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Adenomyoma and Leiomyoma: Differential
Diagnosis with Transvaginal Sonography
Dimitrios Botsis,1 Dimitrios Kassanos,1 George Antoniou, PhD, MD,1 Emanouil Pyrgiotis, PhD, MD,1
Petros Karakitsos, PhD, MD,2 Dimitrios Kalogirou1
1
2
2nd Department of Obstetrics and Gynecology, University of Athens, Areteion Hospital, Athens, Greece
Department of Cytology and Cytogenetics, ‘‘Laiko’’ Hospital, Athens, Greece
Received 27 September 1995; accepted 11 March 1997
Abstract: Purpose. The purpose of this study was to
evaluate the capability of transvaginal sonography to
differentiate adenomyomas from leiomyomas.
Methods. Two hundred six patients scheduled for
surgery for symptomatic uterine masses underwent
preoperative transvaginal sonography. Sonographic
findings were compared with pathologic findings.
Pathologic findings showed that 111 patients had leiomyomas, 48 had diffuse adenomyosis, 31 had adenomyomas, and 4 had leiomyosarcomas.
Results. For the diagnosis of adenomyoma, transvaginal sonography demonstrated a sensitivity of
82.0%, specificity of 88.3%, positive predictive value of
84.6%, and negative predictive value of 87.5% compared with a sensitivity of 95.1%, specificity of 82.0%,
positive predictive value of 90.7%, and negative predictive value of 85.7% for the diagnosis of leiomyoma.
Two sonographic characteristics, lesion margin (p =
0.0001) and lacunae (p = 0.0001), allowed the differentiation of adenomyoma from leiomyoma.
Conclusions. Transvaginal sonography is an effective procedure for the preoperative differentiation of
adenomyoma from leiomyoma. If the status of the lesion’s margins and the presence or absence of hypoechoic lacunae were selected for analysis, leiomyomas could be correctly diagnosed with transvaginal
sonography in 95% of cases. © 1998 John Wiley &
Sons, Inc. J Clin Ultrasound 26:21–25, 1998.
Keywords: adenomyosis; transvaginal ultrasonography; adenomyoma; hysterectomy; leiomyoma
A
denomyosis was first described in 1860 by
Rokitansky.1 In 1896, Von Recklinghausen
published a collection of 30 cases.2 In 1908,
Correspondence to: G. Antoniou, Agiou Meletiou 48, str.,
Kipseli 112 57, Athens, Greece
© 1998 John Wiley & Sons, Inc.
VOL. 26, NO. 1, JANUARY 1998
CCC 0091-2751/98/010021-05
Cullen published a detailed review of 54 cases
seen at The Johns Hopkins Hospital and proposed
the term ‘‘adenomyoma uteri diffusum benignum’’
for what is known today as adenomyosis.3
Adenomyosis is characterized histologically as
a benign invasion of the uterine musculature by
the endometrium, which normally is found lining
only the uterine cavity. Associated with this endometrial invasion is a marked, generalized overgrowth of the muscle elements.
The reported incidence of adenomyosis varies
widely from one institution to another because
adenomyosis is fundamentally a pathologic diagnosis. The frequency, which varies between 8%
and 27%, depends not only on the criteria used for
diagnosis but also on the thoroughness with
which the resected uterus is examined.4 Benson
and Sneeden have suggested the rigid criterion
that the endometrium must extend into the myometrium at least 2 low-power fields (8 mm) from
the basalis.5 Bird et al recorded a 61.5% incidence
of adenomyosis in 200 consecutive hysterectomies, but half of their cases occurred less than 1
low-power field below the basal endometrium.6
Mathur et al diagnosed adenomyosis in 39.1% of
741 uteri removed surgically by using endometrial invasion by at least 1 low-power field as a criterion.7
The purpose of our prospective study was (1) to
ascertain the incidence of adenomyosis in a population of patients undergoing hysterectomy, (2) to
correlate the symptoms and preoperative diagnosis with the histopathologic features, and (3) to
select characteristics commonly found with transvaginal sonography that could be used to differentiate adenomyomas from leiomyomas.
21
BOTSIS ET AL
PATIENTS AND METHODS
Of 672 patients who underwent hysterectomy for
various reasons on the gynecologic service of Areteion Hospital during the years 1993–1994, 206
(31%) had symptomatic uterine masses. The indication for surgery in the 206 patients was an enlarged uterus with the following clinical findings:
menorrhagia and/or dysmenorrhea (172 patients), pressure or pain consistent with a mass
lesion (5), dyspareunia (21), pollakiuria and nocturia (6), and rapid tumor growth (2). The mean
age of the 206 patients investigated was 46.7
years [range, 35.7–51.8 years; standard deviation
(SD), 3.82]. The mean weight of the patients was
70 kg (range, 52–86 kg; SD, 9.5). The mean
weight of the uteri was 160 g (range, 60–370 g;
SD, 61.4). The mean duration of menstruation in
this group was 6.0 days (range, 3–12 days; SD,
1.83). In all of the patients, transvaginal sonography had confirmed the presence of an enlarged
uterus, and all patients had already been scheduled for surgery independent of the findings of the
sonographic examination. This study was approved by the ethics committee of Athens University, and informed consent was obtained from all
participants.
Sonographic examination was performed using
a Toshiba SSA-340 A ECCOCEE scanner
(Toshiba Medical Systems, Delft, The Netherlands) with a 5-MHz transvaginal probe. Five
sonographic characteristics were evaluated: the
location of the uterine mass, either anterior or
posterior to the endometrium; the number of
masses, 1, 2, or more than 2; the appearance of
the margin of the mass, either distinct or indistinct; the echogenicity, hyperechoic, hypoechoic,
or of mixed echogenicity; and the presence or absence of lacunae, with a lacuna defined as a hypoechoic area larger than 5 mm within the mass
(Figure 1). An adenomyoma was diagnosed when
there was a nonhomogeneous circumscribed area
in the myometrium, with an indistinct margin,
containing hypoechoic areas larger than 5 mm. A
leiomyoma was diagnosed when a well-circumscribed nodule with a distinct margin and heterogeneous structure was identified in the myometrium (Figure 2). The sonographic criteria for the
diagnosis of adenomyosis were heterogeneous
myometrial areas that were not encapsulated and
that contained anechoic lacunae measuring 1–3
mm in diameter and an area characterized by irregular cystic spaces measuring 1–7 mm in diameter (honeycomb pattern) and disrupting the normal fine speckled echo pattern of the uterus. The
sonographic examination was considered diag22
nostic of adenomyosis when at least 3 parameters
were positive.
A histopathologic diagnosis of adenomyosis
was made only when endometrial glands and
stroma were found within the myometrium more
than 1 high-power microscopic field below the
basal endometrium. The severity of adenomyosis
was graded as minimal when only the inner layer
of the myometrium had been invaded, moderate
when the middle layer had been penetrated, and
marked or severe when all the layers were involved. Adenomyoma was diagnosed when a circumscribed nodular aggregate of smooth muscle
and endometrial glands was seen together with
compensatory hypertrophy of the myometrium
surrounding the site of ectopic endometrium. The
presence of endometrial stroma was not required
for the diagnosis of adenomyoma. The characteristic feature of leiomyoma was bundles of smooth
muscle cells arranged in an interlacing pattern.
There was a pseudocapsule of loose tissue separating the lesion from the surrounding normal
uterine musculature.
The sonographic results were compared with
the corresponding histopathologic findings. Statistical analysis was done using the chi-squared
test to select significant predictors to distinguish
adenomyoma from leiomyoma. A multivariate
stepwise logistic regression (Statistica, edition 5;
Statsoft, London, England) was used to determine
variables of statistical significance. A p value of
less than 0.05 was considered significant.
RESULTS
Among the 206 patients investigated, 12 were
found to have uterine nodules less than 2 cm in
diameter and so were excluded from further
study. The histopathologic diagnoses for the remaining 194 patients were adenomyoma in 31,
leiomyoma in 111, diffuse adenomyosis in 48, leiomyosarcoma in 2, and borderline leiomyosarcoma
in 2. Transvaginal sonographic findings are
shown in Table 1. In the diagnosis of adenomyoma, transvaginal sonography had a sensitivity of
82.0%, specificity of 88.3%, positive predictive
value of 84.6%, and negative predictive value of
87.5%. For adenomyosis, the sensitivity was
80.0%, specificity was 90.3%, positive predictive
value was 80.6%, and negative predictive value
was 89.7%. For the diagnosis of leiomyoma, transvaginal sonography had a sensitivity of 95.1%,
specificity of 82.0%, positive predictive value of
90.7%, and negative predictive value of 85.7%.
The number and margin appearance of uterine
nodules and the presence or absence of lacunae
JOURNAL OF CLINICAL ULTRASOUND
ADENOMYOMA VERSUS LEIOMYOMA
TABLE 1
Transvaginal Sonographic Findings
Parameter
Adenomyosis
Adenomyoma
Leiomyoma
p Value*
0
48
4
27
101
10
<0.0001
0
48
7
24
65
46
<0.003
40
8
25
6
9
102
<0.0001
7
6
4
31
12
14
5
0
35
49
27
0
0
0
0
24
5
2
55
37
19
Margin of lesion
Well-circumscribed
Indistinct
Echogenicity of lesion
Hyperechoic
Hypoechoic
Lacunae
Present
Absent
Mass position
Posterior
Anterior
Other
Diffuse development
Mass number
1
2
>2
NS
NS
*
Univariate analysis by chi-squared test of parameters (adenomyoma versus leiomyoma).
were significantly different between adenomyoma
and leiomyoma. The results of stepwise logistic
regression (Table 2) showed that margin appearance (p 4 0.0001) and presence or absence of hypoechoic lacunae (p 4 0.0001), calculated independently, had the discriminatory power to
distinguish adenomyoma from leiomyoma. The
two most significant predictors, margin appearance and lacunae, were then selected to divide all
patients into 4 groups. The results are shown in
Table 3. Most patients (102/111) diagnosed as
having a leiomyoma had a distinct lesion margin
and absence of lacunae. When these 2 conditions
were met, a leiomyoma could be accurately diagnosed by transvaginal sonography in 95% of
cases.
Among the 48 patients with diffuse adenomyosis, the following associated abnormalities were
observed: endometrial hyperplasia without atypia
(9), ovarian cysts (6), ovarian endometriosis (2),
ovarian leiomyoma (1), or fibromatosis (5). An irregular, enlarged uterus was observed by sonography in all the patients with adenomyosis; the
TABLE 2
Coefficient of Variables in Logistic Regression for
Leiomyoma and Adenomyoma
Coefficient
Variable
Constant
Margin
Echogenicity
Lacunae
Leiomyoma
Adenomyoma
−16.4
36.51
17.31
−19.30
14.40
−32.09
−15.31
16.88
0.87
0.87
Model (R)
VOL. 26, NO. 1, JANUARY 1998
FIGURE 1. Transvaginal sonogram showing hypoechoic lacunae
within the hyperechoic mass.
mean longitudinal diameter was 13 ± 3 cm. In
these patients, menorrhagia was present in
52.8%.
DISCUSSION
It is difficult to diagnose adenomyosis because
there are no pathognomonic signs, symptoms, or
physical findings. Adenomyosis is frequently accompanied by additional pelvic abnormalities
such as uterine myomas, and it occurs concomitantly in 6–20% of patients with endometriosis.8
Adenomyosis is also associated with an increased
incidence of endometrial hyperplasia and endometrial adenocarcinoma.9 Adenomyosis can occur
23
BOTSIS ET AL
FIGURE 2. Transvaginal sonograms showing a uterine leiomyoma (A; arrows) with a distinct margin and an adenomyoma (B; arrows) with an
indistinct margin.
TABLE 3
Positive Predictive Value of Transvaginal Sonography for
Diagnosing Leiomyoma and Adenomyoma
Margin
Lacunae
Leiomyoma
(No.)
PPV
(%)
Adenomyoma
(No.)
PPV
(%)
Well-defined
Well-defined
Indistinct
Indistinct
Absent
Present
Absent
Present
102
13
10
5
95
79
50
12
7
8
14
16
3
21
50
88
Abbreviation: PPV, positive predictive value.
in any portion of the uterus as a more or less
circumscribed lesion (adenomyoma) or, more commonly, as a diffuse process in several portions of
the organ. In clinical practice, these 2 types are
considered together.
Multiple modalities have been used in an attempt to improve diagnostic accuracy. Hysterosalpingography may demonstrate a spiculated
pattern in adenomyosis but in general gives poor
diagnostic sensitivity and specificity.10 Hysteroscopic evaluation does not allow for an accurate
assessment of the extent of myometrial involvement. Transabdominal sonography exhibits a
higher degree of diagnostic sensitivity but a poor
specificity. Transvaginal sonography is particularly useful and exhibits a satisfactory predictive
value in diagnosing adenomyosis.
Histopathologically, adenomyomas appear as
ill-defined areas in which the myometrium is interspersed with endometrial glands and stroma.
Surgical removal of this type of lesion is difficult
or even impossible; therefore, the definitive treatment for adenomyomas is usually hysterectomy.
It has been reported that magnetic resonance imaging is highly accurate in distinguishing between adenomyoma and leiomyoma.11,12 However, access to magnetic resonance imaging
24
equipment is limited in some regions, and the
equipment is expensive. The recent availability of
transvaginal sonography has provided a relatively inexpensive alternative.
On sonograms, an adenomyoma may appear as
an anechoic area of thickened myometrium in the
posterior portion of the uterus,13 consisting of
blood-filled, irregular cystic spaces,14 or as an
area of hyperechoic myometrium with several
cysts (hypoechoic lacunae).15 In order of significance, lesion margin, lacunae, and echogenicity
were useful parameters for distinguishing between adenomyoma and leiomyoma in our study.
Fedele et al studied the use of transvaginal sonography for the differential diagnosis of symptomatic uterine nodules in more than 400 patients.16 In their study, the positive predictive
value of transvaginal sonography was not satisfactory (74.1%), and in about a quarter of cases,
an incorrect diagnosis of adenomyoma was made
instead of leiomyoma.
Myometrial biopsy may prove to be a valuable
tool for the preoperative diagnosis of myometrial
diseases. Popp et al17 have performed 70 myometrial biopsies during laparoscopy, and transvaginal sonographically guided myometrial biopsy
was performed in 6 patients with adenomyosis
without complications. The sensitivity ranged
from 8% to 18.7%, and the specificity was 100%.
Popp et al concluded that the small number of
positive findings in their series of myometrial biopsies from uteri in situ was due not only to the
low sensitivity of the method but also to the poor
correlation of clinical signs with histologic diagnosis.17
Leiomyoma and adenomyoma of the uterus
may have the same clinical presentation. Differential diagnosis is very difficult, but for patients
JOURNAL OF CLINICAL ULTRASOUND
ADENOMYOMA VERSUS LEIOMYOMA
who wish to remain fertile, an accurate diagnosis
is essential. In our study, 5 sonographic criteria
were evaluated for distinguishing between adenomyoma and leiomyoma. Lesion margin appearance, presence or absence of hypoechoic lacunae,
and echogenicity, in order of significance, were
useful parameters for distinguishing between
these 2 conditions. Using the margin appearance
and the presence or absence of lacunae, 95% of
leiomyomas could be correctly diagnosed with
transvaginal sonography.
In conclusion, our results show that transvaginal sonography is useful in differentiating adenomyomas from leiomyomas. Patients undergoing a
hysterectomy for nonmalignant conditions have
many symptoms, but we could find none that are
specific to adenomyosis. Diagnosis of adenomyosis remains very difficult and until now has usually depended on the results of pathologic examination.
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VOL. 26, NO. 1, JANUARY 1998
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