2/24/19. Myometrial evaluation. Size Echotexture. Homogeneous Heterogeneous. Adenomyosis Fibroids. Adenomyosis. MUSA guidelines
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1 Content Adenomyosis and MUSA guidelines for myometrial disorders Adenomyosis MUSA guidelines Dr Lufee Wong FRANZCOG, MPH, DDU Recommended reporting guidelines Fibroids Adenomyosis Myometrial evaluation Size Echotexture Homogeneous Heterogeneous Adenomyosis Fibroids Prevalence 5-70% (no consensus on histopath definitions) Definition Ectopic endometrium in myometrium Risk Factors Age (>40yo), Obesity Early menarche Multiparity Prior uterine surgery vs Endometriosis Risk Factors Young Nulliparous Family history Adenomyosis vs Endometriosis MUSA guidelines Clinical Impact Dysmenorrhoea Prolonged periods Pelvic pain Infertility? Miscarriage? Obstetrical outcomes? Clinical Impact Dysmenorrhoea Dyspareunia Dyschezia Pelvic pain Infertility Obstetrical outcomes? Vigano et al. Fertil Steril
2 MUSA Adenomyosis: ultrasound features MUSA Asymmetrical thickening Asymmetrical thickening Cysts Hyperechoic islands Fan-shaped shadowing 1.5 Echogenic subendometrial lines and buds Translesional vascularity Irregular JZ Interrupted JZ MUSA Fan-shaped shadowing MUSA Cysts MUSA - Hyperechoic islands MUSA Echogenic subendometrial lines and buds 2
3 MUSA - Translesional vascularity MUSA Junctional zone MUSA Irregular junctional zone MUSA Interrupted junctional zone MUSA Diagnosis of Adenomyosis Other signs? Question-mark sign of uterus - Sensitivity (75%) and specificity (93%) 1 - Mainly marker of DIE AV RF - Only validated in 24/50 women Di Donato et al. Question mark form of uterus: a simple sonographic sign associated to the presence of adenomyosis. UOG 2015;46: Asymmetrical thickening Cysts Hyperechoic islands Fan-shaped shadowing 1.5 Heterogeneous myometrium Internal or External adenomyosis Invasion by mucosa Invasion from serosa Misplaced endometrial tissue in uterine wall Translesional vascularity Irregular JZ 3D Interrupted JZ Focal or diffuse adenomyosis 3
4 Epub. UOG. 22 May 2018 Should we always report incidental findings of adenomyosis? Correlation with symptoms? When to report? Take a detailed history of dysmenorrhoea and/or heavy/irregular bleeding 205 women referred for contraception Prevalence of diffuse adenomyosis on 2D-TVS criteria: 34% Symptomatic in 83% 4
5 Impact on fertility What impact does adenomyosis have on fertility? Endometriosis of the uterus? Exacoustos et al. Adenomyosis: 3D sonographic findings of the JZ and correlation with histology. UOG 2011 Adenomyosis can coexist with endometriosis in younger women, suggesting a common pathogenesis Benagiano, Brosens, Habiba. Hum Reprod Update 2014 Possible negative effect on female fertility Debatable Anatomical distortion?tubal ostia obstruction?impaired sperm migration?impaired embryo transportation Uterine dysperistalsis abnormal contractility Altered implantation Intrauterine free radicals What impact does adenomyosis have on fertility? Which features have greatest impact on fertility? Eisenberg et al. BioMed Research International 2017 Treatment of adenomyosis GnRH agonists MRgFUS / High intensity focused ultrasound (HIFU)?accidental direct sonication of ovaries?accidental sonication of endometrium/adhesions Uterus-sparing surgical treatment Adenomyomectomy Eisenberg et al. BioMed Research International 2017 Ultrasound features of fibroid Fibroids Well-defined lesion Round, oval or lobulated Variable echogenicity Vascularity Circumferential Otherwise à Atypical fibroids 5
6 Simplified assessment FIGO Number 1, 2, 3 or estimation when >4 Location Largest/clinically relevant lesion(s) (esp SM) Site FIGO Size Maximum diameter Atypical fibroids Degeneration Spontaneous / Ut Art Embolization / MRgFUS / Radiofreq ablation Types: Red Hyaline Cystic Hydropic Calcification Fatty Cystic Cystic Calcified Fatty Submucosal fibroid Fibroid vs sarcoma Protrusion into cavity Importance of diagnosis: Missed diagnosis Non-surgical treatment options Risk of dissemination with uterine disruption (myomectomy/hysterectomy with morcellation during laparoscopic surgery) Avoid unnecessary surgery External free margin 6
7 Fibroid vs sarcoma No reliable distinguishing markers Fibroids and sarcoma can appear similar Focal Central necrosis Irregularly vascularized mass Best warning signs: Postmenopausal (not always!) Rapid increase in size Symptomatic Leiomyosarcoma Leiomyosarcoma Endometrial stromal sarcoma Leiomyosarcoma CONCLUSION Adenomyosis - key features + detailed standardized reporting TV US 2D and 3D are as good as MRI When to report in younger women: ask re symptoms (heavy periods, irregular periods) Detail features of adenomyosis as correlates with fertility THANK YOU 7
8 Which will you pick to be the sarcoma? sentation?token= f55896c61 A B Which will you pick to be the sarcoma? Suspected sarcoma Newly diagnosed pelvic mass Marked change in size AUB Exclude other causes of uterine enlargement Pelvic US Pelvic MRI with gadolinium contrast A Sarcoma B Fibroid 8
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