Real-time elastography for assessment of uterine disorders

Mapping the way to successful euploid frozen embryo transfer: a prospective pilot study of uterine elastography

STUDY QUESTION

Does the objective and quantitative assessment of uterine tissue stiffness via ultrasound shear wave elastography (SWE) predict the outcome after single euploid frozen embryo transfer (FET)?

SUMMARY ANSWER

Uterine SWE data might be predictive of clinical pregnancy in good prognosis patients undergoing single euploid FET.

WHAT IS KNOWN ALREADY

Few prior studies have evaluated the usefulness of strain uterine elastography in assessing the likelihood of conception in an infertile patient population following IUI or FET. These studies suggest that elastography parameters may be predictive of pregnancy following ART treatments. However, these studies are limited based on their use of strain uterine elastography, which provides a relative measurement between two areas of interest. No prior study has evaluated the more robust technology of SWE, which provides quantitative and objective measurements, on likelihood of conception following infertility treatment.

STUDY DESIGN, SIZE, DURATION

This is a prospective pilot study of 153 patients with no known uterine pathology undergoing single euploid FET at a university-affiliated center between June 2022 and December 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients scheduled for upcoming single euploid blastocyst FET during the study period were evaluated for study participation. On the day prior to embryo transfer, SWE assessment of 15 regions of interest of the sagittal uterus measuring 6 mm in diameter was performed on included participants. Regions of interest included the cervix, anterior/posterior distal myometrium, anterior/posterior lower uterine segment, fundus, endometrium, and the anterior myometrial/endometrial interface. The elastography data points generated were collected in a standardized fashion by a single investigator blinded to patient outcome. The elasticity parameters analyzed included the mean, SD, minimum, and maximum values in kilopascals and meters per second. These data were assessed for relationship to clinical pregnancy, defined as discharge from fertility care at 9 weeks' gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 22 uterine elastography parameters that showed a significant relationship to clinical pregnancy with P < 0.10 using univariant analyses. Regions of interest that were predictive of clinical pregnancy with P < 0.10 included the cervix, the anterior myometrium, the posterior myometrium, the fundus, and the anterior myometrial/endometrial interface. Increased mean (stiffer elastography metrics) in the posterior myometrium and anterior myometrial/endometrial interface was associated with increased likelihood of clinical pregnancy in comparison to FETs that did not result in clinical pregnancy. These values were then subjected to a multivariable logistic regression model to estimate areas under the curves and predictive values with and without clinical parameters. Using elastography data only, the model for predicting clinical pregnancy resulted in a significant AUC of 0.826 (95% CI: 0.748, 0.904). Next, an additional model was generated using both elastography data and patient demographic and cycle characteristics, which also had a significant AUC of 0.923 (95% CI: 0.874, 0.973). Receiver operating characteristic curves were compared to demonstrate that SWE and clinical parameters together provide a significantly better predictive value compared with just clinical parameters alone to forecast clinical pregnancy. We then ran a 5× cross-validation, confirming that the system was robust.

LIMITATIONS, REASONS FOR CAUTION

There are several limitations to this study. The model developed is predictive of clinical pregnancy in a good prognosis patient population with high-quality euploid embryos, thereby limiting the generalizability of the model in alternative patient populations. Further work is needed to validate our findings in larger patient populations. Additionally, SWE data may be limited by patient parameters beyond the sonographer's control.

WIDER IMPLICATIONS OF THE FINDINGS

Quantitative assessment of tissue elasticity using SWE of a morphologically normal uterus, assessed the day prior to single euploid FET, was found to result in a model predictive of clinical pregnancy in a good prognosis population.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this study was provided by IVIRMA Global. There are no conflicts of interest for any of the authors.

TRIAL REGISTRATION NUMBER

NCT05397912.

Elastographic and vascular findings of uterine myomas assessed by ultrasound

OBJECTIVE

The objectives of this study were to evaluate the vascularization pattern of uterine myoma (UM) by ultrasonography using Superb Microvascular Imaging (SMI) and tissue stiffness elastography.

METHOD

A prospective and cross-sectional study was carried out between March 2020 and December 2022 among women with clinical and ultrasound diagnosis of UM who would subsequently undergo radiofrequency ablation. Ultrasound examination was performed using both transvaginal and transabdominal routes. UM vascularization pattern was assessed by power Doppler (PD) and SMI, while elastographic pattern was assessed by shear wave (SWE) and strain (STE). FIGO classification, location, and measurement of the largest UM were also described.

RESULTS

A total of 21 women diagnosed with UM were evaluated. There was a predominance of nulliparous women and 20 women (95.2%) reported desire for pregnancy. Of the 18 women with abnormal uterine bleeding, 15 (83.3%) had abdominal cramping. As far as previous treatment, 7 (33.3%) had undergone myomectomy for other UM. The mean uterine and UM volumes were 341.9 cm3 (90-730) and 126.52 cm3 (6.0-430), respectively. There was a predominance of hypoechogenic lesions (90.5%). There was also preponderance of UM in the FIGO 2-5 classification (n = 9; 42.9%). Vascularization patter was mostly moderate (score 2) in 9 cases (42.9%). The majority of UM were considered to have intermediate stiffness (n = 10; 47.6%).

CONCLUSION

The majority of UM showed vascularization and moderate stiffness. A relationship was observed between the stiffness of the UM assessed by elastography and its FIGO classification.

Relationship between endometriosis and uterine cervical elasticity assessed using ultrasound strain elastography

PURPOSE

Internal cervical os (ICO) stiffness is related to menstrual pain, a key symptom of endometriosis. The study evaluated whether women with endometriosis have a stiffer ICO than unaffected women.

METHODS

A retrospective cross-sectional analysis was conducted using prospectively collected data from women with and without endometriosis, spanning from June 2020 to September 2022. Endometriosis was diagnosed through clinical and ultrasound evaluations, with histological confirmation in a subset of participants. Strain elastography (SE) was employed to measure tissue elasticity in four cervical regions of interest: the ICO and the anterior, posterior, and middle cervical compartments (ACC, PCC, and MCC, respectively). Tissue elasticity was quantified using a color-based scoring system ranging from 0.1 (blue, indicating less elasticity) to 3.0 (red, indicating greater elasticity).

RESULTS

Overall, 287 women were included, with 157 diagnosed with endometriosis and 130 controls. On SE, women with endometriosis exhibited a lower color score (mean±standard deviation), indicating lower elasticity, for the ICO (0.56±0.28 vs. 0.70±0.26, P=0.001) and PCC (0.69±0.30 vs. 0.80±0.27, P=0.002). Additionally, they had a lower ICO/MCC ratio (0.45±0.28 vs. 0.60±0.32, P=0.001) and ICO/ACC ratio (0.68±0.42 vs. 0.85±0.39, P=0.001). Multiple logistic regression analysis revealed that endometriosis was associated with the ICO color score (odds ratio, 0.053; 95% confidence interval, 0.014 to 0.202; R2=0.358; P=0.001), even after adjusting for confounding factors like the presence of myomas (P=0.040) and the use of hormonal therapy (P=0.001). The results were corroborated in women with histologically confirmed endometriosis (n=71).

CONCLUSION

The findings suggest a potential relationship between a stiffer ICO and endometriosis.

Adenomyosis and Adolescence: A Challenging Diagnosis and Complex Management

Adenomyosis is a chronic, hormone-related disease characterized by the presence of the endometrial glands and stroma within the myometrium. This condition can manifest in various features, focal or diffuse adenomyosis or as an adenomyoma, and it may involve different uterine walls (posterior, anterior, and/or lateral walls). The disease can also be classified into different degrees, as mild, moderate and severe, which can be associated with more intense symptoms, although this correlation is not always directly proportional. In fact, adenomyosis can be asymptomatic in about a third of cases or it can significantly impact patients' quality of life through painful symptoms, such as dysmenorrhea and dyspareunia, abnormal uterine bleeding-particularly heavy menstrual bleeding-and potential effects on fertility. Historically, adenomyosis has been considered a disease primarily affecting premenopausal women over the age of 40, often multiparous, because the diagnosis was traditionally based on surgical reports from hysterectomies performed after the completion of reproductive desire. Data on the presence of adenomyosis in adolescent patients remain limited. However, in recent years, advancements in noninvasive diagnostic tools and increased awareness of this pathology have enabled earlier diagnoses. The disease appears to have an early onset during adolescence, with a tendency to progress in terms of extent and severity over time. Adenomyosis often coexists with endometriosis, which also has an early onset. Therefore, it is important, when diagnosing adenomyosis, to also screen for concomitant endometriosis, especially deep endometriosis in the posterior compartment. The aim of this narrative review is to investigate the prevalence of different types and degrees of adenomyosis in younger patients, assess the associated symptoms, and describe the most appropriate diagnostic procedures for effective therapeutic management and follow-up, with the goal of improving the quality of life for these young women.

Deep learning based uterine fibroid detection in ultrasound images

Uterine fibroids are common benign tumors originating from the uterus's smooth muscle layer, often leading to symptoms such as pelvic pain, and reproductive issues. Early detection is crucial to prevent complications such as infertility or the need for invasive treatments like hysterectomy. One of the main challenges in diagnosing uterine fibroids is the lack of specific symptoms, which can mimic other gynecological conditions. This often leads to under-diagnosis or misdiagnosis, delaying appropriate management. In this research, an attention based fine-tuned EfficientNetB0 model is proposed for the classification of uterine fibroids from ultrasound images. Attention mechanisms, permit the model to focus on particular parts of an image and move forward the model's execution by empowering it to specifically go to imperative highlights whereas overlooking irrelevant ones. The proposed approach has used a total of 1990 images divided into two classes: Non-uterine fibroid and uterine fibroid. The data augmentation methods have been connected to improve generalization and strength by exposing it to a wider range of varieties within the training data. The proposed model has obtained the value of accuracy as 0.99. Future research should focus on improving the accuracy and efficiency of diagnostic techniques, as well as evaluating their effectiveness in diverse populations with higher sensitivity and specificity for the detection of uterine fibroids, as well as biomarkers to aid in diagnosis.

Ultrasound Elastography in Benign Gynecology: A Scoping Review

OBJECTIVE

To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations.

METHODS

A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations.

RESULTS

The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer.

CONCLUSION

Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions.

Clinical signs and diagnosis of fibroids from adolescence to menopause

The aim of this review was to provide an updated assessment of the present diagnostic tools and clinical symptoms and signs to evaluate uterine fibroids (UFs) on the basis of current guidelines, recent scientific evidence, and a PubMed and Google Scholar search for peer-reviewed original and review articles related to clinical signs and diagnosis of UFs. Approximately 50%-75% of UFs are considered nonclinically relevant. When present, the most common symptoms are abnormal uterine bleeding, pelvic pain and/or bulk symptoms, and reproductive failure. Transvaginal ultrasound is recommended as the initial diagnostic modality because of its accessibility and high sensitivity, although magnetic resonance imaging appears to be the most accurate diagnostic tool to date in certain cases. Other emerging techniques, such as saline infusion sonohysterography, elastography, and contrast-enhanced ultrasonography, may contribute to improving diagnostic accuracy in selected cases. Moreover, artificial intelligence has begun to demonstrate its ability as a complementary tool to improve the efficiency of UF diagnosis. Therefore, it is critical to standardize descriptions of transvaginal ultrasound images according to updated classifications and to individualize the use of the different complementary diagnostic tools available to achieve precise uterine mapping that can lead to targeted therapeutic approaches according to the clinical context of each patient.

The use of real time strain endometrial elastosonography plus endometrial thickness and vascularization flow index to predict endometrial receptivity in IVF treatments: a pilot study

BACKGROUND

The usefulness of endometrium strain elastosonography (SE) for the evaluation of endometrial receptivity in women undergoing in vitro fertilization (IVF) remains controversial. The objective of this prospective, observational study was to evaluate the correlation between endometrial thickness (EMT) and its related strain (ESR) on the day of ovulation triggering (hCG-d) and in vitro fertilization outcomes. Additionally, 3D Power Doppler vascular indices (3DPDVI) were also analysed.

METHODS

We included all the patients undergoing fresh IVF-single blastocyst transfer cycle from January 2021 to August 2021 at our center. On hCG-d, after B-mode scanning was completed to measure the EMT, the mode was changed to elastosonography to evaluate the ESR (ratio between endometrial tissue and the myometrium below). At the end of examination, the Endometrial Volume (EV) and 3DPDVI (vascularization index [VI], flow index [FI] and vascularization flow index [VFI]), were assessed. Statistical analysis was completed using STATA MP16 software.

RESULTS

A total number of 57 women were included. Based on the EMT on hCG-d, women were divided into two groups, Group 1: <7 mm and Group 2 ≥ 7 mm. Women with EMT < 7 mm had a significantly higher ESR (p = 0.004) and lower pregnancy rate (p = 0.04). Additionally, low ESR values were correlated with high VFI values (rho = -0.8; 95% CI = -0.9- -0.6; p < 0.0001) and EMT ≥ 7 mm could be predicted by low ESR (OR = 0.01; 95% CI = 0.01-0.30; p = 0.008, area under the ROC curve: 0.70). After all, in multiple logistic regression analysis, low values of ESR (p = 0.050) and high values of EMT (p = 0.051) on hCG-d had borderline statistical effects on pregnancy rate.

CONCLUSIONS

The ESR may be useful to improve the ultrasound evaluation of the endometrial quality in infertile women candidates to IVF/ICS. Given the small sample size of our study, the usefulness of strain elastosonography in this patients, needs further investigation.

Automated Uterine Fibroids Detection in Ultrasound Images Using Deep Convolutional Neural Networks

Fibroids of the uterus are a common benign tumor affecting women of childbearing age. Uterine fibroids (UF) can be effectively treated with earlier identification and diagnosis. Its automated diagnosis from medical images is an area where deep learning (DL)-based algorithms have demonstrated promising results. In this research, we evaluated state-of-the-art DL architectures VGG16, ResNet50, InceptionV3, and our proposed innovative dual-path deep convolutional neural network (DPCNN) architecture for UF detection tasks. Using preprocessing methods including scaling, normalization, and data augmentation, an ultrasound image dataset from Kaggle is prepared for use. After the images are used to train and validate the DL models, the model performance is evaluated using different measures. When compared to existing DL models, our suggested DPCNN architecture achieved the highest accuracy of 99.8 percent. Findings show that pre-trained deep-learning model performance for UF diagnosis from medical images may significantly improve with the application of fine-tuning strategies. In particular, the InceptionV3 model achieved 90% accuracy, with the ResNet50 model achieving 89% accuracy. It should be noted that the VGG16 model was found to have a lower accuracy level of 85%. Our findings show that DL-based methods can be effectively utilized to facilitate automated UF detection from medical images. Further research in this area holds great potential and could lead to the creation of cutting-edge computer-aided diagnosis systems. To further advance the state-of-the-art in medical imaging analysis, the DL community is invited to investigate these lines of research. Although our proposed innovative DPCNN architecture performed best, fine-tuned versions of pre-trained models like InceptionV3 and ResNet50 also delivered strong results. This work lays the foundation for future studies and has the potential to enhance the precision and suitability with which UF is detected.

Ultrasound Elastography for the Diagnosis of Endometriosis and Adenomyosis: A Systematic Review with Meta-analysis

Elastography is capable of measuring tissue mechanical properties and elasticity. It is used to help diagnose various diseases, although its use in pelvic endometriosis remains to be established. A systematic review and meta-analysis were conducted to assess transvaginal ultrasound elastography for the diagnosis of different manifestations of endometriosis and adenomyosis. PRISMA guidelines were used for a Medline, PubMed, Embase, BVS/Bireme, Scopus, Cochrane Library and Escudos database search. Studies indexed until March 2021 that evaluated elastography compared with histopathological results (gold standard), ultrasound or magnetic resonance imaging for diagnosis of pelvic endometriosis and adenomyosis were eligible. The Rayyan platform was used to select studies. Sensitivity (S), specificity (Ps), positive and negative predictive values and receiver operating characteristic curves were calculated for elastographic diagnosis of endometriosis. A meta-analysis using Review Manager 5 and Open Meta Analyst was performed. Bias risk in the studies was analyzed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. This systematic review was prospectively registered in the PROSPERO database: CRD42021244555. Among the 163 identified citations, 10 studies were eligible for review (5 for diagnosis of adenomyosis, 2 for endometrioma, 3 for deep intestinal endometriosis and rectovaginal septum [deep pelvic endometriosis], N = 744 women). In deep pelvic endometriosis, lesions diagnosed by elastography were found to correlate with histopathology results. Increased "stiffness" (elastography) was associated with a higher fibrotic component, with S = 78%-100% and Ps = 100%, according to the authors. On elastography, endometriomas were stiffer than hemorrhagic cysts (S = 82%, Ps = 79%) and malignant tumors (S = 86%, Ps = 100%). For these lesions, a meta-analysis could not be performed because the small number of studies and insufficient data. In adenomyosis, meta-analysis and receiver operating characteristic curve analysis revealed that elastography had good sensitivity and specificity. Studies indicated a low bias risk by QUADAS-2. Elastography had high sensitivity and specificity for deep pelvic endometriosis diagnosis, and its findings correlated with histopathology results. For adenomyosis, the meta-analysis confirmed the sensitivity and specificity results of the studies. Given these results, elastography may be a promising imaging test, contributing to non-invasive diagnosis of endometriosis and adenomyosis.

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

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.

The 'chicken-egg-model': a simple in vitro model for 3D-ultrasonography and elastography

Background

Three-dimensional ultrasound (3D-ultrasound) and elastography are imaging techniques facilitating the diagnosis of gynaecological diseases and uterine anomalies. These non-invasive ultrasound applications may be of important added diagnostic value in gynaecological ultrasonography.

Objectives

The main objective of this study was to develop a simple and cheap in vitro model for elastography and 3D-ultrasound, with an adaptable probe-target distance. The target should be visible within the model and its hardness should be modifiable. The orientation and inclination of the model should also be adjustable.

Materials and Methods

We used a boiled chicken egg in a gel basis as this mimics the elastic properties of human tissues. Different boiling times were compared with the stiffness at elastography. Both 3D-ultrasonography and strain elastography were conducted with a Voluson™ E10 4-9 MHz vaginal probe.

Results

Altering the eggs' boiling times modulates the levels of stiffness, and hence the aspect on elastography.

Conclusions

Our model can help trainees to practice acquisition and interpretation of elastography images. This cheap and easy-to-reproduce, in vitro "chicken-egg-model" allows for education and training of 3D-ultrasound and elastography, without causing discomfort to patients.

What is new?

We created a cheap and easy to reproduce in vitro model for the education of 3D-ultrasound and elastography.

Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study

BACKGROUND

This study aimed to examine the clinical characteristics of 11 patients undergoing laparoscopic adenomyomectomy guided by intraoperative ultrasound elastography and this technique's feasibility.

PATIENTS AND METHODS

Eleven patients undergoing laparoscopic adenomyomectomy using ultrasound elastography for adenomyosis at Kawasaki Medical School Hospital in Okayama, Japan between March 2020 and February 2021 were enrolled. Operative outcomes included operative time, operative bleeding, resected weight, operation complications, percent change in hemoglobin (Hb) values, and uterine volume pre- and postoperatively. Dysmenorrhea improvement was evaluated by changes in visual analog scale (VAS) scores pre- and 6- and 12-months postoperatively.

RESULTS

The median operative time and bleeding volume was 125 min (range, 88-188 min) and 150 mL (10-450 mL), respectively. The median resected weight was 5.0 g (1.5-180 g). No intraoperative or postoperative blood transfusions or perioperative complications were observed. The median changes in uterine volume, Hb value, and VAS score were -49% (-65 to -28%), -3% (-11 to 35%), and -80% (-100 to -50%), respectively. The median follow-up period post-surgery was 14 months (7-30 months). Adenomyosis recurrence was not observed in the patients during the follow-up period.

CONCLUSIONS

Laparoscopic adenomyomectomy using ultrasound elastography guidance is minimally invasive and resects as many adenomyotic lesions as possible.

ACR Appropriateness Criteria® Fibroids

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Transvaginal Ultrasound Combined with Strain-Ratio Elastography for the Concomitant Diagnosis of Uterine Fibroids and Adenomyosis: A Pilot Study

Uterine fibroids (UFs) and adenomyosis (AM) represent two benign uterine conditions that can affect fertility and are most frequently commonly responsible for abnormal uterine bleeding and chronic pelvic pain. Their differential diagnosis still represents a challenge, and several authors advise the addition of elastography to transvaginal ultrasound (TVUS) for a more accurate imagistic recognition. Through this study, we aimed to assess the diagnostic accuracy of TVUS combined with strain-ratio elastography (SRE) in concomitant AM and UFs. We conducted a study on 17 patients diagnosed with concomitant UFs and AM undergoing hysterectomy and 46 healthy patients. TVUS combined with SRE was conducted in each patient, focusing on identifying rigidity patterns of the lesions. Significantly higher mean SR and maximum SR values were identified among both AM and UF lesions as opposed to controls (p < 0.01), with the highest tissue stiffness being encountered among AM lesions, which allows for the differentiation of UF (p < 0.01) and concomitant identification of both lesions. These results are reflected by higher cut-off values obtained for AM, both for mean SR (5.42 vs. 2.85) and maximum SR (5.80 vs. 3.30). TVUS combined with SRE showed good diagnostic performance in identifying coexisting UFs and AM within the same uterine specimen. Future studies on wider populations are required to validate our findings.

The characteristics of real-time transvaginal sono-elastography in endometrial cancer

Background:

Endometrial cancer is the most common gynecological cancer among women in developed countries. Sono-elastography is an extended ultrasonographic technique that has been shown to be useful in a wide range of conditions ranging from breast, prostate, and thyroid nodules to chronic liver disease and musculoskeletal conditions. The aim of this study is to compare the sonoelastographic features of endometrial malignancy and normal endometrium.

Methods:

This case–control observational study was conducted at a single institution. Participants with histologically proven endometrial cancer according to the results from microcurettage or hysteroscopic biopsy and scheduled for total hysterectomy were included as cases, while asymptomatic women scheduled for routine screening ultrasound examination were recruited as controls. Both cases and controls underwent conventional B-mode transvaginal ultrasonography and strain elastography. Demographic, ultrasonographic, and histopathologic findings were analyzed.

Results:

A total of 29 endometrial cancer patients (cases) and 28 normal females (controls) were included in the analysis. There was no significant difference in the mean age between the two groups, but the mean body weight was significantly higher in the case group (P < 0.001). The strain ratio and elastographic thickness ratio of the endometrium were statistically significantly different between the case and the control group (P ≤ 0.05) due to increased endometrial stiffness in cancer patients as compared to the normal group.

Conclusion:

Our results suggest that endometrial cancer can result in increased stiffness that is detectable by transvaginal sonoelastography. Sonoelastography may serve as an adjunct to conventional ultrasound in evaluating the endometrium of women with abnormal uterine bleeding.

Transvaginal Shear Wave Elastography for Assessment of Endometrial and Subendometrial Pathologies: A Prospective Pilot Study

OBJECTIVE

To assess the role of shear wave elastography (SWE) in characterizing different endometrial and subendometrial pathologies.

METHODS

Seventy-three women with pathologically proven endometrial and subendometrial pathologies were enrolled in this prospective study and assessed with transvaginal SWE. The elasticity values (in kiloPascals), and the ratio of mean elasticity of the endometrial lesion to myometrial elasticity (E/M ratio) were compared in different pathologies.

RESULTS

There was a statistically significant difference (P <.001) in the mean, minimum, and maximum elasticity of the pathologies as well as the E/M ratio (P <.00001). In the analysis of the subgroups, the mean elasticity of endometrial polyp was statistically significantly lower than other subgroups (P <.01), while submucosal leiomyoma and focal adenomyoma had significantly higher values than other subgroups (P <.01). No statistically significant difference was noted in the mean elasticity of carcinoma and hyperplasia (P-.19).

CONCLUSION

SWE is a potential adjunct to ultrasound that provides an additional paradigm to characterize endometrial and subendometrial masses.

A Comparison of Shear Wave Elastography between Normal Myometrium, Uterine Fibroids, and Adenomyosis: A Cross-Sectional Study

Background

The differential diagnosis between uterine fibroid and adenomyosis is sometimes difficult; a precise diagnosis is required in women with infertility because of the different choice of treatments. Ultrasound elastography (UE) is a novel technique to evaluate the elasticity or the stiffness of the tissue of interest. The present study aims to compare UE shear wave velocity (SWV) among normal uterine myometrium, uterine fibroid, and adenomyosis, and assess the accuracy of shear wave elastography in the diagnosis of adenomyosis.

Materials and Methods

This cross-sectional study recruited 25 subjects for each group (control, adenomyosis, and fibroid) from April 2019 to April 2020. Transvaginal UE using an Aplio 500 (Toshiba Medical Systems, Japan) with ultrasound mapping for point of tissue biopsy was performed for all subjects. The diagnosis was confirmed by histology. Masson’s trichrome staining for collagen was performed and quantified

Results

The mean ± standard deviation (SD) for SWV was 3.44 ± 0.95 m/seconds (control group), 4.63 ± 1.45 m/seconds (adenomyosis group), and 4.53 ± 1.07 m/seconds (fibroid group). The mean SWV differed when comparing normal myometrium and adenomyosis after adjustments for age and endometrial pathology (P=0.019). The cut-off point of SWV at 3.465 m/seconds could differentiate adenomyosis from the normal uterus with an 80% sensitivity, 80% specificity, and an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.68-0.93) (P<0.001). No significant difference in SWV between the adenomyosis and fibroid groups was detected.

Conclusion

Shear wave elastography could be an alternative tool to distinguish between normal myometrium and adenomyosis; however, it could not differentiate adenomyosis from uterine fibroid or uterine fibroid from normal myometrium.

The Value of Shear Wave Elastography in Predicting the Risk of Endometrial Cancer and Atypical Endometrial Hyperplasia

OBJECTIVES

To evaluate shear wave elastography (SWE) technology diagnosis value of endometrial cancer (EC) and atypical endometrial hyperplasia (AEH), and to establish predictive logistic regression models for the diagnosis of EC and AEH.

METHODS

Clinical information collection, transvaginal conventional ultrasonography, and SWE check were performed on 122 patients, who were perimenopausal or postmenopausal vaginal bleeding with ≥4.5 mm thick endometrium. The maximal (Emax) and mean (Emean) of Young's modulus for the endometrium were obtained. Using pathology as the gold standard, ROC curves were plotted to evaluate Young's modulus on the diagnostic effectiveness of EC and AEH. Single-factor analysis and bivariate logistic regression methods were applied to assess the clinical variables, transuaginal conventional ultrasonography variables, and Young's modulus on the identification of EC and AEH.

RESULTS

Out of 122 cases of endometrial lesions, 85 cases were benign lesions, and the remaining 37 cases were EC and AEH. The Emax and Emean for the benign group were 29.80 ± 11.40 and 17.96 ± 8.05 kPa, respectively. The Emax and Emean values for EC and AEH group were 59.49 ± 16.95 and 38.46 ± 17.10 kPa, respectively. Emax and Emean for both groups were statistically significant, with p <.001. In the logistical regression analysis, endometrial thickness, Color score, and Young's modulus were identified as independent risk factors for EC and AEH.

CONCLUSIONS

SWE technology plays an important role in the diagnosis of EC and AEH, and the diagnostic effectiveness would be higher when combined with conventional ultrasonography.

Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for Adenomyosis: Systematic Review and Meta-Analysis and Review of Sonographic Diagnostic Criteria

We aim to first systematically review and perform a meta-analysis of the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) and, second, to evaluate the accuracy of various sonographic diagnostic criteria for adenomyosis. A search of PubMed and Embase yielded 32 eligible studies. In diagnosing adenomyosis, the diagnostic performance of TVUS was found to be high and comparable to the performance of MRI. Of the eight sonographic criteria, only five were assessable. The best individual criterion was echogenic subendometrial lines and buds. Limited data exist for the various sonographic criteria, and further studies are required to compare their performance.

Using rheology to quantify the effects of localized collagenase treatments on uterine fibroid digestion

Uterine fibroids are stiff, benign tumors containing excessive, disordered collagens that occur in 70-80% of women before age 50 and cause bleeding and pain. Collagenase Clostridium histolyticum (CCH) is a bacterial enzyme capable of digesting the collagens present in fibroids. By combining CCH with injectable drug delivery systems to enhance effectiveness, a new class of treatments could be developed to reduce the stiffness of fibroids, preventing the need for surgical removal and preserving fertility. In this work, we achieved localization of CCH via physical entrapment by co-injecting a thermoresponsive pNIPAM-based polymeric delivery system called LiquoGel (LQG), which undergoes a sol-gel transition upon heating. Toxicity study results for LQG injected subcutaneously into mice demonstrate that LQG does not induce lesions or other adverse effects. We then used rheology to quantify the effects of localized CCH injections on the modulus and viscoelasticity of uterine fibroids, which exhibit gel-like behavior, through ex vivo and in vivo digestion studies. Ex vivo CCH injections reduce the tissue modulus by over two orders of magnitude and co-injection of LQG enhances this effect. Rheological results from an in vivo digestion study in mice show a significant reduction in tissue modulus and increase in tissue viscoelasticity 7 days after a single injection of LQG+CCH. Parallel histological staining validates that the observed rheological changes correspond to an increase in collagen lysis after treatment by LQG+CCH. These results show promise for development of injectable and localized enzymatic therapies for uterine fibroids and other dense tumors. STATEMENT OF SIGNIFICANCE: Uterine fibroids are stiff, benign tumors containing high collagen levels that cause bleeding and pain in women. Fertility-preserving and minimally-invasive treatments to soften fibroids are needed as an alternative to surgical removal via hysterectomy. We demonstrate through ex vivo and in vivo studies that co-injecting a thermoresponsive polymer delivery system (LQG) alongside a bacterial collagenase (CCH) enzyme significantly increases treatment effectiveness at softening fibroids through CCH localization. We use rheology to measure the modulus and viscoelasticity of fibroids and histology to show that fibroid softening corresponds to a decrease in collagen after treatment with LQG+CCH. These results highlight the utility of rheology at quantifying tissue properties and present a promising injectable therapy for fibroids and other dense tumors.

Value of Strain-Ratio Elastography in the Diagnosis and Differentiation of Uterine Fibroids and Adenomyosis

Benign uterine disorders, including uterine fibroids (UF) and adenomyosis (AM), can impact the life quality and fertility of women of reproductive age. Transvaginal ultrasound (TVUS) has long been used for their early identification, but its combined use with elastography seems to improve diagnostic accuracy of UF and AM. Thus, a prospective pilot study was conducted on 79 patients who underwent hysterectomy (25 microscopically diagnosed with AM and 53 with UF), with the aim of assessing the ability of TVUS combined with strain ratio elastography (SE) to accurately diagnose and distinguish UF and AM. Significantly higher mean and maximal strain ratio (SR) values were identified for patients with histologically confirmed AM as opposed to those with UF (p < 0.001). Diagnostic sensitivity and specificity, calculated in comparison with histology results, were higher for UF than AM. Receiver operating characteristic (ROC) analysis was applied between the two study groups, revealing cutoff values of 7.71 for mean SR and 8.91 for maximal SR, respectively, with good sensitivity and specificity parameters (100% and 96.23%; 96% and 96.23%). Our results support the use of TVUS in combination with SE for the positive and differential diagnosis of UF and AM, through identification of their particular tissue stiffness features.

The importance of compression sonoelastography in improving the diagnostics of the pathology of myometrium

The diversity of the clinical picture and the asymptomatic nature of the clinical manifestations of myometrial pathology cause difficulties in diagnosis. There is a lack of reliable diagnostic criteria for this pathology, in particular, imaging, especially with the simultaneous combination of adenomyosis and leiomyoma. The aim of the research. Determination of the possibility of compression sonoelastography in the diagnosis of myometrial pathology and determination of its sonoelastography characteristics in leiomyoma and adenomyosis, as well as comparison of sonoelastography results with histological data. Materials and methods. Elastography images of 155 patients with adenomyosis and leiomyoma, as well as combined pathology, were analyzed, the elastography diagnosis of which was confirmed by histological examination. Results. Leiomyoma and adenomyosis had different elastography characteristics (strain ratios) with different color mapping; their specific characteristics and main differences are determined. Based on sonoelastography, the majority of patients (n=30) were suspected of having uterine fibroids, 14 had adenomyosis, and 42 had adenomyosis and fibroids. Sonoelastography revealed histological signs of adenomyosis in 3 patients with uterine leiomyoma. Conclusions. Ultrasound examination using compression sonoelastography in such pathological conditions of the myometrium as adenomyosis and leiomyoma, as well as unchanged myometrium, makes it possible to determine changes in the degree of elasticity of the myometrium in the corresponding pathology. Sonoelastography allows the identification of clear distinguishing features of fibroids and adenomyosis. The unchanged myometrium has a certain elasticity, which can be equated to a specific numerical value – the coefficient of deformation. This indicator has different meanings in myoma and adenomyosis, which makes it possible to differentiate these pathological conditions of the myometrium. Compression sonoelastography is able to identify clear distinguishing features of leiomyoma and adenomyosis, and consistency of diagnoses based on sonoelastography and histology is significant but not optimal.

Adenomyosis: Impact on Fertility and Obstetric Outcomes

In this commentary, we discuss the associations between adenomyosis, fertility, and obstetric outcomes. A recent meta-analysis on the impact of adenomyosis on reproductive outcomes found a 43% reduction in the odds ratio (OR) for clinical pregnancy and a threefold increase in the risk of miscarriage in women with adenomyosis compared with controls. Moreover, adenomyosis seems to be strongly associated with pre-eclampsia with an OR of almost 8. Also, the risk for small for gestational age was almost fourfold increased, whereas for preterm deliveries was threefold increased. The presence of deep infiltrating endometriosis and adenomyosis seems associated with particularly adverse obstetric outcomes, especially concerning natural conception. Some observations suggest that the probability of clinical pregnancy is considerably low in these cases, around 11.8%. Although several methodological drawbacks prevent definitive conclusions, all these elements should be considered in counseling women with adenomyosis seeking pregnancy, especially in cases of IVF.

Menstrual Pain and Elasticity of Uterine Cervix

Menstrual pain is consequent to intense uterine contraction aimed to expel menstrual flow through downstream uterine cervix. Herein it was evaluated whether characteristics of uterine cervix are associated with intensity of menstrual pain. Ultrasound elastography was used to analyze cervix elasticity of 75 consecutive outpatient women. Elasticity was related to intensity of menstrual pain defined by a Visual Analogue Scale (VAS). Four regions of interest (ROI) were considered: internal uterine orifice (IUO), anterior (ACC) and posterior cervical (PCC) compartment and middle cervical canal (MCC). Tissue elasticity, evaluated by color score (from 0.5 = blue/violet (low elasticity) to 3.0 = red (high elasticity), and percent tissue deformation was analyzed. Elasticity of IUO was lower (p = 0.0001) than that of MCC or ACC, and it was negatively related (R2 = 0.428; p = 0.0001) to menstrual VAS (CR −2.17; 95%CI −3.80, −0.54; p = 0.01). Presence of adenomyosis (CR 3.24; 95% CI 1.94, 4.54; p = 0.0001) and cervix tenderness at clinical examination (CR 2.74; 95% CI 1.29, 4.20; p = 0.0004), were also independently related to menstrual VAS. At post hoc analysis, women with vs. without menstrual pain had lower IUO elasticity, expressed as color score (0.72 ± 0.40 vs. 0.92 ± 0.42; p = 0.059), lower percent tissue deformation at IUO (0.09 ± 0.05 vs. 0.13 ± 0.08; p = 0.025), a higher prevalence of cervical tenderness at bimanual examination (36.2% vs. 9.5%; p = 0.022) and a higher prevalence of adenomyosis (46.5% vs. 19.9%; p = 0.04). These preliminary data indicate that IUO elasticity is associated with the presence and the intensity of menstrual pain. Mechanisms determining IUO elasticity are useful to be explored.

Temperature Elevation in an Instrumented Phantom Insonated by B-Mode Imaging, Pulse Doppler and Shear Wave Elastography

Diagnostic ultrasound is the gold standard for obstetric scanning and one of the most important imaging techniques for perinatal and neonatal monitoring and diagnosis. Ultrasound provides detailed real-time anatomic information, including blood flow measurements and tissue elasticity. The latter is provided through various techniques including shear wave elastography (SWE). SWE is increasingly used in many areas of medicine, especially in detection and diagnosis of breast, thyroid and prostate cancers and liver disease. More recently, SWE has found application in gynaecology and obstetrics. This method mimics manual palpation, revealing the elastic properties of soft biological tissues. Despite its rising potential and expanding clinical interest in its use in obstetrics and gynaecology (such as for assessment of cervical ripening or organ development and structure during pregnancy), its effects on and potential risks to the developing fetus remain unknown. Risks should be evaluated by regulatory bodies before recommendations are made on the use of SWE. Because ultrasound is known to produce thermal and mechanical effects, this study measured the temperature increase caused by B-mode, pulse Doppler (PD) and SWE, using an instrumented phantom with 11 embedded thermocouples. Experiments were performed with an Aixplorer diagnostic ultrasound system (Supersonic Imagine, Aix-en-Provence, France). As expected, the greatest heating was detected by the thermocouple closest to the surface in contact with the transducer (2.9°C for SWE, 1.2°C for PD, 0.7°C for B-mode after 380-s excitation). Both conduction from the transducer face and direct heating owing to ultrasound waves contribute to temperature increase in the phantom with SWE associated with a larger temperature increase than PD and B-mode. This article offers a methodological approach and reference data for future safety studies, as well as initial recommendations about SWE safety in obstetrics and gynaecology.

Diagnosing adenomyosis: an integrated clinical and imaging approach

BACKGROUND

Adenomyosis is a benign uterine disorder where endometrial glands and stroma are pathologically demonstrated within the uterine myometrium. The pathogenesis involves sex steroid hormone abnormalities, inflammation, fibrosis and neuroangiogenesis, even though the proposed mechanisms are not fully understood. For many years, adenomyosis has been considered a histopathological diagnosis made after hysterectomy, classically performed in perimenopausal women with abnormal uterine bleeding (AUB) or pelvic pain. Until recently, adenomyosis was a clinically neglected condition. Nowadays, adenomyosis may also be diagnosed by non-invasive techniques, because of imaging advancements. Thus, a new epidemiological scenario has developed with an increasing number of women of reproductive age with ultrasound (US) or magnetic resonance imaging (MRI) diagnosis of adenomyosis. This condition is associated with a wide variety of symptoms (pelvic pain, AUB and/or infertility), but it is also recognised that some women are asymptomatic. Furthermore, adenomyosis often coexists with other gynecological comorbidities, such as endometriosis and uterine fibroids, and the diagnostic criteria are still not universally agreed. Therefore, the diagnostic process for adenomyosis is challenging.

OBJECTIVE AND RATIONALE

We present a comprehensive review on the diagnostic criteria of adenomyosis, including clinical signs and symptoms, ultrasound and MRI features and histopathological aspects of adenomyotic lesions. We also briefly summarise the relevant theories on adenomyosis pathogenesis, in order to provide the pathophysiological background to understand the different phenotypes and clinical presentation. The review highlights the controversies of multiple existing criteria, summarising all of the available evidences on adenomyosis diagnosis. The review aims also to underline the future perspective for diagnosis, stressing the importance of an integrated clinical and imaging approach, in order to identify this gynecological disease, so often underdiagnosed.

SEARCH METHODS

PubMed and Google Scholar were searched for all original and review articles related to diagnosis of adenomyosis published in English until October 2018.

OUTCOMES

The challenge in diagnosing adenomyosis starts with the controversies in the available pathogenic theories. The difficulties in understanding the way the disease arises and progresses have an impact also on the specific diagnostic criteria to use for a correct identification. Currently, the diagnosis of adenomyosis may be performed by non-invasive methods and the clinical signs and symptoms, despite their heterogeneity and poor specificity, may guide the clinician for a suspicion of the disease. Imaging techniques, including 2D and 3D US as well as MRI, allow the proper identification of the different phenotypes of adenomyosis (diffuse and/or focal). From a histological point of view, if the diagnosis of diffuse adenomyosis is straightforward, in more limited disease, the diagnosis has poor inter-observer reproducibility, leading to extreme variations in the prevalence of disease. Therefore, an integrated non-invasive diagnostic approach, considering risk factors profile, clinical symptoms, clinical examination and imaging, is proposed to adequately identify and characterise adenomyosis.

WIDER IMPLICATIONS

The development of the diagnostic tools allows the physicians to make an accurate diagnosis of adenomyosis by means of non-invasive techniques, representing a major breakthrough, in the light of the clinical consequences of this disease. Furthermore, this technological improvement will open a new epidemiological scenario, identifying different groups of women, with a dissimilar clinical and/or imaging phenotypes of adenomyosis, and this should be object of future research.

Which imaging method is better for the differentiation of adenomyosis and uterine fibroids?

OBJECTIVE

The paper compares shear wave elastography (SWE), strain elastography (SE) and magnetic resonance imaging apparent diffusion coefficient (MRI ADC) values, to evaluate their efficacy for differentiating between adenomyosis (AM) and uterine fibroids (UF).

METHODS

Patients who were scheduled for hysterectomy for AM or UFs, with a preliminary diagnosis, were additionally evaluated before surgery by transabdominal and transvaginal ultrasound elastography. SE of patients were evaluated by transvaginal ultrasound, and SWE of patients and control subjects were evaluated by transabdominal ultrasound. Then, the patients with a definitive histopathological diagnosis as AM or UFs were evaluated retrospectively and compared to the control group without myometrial pathology. In addition, MRI images of patients with UFs and AM were examined for ADC values.

RESULTS

The results of 98 patients in the UF group, 37 patients in the AM group, and 40 volunteers with a healthy myometrium in the control group were compared. There were no statistically significant differences in age and body mass index between the groups (P > 0.05). Uterine size was significantly higher in the UF and AM group than the control group (P < 0.001). A statistically significant difference was found between strain ratio (mean), strain ratio (max), and ADC values between the UF and AM groups (P < 0.001 for all three). There was a statistically significant difference in elastography scores distribution between the groups (P < 0.001). There was a statistically significant difference between the UF and control (P < 0.001) and between the UF and AM (P < 0.001) groups in terms of SWE (kilopascal (kPa)) averages (P < 0.001). We found that none of these discrimination methods were statistically superior to each other in differentiating the UFs from the AM.

CONCLUSION

In the differentiation of myometrial pathologies in gynecological imaging, both SE and SWE are cheaper, provide faster results, are non-invasive and easy to apply, and hence are as promising as the more expensive MRI ADC. Our study is the first to use both modalities of elastography and MRI ADC values together, compare these methods with each other and confirm the results pathologically.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Current and Future Medical Therapies for Adenomyosis

There is no approved medical therapy for adenomyosis and limited evidence to guide treatments in part due to the complexity of nonhistologic diagnosis and the prevalence of concomitant gynecologic conditions. Most available evidence focuses on the treatment of heavy menstrual bleeding, painful menses, and pelvic pain. Data evaluating fertility outcomes, sexual function, and quality of life following treatment are lacking. Additionally, there is no disease-specific measure of quality of life for adenomyosis. The levonorgestrel-releasing intrauterine system appears to be the most effective first-line therapy based on efficacy compared with oral agents, maintenance of steady-state hormonal levels, and contraceptive benefit. In areas where it is marketed, the progestin dienogest appears superior to combined oral contraceptives. Long-acting gonadotropin-releasing hormone agonists are effective and should be considered second-line therapy but are limited by hypogonadal effects. Additional data regarding oral gonadotropin-releasing hormone antagonists are required. While aromatase inhibitors demonstrate improvement in heavy menstrual bleeding and pelvic pain, further research is needed to determine their role in the management of adenomyosis. Progesterone receptor modulators may have a role for this disease if released again to market with appropriate safety parameters. Finally, modulation of prolactin and/or oxytocin may provide novel nonsteroidal treatment options.

The Utility of Myometrial and Cervical Ultrasound Shear Wave Elastography in the Diagnosis of Ectopic Pregnancy

We aimed to assess the potential utility of myometrial and cervical elasticity measurement in the diagnosis of ectopic pregnancy (EP), which could facilitate the diagnosis process. Myometrial and cervical elasticity values were measured in women with EP, women with early intrauterine pregnancy (IP) and non-pregnant women. Transabdominal point shear wave elastography (pSWE) was used for elasticity measurements. A reliability study was performed in 20 patients of the non-pregnant group. Cervical pSWE showed poor reliability and high measurement failure rate; thus, we excluded cervical elasticity assessment from the study. In this study, 32 women with EP, 28 women with early IP and 38 non-pregnant women were enrolled for myometrial elasticity assessment by pSWE. Myometrial elasticity values were statistically significantly lower in EP (8.31 kPa [5.1-27]) and early IP (8.83 kPa [4.5-46.2]) groups than in non-pregnant women (14.85 kPa [5.1-28]) (p = 0.003). However, myometrial pSWE results were not significantly different between EP and early IP groups. In light of this data, quantitative assessment of the uterus elasticity using pSWE does not seem to be an adequate diagnostic method for EP.

New surgical technique of laparoscopic resection of adenomyosis under real-time intraoperative ultrasound elastography guidance: A case report

Detecting adenomyosis in the myometrium is a challenge since it is infiltrative with ill-defined margins and can be often confused with uterine fibroids. However, recent advances, such as ultrasound elastography, have enabled its detection in the myometrium, thereby facilitating its accurate diagnosis. We report our experience of performing complete laparoscopic resection of adenomyosis under real-time ultrasound elastography guidance in a 32-year-old woman who underwent laparoscopic adenomyomectomy following severe dysmenorrhea and heavy menstrual bleeding. Real-time ultrasound elastography was also utilized intraoperatively to detect residual adenomyosis. Complete adenomyosis resection and uterine reconstruction were achieved. Follow-up magnetic resonance imaging was conducted to confirm successful uterine reconstruction. The patient recovered rapidly with no complications. Intraoperative elastography-guided laparoscopic adenomyomectomy was feasible and effective in completely removing adenomyotic lesions.

Ultrasound vibro-elastography for assessing mechanical properties of porcine reproductive tissues in an ex vivo model

BACKGROUND

The aim of this study was to use ultrasound vibro-elastography (UVE) for measuring surface wave speed and assessing mechanical properties of ex vivo porcine reproductive tissues, including the uterus, bladder, cornua and cervix.

METHODS

In UVE, a 0.1-s harmonic vibration at low frequency was generated on the tissue surface with a handheld shaker. A linear-array ultrasound probe was used to measure the resulting surface wave propagation. Surface wave speeds of tissues were measured in the frequency range of 100-300 Hz. Mechanical properties of the tissue were calculated based on wave speed dispersion with frequency.

FINDINGS

The obtained results showed that the surface wave speeds of porcine bladder, cervix, cornua and uterus increased with frequency. There were no statistically significant differences in the wave speeds or mechanical properties among the porcine bladder, cervix, cornua and uterus.

INTERPRETATION

Experimental data obtained in this study may be used as a reference to study in vivo surface wave speed or mechanical properties for porcine or human reproductive tissues.

Assessment of the cervix in pregnant women with a history of cervical insufficiency during the first trimester using elastography

INTRODUCTION

To investigate changes in first trimester cervical elastography, cervical length and endocervical canal width in pregnant women with a history of cervical insufficiency, and further discuss the possibility of using these markers as predictors of cervical insufficiency in early pregnancy.

MATERIAL AND METHODS

This was an observational ultrasound study of first trimester cervical changes in singleton pregnancies between January 2016 and June 2018. Cervical elastography, cervical length and endocervical canal width were measured during the first trimester. Strain elastography was used to estimate the softness of anterior and posterior cervical lips and was expressed as percentages (strain rate).

RESULTS

Of the 339 pregnant women enrolled, 24 had a history of cervical insufficiency. The anterior cervical lip was significantly softer in the cervical insufficiency group (strain rate: 0.19% ± 0.05% vs 0.11% ± 0.04%; P < .001). Cervical length was significantly shorter in the cervical insufficiency group (36.3 ± 4.8 mm vs 38.3 ± 3.8 mm; P = .014). Endocervical canal width was significantly wider in the cervical insufficiency group (5.7 ± 1.1 mm vs 5.2 ± 0.7 mm; P = .001). Receiver operating characteristic curve analyses revealed that the optimal cut-off values of anterior cervical lip, cervical length and endocervical canal width to confirm the diagnosis of cervical insufficiency were 0.15%, 35.5 mm and 5.75 mm, respectively. In multivariate logistic regression analysis, significant differences were still observed in anterior cervical strain rate (adjusted odds ratio [OR] 53.78, 95% [confidence interval [CI] 11-270; P < .001) and endocervical canal width (adjusted OR, 5.41, 95% CI,1.2-24.7; P = .029).

CONCLUSIONS

First trimester cervical elastography is a valuable tool in the assessment of women with a history of cervical insufficiency. The anterior cervical lip was significantly softer in women with a history of cervical insufficiency, and the sensitivity and specificity of anterior cervical lip strain were better than that of cervical length and endocervical canal width.

Ultrasound Shear Wave Velocity Varies Across Anatomical Region in Ex Vivo Bovine Ovaries

The physical properties of the ovarian extracellular matrix (ECM) regulate the function of ovarian cells, specifically the ability of the ovary to maintain a quiescent primordial follicle pool while allowing a subset of follicles to grow and mature in the estrous cycle. Design of a long-term, cycling artificial ovary has been hindered by the limited information regarding the mechanical properties of the ovary. In particular, differences in the mechanical properties of the two ovarian compartments, the cortex and medulla, have never been quantified. Shear wave (SW) ultrasound elastography is an imaging modality that enables assessment of material properties, such as the mechanical properties, based on the velocity of SWs, and visualization of internal anatomy, when coupled with B-mode ultrasound. We used SW ultrasound elastography to assess whole, ex vivo bovine ovaries. We demonstrated, for the first time, a difference in mechanical properties, as inferred from SW velocity, between the cortex and medulla, as measured along the length (cortex: 2.57 ± 0.53 m/s, medulla: 2.87 ± 0.77 m/s, p < 0.0001) and width (cortex: 2.99 ± 0.81 m/s, medulla: 3.24 ± 0.97 m/s, p < 0.05) and that the spatial distribution and magnitude of SW velocity vary between these two anatomical planes. This work contributes to a larger body of literature assessing the mechanical properties of the ovary and related cells and specialized ECMs and will enable the rational design of biomimetic tissue engineered models and durable bioprostheses. Impact Statement Shear wave (SW) ultrasound elastography can be used to simultaneously assess the material properties and tissue structures when accompanied with B-mode ultrasound. We report a quantitative difference in mechanical properties, as inferred from SW velocity, between the cortex and medulla, with SW velocity being 11.4% and 8.4% higher in the medulla than the cortex when measured along the length and width, respectively. This investigation into the spatial and temporal variation in SW velocity in bovine ovaries will encourage and improve design of more biomimetic scaffolds for ovarian tissue engineering.

The effect of placental elasticity on intraoperative bleeding in pregnant women with previous cesarean section

Background We aimed to evaluate the efficiency of placental elasticity in predicting the amount of intraoperative bleeding via real-time tissue elastography technique. Methods Pregnant women in the third trimester of pregnancy who had planned delivery via cesarean section due to the recurrent cesareans were enrolled in the research (n = 78). Elastographic measurements of placental tissues of all cases were carried out by real-time elastographic ultrasonography. It is a tissue elastography software (Esaote MyLabSeven) that uses a 8-1-MHz multifrequency AC2541 Probe. Results A significant relationship was found between placental elasticity and intraoperative bleeding. There was a significant correlation between alterations in the preoperative and postoperative hemoglobin (Hb) and hematocrit (Hct) levels and placental strain ratio (SR) (P < 0.001, r: 0.831; P < 0.001, r: 0.733, respectively). Conclusion These findings may reflect an alteration at the tissue elasticity level. We hope that the use of real-time elastographic ultrasonography technique may give an idea about the amount of bleeding during the cesarean section.

Quantitative ultrasound elastography and biometry of the bitch uterus in the early puerperium after vaginal delivery and caesarean section

Elastography is an actual imaging method used to qualitatively and quantitatively evaluate the elastic properties of tissues. The aim of this study was to evaluate and compare uterine tissue biometry and stiffness during post-partum period in brachycephalic bitches (n = 12) after c-section (GCS; n = 8) or normal delivery (GNB; n = 4). These animals were evaluated daily by abdominal ultrasound from the day of delivery until the 10th day post-partum; measuring uterine diameter, myometrial and endometrial thickness (mm) and shear wave velocity (SWV; m/s), by B-mode and ARFI (acoustic radiation force impulse) elastography, respectively. Uterine diameter was higher (p = .012) in animals submitted to c-section (15.26 ± 4.73 mm) than in normal birth (12.53 ± 2.64 mm) during the first 7 days post-partum. Uterine thickness gradually involuted in both groups (p < .0001), the myometrium during the first 9 days (p = .005) and the endometrium during the first 6 days (p = .003). The myometrial and endometrial SWVs were similar between types of delivery (p = .7846 and .8273) and presented a gradual increase (p = .411; .0043, respectively), during the first 10 days post-partum. It was concluded that bitches with normal delivery had smaller uterine thickness and faster puerperal involution than submitted to c-section, while uterine tissue stiffness was similar between delivery types and increased gradually during post-partum.

Quantitative Sonoelastographic Assessment of the Normal Uterus Using Shear Wave Elastography: An Initial Experience

OBJECTIVES

To describe the sonoelastographic characteristics of the normal endometrium, myometrium, and cervix and to assess their variability with age and different menstrual phases.

METHODS

A total of 56 women were enrolled in this prospective study, who underwent transvaginal ultrasound examinations, including B-mode imaging and shear wave elastography. The elasticity parameters (in kilopascals) of the normal endometrium, myometrium, and cervix were studied. The variability of the mean elasticity value of the endometrium in different menstrual phases and age groups was analyzed. The variability of the mean elasticity of the cervix across different age groups was also studied.

RESULTS

The mean age of the participants was 40 years (range, 25-69 years). The normal mean elasticity values ± SDs were 25.54 ± 8.56 kPa for the endometrium, 40.24 ± 8.59 kPa for the myometrium, and 18.90 ± 4.22 kPa for the cervix. A mean endometrial-to-myometrial elasticity ratio was calculated, which was found to be 0.65 ± 0.22. There was no significant difference in the mean endometrial elasticity values for women in different menstrual phases (P = .176) or in different age groups (P = .376). There was no significant difference in the mean cervical elasticity with age (P = .192).

CONCLUSIONS

Shear wave elastography is a promising adjunct to ultrasound for the evaluation of the uterus, and the results from this study may provide normal data, which may further help in diagnosing various uterine diseases.

Elasticity of adenomyosis is increased after GnRHa therapy and is associated with spontaneous pregnancy in infertile patents

OBJECTIVE

To explore the effects of GnRHa on adenomyosis by transvaginal elastography.

METHODS

A prospective observational study included patients who were diagnosed as adenomyosis by conventional transvaginal ultrasound and infertility. The sonographic characters of elastography, the degree of dysmenorrhea and the values of serum CA125 before and following GnRHa (Triptorelin 3.75 mg were administered every 28 days) plus add-back therapy were reviewed and analyzed. Each case had a 6 months follow up and the information of pregnancy were recorded.

RESULTS

45 patients who completed the 6 months follow-up were included in the analysis. Twelve cases (group 1) were pregnancy during the follow-up and the other thirty-three cases (group 2) failed their attempts. The numerical rating scale and CA125 of all the cases were both significantly reduced 6 months after therapy. All of enlarged uterus decreased to accessible normal size. In group 1, the mean elasticity score was significantly higher for the uterine after therapy than before (3.6 ± 0.3 vs 2.3 ± 0.5, p = 0.004). In group 2, the mean elasticity score did not change for the uterine after therapy than before (2.2 ± 0.5 vs 2.5 ± 0.6, p = 0.77).

CONCLUSION

Elasticity of adenomyosis is increased after GnRHa therapy. And the higher elasticity of adenomyosis after GnRHa therapy is associated with spontaneous pregnancy in infertile patents.

Transvaginal Ultrasound Vibro-elastography for Measuring Uterine Viscoelasticity: A Phantom Study

The purpose of this research was to determine the feasibility of a transvaginal ultrasound vibro-elastography (TUVE) technique for generating and measuring shear wave propagation in the uterus. In TUVE, a 0.1-s harmonic vibration at a low frequency is generated on the abdomen of a subject via a handheld vibrator. A transvaginal ultrasound probe is used to measure the resulting shear wave propagation in the uterus. TUVE was evaluated on a female ultrasound phantom. The shear wave speeds in the region of interest of the uterus of the female ultrasound phantom were measured in the frequency range of 100-300 Hz. The viscoelasticity was analyzed based on the wave speed dispersion with frequency. The measurement of shear wave speed suggests that the uterus of this female ultrasound phantom is much stiffer than the human uterus. This research illustrates the feasibility of TUVE for generating and measuring shear wave propagation in the uterus of a female ultrasound phantom. We will further evaluate TUVE in patients, both normal controls and those with uterine diseases such as adenomyosis.

Transvaginal Ultrasound Shear Wave Elastography for the Evaluation of Benign Uterine Pathologies: A Prospective Pilot Study

OBJECTIVES

This study evaluated the diagnostic performance of transvaginal ultrasound (TVUS) shear wave elastography (SWE) for evaluating uterine adenomyosis and leiomyomas.

METHODS

Institutional Review Board approval was obtained for prospective enrollment of 34 premenopausal women with pelvic pain and/or bleeding between January 2015 and June 2016. TVUS SWE was performed with regions of interest in multiple uterine segments and shear wave velocities(SWVs) were recorded. Reference pelvic magnetic resonance examinations were performed and reviewed without access to the ultrasound results.

RESULTS

Continuous variables were analyzed using means, t tests, and analysis of variance. Magnetic resonance imaging revealed adenomyosis in 6 women (12 uterine segments) and leiomyomas in 12 women (28 segments). On a per-patient basis, mean SWV in 16 women with no adenomyosis or leiomyoma was 4.3 ± 1.7 m/s, compared with 5.7 ± 2.3 m/s in 18 women with a magnetic resonance diagnosis of myometrial pathology (P < .0002; 95% confidence interval, -2.2, -0.6). On a per-segment basis, SWV in normal myometrium was 4.8 ± 1.9 m/s, compared with 4.9 ± 2.5 m/s in adenomyosis and 5.6 ± 2.5 m/s in leiomyoma (P = .34 by one-way analysis of variance). In pairwise comparison, SWV for adenomyosis and leiomyoma did not differ significantly (P = .40).

CONCLUSIONS

TVUS SWE did not distinguish adenomyosis from leiomyoma. However, our pilot study demonstrated that myometrial SWVs were higher in uteri with adenomyosis and leiomyomas than in uteri with myometrium with no abnormalities suggesting a potential role for SWE in treatment response assessment.

Accuracy and Reproducibility of Sonoelastography for the Assessment of Fibroids and Adenomyosis, with Magnetic Resonance Imaging as Reference Standard

The aims of this prospective diagnostic evaluation study were (i) to estimate the inter-observer agreement and reproducibility of real-time sonoelastography and real-time gray-scale ultrasound in the measurement of uterine and fibroid volumes; (ii) to evaluate the agreement between real-time gray-scale ultrasound, sonoelastography and magnetic resonance imaging with respect to these outcomes; and (iii) to evaluate the diagnostic accuracy of sonoelastography in the diagnosis of uterine pathology on stored sonoelastography and gray-scale cine loops. Women without a history of uterine pathology and with the diagnosis intrauterine fibroids or adenomyosis were included. All participants underwent gray-scale ultrasound, sonoelastography and magnetic resonance imaging. Compression sonoelastography was found to have high inter-observer and inter-method agreement for the measurement of uterine and fibroid volumes. The addition of sonoelastography to gray-scale ultrasound seems to be useful in the differentiation between fibroids, adenomyosis and normal uteri as reflected by an increase in accuracy and diagnostic agreement.

Use of Contrast-Enhanced Ultrasound in the Assessment of Uterine Fibroids: A Feasibility Study

Contrast-enhanced ultrasound (CEUS) is an innovative ultrasound technique capable of visualizing both the macro- and microvasculature of tissues. In this prospective pilot study, we evaluated the feasibility of using CEUS to visualize the microvasculature of uterine fibroids and compared CEUS with conventional ultrasound. Four women with fibroids underwent gray-scale ultrasound, sonoelastography and power/color Doppler scans followed by CEUS examination. Analysis of CEUS images revealed initial perfusion of the peripheral rim, that is, a pseudo-capsule, followed by enhancement of the entire lesion through vessels traveling from the exterior to the interior of the fibroid. The pseudo-capsules exhibited slight hyper-enhancement, making a clear delineation of the fibroids possible. The centers of three fibroids exhibited areas lacking vascularization, information not obtainable with the other imaging techniques. CEUS is a feasible technique for imaging and quantifying the microvasculature of fibroids. In comparison with conventional ultrasound imaging modalities, CEUS can provide additional diagnostic information based on the microvasculature.

Ultrasound elastography of the lower uterine segment in women with a previous cesarean section: Comparison of in-/ex-vivo elastography versus tensile-stress-strain-rupture analysis

OBJECTIVES

The purpose of this study was to assess, if the biomechanical properties of the lower uterine segment (LUS) in women with a previous cesarean section (CS) can be determined by ultrasound (US) elastography. The first aim was to establish an ex-vivo LUS tensile-stress-strain-rupture(break point) analysis with the possibility of simultaneously using US elastography. The second aim was to investigate the relationship between measurement results of LUS stiffness using US elastography in-/ex-vivo with results of tensile-stress-strain-rupture analysis, and to compare different US elastography LUS-stiffness-measurement methods ex-vivo.

STUDY DESIGN

An explorative experimental, in-/ex-vivo US study of women with previous CS was conducted. LUS elasticity was measured by point Shear Wave Elastography (pSWE) and bidimensional Shear-Wave-Elastography (2D-SWE) first in-vivo during preoperative examination within 24 h before repeat CS (including resection of the thinnest part of the LUS = uterine scar area during CS), second within 1 h after operation during the ex-vivo experiment, followed by tensile-stress-strain-rupture analysis. Pearson's correlation coefficient and scatter plots, Bland-Altman plots and paired T-tests, were used.

RESULTS

Thirty three women were included in the study; elastography measurements n = 1412. The feasibility of ex-vivo assessment of LUS by quantitative US elastography using pSWE and 2D-SWE to detect stiffness of LUS was demonstrated. The strongest correlation with tensile-stress-strain analysis was found in the US elastography examination carried out with 2D-SWE (0.78, p < 0.001, 95%CI [0.48, 0.92]). The laboratory experiment illustrated that, the break point - as a surrogate marker for the risk of rupture of the LUS after CS - is linearly dependent on the thickness of the LUS in the scar area (Coefficient of correlation: 0.79, p < 0.001, 95%CI [0.55, 0.91]). Two extremely stiff LUS-specimens (outlier or extreme values) rupture even at less stroke/strain than would be expected by their thickness.

CONCLUSION

This study confirms that US elastography can help in determining viscoelastic properties of the LUS in women with a previous CS. The data from our small series are promising. However whether individual extreme values of high stiffness and consecutive restricted biomechanical resilience can explain the phenomenon of rupture during TOLAC in cases of LUS with adequate thickness remains a question which prospective trials have to analyze before US elastography can be introduced into clinical practice.

From Clinical Symptoms to MR Imaging: Diagnostic Steps in Adenomyosis

Adenomyosis or endometriosis genitalis interna is a frequent benign disease of women in fertile age. It causes symptoms like bleeding disorders and dysmenorrhea and seems to have a negative effect on fertility. Adenomyosis can be part of a complex genital and extragenital endometriosis but also can be found as a solitary uterine disease. While peritoneal endometriosis can be easily diagnosed by laparoscopy with subsequent biopsy, the determination of adenomyosis is difficult. In the following literature review, the diagnostic methods clinical history and symptoms, gynecological examination, 2D and 3D transvaginal ultrasound, MRI, hysteroscopy, and laparoscopy will be discussed step by step in order to evaluate their predictive value in the diagnosis of adenomyosis.