Accuracy of ultrasound signs on two-dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study

OBJECTIVE

Two-dimensional (2D) transvaginal ultrasound (TVS) is an accessible and cost-effective diagnostic tool for the detection of adenomyosis. Different ultrasound features related to adenomyosis have been described, but the predictive value of each ultrasound sign and their combinations requires further investigation. We aimed to analyze the accuracy of 2D-TVS and describe possible combinations of ultrasound signs with a high predictive value in the diagnosis of adenomyosis.

METHODS

This was a prospective multicenter study of patients scheduled for laparoscopic hysterectomy who had been examined using standardized 2D-TVS at nine expert centers specializing in the diagnosis and treatment of endometriosis. 2D-TVS examination included nine typical adenomyosis ultrasound features, comprising heterogeneous myometrium, myometrial linear striations, myometrial cysts, subendometrial microcysts, asymmetrical myometrial thickening, uterine enlargement, the 'question mark sign', thickening of the junctional zone and hyperechoic myometrial spots, in order to predict or exclude the presence of adenomyosis. Ultrasound examination results were compared with histology after hysterectomy. The diagnostic reliability of the nine ultrasound signs and their combinations, and the influence of concurrent fibroids on the accuracy of the results, were analyzed.

RESULTS

A total of 202 patients were enrolled into the study. Histopathological examination revealed adenomyosis in 130 patients (64.4%). The accuracy of prediction of adenomyosis by 2D-TVS examination using all signs was 63.4% (positive predictive value, 71.5%; negative predictive value, 48.6%; sensitivity, 71.5%; specificity, 48.6%). Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy (55.7-62.1%) as individual ultrasound signs for the prediction of adenomyosis. The combination of the most accurate ultrasound signs (subendometrial microcysts, myometrial cysts and heterogeneous myometrium) improved the specificity of prediction (86.1%) when compared with that of these three single markers (35.2-81.7%). Uterine enlargement and asymmetry showed both low sensitivity (60.8% and 52.3%, respectively) and specificity (41.7% and 49.3%, respectively) as individual sonographic signs.

CONCLUSIONS

Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy for the detection of adenomyosis in this study, while uterine enlargement and asymmetry led to high false-positive and false-negative results. A combination of ultrasound features including the most accurate signs increases specificity. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[S2k guidelines for the diagnosis and treatment of endometriosis-Recommendations for pathology]

Die vorliegende Übersicht fasst die relevanten Aspekte der S2k-Leitlinie Endometriose zusammen. Die Empfehlungen umfassen die Aufarbeitung und Befunderhebung bei Biopsien und Resektaten, die bei der klinischen Diagnose einer Endometriose entnommen wurden. Die Leitlinie berücksichtigt neben praktischen Aspekten der Pathologie ebenso die klinischen Notwendigkeiten an die Histopathologie für eine optimale Diagnostik und Therapie der Patientinnen.

Basierend auf der in der pathologischen Literatur gebräuchlichsten Definition der Endometriose des Corpus uteri (Adenomyosis uteri) wurde diese in der Leitlinie definiert als der Nachweis des Endometrioseherdes im Myometrium in einem Abstand zur endomyometranen Grenze von einem mittelgroßen Gesichtsfeld (100fache Vergrößerung), was metrisch rund 2,5 mm entspricht. Bei Darmresektaten soll zum Status der Resektionsränder Stellung genommen werden.

Ebenso definiert werden Anforderungen im Kontext endometrioseassoziierter Karzinome (z. B. Hormonrezeptorbestimmungen, immunhistochemische Untersuchung auf Ausfall der DNA-Mismatch-Reparaturproteine).

Strain Elastography as a New Method for Assessing Pelvic Floor Biomechanics

Strain elastography (SE) is a new technique of parametric imaging that allows quantification of the elasticity of tissue. The aim of our study was to determine if the elasticity of para-urethral tissue correlates with urethral mobility and urinary incontinence (UI). Ninety-nine unselected women were investigated with SE. They were given a standardized interview about UI, and SE raw data for the para-urethral tissue were acquired in a sagittal standard urethra-symphysis view while being stimulated by a coughing fit. We placed one region of interest (ROI A) in the tissue between the urethra and vagina at midlevel of the urethra bordering the urethral wall. The second ROI (ROI B) was set at the level of the os urethra internum in the tissue of the bladder neck in one line to ROI A. We measured elasticity in both ROIs with TDI-Q (Tissue Doppler Imaging-Quantification Software) and calculated the ratio between ROI A and ROI B (A/B). Mobility of the urethra was quantified by measuring the angle between a line parallel to the urethra and a line parallel to the bladder neck during stress and rest. SE analysis was feasible in all cases. A/B was found to be correlated with the incidence of urethral mobility (p < 0.001). The incidence of UI was associated with an increase in urethral mobility (p = 0.04). No correlation between UI and A/B could be shown (p = 0.24). We observed a correlation between urethral mobility and elasticity of the para-urethral tissue. In case of increasing urethral mobility, the para-urethral tissue close to the bladder neck seems to be more elastic, and the patients reported about more symptoms of UI. No noticeable correlation between UI and urethral elasticity was shown. SE may be a useful technique for direct quantification of tissue elasticity and assessment of pelvic floor biomechanics.

Importance of Transvaginal Elastography in the Diagnosis of Uterine Fibroids and Adenomyosis

PURPOSE

To evaluate normal uterine tissue with special regard to age and the presence of uterine fibroids and adenomyosis with transvaginal elastography.

MATERIALS AND METHODS

In a prospective study elastographic data of the uterus were obtained in 206 unselected women with transvaginal ultrasound. Women who presented without any uterine pathology in ultrasonography were included in a control group, women with uterine fibroids in a uterine fibroid group, and women with adenomyosis in an adenomyosis group. In the control group strain values were measured at two regions of interest (ROIs) placed one upon the other in the anterior inferior uterine segment during a cycle of compression. The maximum strain ratio (ROI1 / ROI2) was stored as the "age index". In all groups strain values were measured at two ROIs placed side by side in a uterine fibroid (uterine fibroid group) or adenomyosis (adenomyosis group) or healthy homogeneous tissue (control group) and adjacent healthy tissue. Maximum strain ratios (ROI3 / ROI4) were stored as the "lesion index".

RESULTS

The "age index" was significantly negatively correlated with the age of the women (r = -0.49, p < 0.001). The median "lesion indices" were significantly (p < 0.001) different between the uterine fibroid, adenomyosis and control groups. Median "lesion indices" were 2.65, 0.44 and 1.19, respectively.

CONCLUSION

The "age index" shows that normal uterine tissue has a certain age-dependent stiffness that increases with age. The "lesion index" allows for the assessment of the presence of a uterine fibroid or adenomyosis and helps to differentiate between both focal findings. Thus the use of elastography in addition to conventional ultrasound could help to diagnose uterine focal lesions and may be useful in preoperative planning.

miR-142-3p is a novel regulator of cell viability and proinflammatory signalling in endometrial stroma cells

Endometriosis is associated with severe pelvic pain and reduced fertility. Recently, it has been linked to a dysregulation of microRNAs (miRNAs), which are post-transcriptional regulators of gene expression. The functional effect of dysregulated miR-142-3p expression in endometrial stroma cells was investigated. An increased expression of miR-142-3p resulted in a significantly reduced expression of steroid sulfatase and interleukin-6-coreceptor gp130 as well as reduced interleukin-6-mediated activation of the STAT3-pathway, suggesting an effect of miR-142-3p both on steroid hormone- and cytokine-mediated signalling events. At the functional level, miR-142-3p overexpression significantly reduced cell viability (P ≤ 0.01). miR-142-3p regulation emerges as a future therapeutic strategy for endometriosis.

Importance of transvaginal ultrasound applying elastography for identifying deep infiltrating endometriosis - a feasibility study

PURPOSE

To evaluate the presence of a lesion indicative of endometriosis with transvaginal elastography.

MATERIALS AND METHODS

Transvaginal ultrasound and clinical examination were carried out in 48 women with clinical symptoms indicative of endometriosis. In 31 cases strain values were measured at two regions of interest (ROIs) in the Douglas's cul-de-sac during a cycle of compression and decompression with a vaginal probe.

RESULTS

A significant difference was found for the ratio of the ROI measuring points in the Douglas' cul-de-sacs of women with a palpable nodule in examination compared to women without a palpable nodule (p = 0.002).

CONCLUSION

The ratio of strain values between two ROIs in the Douglas' s cul-de-sac is associated with the presence of an endometriotic lesion. In the future, these findings could allow for a more detailed pre-surgical evaluation and possibly serve as a novel diagnostic tool for predicting deep infiltrating endometriosis.