals and levels of details. Main discrepancy lies in evaluation of tubal ovarian conditions. These adhesions we are not that yes tubal patency we are not able to tell that correctly. Which is not fully accessible by MRI. Furthermore endometriosis is a complex disease we already said. MR reporting should be clear well organized for that NZN will help us. The author group both radiologist and gynaecologist proposes a structural MRI report of endometriosis in correlation with NZN classification. Merging detail anatomical and preoperative information provided by MRI. So key points here are applicable to many aspects of MR evaluation of endometriosis. MR evaluation of tubal ovarian unit. As defined by hashtag NZN is limited. And use of hashtag NZN based structure report may be clinically relevant. So this is the NZN classification. We had divided it into these are these nomenclature. P O T, P for peritonium, O for ovaries, T for tube. A for this compartment with recto vaginal space, vagina, rectus cervical area. Then B compartment sacro uterine ligament, cardinal ligament and pelvic sidewalls. C is rectal involvement. Then there are other sub terminologies that is F A adenomyosis, F B. If bladder involvement is there, you have to mention F B. If there is intestinal involvement other than rectum, then that is F I, F intestinum. Then F U, that is if uratric involvement is there. And other locations like extra pelvic locations, they can be diaphragm, lung, nerve and in that ovary is mentioned as on the left side. So here how they have mentioned it is, if peritoneal involvement is deposited is there. If it is less than 3 centimeter, it is 1. If it is 3 to 7 centimeter, it is P 2. If it is more than 7 centimeter, it is P 3. For the ovary, left ovary and right ovary, it is the combined length of the endometrium mass. So whatever the maximum length, if there are 3 endometrium mass, then the maximum length is 1 is 2, other is 3 and the third is 2 centimeter. Then it becomes 7 centimeter. So for a left ovary, it will go to O 2. It is 3 to 7. So it is not one single largest endometriotic cyst. It is the total of all the endometriotic cyst on that side, that is on the right side or it is on the left side. Then involvement of the tube where MR has limited role, but it can tell most of the things. That is the tubovarion conditions like adhesions, motility and patency test. Patency test is not that on the MR we can do. It is the T1 is if just the pelvic sidewall adhesions are there, then T2 is pelvic sidewall and uterus. Both adhesions are there. And T3 when we are describing, that is both on right side and left side separately we have to mention. That is pelvic sidewall, uterus, bowel and uterus sacral ligaments are involved. If tube is missing, we have to mention just MR. And if it is not visible, X. And for patency, they have mentioned plus and minus, but that is not that applicable in MR. Then coming to the compartments, that is the A compartment. So here what they have mentioned is the recto vaginal space, vagina recto cervical area. Here if deposit is there which is less than 1 centimeter, it will be A1. There is no side on this. If deposit is there 1 to 3 centimeter, then it is A2. And if deposit is more than 3 centimeter, it is A3. What they mentioned is compartment A assesses the involvement of recto cervical area, posterior vaginal formics and recto vaginal space. And the maximum diameter of the legion is measured in the sagittal plane and it is classified as follows. A1 less than 1 centimeter, A2 1 to 3 centimeter, A3 more than 3 centimeter. In case of multiple involvements, which is we normally will have doubt. Involvement of these structures, the maximum diameter of whole involvement should be measured. Like endometriotic cyst. We have to just calculate that and whatever the maximum is, then that will be A1, A2 or A3. Moving back to compartment B, that is the sacro uterine ligament, cardinal ligament and pelvic sidewalls, mainly the pelvic sidewalls. The similar findings, this is for both sides, right side and left side. Left comes first, right comes second. And for the compartment B, uterosexual ligament, cardinal ligament and pelvic sidewall as we already mentioned. It is the medial lateral axis mainly includes the paramaterial area, uterosexual ligaments and the description of legions in these compartments. It is classified as B1 that is less than 1 centimeter, B2 1 to 3 centimeter and B3 is more than 3 centimeter. Although the involvement of the B compartment may cause hydronephrosis, the urethral involvement and the hydronephrosis are classified as FU. So, the urethral involvement will be separate. On MRI, B compartment can be evaluated and measured on axial T2 images and possibly with small field of view. Applicability of enzyme classification to MRI, they have mentioned yes in this case. So, here we will see few, two or three examples what they have mentioned. This is a case, 33 year old female. If you can mention your enzyme for this just mention in the chat box. She is a 33 year old patient with pelvic and diaphragmatic endometriosis. So, here is the diaphragmatic endometriosis deposit. Then there is a endometrioma in the right ovary and left ovary on both sides. As well as there is involvement of the rectum that is rectal endometriosis that is for this particular length. So, enzyme here is hashtag enzyme M that is M for MRI, O that is ovary. We are not having peritoneal deposits. So, we are not taking P, we are not taking T because there is no involvement of the tube. And on the left side it is 2, it is up to 3 to 7 centimetres or more than 3 centimetre on both sides the cyst endometriomas. And the third part is C3 compartment as there is no involvement of A1 anterior A compartment and P compartment. Now we are coming to C compartment which is the rectal involvement that is 3 more than 7 centimetre C3. And in addition there is no fibro, there is no adenomyosis but there is diaphragmatic deposit. So, F diaphragm that is those extra pelvic locations. Now moving to the next case which is 38 year old patient with abdominal wall endometriosis. Here is this T1 fat satimages and this is T2 non-fat satimages. You have to see how is the anterior abdominal muscle on the right side. And there is some T2 hypo intensity on the left side which corresponds to foci of T1 hyper intensity on the left T1 fat satimages. So, this is the anterior wall endometriotic deposit. Patient is having anti grade it is antiverted and retroflexed uterus. Posterior junction zone with the uterus is thickened. So, there is focal adenomyosis. There is plaque recto vaginal recto cervical legion which is measuring around 3.6 centimetre what they have mentioned. Just mention your enzyme what you think ignore what they have given and elevation of the posterior vaginal pharynx. As well as nodular legion in the left rectus abdominis we already discussed about that. In total, hashtag in N is A1 anterior compartment A1 that is the then adenomyosis and F is abdominal wall involvement. This is the enzyme what they have mentioned and I conclude the session here and thanks for patient listening. Thank you so much Gayatri for that excellent detailed review of the articles and I am sure it will help everyone providing a more structured report. Currently Gayatri no questions as such but in case if you all do have any questions you can always email them to me or Dr. Gayatri and we will definitely get back. So, I think with that we can bring the session to end. So, thanks again Gayatri and to everyone who has joined in. So, all these videos are also available on the Indian Radiologist YouTube channel. So, you all can definitely go back and review those videos. Please let your friends know as well. And those of you all who are interested in workshops so in the 23rd MRI teaching course we also have workshops planned in breast MRI, liver, cardiac and neuroimaging. So, do send us your emails in case you are interested and please register for the conference. And we are also looking for entries for the MR mania quiz. So, you can please email your entries in teams of two. You can email them to Dr. Abhishek or me or Dr. Mithusha. And we also have these interesting sessions planned. I have shared the links for registration in the chat box. You all will get all the details there also we've shared all this in our on our various WhatsApp groups. So, thank you once again and I we hope to see you all in our next journal club which is on 31st of March, which will be taken by Dr. Mithusha Verma. And we also have one planned in April on the 28th and MSK imaging and one on May or one on 26th of May in neuroimaging by Dr. Arthi. So, hope to see you all there and thanks Gayatri once again. Thanks Gayatri and thanks to all. So, thank you and I think we can end the session here.