{"paper_id":"35d1d619-d2bb-410d-8b4d-ade40faa5adb","body_text":"RESEARCH\nAbdominal Radiology\nhttps://doi.org/10.1007/s00261-026-05374-8\nIntroduction\nBenign uterine disorders encompass a heterogeneous \ngroup of gynaecological pathologies, including leiomyo -\nmas (fibroids) and adenomyosis. Leiomyomas represent \nthe most prevalent uterine mass, reported to occur in over \n70% of women by the onset of menopause [ 1]. Adenomyo-\nsis, characterized by the presence of endometrial glands and \nstroma within the myometrium, has an estimated prevalence \nranging between 5 and 70%, depending on the diagnostic \nmethod applied [2], and is commonly associated with deep \nendometriosis (DE) [3]. Collectively, these disorders repre-\nsent a significant clinical burden, not only because of their \nimpact on quality of life but also due to their implications \nfor fertility and reproductive health [4–6].\n \r Sabrine Q. Kol\ns.kol@amsterdamumc.nl\nNienke P.M. Wassenaar\nn.p.wassenaar@amsterdamumc.nl\nRobert A. de Leeuw\nr.a.deleeuw@amsterdamumc.nl\nShandra Bipat\ns.bipat@amsterdamumc.nl\n1 Department of Radiology and Nuclear Medicine, Amsterdam \nUniversity Medical Centers, Amsterdam, Netherlands\n2 Imaging and Biomarkers, Cancer Center Amsterdam, \nAmsterdam, Netherlands\n3 Department of Obstetrics and Gynaecology, Amsterdam \nUniversity Medical Centers, Amsterdam, Netherlands\n4 Amsterdam Reproduction and Development (AR&D), \nResearch Institute, Amsterdam, Netherlands\nAbstract\nObjective To review magnetic resonance elastography (MRE) techniques and evaluate the feasibility of quantifying the \nextent of fibrosis in patients with benign uterine disorders.\nMaterials and methods A systematic search of the MEDLINE and EMBASE databases was performed for identifying rel -\nevant articles published between January 1, 2007, and September 2025. Studies meeting predefined inclusion criteria were \nselected. Two independent reviewers extracted data on study design, patient population, MRI protocol characteristics, MRE \nparameters and MRI/MRE features. Mean stiffness (kPa), including standard deviation were either extracted or calculated. \nThe same reviewers also assessed the methodological quality of each study.\nResults Six studies comprising a total of 162 patients (mean age range: 40.5 to 49 years) were included. Five studies \nfocused on stiffness measurements in leiomyomas, while one study investigated the feasibility of stiffness measurements in \npatients with adenomyosis. All studies were classified as either pilot or feasibility studies. In studies reporting reproductive \nstatus, most patients were premenopausal (89 out of 125). The mean stiffness in evaluating leiomyomas ranged from 3.02 to \n7.10 kPa across the included studies, resulting in a pooled mean stiffness of 4.72 ± 1.83 kPa.\nUterine stiffness was higher in women with adenomyosis (2.93 kPa; range, 2.34–3.39 kPa) than in the \nhealthy volunteer (2.04 kPa). Two studies correlated stiffness measurements with histopathological \nfindings of fibrosis. All included studies were rated as having good methodological quality.\nConclusions Despite the small number of studies, current findings suggest that MRE is a feasible imaging modality for \nmeasuring fibrosis.\nKeywords Magnetic resonance imaging · Magnetic resonance elastography · Uterine leiomyomas · Adenomyosis · \nBenign uterine pathology · Systematic review\nReceived: 12 November 2025 / Revised: 24 December 2025 / Accepted: 1 January 2026\n© The Author(s) 2026\nMagnetic resonance elastography (MRE) for the evaluation of fibrosis \nin patients with benign uterine disorders: a systematic review\nSabrine Q. Kol1 · Nienke P .M. Wassenaar1,2 · Robert A. de Leeuw3,4 · Shandra Bipat1\n1 3\n\n\nAbdominal Radiology\nAlthough these benign uterine disorders differ in their \npathogenesis and clinical presentation, they all are associ -\nated with alterations in the extracellular matrix and increas-\ning amounts of fibrosis. Leiomyomas are defined by smooth \nmuscle proliferation within a fibrotic stroma [7], while ade-\nnomyosis results from the pathological invasion of endo -\nmetrial tissue into the myometrium, which triggers smooth \nmuscle hyperplasia and hypertrophy, ultimately leading to \nfibrotic remodeling [8, 9]. This fibrotic remodeling is driven \nby fibroblast activity and excessive extracellular matrix \ndeposition, which play a critical role in symptomatology, \nincluding pain and abnormal uterine bleeding [ 10]. More-\nover, fibrotic changes can impair uterine contractility and \nincrease the risk of obstetric complications, including uter -\nine rupture, which has been reported to be more frequent \nin adenomyosis than in other uterine pathologies [ 11, 12]. \nAdenomyosis may develop from the endometrium outward \nor from the serosal surface inward, the latter form being \nstrongly associated with deep endometriosis, which under -\ngoes extensive fibrotic transformation contributing to its \ninfiltrative behavior [13]. In leiomyomas, fibrosis not only \ncontributes to lesion growth and symptom severity but also \nimpacts treatment response, influencing outcomes of inter -\nventions such as uterine artery embolization [ 14]. Across \nboth conditions, the degree of fibrosis adds complexity to \nmedical and surgical management, highlighting the impor -\ntance of incorporating fibrosis assessment into pre-treatment \nplanning [ 15, 16]. Consequently, non-invasive imaging \ntechniques capable of evaluating tissue stiffness and detect-\ning fibrosis in vivo, such as elastography, may offer valuable \ndiagnostic and prognostic insights across the spectrum of \nbenign uterine pathologies.\nElastography is an imaging technique used to assess tis -\nsue stiffness and can be performed with either ultrasound \nor magnetic resonance imaging (MRI). Ultrasound elastog-\nraphy may be carried out using strain elastography, which \nis qualitative and operator-dependent, or shear wave elas -\ntography, which provides quantitative values but has tech -\nnical limitations [17]. Both techniques face reproducibility \nchallenges, particularly due to the selection of the region of \ninterest (ROI) in heterogeneous lesions. In benign gynae -\ncology, ultrasound elastography (USE) has been applied to \nthe evaluation of the normal uterus, the myometrium (leio -\nmyomas and adenomyosis), the endometrium (polyps), and \npelvic endometriosis [18–22]. Acar et al. [19] demonstrated \nthat myometrial stiffness measured with shear wave elas -\ntography (SWE) was significantly higher in adenomyosis \nthan in healthy controls. Similarly, V ora et al. [20] reported \nincreased stiffness in submucosal leiomyomas and focal \nadenomyomas.\nMagnetic resonance elastography (MRE) also provides \nquantitative measurements of tissue stiffness, achieved \nby applying low-frequency vibrations and tracking shear \nwave propagation with MRI. MRE is already used in clini -\ncal practice for liver fibrosis [ 23] and is being explored \nin areas such as pancreatic [ 24], cardiovascular [ 25], and \nneurological diseases [26]. The limitations of MRE include \nits high cost, limited availability, longer examination time, \nMRI-related contraindications, and the need for patients to \nremain still during image acquisition. Nevertheless, MRE \noffers several advantages over USE, including being able to \nassess whole organs (e.g. the uterus), not being as limited \nby depth or acoustic windows (e.g. body habitus, ascites), \nproviding quantitative measurements and not being opera -\ntor dependent [ 27,28]. Furthermore, because MRE is per -\nformed within the context of an MRI examination, it also \ndelivers high-resolution anatomical information along with \ntissue stiffness data.\nThis study aims to systematically review MRE techniques \nand reported outcomes related to the use of MRE in quanti-\nfying fibrosis in patients with benign uterine disorders.\nMaterials and methods\nStudy design\nThis systematic review was conducted and reported in \naccordance with the Preferred Reporting Items for System -\natic Reviews and Meta-analyses (PRISMA) guidelines: as \noutlined by Page et al. [29].\nSearch strategy\nA literature search was performed in the MEDLINE and \nEMBASE databases to identify relevant articles published \nfrom 2007 to date of search (Sept 1, 2025), as MRE was \nfirst introduced as a clinical test in 2007. The search strat -\negy included the following search terms: “Magnetic Reso -\nnance Imaging” AND “Elastography” AND “Fibroids” OR \n“Leiomyomas” OR “Endometriosis” OR “ Adenomyosis”. \nThe search strategy is described in detail in Supplement A. \nTo identify additional articles, the citation indexes and the \nreference lists of relevant articles were checked.\nSelection of relevant articles\nThe title and/or abstract of all retrieved articles were screened \nfor potential relevance by Reviewer 2 (X1), a methodolo -\ngist with extensive experience in systematic reviews. The \nfollowing were excluded from further analysis: duplicates, \nconference abstracts, clinical registry entries, editorials, \ncommentaries, letters-to-the-editor, non-relevant literature \n1 3\n\nAbdominal Radiology\n(e.g., not disease-related or involving other imaging tech -\nniques), narrative reviews, and case-reports.\nInclusion criteria\nSubsequently, the full texts of the remaining articles were \nassessed by the same reviewer. The inclusion criteria were: \n1) studies involving patients with a benign uterine disorder \n(including but not limited to: leiomyomas, deep endome -\ntriosis and/or adenomyosis); 2) evaluation of fibrosis using \nMRE. All articles meeting these criteria were included for \nfurther data extraction.\nData-extraction\nData-extraction was performed independently by two \nreviewers, X1 and X2, the latter being an abdominal radiol-\nogist with five years of dedicated experience in pelvic MRI. \nAny discrepancies between the reviewers were resolved \nthrough discussion. The following data were extracted: 1) \nStudy characteristics, 2) Study population characteristics, 3) \nMRI protocol characteristics, 4) MRE parameters and main \noutcomes, 5) MRI and MRE features of leiomyomas, 6) \nMethodological quality of the included studies.\nStudy characteristics\nThe following data were extracted: 1) First author and year \nof publication, 2) Study period, 3) Country of origin, 4) Set-\nting (academic or other), 5) Study type (pilot, feasibility \nor cohort), 6) Study design (single-center or multi-center, \nmulti-center indicating involvement of authors from differ -\nent institutions), 7) Department of first author, 8) Data col -\nlection method (retrospective or prospective), 9) Funding \ninformation, 10) Ethical approval status (No, Yes – whether \ninformed consent was waived or obtained), and 11) Disclo-\nsure of conflict of interest.\nStudy population characteristics\nThe following study population-related data were obtained: \n1) Inclusion and exclusion criteria, 2) Number of included \npatients, 3) Age (reported as mean ± standard deviation \n(SD) and/or range), 4) Body Mass Index (BMI) (reported \nas mean ± SD or median and range), 5) Menopausal status \n(premenopausal, perimenopausal or postmenopausal), 6) \nSymptoms, 7) Ethnicity, and 8) Type of surgery performed.\nMRI protocol characteristics\nThe following technical aspects of MRI were extracted: 1) \nMRI vendor, 2) Magnetic field strength, 3) Type of coil used \n(body, phased array, or other), 4) MRI sequences performed \n(e.g., fat-saturated T1, post-contrast T1, T2-weighted, \nT2 HASTE, diffusion-weighted imaging (DWI) and/or \ndynamic contrast-enhanced (DCE) imaging).\nMRE parameters\nThe summarized technical aspects of MRE included: 1) \nMechanical wave frequency (in Hertz), 2) Method used to \ndefine the region of interest (ROI), 3) MRE post process -\ning method, 4) Stiffness measurements reported for benign \nuterine disorder.\nMRI and MRE features of leiomyomas\nThe following data were extracted: 1) Leiomyoma vol -\nume (cm 3), 2) Leiomyomadiameter (cm), 3) Number of \nleiomyomas, 4) Location of leiomyoma in uterus wall, 5)\nLeiomyoma characteristics on T2-WI, 6) Leiomyoma char-\nacteristics on post-contrast imaging and, 7) MRE data of \nstiffness of leiomyoma in kPa (mean ± SD and/or median \nwith ranges). In case MRE data were presented for any sub-\ngroups, these data were also extracted.\nStatistical analysis\nDue to the expected small number of studies and limited \npatient cohorts, mostly originating from pilot and feasibility \ninvestigations, a formal meta-analysis was not conducted. \nInstead, pooled means and pooled standard deviations were \nestimated by weighting each study according to its sample \nsize, mean, and standard deviation, thereby giving greater \ninfluence on studies with larger population. Details on pool-\ning of the means and the standard deviations are given in \nSupplement B.\nMethodological quality assessment\nThe methodological quality of the included studies was eval-\nuated based using the National Institutes of Health (NIH) \nquality Assessment Tool for Case Series Studies ( h t t p  s : /  / w w \nw  . n  h l b  i . n i  h . g  o v /  h e a  l t h  - t o p  i c  s / s  t u d y  - q u  a l i  t y - a s s e s s m e n t - t o o \nl s) (Supplement C). As all articles described cross-sectional \nstudies (no cohort with exposure, no diagnosis with refer -\nence standard and no treatment), we choose a checklist for \ncross-sectional studies to assess the methodological qual -\nity. And as these cross-sectional studies were predominantly \npilot or feasibility studies, we choose the NIH checklist for \ncase series (low number of patients in each study) [30].\nThis tool consists of several questions addressing key \ndomains of bias including, selection bias, performance bias, \ndetection bias and attrition bias (i.e., lost to follow-up). \n1 3\n\nAbdominal Radiology\nin leiomyomas, while one study investigated the feasibil -\nity of stiffness measurements in patients with adenomyosis. \nAdditional study details are summarized in Table 1.\nStudy population characteristics\nA total of 162 patients were included across all studies: 157 \npatients underwent MRE to assess fibrosis in uterine leio -\nmyomas, 4 underwent MRE for the evaluation of fibrosis in \nadenomyosis, and one was a healthy volunteer. The reported \nmean age ranged from 40.5 to 49 years. In the studies where \nreproductive status was documented, most patients were \npremenopausal (89 out of 125). Other patient characteristics \nare listed in Table 2.\nMRI protocol characteristics & MRE parameters\nFour out of the six studies used a 1.5-T MRI, and 2 studies \nused a 3-T MRI. All patients were placed in supine posi -\ntion in the MRI scanner for image acquisition. None of the \nstudies reported the use of spasmolytics or other prepara -\ntion protocols as part of their imaging procedures. MRE was \nperformed using phased-array coils to ensure adequate sig -\nnal reception across the pelvic region. A passive driver was \nplaced on the lower abdomen, directly over the uterus, and \nsecured with a belt in three studies [33, 35, 36]. Aphinives et \nal. [35] reported using a soft pad placed beneath the passive \ndriver to decrease patient vibrating sensations. The passive \ndriver was connected via a flexible tube to an active driver, \nwhich was located outside the MRI suite, typically in the \nequipment room. The active drivers generated mechanical \nEach question was rated with “yes”, “no”, “other” (“cannot \ndetermine” (CD), “not applicable” (NA), or “not reported” \n(NR)). Finally, overall quality was determined based on the \noutcomes of the questions. If 6–8 questions were answered \nwith YES, the quality rating of the study was assessed as \n“Good”. If 4–5 questions were answered with YES, the \nquality of the study was assessed as “Fair’’. In all of the \nother cases the quality was assessed as “Poor”.\nResults\nSearch strategy, selection and inclusion\nThe initial search of the MEDLINE and EMBASE data -\nbases yielded 116 records (Fig. 1). After screening titles \nand abstracts, 108 studies were excluded for not meeting \nthe inclusion criteria. The full texts of the remaining eight \narticles were reviewed in detail, resulting in the exclusion of \ntwo additional studies. Ultimately six articles were included \nfor data extraction, five evaluating MRE in patients with \nleiomyomas [ 31–35] and one evaluating MRE in patients \nwith adenomyosis [36].\nStudy characteristics\nAll included studies were conducted in academic settings \nand were classified as either feasibility (2 studies) or pilot \nstudies (4 studies). Five out of six studies were prospectively \nperformed and all had received ethical approval. Further -\nmore, 5 of the 6 studies focussed on stiffness measurements \nFig. 1 Search, selection and inclu-\nsion of relevant articles\n \n1 3\n\nAbdominal Radiology\net al.[ 31] additionally presented histograms of stiffness \ndistributions.\nNone of the studies reported any adverse events during \nthe MRE examination.\nThe MRI protocol characteristics and MRE technical \nfeatures are summarized in Supplements D and E respec -\ntively. Additional MRE parameters and outcomes are listed \nin Table 3.\nLeiomyomas\nMRI and MRE features of leiomyomas\nThree of the five studies (Jondal et al.  n = 102, Ichikawa et \nal. n  = 11, and Aphinives et al.  n = 26) reported that most \nof the patients, ranging from 62 to 100% had multiple \nleiomyomas [32, 33, 36]. Among the studies reporting on \nleiomyoma size (Stewart et al.  n = 6, Jondal et al.  n = 102 \nand Obrzut et al.  n = 12), the diameter ranged from 4 cm \nto 22.5 cm [31, 32, 34]. The mean stiffness of leiomyomas \nranged from 3.02 to 7.10 kPa across all the included studies. \nvibrations all at the frequency of 60 Hz, which was transmit-\nted through the tube to the passive driver and subsequently \npropagated through the abdominal wall to the uterus.\nShear wave imaging was evaluated in three studies [ 31, \n32, 34] using a modified two-dimensional (2D) gradient-\nrecalled echo–based elastography pulse sequence. In a \nsubset of patients in the Jondal et al. [ 32] study, additional \nthree-dimensional (3D) multi-slice spin-echo–based planar \nimaging sequences were acquired, while Jain et al. [ 36] \nemployed a 3D EPI MRE approach.\nFollowing image acquisition, ROIs were selected. In three \nstudies, the person responsible for delineating the ROIs was \nspecified: in two studies ([ 31, 33], a radiologist performed \nthis task, while in Aphinives et al. [ 35], an MRI technician \nwas responsible. Additionally, three studies reported using \nthe T2-weighted images as a guide when defining the ROIs, \nto avoid areas of degeneration in the leiomyoma, identified \nby T2 hyperintense areas.\nStiffness values were reported across studies using a \ncombination of mean, median, standard deviation, and, in \nsome cases, minimum and maximum values (kPa). Stewart \nTable 1 Study characteristics of included articles\nLeiomyoma\nAuthor Department \nof first \nauthors\nCountry of \norigin\nStudy \ntype\nStudy design Study \nSetting\nStudy \nperiod\nData \ncollection\nInformation \non funding\nInformation \non ethical \napproval\nCon-\nflict of \ninterest\nStewart@, \n[ 31]\nObstetrics \nGynecology\nU.S.A Feasibility Single-center Academic Apr. \n2008-\nMar. \n2009\nProspective Yes, with \nfunding \ndisclosed\nApproved \nand informed \nconsent \nobtained\nNone \ndeclared\nJondal@, \n[32]\nRadiology U.S.A Pilot Single-center Academic N. A.* Prospective Yes, with \nfunding \ndisclosed\nApproved \nand informed \nconsent \nobtained\nYes, \ndeclared\nIchikawa, \n[33]\nRadiology Japan Pilot Multi-center# Academic Feb. \n2013- \nDec. \n2014\nRetrospective Not reported Approved \nand informed \nconsent \nobtained\nNone \ndeclared\nObrzut, \n[34]\nBiophysics Poland Pilot Multi-center# Academic Sept. \n2016- \nFeb. \n2017\nProspective Yes, with \nfunding \ndisclosed\nApproved \nand informed \nconsent \nobtained\nNot \nreported\nAphini-\nves, [35]\nRadiology Thailand Pilot Single-center Academic Sept. \n2020- \nOct. \n2021\nProspective Yes, with \nfunding \ndisclosed\nApproved \nand informed \nconsent \nobtained\nNone \ndeclared\nAdenomyosis\nAuthor Department \nof first \nauthors\nCountry of \norigin\nStudy \ntype\nStudy design Study \nSetting\nStudy \nperiod\nData \ncollection\nInformation \non funding\nInformation \non ethical \napproval\nCon-\nflict of \ninterest\nJain, [36] Centre for \nReproduc-\ntive Health\nUnited \nKingdom\nFeasibility Multi-center# Academic N. A.* Prospective Yes, with \nfunding \ndisclosed\nApproved \nand informed \nconsent \nobtained\nNot \nreported\n*N.A. Not available, #Multi-center indicating involvement of authors from different institutions; @ studies performed at the same institute\n1 3\n\nAbdominal Radiology\nTable 2 Study population characteristics of included articles\nLeiomyoma\nAuthor Inclusion/\nexclusion criteria\nNo. of \npatients\nAge\n(years)\nBMI\n(kg/m2)\nReproductive status\n(Pre-/peri-/\npost-menopausal)\nSymptoms Ethnicity Treatment (# of \npatients)\nStewart, \n[31]\nPlanned for surgical \nexcision of uterine \nleiomyomas\n6 Mean: \n42 ± 10\nRange: \n34–60\nMean: \n28.9 ± 6.2\nRange: \n23–38\nPre: 5\nPost: 1\nEnlarged uterus/\nfibroid: 3\nMenorrhagia: 11\nBulk symptoms: 1\nDegenerating fibroid \n& preterm labor: 1\nCaucasian: \n3\nAsian: 2\nAfrican-\nAmerican: \n1\nHysterectomy: 3\nMyomectomy: 2\nDiagnostic hys-\nteroscopy: 1\nJondal, \n[32]\nPatients between 18 \nand 89 years sched-\nuled for a pelvic MRI \nfor uterine fibroids \nor other uterine \nproblems®\n102 Mean: \n44 ± 8.8\nN.R Pre: 68\nPeri: 29\nPost: 5\nMenorrhagia: 89\nDysmenorrhea: 37\nIncreased urinary \nfrequency: 51\nPain or pressure in \nabdomen/back: 65\nCaucasian: \n82\nAfrican-\nAmerican: \n11\nOther: 9\nNone: 39\nFUS: 13\nUAE: 15\nSurgery: 35\nIchikawa, \n[33]\nPatients who under-\nwent MRgFUS for \nuterine fibroids\n11 Mean: \n45.5 ± 4.4\nrange \n38–52\nN.R N.R Hypermenorrhoea: 8\nAbdominal tight-\nness: 2\nIncreased urinary \nfrequency: 1\nN.R MRgFUS: 26*\nObrzut, \n[34]\nPatients with symp-\ntomatic leiomyomas, \nwho underwent \nsurgical treatment\n12 Mean \n40.5\nrange \n26–61\nMedian \n22.45\nrange \n19.16–\n27.24\nPre: 11\nPost: 1\nN.R N.R Hysterectomy: 7\nMyomectomy: 5\nAphini-\nves, [35]\n > 18 years old, diag-\nnosed with myoma \nuteri, and requested \nfor pelvic MRI\nExcluded: patients \nwith pregnancy or \nemergency medical \nconditions\n26 Mean: 49\nrange \n26–70\nN.R N.R N.R N.R N.A\nAdenomyosis\nAuthor Inclusion/\nexclusion criteria\nNum-\nber of \npatients\nAge\n(years)\nBMI\n(kg/m2)\nReproductive status\n(Pre-/peri-/post-menopausal)\nSymptoms Ethnicity Treatment \n(# of \npatients)\nJain, [36] Patients with sus-\npected adenomyosis \nand heavy menstrual \nbleeding diagnosed \nby TVUS\n5α N.R N.R Pre: 5 Heavy men-\nstrual bleeding: \n4\nNone: 1α\nN.R Hysterec-\ntomy: 2\nN.R.: not reported, N.A.: not applicable, FUS: Focused Ultrasound Surgery, UAE: Uterine artery embolization, TVUS: transvaginal ultra -\nsound, MRgFUS: Magnetic Resonance-guided Focused Ultrasound Surgery\n®: all patients included had uterine leiomyomas, *: refers to number of leiomyomas treated not number of patients\nα: including 1 healthy volunteer\n1 3\n\nAbdominal Radiology\nAssociation between leiomyoma stiffness and histological \ncomposition\nObrzut et al. ( n = 12) examined the relationship between \nmean stiffness and histological composition. Surgical speci-\nmens were stained to differentiate muscle fibers, collagen \nfibers, and nuclei, and were categorized based on the per -\ncentage of connective tissue content. Leiomyomas con -\ntaining more than 30% fibrous tissue exhibited a higher \nmedian stiffness (6.15 kPa) compared to those with up to \n15% fibrous content (4.46 kPa) and between 15 and 30% \n(5.78 kPa) [34].\nAssociation between leiomyoma stiffness and treatment \noutcome\nIchikawa et al. ( n =11) compared treatment stiffness values \nin patients undergoing MR-guided focused ultrasound and \nfound that patients who experienced a substantial volume \nreduction had significantly higher pre-treatment stiffness \nvalues (mean 8.3 kPa, range 6.9–10.3) compared to patients \nwithout substantial volume reduction (mean 6.1 kPa, range \n5.2–8.0) [33].\nThe pooled mean with pooled SD was 4.72 ± 1.83 (Fig.2). \nOther features are listed in Table 4.\nAssociation between leiomyoma stiffness and T2 weighted \nsignal intensity or contrast enhancement\nIn the study conducted by Stewart et al., 50% of the patients \n(3 out of 6) demonstrated homogenously hypointense leio -\nmyomas on T2-WI, which corresponded with higher mean \nstiffness values. Conversely, one patient with a heterog -\nenous leiomyoma on T2-WI showed the lowest mean stiff -\nness [31]. \nSimilarly, Jondal et al. ( n = 102) found a correlation \nbetween T2 signal characteristics and stiffness values. \nTheir study reported that hyperintense leiomyomas on \nT2-WI had significant lower stiffness than hypointense, \nminimally heterogenous leiomyomas. The mean stiffness \ndifference between the two groups was 2.38 kPa: hyperin-\ntense leiomyomas had a mean stiffness of 2.88 ± 0.98 kPa, \nwhereas hypointense leiomyomas measured 5.27 ± 2.16 kPa \n(p = 0.0147). Notably, mean stiffness did not differ signifi -\ncantly across varying contrast enhancement patterns [32].\nAuthor Wave \nFre-\nquency \n(Hz)\nRegion of Interest (ROI) Placement Stiffness \nMeasurements \nReported (kPa)\nMain Outcome of Study\nStewart, \n[31]\n60 ROIs were manually drawn by \nradiologists within the uterine leio-\nmyoma using the stiffness maps\nMean stiffness, \nSD and histo-\ngrams of tissue \nstiffness\nAssess the in vivo stiff-\nness of uterine leiomyo-\nmas using MRE\nJondal, \n[32]\n60 ROIs were manually drawn on the \nlargest leiomyoma, guided by cor-\nresponding T2-weighted images\nMean stiffness \nand SD of the \nROIs\nCorrelate fibroid MRE \nstiffness with MRI \ncharacteristics\nIchikawa, \n[33]\n60 Two radiologists placed ROIs \nwithin the uterine fibroid on stiff-\nness maps, guided by T2-weighted \nimages, avoiding areas of \ndegeneration\nMean stiff-\nness pre-and \nposttreatment\nEvaluate usefulness \nof MRE for predicting \ntreatment outcomes \nof patients receiving \nMRgFUS*\nObrzut, \n[34]\n60 ROIs were manually drawn on the \nlargest leiomyoma, guided by cor-\nresponding T2-weighted images\nMean stiffness \nand SD were \nreported\nInvestigated stiffness of \nleiomyomas in correla-\ntion with histopatho-\nlogic composition\nAphinives, \n[35]\n60 ROIs for the whole uterus were \ndrawn manually on axial FFE \nimages by an MRI technologist\nAverage, median, \nminimum, maxi-\nmum stiffness \nand SD\nAssess the feasibility \nof MRE in evaluating \nuterine fibroid stiffness \nin Thai patients\nJain, [36] 60 ROI demarcating the whole uterus \nas appeared on T2-WI and trans-\nferred and superimposed on the \nrelevant stiffness map\nGlobal estimated \nuterine stiffness\nAsses the feasibility to \nmeasure uterine stiffness \nin adenomyosis and a \nhealthy volunteer, and \ncorrelate findings with \nhistology in 2 cases\nTable 3 MRE Parameters and \nMain Outcomes\n*MRgFUS: MRI Guided \nFocused Ultrasound, FFE: fast \nfield echo\n \n1 3\n\nAbdominal Radiology\nAdenomyosis\nIn one study MRE was evaluated in four patients with sus -\npected adenomyosis (diffuse  n  = 3; focal  n  = 1) and one \nhealthy volunteer (Jain 2025) [36]. Two patients underwent \nhysterectomy, and histologic analysis of the tissue samples \nwas performed. Uterine stiffness was higher in women with \nadenomyosis (2.93 kPa; range, 2.34–3.39 kPa) than in the \nhealthy volunteer (2.04 kPa).\nMethodological quality assessment\nAll included studies were either pilot or feasibility stud -\nies and were rated as having good methodological quality \naccording to the National Institutes of Health (NIH) quality \nAssessment Tool for Case Series Studies. Table 5.\nDiscussion\nThis systematic review identified four pilot studies and two \nfeasibility studies investigating the use of MRE for evaluat-\ning fibrosis in benign uterine disorders, specifically leiomy-\nomas and adenomyosis [ 31–36]. Despite their small scale, \nfindings suggest that MRE is a technically feasible imaging \nmodality to assess fibrosis.\nTable 4 MRI and MRE Features of Leiomyomas\nAuthor Leiomyoma \nvolume\n(cm3)\nLeiomyoma \ndiameter\n(cm)\nNumber of \nleiomyomas\nLocation of \nleiomyoma in \nuterus wall\nLeiomyoma charac-\nteristics on T2-WI\nLeiomyoma \ncharacteristics on \npost-contrast\nStiffness on MRE\nMean ± SD\n/median, range \n(kPa)\nStewart, \n[31]\nN.R Mean: \n13.86*∅\nRange \n4.5–22.5∅\nN.R N.R Dark: 4\nHeterogenous: 1\nN.A.: 1\nHeterogenous: 1\nHomogenous: 3\nNo enhancement: 1\nN.A.: 1\nMean \n5.09 ± 1.01*\nRange 3.95–6.68\nJondal, \n[32]\nMean: \n283.0 ± 398.0\nRange \n4.5—22.5\nSingle: 21\nMultiple: 81\nSubmucosal: \n17\nIntramural: 75\nSubserosal: 6\nPedunculated: \n4\nDark min. heteroge-\nneity: 69\nDark substantial \nheterogeneity: 20\nIso/Hyperintense: 13\nGreater/equal^: 59\nLess^: 31\nNone^:7\nNo Gd adminis-\ntered: 5\nMean 4.81 ± 2.12\nIchikawa#, \n[33]\nMean: 412.1\nRange 29.3 \n−864.6)\nN.R Single:0\nMultiple:11\n(Mean 8\nRange 2–17)\nSubmucosal: 5\nIntramural: 12\nSI ratio of leiomy-\noma-to-muscle: \nmean 1.23, range \n(0.81–1.84)\nN.R Mean 7.3 ± 1.60*\nRange 5.2–10.3\nObrzut, \n[34]\nN.R Median: \n6.851∅\nRange 4 \n−10.9∅\nN.R N.R N.R N.R Mean \n5.09 ± 0.96*\nMedian 4.9\nRange 3.7–6.9\nAphinives, \n[35]\nMean: \n237.74 ± 187.63\nRange \n56.24—716.35#\nN.R Single: 10\nMultiple: 16\nN.R N.R N.R Mean 3.02 ± 0.79\nRange 1.83–5.06\nN.R. Not recorded, SI Signal intensity, * mean and SD calculated using available data, ^ enhancement compared to myometrium, ∅ measure -\nment corresponds to largest leiomyoma, # in case of multiple leiomyomas, the total was summation of all leiomyomas\nFig.  2 Mean stiffness (kPa) per study and pooled results in patients \nwith leiomyomas\n \n1 3\n\nAbdominal Radiology\nand quantify fibrosis in adenomyosis, with potential impli -\ncations for diagnosis and monitoring.\nA major strength of this review is the inclusion of studies \nthat employed quantitative stiffness measurements, provid -\ning objective data on uterine tissue properties. Across the \navailable evidence, a consistent MRE set-up was used, with \nall studies applying the same driver system (a passive driver \nover the lower abdomen and an active driver producing \n60 Hz vibrations), which supports technical comparability. \nTo our knowledge, this is the first systematic review to spe-\ncifically evaluate MRE for fibrosis in benign uterine disor -\nders, namely leiomyomas and adenomyosis.\nHowever, this systematic review highlights several \nimportant limitations in the current evidence base on MRE \nfor benign uterine disorders. A key constraint across the \nincluded studies is the absence of large cohort data, which \nsignificantly limits the generalizability of the findings. \nMoreover, the small number of studies, heterogeneity in \nuterine pathologies investigated (five on leiomyomas and \none on adenomyosis), and variability in outcome measures \nprecluded the performance of a meta-analysis.\nAlso, the studies fail to elaborate on the criteria for \npatient selection, which may have introduced selection bias. \nThe reported mean age ranged from 40.5 to 49 years, and \namong the 120 patients for whom reproductive status was \nreported, 24.2% were perimenopausal and 5.8% were post-\nmenopausal. This is noteworthy, as leiomyomas are gener -\nally most clinically significant in women of reproductive \nage, particularly in those with a desire to conceive.\nTechnical variability further complicates interpretation. \nThe studies applied different MRI acquisition sequences; \nMRE in leiomyomas- For leiomyomas, the studies sug -\ngest that MRE-derived stiffness could serve as a biomarker \nof fibrosis. Jondal et al. [ 32]and Stewart et al. [ 31] found \nthat T2-hypointense leiomyomas showed higher stiffness \nvalues, consistent with Oguchi et al. [ 37], who linked low \nT2 signal with reduced proliferative activity and increased \nfibrosis. Obrzut et al. [ 34] confirmed this relationship his -\ntologically, showing significantly higher stiffness in leio -\nmyomas with > 30% fibrous content (6.15 kPa) compared \nto less fibrotic lesions (4.46 kPa). Aphinives et al. [ 35]. \nalso reported leiomyoma stiffness exceeding that of normal \nmyometrium, while Stewart et al. [31] noted values compa-\nrable to fibrotic liver disease.\nMRE may also help predict treatment outcomes. \nIchikawa et al. [ 33] suggested that leiomyomas with high \nstiffness respond better to MR-guided focused ultrasound, \nwhile those with high T2 signal and high-water content may \nresist ablation. This likely reflects treatment mechanisms: \nthermal ablation is more effective in dense fibrotic tissue, \nwhereas embolization depends on vascular supply and may \nbe less effective in poorly perfused leiomyomas. Consistent \nwith this, Chung et al. [ 38] reported that leiomyomas with \nhigh T2 signal intensity were more likely to respond favor -\nably to uterine artery embolization (UAE).\nMRE in adenomyosis- For adenomyosis, evidence is \nmore limited. In Jain et al. [ 36], regions of increased stiff -\nness on MRE corresponded with adenomyotic areas on MRI \nand with histological fibrosis in hysterectomy specimens, \nstrengthening the hypothesis that MRE reflects disease-\nrelated remodeling. While preliminary, these results indi -\ncate that MRE may provide a non-invasive means to detect \nTable 5 Methodological quality assessment of included articles\nAuthor Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Overall \nquality\nStewart, [31] YES YES NR NO YES YES YES YES Good\nJondal, [32] YES YES NR YES YES YES YES YES Good\nIchikawa, [33] YES NO YES YES YES YES YES YES Good\nObrzut, [34] YES YES NR YES YES YES YES YES Good\nAphinives, [35] YES NO NR YES YES YES YES YES Good\nJuan, [36] YES NO NR YES* YES YES YES YES Good\nQ1. Was the study question or objective clearly stated? Yes, if clearly described in the introduction\nQ2. Was the study population clearly and fully described? Yes, if inclusion and exclusion criteria, patient age, and menstrual status are \nclearly stated\nQ3. Were the cases consecutive? Yes, if clearly mentioned in the methods\nQ4. Were the subjects comparable? Yes, if only patients with either leiyomomas, deep endometriosis or adenomyosis were included\nQ5. Was the intervention clearly described? Yes, provided that MRE techniques are clearly defined\nQ6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Yes, if MRE \nevaluation was done in all patients in the same way to calculate stiffness\nQ7. Were the statistical methods well-described? Yes, if it is reproducible and all details are mentioned\nQ8. Were the results well-described? Yes, if all results matched the method section\nQuality Rating. If 6–8 questions were answered with YES, the quality rating is assessed as “Good”. If 4–5 questions were answered with \nYES, the quality was assessed as ‘Fair’’. All other cases were assessed as poor quality\nNR: Not reported; *Feasibility study including a healthy volunteer\n1 3\n\nAbdominal Radiology\nRecommendations\nFuture research should aim to move the technique beyond \nexperimental use toward clinical applicability (e.g. for \ndifferentiation between symptomatic and asymptomatic \nleiomyomas, and for guiding the choice between surgical, \nembolization, and ablative therapies). \nProspective studies should be designed:\n1) including all patients undergoing MRI in routine clini-\ncal practice, rather than focusing solely on those scheduled \nfor surgery, to ensure representative and generalizable find-\nings. In this case, the time and accompanying costs of the \nadditional MRE could be limited.\n2) with standardization of MRE acquisition protocols, \nas different algorithms will have effect on measurements \nand with standardization of fibrosis assessment methods, as \ndifferent way of ROI placements will also have effect on \nmeasurements.\n3) with incorporation of normal myometrial measure -\nments as reference values (e.g. as additional sequence in \npatient undergoing pelvic MRI for other conditions) and \nalso reporting other factors such as tissue cellularity, vas -\ncularity, edema, hormonal status, as intrinsic heterogeneity \nof uterus masses will also have effect on quantifying tissue \nproperties (fibrosis).\n4) to validate MRE-derived stiffness measurements \nagainst histopathological results or to assess its added value \nalongside conventional imaging modalities, particularly in \nrelation to disease progression, symptom severity, treatment \nplanning, and patient-reported outcomes.\nSuch studies may help establish the potential of MRE \nas a clinically valuable tool for assessing fibrosis in benign \nuterine disease.\nSupplementary Information  The online version contains \nsupplementary material available at  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 0 7  / s 0  0 2 6 1 - 0 \n2 6 - 0 5 3 7 4 - 8.\nAuthor Contribution All authors made substantial contributions to all \nof the following: (1) the conception and design of the study, or acqui -\nsition of data, or analysis and interpretation of data, (2) drafting the \narticle or revising it critically for important intellectual content, (3) \nfinal approval of the version to be submitted.\nFunding The authors did not receive support from any organization \nfor the submitted work.\nData availability All extracted data are available in tables and supple-\nmentary files. Details on the search results is available on request (end-\nnote files).\nDeclarations\nCompeting interests The authors declare no competing interests.\n2D gradient-recalled echo (GRE) and spin echo–echo pla -\nnar imaging (SE-EPI)—which have been reported to differ \nin technical reliability at various field strengths. Kim et al. \n[39] showed that GRE had higher failure rates at 3 T com-\npared to 1.5 T, while SE-EPI performed more reliably at \n3 T. Reflecting this, Resoundant, a Mayo Clinic–founded \ncompany supporting MRE technology, recommends GRE \nat 1.5 T and SE-EPI at 3 T; most studies in this review fol -\nlowed these guidelines, suggesting appropriate sequence \nselection despite heterogeneity.\nAlthough all studies used the same MRE system, details \nof the inversion algorithms used to calculate stiffness maps \nwere not reported, limiting comparability, as different algo-\nrithms can affect stiffness measurements.\nOnly three of the six studies specified who placed ROIs, \nhowever none of the studies reported inter or intra-observer \nvariability, and reproducibility seems to be major limitation \nin imaging studies; different way of ROI placements can \nalso affect stiffness measurements.\nFurthermore, none of the studies included a reference \nROI in the normal myometrium, so normal values are \nmissing.\nScan times were generally short (< 1 min in most stud -\nies), suggesting feasible integration into MRI workflows. \nHowever, variability remains (e.g., Jain et al.) and the addi-\ntional time needed for post-processing and interpretation \nis not well quantified, highlighting the need for workflow \noptimization [36].\nLimitations of this review itself include the small pool of \neligible studies and the inability to perform a meta-analysis. \nThese reflect the early stage of research in this field rather \nthan shortcomings of the review methodology.\nConclusion\nDespite the limited number of available studies, current \nfindings suggest that MRE is a feasible imaging modality \nfor measuring fibrosis in benign uterine disorders.\nClinical relevance\nHowever, at this stage, these data cannot be translated to \nclinical practice, due to small number of studies performed \n(pilot and feasibility studies), missing data on normal stiff -\nness values, technical heterogeneity (different algorithms), \ndifferent interpretation aspects (ROI placement variability) \nof uterine stiffness by MRE and missing data on time and \ncosts.\n1 3\n\nAbdominal Radiology\n13. 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Aphinives C, Nawapun S, Likitdee N, Aphinives P, Phuttharak \nW (2023) Myoma uteri: stiffness from MR elastography in Thai \npatients: a pilot study. J Med Assoc Thai 106:265-269\n1 3","source_license":"CC-BY-4.0","license_restricted":false}