Endometriosis
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Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique

Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique

Table of Contents

Video Description

Our video is focused on imaging classification for severe adenomyosis and focal adenomyosis of the outer myometrium (FAOM). We provide an overview of adenomyosis, including diagnosis and management options. The highlight of our video is to review the MUSA criteria and imaging features specific to severe adenomyosis, with a focus on the subtype of FAOM. The case shown in this video is a 36 year old female with secondary infertility and deep-infiltrating endometriosis. By reviewing her imaging, it is clear she not only has adenomyosis, but also focal adenomyosis of the outer myometrium on the left aspect of the uterus, which corresponds to her location of pain and symptomatology. Based on these findings, we were able to suggest specific management options, including focused resection for fertility sparing or definitive management. We hope that our video reinforces the need for focused imaging review to assess for severe adenomyosis to individualize treatment.

Presented By

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Dr. Anisha Dubey
Dr Maera Haider
Dr. Andrea Gallo Hoyos
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Dr. Jessica N Blom
Dr. Olga Bougie
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Affiliations

Queens University

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What is Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique?

Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique is a clinical approach that uses advanced imaging methods and detailed classification systems to accurately diagnose and understand the extent of adenomyosis, a condition where endometrial tissue grows into the uterine muscle wall. This approach aims to improve treatment planning and surgical outcomes by tailoring interventions based on each patient’s specific type, severity, and location of adenomyosis.

  • Imaging Techniques: MRI and ultrasound are the primary imaging tools used. MRI provides detailed visualization of the uterine layers, helping to assess the depth and spread of adenomyotic tissue, while ultrasound can detect characteristic patterns of adenomyosis and distinguish it from other conditions like fibroids.

  • Classification Systems: Based on imaging, adenomyosis can be classified by factors such as the depth of infiltration, location (e.g., anterior, posterior uterine wall), and whether it is focal (isolated areas) or diffuse (spread throughout the uterine muscle). Classification helps predict symptom severity, fertility implications, and potential treatment responses.

  • Treatment Guidance: The information gathered from imaging and classification informs whether to pursue conservative treatments (e.g., hormonal therapy, pain management) or more invasive interventions like myometrial-sparing surgery or hysterectomy. Classification helps surgeons plan precise procedures that target affected areas, minimize complications, and preserve fertility when possible.

By using a structured approach to imaging and classification, clinicians can provide a more personalized treatment plan for patients with adenomyosis, improving symptom relief and surgical success.

What are the Risks of Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique? 

The risks associated with imaging and classification of adenomyosis to guide management and surgical technique include:

  • Misdiagnosis or Overdiagnosis: Imaging may sometimes misinterpret normal tissue or other gynecological conditions (e.g., fibroids) as adenomyosis, potentially leading to unnecessary or inappropriate treatments.

  • Inadequate Classification: Inaccurate classification or underestimation of disease extent may affect treatment choices, potentially leading to incomplete symptom relief or suboptimal outcomes.

  • Radiation Exposure: Certain imaging techniques, such as CT scans (less common for adenomyosis), involve radiation exposure, which can accumulate over time and pose risks, particularly in younger patients.

  • Invasive Procedures: In some cases, further invasive diagnostic procedures (e.g., biopsies) may be recommended if imaging results are inconclusive, posing additional risks like infection, bleeding, or pain.

  • Delayed Treatment: Complex classification processes or inconclusive imaging results can delay the start of effective treatments, potentially worsening symptoms or the disease itself.

  • Impact on Fertility: Invasive surgical techniques guided by imaging findings might carry a risk of affecting fertility, particularly if tissue around reproductive organs is involved in treatment planning.

  • Cost and Accessibility: Advanced imaging modalities (e.g., MRI) and comprehensive classification processes may be costly and not readily accessible, which can limit timely and accurate diagnosis and management.

Accurate imaging and classification are crucial, but they require careful interpretation to balance effective treatment and minimize unnecessary risks or interventions.

Video Transcript: Imaging and Classification of Adenomyosis to Guide Management and Surgical Technique

Imaging and classification of adenomyosis to guide management and surgical technique. In this video, we will review adenomyosis and its clinical manifestations, as well as the diagnosis and imaging findings. We will present a case of severe adenomyosis and focal adenomyosis of the outer myometrium and discuss techniques for surgical management.

Adenomyosis is a benign gynaecologic condition, characterised by invasion of endometrial glands and stroma into the myometrium. 21 to 34% of reproductive-aged women have sonographic features of adenomyosis and approximately 26% of patients will have coexisting endometriosis. Patients may experience symptoms including pelvic pain, heavy or abnormal uterine bleeding, infertility or recurrent pregnancy loss and adverse pregnancy outcomes.

The diagnosis of adenomyosis is made by histologic confirmation or via imaging with ultrasound or MRI. For histology, tissue sampling techniques include hysteroscopic or laparoscopic surgery to obtain core needle biopsies of the myometrium.

Less invasive and more accessible, ultrasound imaging is a gold standard for diagnosis, with a sensitivity of up to 82% and a specificity of up to 85%. This method of diagnosis identifies the presence of specific adenomyosis features, which we will review in more detail in this video.

 MRI has also been used for diagnosis. However, it is not as cost effective. MRI can be considered for surgical planning if other gynaecologic conditions are present, such as endometriosis.

The morphological uterus sonographic assessment or MUSA criteria are used for diagnosis and identification of specific adenomyosis features. This includes direct features such as myometrial cysts, hyperechoic islands and echogenic sub-endometrial lines and buds. The indirect features include asymmetrical thickening, fan-shaped shadowing, globular uterus, translesional vascularity, irregular junctional zone or interrupted junctional zone.

In addition to the MUSA criteria, adenomyosis can be differentiated based on estimating the relative proportions of the lesion and the surrounding normal myometrium. Adenomyotic lesions can be defined as focal if greater than 25% or diffuse if less than 25% of the circumference is surrounded by normal myometrium. An adenomyoma is defined when focal adenomyosis is demarcated by hypertrophic myometrium.

Based on the type of adenomyosis identified, sonographic scoring systems have been developed to determine severity of disease. Details of the scoring system are outside the scope of this video.

Here we present a case which highlights the diagnosis and management of severe disease with a focal lesion in the outer myometrium. Our patient is a 36-year-old G3P2 with a history of deep infiltrating endometriosis and subfertility. She previously underwent a laparoscopic right ovarian cystectomy for an endometrioma and then was subsequently medically managed on an oral contraceptive pill.

She represented to care, interested in conceiving, and underwent a pelvic ultrasound as part of her subfertility workup. Her initial ultrasound demonstrated both direct and indirect features of adenomyosis based on our MUSA criteria. Here you can see the asymmetric wall thickening, fan-shaped shadowing and globular uterus in keeping with indirect features. Direct features identified here are hyperechoic islands and myometrial cysts.

During this ultrasound, a left-sided lesion was identified and appeared to meet criteria for focal adenomyosis of the outer myometrium based on specific features of myometrial asymmetry, round, oval shape, translesional flow and internal fan-shaped shadowing, as well as an ill-defined, heterogeneous, solid cystic mass, indistinct margins from the outer myometrium and mild translesional vascularity.

MRI can differentiate between internal adenomyosis impacting the junctional zone, external adenomyosis impacting the outer myometrium and serosa, and focal adenomyosis. Our patient had an MRI completed for surgical planning. The T2-weighted images showed adenomyosis features, including hyperintense cystic spaces and a mass with ill-defined margins extending to the exterior layer of the bladder roof, and is labelled here as a bladder extension.

Our patient was then offered various treatment options to manage her symptoms, which included medical and surgical interventions. Given her wishes around fertility, she initially proceeded with surgical excision of endometriosis without addressing the focal adenomyotic lesion.

 Pathology confirmed endometriosis was removed and she had recovered well. She stopped medical suppression in hopes of conceiving. However, her symptoms of significant pelvic pain recurred. She therefore underwent repeat imaging.

As you can see here, the same indirect and direct features of adenomyosis were redemonstrated on ultrasound. This also included a 4 cm, ill-defined lesion with translesional vascularity, consistent with the previously identified FAOM. An MRI completed around the same time confirmed a 4.9 by 4.8 cm residual convexity, suspecting focal adenomyosis of the outer myometrium.

Adenomyosis may contribute to infertility and subfertility. However, studies are limited due to the confounding condition of endometriosis. There may be some improvement in fertility outcomes with focussed excision of adenomyotic lesions, and therefore this was offered to our patient. However, she did elect to receive a more definitive management at this point in the form of a total laparoscopic hysterectomy.

Surgical planning is important in the management of complex, coexisting disease. For this patient, specific considerations were anticipating variation in anatomy and possible distortion of ureteric course due to globular enlarged uterus and left-sided FAOM lesion. We anticipated potential retroperitoneal ureterolysis and uterine artery ligation at their origin.

Upon entry, adhesions of the FAOM lesion and the left pelvic side wall were identified and dissected to release the uterus. Once free from the bowel, the uterus is globular, in keeping with adenomyosis. A decision was made to take the uterine arteries at the level of the ureter.

First, ureterolysis was performed on the right and the right uterine artery was skeletonised. Here the uterine artery on the right side is shown off the internal iliac. It is coagulated with electrosurgery while the ureter is retracted. After the utero-ovarian pedicles were separated, dense adhesions from the adenomyotic lesions to the left pelvic side wall were dissected.

On the left side, the ureter was dissected retroperitoneally and the uterine artery was identified and isolated for transection. As you can see here, the adhesion to the presumed FAOM at the left anterior fundus was becoming more apparent as dissection on this side continued.

Additional dense adhesions to the left side wall were transected to free the uterus. Once freed, the remainder of the hysterectomy was completed as routine. Here we visualise the final specimen, which demonstrates the left-sided FAOM lesion.

We have demonstrated that adenomyosis can be diagnosed based on specific ultrasound features and can be classified based on severity. Pre-operative imaging is imperative to guide treatment for diffuse or focal disease, and surgical management should include appropriate pre-operative planning due to the presence of abnormal anatomy.