In Search of an Imaging Classification of Adenomyosis: A Role for Elastography?

Abstract

Adenomyosis is a complex and poorly understood gynecological disease. It used to be diagnosed exclusively by histology after hysterectomy; today its diagnosis is carried out increasingly by imaging techniques, including transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI). However, the lack of a consensus on a classification system hampers relating imaging findings with disease severity or with the histopathological features of the disease, making it difficult to properly inform patients and clinicians regarding prognosis and appropriate management, as well as to compare different studies. Capitalizing on our grasp of key features of lesional natural history, here we propose adding elastographic findings into a new imaging classification of adenomyosis, incorporating affected area, pattern, the stiffest value of adenomyotic lesions as well as the neighboring tissues, and other pathologies. We argue that the tissue stiffness as measured by elastography, which has a wider dynamic detection range, quantitates a fundamental biologic property that directs cell function and fate in tissues, and correlates with the extent of lesional fibrosis, a proxy for lesional “age” known to correlate with vascularity and hormonal receptor activity. With this new addition, we believe that the resulting classification system could better inform patients and clinicians regarding prognosis and the most appropriate treatment modality, thus filling a void.

Postmenopausal giant uterine adenomyoma with adipose metaplasia: A case report and literature review

“…Elastography, with 2 types one based on shear waves and the other on strain elastography, may be superior to TVUS in differentiating uterine fibroids from UAs, but its sensitivity and specificity as well as intra-and interoperator variability need to be further quantified and more studies are needed to clarify its place in the diagnosis of UAs. [11] UA is similar to uterine smooth muscle tumor so the differentiation is particularly important. Some differentiation can be made by the above examination tools, but the main difference is that adenomyomas do not have a parafilm and are poorly demarcated from the surrounding uterine myometrium, making it difficult to completely remove them during surgery.…”

Current perspectives on endometrial receptivity: A comprehensive overview of etiology and treatment

“…15,16 Additionally, several studies have proposed optimal classification criteria for uterine adenomyosis. [146][147][148][149][150][151] Recent evidence suggests that, despite its heterogeneous manifestation, uterine adenomyosis may have a negative impact on endometrial receptivity overall [1][2][3][4][5][6][7][8][9][10][11][12][13] via multiple molecular and cellular dysregulations with a background of chronic inflammation. 18 Pretreatment with GnRH agonists prior to ET may improve the uterine environment by ameliorating the disease and normalizing the expression of several genes deemed essential for successful embryo implantation.…”

“…For example, the MUSA group proposed diagnostic criteria for uterine adenomyosis using TVUS in 2015 and 2022 15,16 . Additionally, several studies have proposed optimal classification criteria for uterine adenomyosis 146–151 . Recent evidence suggests that, despite its heterogeneous manifestation, uterine adenomyosis may have a negative impact on endometrial receptivity overall 1–13 via multiple molecular and cellular dysregulations with a background of chronic inflammation 18 .…”

The Asian Society of Endometriosis and Adenomyosis guidelines for managing adenomyosis

“…Even though the awareness of adenomyosis has increased in recent two decades as evidenced by the growing number of publications, a lack of a regional or international guideline reflects, perhaps in no small part, the enormous heterogeneity in diagnosis and treatment, as seen, for example, from substantial differences between criteria for the histopathologic study and imaging study 5 and the fact that as of now well over 95% of fertility‐sparing adenomyomectomy surgeries worldwide are performed in Asia. In addition, there exist several classification methods of adenomyosis based on morphology 6 . The establishment of a widely accepted approach to the diagnosis and classification of adenomyosis certainly needs extensive discussion.…”

“…In addition, there exist several classification methods of adenomyosis based on morphology. 6 The establishment of a widely accepted approach to the diagnosis and classification of adenomyosis certainly needs extensive discussion.…”