Value of Magnetic Resonance Imaging in Diagnosis of Adenomyosis and Myomas of the Uterus

doi:10.1016/j.jmig.2012.06.003

Journal of Minimally Invasive Gynecology

Volume 19, Issue 5, September–October 2012, Pages 620-626

https://doi.org/10.1016/j.jmig.2012.06.003 Get rights and content

Abstract

Study Objective

To estimate the diagnostic performance of magnetic resonance imaging (MRI) in detection of myomas and adenomyosis of the uterus.

Design

Prospective cohort observational study (Canadian Task Force classification II-2).

Setting

Department of obstetrics and gynecology, tertiary academic hospital.

Patients

One hundred fifty-three consecutive women with an enlarged uterus accompanied by gynecologic symptoms and/or with an asymptomatic pelvic mass.

Intervention

Total abdominal hysterectomy. All patients underwent MRI before the operation.

Measurements and Main Results

The sensitivity, specificity, positive, and negative predictive value of MRI for the diagnosis of uterine pathology was calculated using histologic findings as the standard criterion for final diagnosis. Receiver operating characteristics curves were constructed to describe the diagnostic performance of MRI. In the diagnosis of myomas, MRI demonstrated sensitivity of 94.1%, specificity of 68.7%, PPV of 95.7%, and NPV of 61.1%. In the diagnosis of adenomyosis, MRI demonstrated sensitivity of 46.1%, specificity of 99.1%, PPV of 92.3%, and NPV of 88.5%. The area under the curve (AUC) for the diagnostic performance of MRI in the detection of myomas and adenomyosis was 0.81 and 0.73, respectively. Uterine sarcoma was diagnosed in 5 patients; in these cases, MRI demonstrated sensitivity of 60.0%, specificity of 99.2%, PPV of 75.0%, and NPV of 98.4%. The AUC for MRI in the diagnosis of uterine sarcomas was 0.80.

Conclusions

MRI exhibits a high AUC for the diagnosis of both adenomyosis and myomas. The PPV of MRI in the diagnosis of adenomyosis and myomas of the uterus is high as well. MRI seems to be a useful technique in everyday clinical practice in the diagnostic approach of these common conditions, enabling clinicians to select the most appropriate management.

Section snippets

Study Design and Power Analysis

This prospective cohort study was designed and executed in the Department of Obstetrics and Gynecology of a tertiary academic hospital. Ethics committee approval was obtained. The ROC curve is a graph that plots the sensitivity of a diagnostic test as a function of its corresponding specificity (1-specificity or false-positive rate). In tests that are both sensitive and specific, the area under the ROC curve (AUC) approaches 1.0, whereas in tests neither sensitive nor specific, the AUC lies

Results

Of 153 women with gynecologic symptoms and/or an enlarged uterus, 135 fulfilled inclusion and exclusion criteria and agreed to participate in the study. The mean (SD; 95% CI) age of the study population was 46.7 (11.20; 44.83–48.65) years. Parity was 1.6 (1.04; 1.44–1.81) children (2 [0–5]). The referring symptom was heavy menstrual bleeding in 78 patients, postmenopausal bleeding in 12, abdominal heaviness, bloating, and suprapubic pain in 24, and pelvic mass in 9. In 5 patients, enlarged

Discussion

The results of the present study highlight the value of MRI in the diagnosis of myomas and adenomyosis of the uterus. The most important finding is that after the construction of ROC curves, the AUC is high, 0.81 for the diagnosis of myomas and 0.73 for adenomyosis. Moreover, it seems that MRI is a diagnostic method characterised primarily by a high PPV in the diagnosis of myomas (95.7%) and adenomyosis (92.3%).

The significance of our results is apparent in everyday clinical practice. Myomas

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Cited by (54)

Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE)
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).
The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term “Uterine Myomectomy” (MeSH Unique ID: D063186) in combination with ‘‘Myoma” (MeSH Unique ID: D009214) and ‘‘Hysteroscopy” (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.
The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1–2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).
HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.
The Prevalence of Uterine Fibroids in African American Women with Hemoglobin SS Sickle Cell Disease as Determined by Pelvic Magnetic Resonance Imaging
2021, Academic Radiology
This study explores the relationship between the development of uterine fibroids and hemoglobin SS sickle cell disease (SCD) by examining the prevalence of uterine fibroids as detected by pelvic magnetic resonance imaging (MRI) in African American (AA) women with and without SCD.
A single-center, retrospective review was performed of all adult AA women at a large, academic medical center who received pelvic MRI from January 1, 2007 to December 31, 2018. Propensity score matching conditional on age and ZIP code evaluated the differences in fibroid prevalence between the two groups. Subanalyses by age in 10-year intervals were also performed.
Twenty-one (23.9%) of 88 patients with SCD had fibroids on pelvic MRI versus 1493 (52.1%) of 2868 patients without SCD (p value <0.001). After propensity score matching, 21 (24.7%) of 85 patients with SCD compared to 52 (61.2%) of 85 patients without SCD had fibroids (p value <0.001). Subanalyses in 10-year age intervals showed significance for patients between 30 and 39 years old in which 4 (13.8%) of 29 SCD patients versus 374 (65.3%) of 573 no SCD patients had fibroids (p value <0.001), and for patients between 40 and 49 years old in which 9 (42.9%) of 21 SCD patients versus 667 (73.8%) of 904 no SCD patients had fibroids (p value = 0.002).
These findings indicate an overall significantly lower prevalence of uterine fibroids in AA women with SCD, suggesting that SCD may be protective against the development of uterine fibroids in these patients.
Benign Uterine Disease: The Added Role of Imaging
2021, Obstetrics and Gynecology Clinics of North America
A Systematic Review of Adenomyosis: It Is Time to Reassess What We Thought We Knew about the Disease
2021, Journal of Minimally Invasive Gynecology
Citation Excerpt :
For instance, either ectopic endometrium present ≥2 mm deep in the myometrium or ectopic endometrium visible ≥1 microscopic field at 10-fold magnification from the endomyometrial junction merit an adenomyosis diagnosis. Adenomyosis foci are often circumferentially surrounded by bundles of hypertrophic smooth muscle cells or stromal fibroblasts [14]. Although only a few articles define the surrounding changes of hypertrophy and reactive fibrosis as adenomyosis, these changes may be as important in the pathogenesis of the disease as the actual presence of ectopic endometrial glands [15–17].
To summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms.
Systematic review of PubMed between January 1972 and April 2020. Search strategy included: “adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[text word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word].
Articles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. The included articles described pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis.
Sixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. The prevalence estimates range from 20% to 88.8% in women who are symptomatic (average 30%–35%), with most diagnosed between the ages of 32 years and 38 years. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report that younger women who are symptomatic are being diagnosed with adenomyosis on the basis of both magnetic resonance imaging and/or transvaginal ultrasound. High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis.
Adenomyosis remains a challenge to identify, assess, and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathologic and imaging diagnoses to gain a deeper understanding of adenomyosis.
Focal adenomyosis is associated with primary infertility
2020, Fertility and Sterility
Citation Excerpt :
The diagnosis of adenomyosis was based on strict and previously published MRI criteria, which is a widely accepted technique for diagnosing adenomyosis (2, 3, 8). Magnetic resonance imaging is a useful technique for diagnosing adenomyosis as it allows clinicians to diagnose the disease in women who are relatively young, compared with diagnoses based on histology of the uterus, which require a hysterectomy (30). During the preoperative imaging workup, the radiologists were informed that a gynecological disease was suspected, but they were blinded to the results of the clinical findings and the previous imaging examinations.
To study the association between adenomyosis and infertility, according to the adenomyosis phenotype as diagnosed by magnetic resonance imaging (MRI).
A single-center, cross-sectional study.
University hospital–based research center.
Patients between 18 and 42 years of age who were surgically explored for benign gynecological conditions at our institution between May 2005 and May 2018. Only women with uterine MRIs performed by a senior radiologist were retained for this study.
Primary and secondary infertile women were compared with women without infertility. In addition, the women were diagnosed according to the MRI findings as having adenomyosis (focal adenomyosis of the outer myometrium [FAOM] and/or diffuse adenomyosis phenotypes) or no adenomyosis.
Primary and secondary infertility–associated factors.
A total of 496 women were included in the study population. Three groups were compared: a no infertility group (n = 361), a primary infertility group (n = 84), and a secondary infertility group (n = 51). Among them, 248 women did not present adenomyosis lesions and 248 women had a radiological diagnosis of adenomyosis. The presence of FAOM was significantly associated with primary infertility. Diffuse adenomyosis was not found to be associated with infertility. The distribution of endometriosis or leiomyomas was not significantly different between the groups. After a multinomial regression model including the women’s age and associated endometriosis or leiomyoma, the presence of FAOM was identified as an independent associated factor of primary infertility (adjusted odds ratio 1.9; 95% confidence interval 1.1–3.3).
The presence of FAOM was associated with primary infertility. This study opens the door to future clinical and basic studies aimed at better characterization of FAOM and its infertility-related physiopathology.
Asociación de la adenomiosis focal con infertilidad primaria.
Estudiar la asociación entre adenomiosis e infertilidad de acuerdo con el fenotipo de adenomiosis diagnosticada por Resonancia Magnética (MRI).
Estudio transversal en un único centro.
Centro de investigación en un hospital universitario.
Pacientes entre 18 y 42 años de edad exploradas quirúrgicamente por patología benigna en nuestra institución entre mayo de 2005 y mayo de 2018. Únicamente se incluyeron en el estudio aquellas mujeres con MRIs realizadas por un radiólogo senior.
Mujeres con infertilidad primaria y secundaria comparadas con mujeres sin infertilidad. Además, se diagnosticó a las mujeres según los hallazgos de la MRI en mujeres con adenomiosis (adenomiosis focal de la capa externa del miometrio [FAOM]) y/o fenotipos de adenomiosis difusa) o sin adenomiosis.
Factores asociados a infertilidad primaria y secundaria.
Se incluyeron en el estudio un total de 496 pacientes. Se compararon 3 grupos: un grupo sin infertilidad (n=361), un grupo con infertilidad primaria (n=84) y un grupo con infertilidad secundaria (n=51). Entre ellas, 248 mujeres no presentaron lesiones adenomióticas y 248 mujeres tuvieron diagnóstico radiológico de adenomiosis. La presencia de FAOM se asoció significativamente con infertilidad primaria. No se encontró relación entre adenomiosis difusa e infertilidad. La distribución de endometriosis o leiomiomas no fue significativamente diferente entre los grupos. Después de aplicar un modelo de regresión multinomial incluyendo la edad de las mujeres y la asociación de endometriosis o leiomiomas, se identificó la presencia de FAOM como un factor asociado de manera independiente a la infertilidad primaria (OR ajustada 1,9; intervalo de confianza del 95%: 1,1-3,3).
La presencia de FAOM se asoció a infertilidad primaria. Este estudio abre la puerta a futuros estudios básicos y clínicos dirigidos a una mejor caracterización de la FAOM y su fisiopatología relacionada con la infertilidad.
Adenomiosis, infertilidad, MRI, adenomiosis focal, adenomiosis difusa.
Imaging Spectrum of Benign Uterine Disease and Treatment Options
2020, Radiologic Clinics of North America
Citation Excerpt :
MR imaging is highly accurate for the diagnosis of adenomyosis. In a prospective cohort, Stamatopoulos and colleagues64 described a sensitivity of 46.1%, specificity of 99.2%, and positive predictive value of 92.3% of MR imaging in the diagnosis of adenomyosis. An MR imaging classification of adenomyosis was recently proposed by Bazot and Darai,65 including definitions of different forms of adenomyosis.

View all citing articles on Scopus

: The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

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Original ArticleValue of Magnetic Resonance Imaging in Diagnosis of Adenomyosis and Myomas of the Uterus

Abstract

Study Objective

Design

Setting

Patients

Intervention

Measurements and Main Results

Conclusions

Section snippets

Study Design and Power Analysis

Results

Discussion

Best Pract Res Clin Obstet Gynaecol

Fertil Steril

Obstet Gynecol Clin North Am

J Minim Invasive Gynecol

Fertil Steril

Best Pract Res Clin Obstet Gynaecol

Clin Radiol

Curr Surg

Am J Obstet Gynecol

Fertil Steril

Best Pract Res Clin Obstet Gynecol

Best Pract Res Clin Obstet Gynaecol

Fertil Steril

Fertil Steril

Best Pract Res Clin Obstet Gynaecol

Best Pract Res Clin Obstet Gynaecol

Best Pract Res Clin Obstet Gynaecol

Leiomyomata uteri: hormonal and molecular determinants of growth

J Natl Med Assoc

New directions in the epidemiology of uterine fibroids

Semin Reprod Med

Original Article
Value of Magnetic Resonance Imaging in Diagnosis of Adenomyosis and Myomas of the Uterus