Diagnosing deep endometriosis using transvaginal elastosonography
Abstract
Transvaginal ultrasound (TVUS) and MRI are currently two mainstream imaging techniques used to diagnose deep endometriosis (DE) with comparable accuracy, but there is still ample room for improvement. As endometriotic lesions progress to fibrosis concomitant with the increase in tissue stiffness, transvaginal elastosonography (TVESG) is well-suited for diagnosing DE. To test the hypothesis that lesional stiffness as measured by TVESG correlates with the extent of lesional fibrosis, the markers of progression, hormonal receptor expression, and vascularity, we recruited 30 patients suspected to have DE who went through pelvic examination, TVUS and/or MRI, and TVESG and were ultimately diagnosed by histology. Their lesional tissue samples were subjected to immunohistochemistry analysis of markers for epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), estrogen and progesterone receptors (ERβ and PR), microvessel density (MVD), and vascularity, as well as quantification of lesional fibrosis. We found that pelvic examination, TVUS, and MRI detected 83.3%, 66.7%, and 83.3% of all DE cases, respectively, while TVESG detected them all. The lesions missed by pelvic exam, TVUS and MRI were significantly smaller than those detected but nonetheless had higher lesional stiffness. Lesional stiffness correlated closely and positively with the extent of lesional fibrosis, negatively with the markers of EMT, MVD, vascularity, and PR expression, but positively with the marker for FMT and ERβ. Thus, through the additional use of information on differential stiffness between DE lesions and their surrounding tissues, TVESG improves diagnostic accuracy, provides a ballpark estimate on the developmental stage of the lesions, and may help clinicians choose the best treatment modality.
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There is a close correlation between lesional fibrosis and lesional stiffness per elastosonography.
“in view of the close correlation between lesional fibrosis and lesional stiffness per elastosonography (Liu et al., 2018a; Ding et al., 2020)”
From Progressively diminished estrogen signaling concordant with increased fibrosis in ectopic endometrium (2025) · cites this paper as Ding et al., 2020
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“The ReTIAR notion also helps to shed new light on the pathophysiology of endometriosis (11), and help devise novel diagnostics of endometriosis (12).”
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Self-citationIn Search of an Imaging Classification of Adenomyosis: A Role for Elastography?
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“In fact, in view of the close correlation between lesional fibrosis and lesional stiffness per elastoso-nography (Liu et al. , 2018a; Ding et al. , 2020), our finding that the estrogen signaling diminishes concordantly with increasing lesional fibrosis calls for a re-appraisal of current treatment…”
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Self-citationThe Benefit of Transvaginal Elastography in Detecting Deep Endometriosis: A Feasibility Study
Xholli, A., Londero, A. P., Cavalli, E., Scovazzi, U., Ferraro, M. F., Vacca, I., Schiaffino, M. G., Oppedisano, F., Sirito, G., Molinari, F., et al. (2023) · Ultraschall in der Medizin - European Journal of Ultrasound · doi:10.1055/a-2028-8214 · Cited by 13 · see citing works
“In a recent article, share wave elastography proved to be capable of detecting DIE nodules [27].”
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“For patients with DE or certain AD, NSAIDs are unlikely to be efficacious, especially when lesions are stiff per elastography and thus highly fibrotic [51, 52].”
Self-citationUltrasound Elastography in Benign Gynecology: A Scoping Review
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“Indeed, Ding et al. showed that ultrasound elastography outperformed traditional US and MRI for the detection of deep endometriotic disease [28].”
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MethodLooking at endometriosis–diagnosis and disease mechanisms through a mechanical lens
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“A separate study by Ding et al. assessed the mechanical properties of DIE lesions obtained from the Pouch of Douglas (peritoneum space located between the posterior uterus and rectum) or the rectovaginal area (22).”
InfluentialLiang, M., Liu, S.-L., Huang, W.-D., & Jiang, L. (2022) · Cellular and Molecular Biology · doi:10.14715/cmb/2022.68.3.44 · Cited by 2
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Is endometriosis a progressive disease?
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Self-citationEndometriosis and Adenomyosis: Mechanotransduction, Microenvironment, and Mechanisms Beyond Lesions
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“This is all the more important since the extent of lesional fibrosis, a proxy for progression, could be determined by elastography without laparoscopy (7).”
BackgroundSelf-citation
- Authors
- Ding, D., Chen, Y., Liu, X., Jiang, Z., Cai, X., & Guo, S.-W.
- Affiliations
- Shanghai Medical College of Fudan University (CN)
- Corresponding author
- Liu, Xishi
- Venue
- Reproductive Sciences
- Published
- 2020-04-24
- Volume
- 27
- Issue
- 7
- Pages
- 1411-1422
- ISSN
- 1933-7191 (ISSN-L)
- 1933-7205
- OpenAlex
- W3019693459
- Cited by
- 28
- References
- 52
- Citations by year
- 2026: 5 · 2025: 1 · 2024: 6 · 2023: 7 · 2022: 4 · 2021: 2 · 2020: 3
- FWCI
- 3.53
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Reproductive Sciences (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Ultrasound Imaging and Elastography
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- deep infiltrating endometriosis, tissue stiffness, epithelial-mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation, estrogen receptor beta, progesterone receptor, microvessel density, lesion vascularity, diagnostic accuracy
- MeSH terms
- Adult, Endometriosis, Female, Humans, Magnetic Resonance Imaging, Middle Aged, Vagina, Elasticity Imaging Techniques, Young Adult
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