Supplementary Material for: Advancements in Ultrasound Diagnosis of Superficial Endometriosis: Current Challenges and Emerging Techniques

Background: Endometriosis is a chronic disease characterized by endometrial-like tissue outside the uterus. Superficial endometriosis (SE) is the most prevalent form, yet it remains underdiagnosed due to subtle clinical and imaging presentations. Traditionally, diagnosis relies on laparoscopy, which is relatively invasive and often contributes to diagnostic delay. With advancements in imaging techniques, especially transvaginal ultrasound (TVS), a reassessment of the diagnostic approach for SE is needed. This review updates the understanding of SE diagnostics and integrates both historical perspectives and contemporary clinical insights.

Objectives: The review aims to explore advancements in the diagnosis of SE, focusing on the growing role of TVS as a non-invasive diagnostic tool. Additionally, it seeks to highlight emerging diagnostic challenges and present new approaches to managing SE to offer updated recommendations for clinicians.

Methods: A comprehensive literature search was conducted using PubMed, MEDLINE, and Google Scholar. The following keywords were used: "superficial endometriosis," "diagnostic pathways," "endometriosis diagnosis," "superficial lesions," "transvaginal ultrasound," "laparoscopy," "non-invasive imaging," and "diagnostic accuracy." Only English-language articles were included, focusing on original research, metanalyses, and clinical guidelines, offering historical and current perspectives. In addition to the literature review, contemporary insights were gathered from our clinical practice at a tertiary endometriosis clinic to offer real-world context to the literature findings.

Outcome: The review highlights TVS as a promising non-invasive method for diagnosing SE. While SE has historically been diagnosed through laparoscopy, TVS is gaining recognition as a valuable tool for detecting SE lesions, particularly through the identification of key sonographic features such as hyperechoic foci and cystic spaces. These advancements help overcome the challenges posed by the variability of SE presentation on imaging. Emerging techniques, such as SPG (sonoPODography), further enhance SE diagnosis and offer the potential for broader clinical application. Despite challenges such as the need for operator expertise and variability in lesion presentation, the literature and clinical insights support the growing utility of TVS in diagnosing SE.

Conclusions and Outlook: TVS has significant potential as a non-invasive diagnostic tool for SE. While limitations such as variability in sensitivity and the need for operator expertise remain, TVS can significantly reduce reliance on invasive methods like laparoscopy. Additionally, the review provides insights into managing cases where TVS results are negative for SE. In such cases, clinicians must adopt a patient-centred approach that emphasizes symptom management, patient autonomy, and education about possible risks and treatment options. Rather than defaulting to a 'watchful waiting' or a “one size fits all” strategy, it is essential to engage patients in shared decision-making, allowing them to make informed choices about further diagnostic or therapeutic interventions. This review underscores the importance of integrating TVS into routine diagnostic pathways for SE, improving early detection and enhancing patient care. Future research should focus on refining TVS techniques, establishing standardized diagnostic criteria, and exploring alternative diagnostic strategies for patients with negative imaging results. This approach has the potential to shift the paradigm of SE management, reducing diagnostic delays and empowering patients with a more proactive, informed approach to their care.

背景：子宫内膜异位症（Endometriosis）是一种以子宫外出现类似子宫内膜组织为特征的慢性疾病。浅表型子宫内膜异位症（Superficial Endometriosis, SE）是最常见的亚型，但因其临床表现与影像学特征较为隐匿，目前仍存在诊断不足的问题。传统诊断依赖腹腔镜检查（laparoscopy），该方法具有一定侵入性，常导致诊断延迟。随着影像学技术的进步，尤其是经阴道超声（transvaginal ultrasound, TVS）的发展，亟需对SE的诊断路径进行重新评估。本综述更新了对SE诊断的认知，整合了历史研究视角与当代临床见解。

研究目标：本综述旨在探讨SE诊断领域的技术进展，重点关注经阴道超声（TVS）作为非侵入性诊断工具的日益重要的作用。此外，本综述还旨在阐明当前面临的新型诊断挑战，并提出SE管理的新方案，为临床医师提供更新后的诊疗建议。

研究方法：本研究通过PubMed、MEDLINE及Google Scholar开展了全面的文献检索，使用的关键词包括：“浅表型子宫内膜异位症（superficial endometriosis）”、“诊断路径（diagnostic pathways）”、“子宫内膜异位症诊断（endometriosis diagnosis）”、“浅表病灶（superficial lesions）”、“经阴道超声（transvaginal ultrasound）”、“腹腔镜检查（laparoscopy）”、“非侵入性成像（non-invasive imaging）”及“诊断准确性（diagnostic accuracy）”。仅纳入英文文献，聚焦于原创研究、荟萃分析（meta-analyses）及临床指南，涵盖历史与当前的研究视角。除文献综述外，本研究还结合了我们在三级子宫内膜异位症诊疗中心的临床实践经验，为文献研究结果提供真实世界的场景佐证。

研究结果：本综述证实经阴道超声（TVS）是一种极具前景的SE非侵入性诊断方法。尽管SE既往主要通过腹腔镜检查确诊，但TVS作为检测SE病灶的有效工具正获得广泛认可，尤其是通过识别高回声灶（hyperechoic foci）与囊性间隙（cystic spaces）等关键超声特征。这些技术进展有助于克服SE影像学表现异质性所带来的诊断难题。新兴技术如sonoPODography（SPG）可进一步提升SE诊断效能，有望实现更广泛的临床应用。尽管仍存在对操作者专业能力的要求以及病灶表现异质性等挑战，但现有文献与临床经验均支持TVS在SE诊断中的应用价值日益提升。

结论与展望：经阴道超声（TVS）作为SE的非侵入性诊断工具具有显著应用潜力。尽管仍存在灵敏度异质性、对操作者专业能力有要求等局限性，但TVS可显著降低对腹腔镜检查等侵入性诊断方法的依赖。此外，本综述还针对TVS检测结果为阴性的SE疑似病例的管理提供了见解。针对此类病例，临床医师应采用以患者为中心的诊疗模式，强调症状管理、患者自主权以及对潜在风险与治疗方案的健康教育。不应默认采用“等待观察”或“一刀切”的诊疗策略，而应让患者参与共同决策，使其能够对后续的诊断或治疗干预做出知情选择。本综述强调了将TVS纳入SE常规诊断路径的重要性，这有助于提升早期检出率并改善患者护理质量。未来的研究应聚焦于优化TVS技术、建立标准化诊断标准，并针对影像学结果为阴性的患者探索替代诊断方案。该研究方向有望改变SE的诊疗范式，减少诊断延迟，并让患者能够以更主动、更知情的方式参与自身诊疗。