{"paper_id":"4ddff144-70b8-4654-b574-c0f904634210","body_text":"J.Gynecol. Obstet. 2020, 32, N.3\n208\nTIPO ARTICOLO\nGynæcology & Obstetrics\nItalian Journal of\nSeptember 2020 - Vol.32 - N. 3 - Quarterly - ISSN 2385 - 0868\nRole of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: \ncase series with review of literature \nA. S. El-Agwany \nDepartment of Obstetrics and Gynecology, School of Medicine, Alexandria University, Egypt\nABSTRACT\nBackground. In times, Adenomyosis cannot be diagnosed ac-\ncurately and differentiated from leiomyoma before histologi-\ncal assessment in a hysterectomy specimen.  it can be suspect-\ned by gross pictures.\nAim. We aim to provide an assistance to pathological exam-\nination, proposing a role of ultrasound and gross examination \nof the specimen to be helpful.\nCase presentation. We presented different cases with adeno-\nmyosis with different gross pathologies as trabeculation on \nexternal surface, small myometrial cysts, polypodial adeno-\nmyosis and diffuse adenomyosis. \nConclusions. Adenomyosis cannot be diagnosed accurately  \nbefore the pathological assessment of the uterus. It could be \nsuspected from gross pathologies and ultrasound findings.\nSOMMARIO\nL’adenomiosi non può essere diagnosticata accuratamente e \ndifferenziata dal leiomioma prima della valutazione istologica \nin un campione di isterectomia. può essere sospettato da im-\nmagini grossolane.\nScopo. Ci proponiamo di fornire assistenza per l’esame pa-\ntologico, proponendo alcune immagini grossolane ed ecogra-\nfiche come supporto alla diagnosi istologica finale.\nPresentazione del caso. Abbiamo presentato diversi casi di \nadenomiosi con differenti patologie lorde come trabecolazione \nsulla superficie esterna, piccole cisti miometriali, adenomiosi \npolipodiale e adenomiosi diffusa. La presentazione presenta \ndiversi quadri grossolani di adenomiosi che possono sospet-\ntare l’adnomiosi.\nConclusioni. L’adenomiosi non può essere diagnosticata ac-\ncuratamente e differenziata dal leiomioma prima della valu-\ntazione patologica dell’utero. Potrebbe essere sospettato da \npatologie grossolane e risultati ecografici.\nKey words: \nAdenomyosis; cyst: uterus; polyp; hysterectomy.\nCorresponding Author: Ahmed S El-agwany\nE-mail: Ahmedsamyagwany@gmail.com\nCopyright 2020\nDOI: 10.36129/jog.32.03.07\n\nRole of Gross Examination of the specimen and ultrasound \nin Uterine Adenomyosis: case series with review of literature\nA. S. El-Agwany\n209\nBACKGROUND \nAdenomyosis is the presence of endometrial \nglands and stroma in the myometrium (1). When \nadenomyosis is focal, it is similar to a leiomyoma \nin being an intramural, space-occupying mass. it \ndiffers from leiomyoma in which the mass cannot \nbe shelled out easily (2). Adenomyosis cannot be \ndiagnosed accurately nor differentiated from leio-\nmyoma before the pathological assessment of the \nuterus, at times it could be suspected from gross \npathological that are presented here.\nWe aim to provide an assistance during surgery \nand before pathological examination as a guide \nand a preliminary diagnosis, proposing some gross \npictures and ultrasound ones to be helpful as a \nsupport to the final histological diagnosis.\nAll cases did not have chronic illness. BMI of pa-\ntients ranges between 25-30. The Second and third \npatient had history of one cesarean section while \nother patients surgical history is unremarkable. \nThe complaints were not relieved by medical \ntreatment combined of analgesics and hormonal \ntreatment inform of pills and progesterone thera-\npy. Patients refused mirena and continuing medi-\ncation as they were putting on weight, they missed \ntaking the pills and they developed unexpected \nbleeding. They were demanding a permanent \ncure - Patients underwent abdominal hysterecto-\nmy with bilateral salpingectomy. On pathologic \nassessment, the abnormality in uterus was adeno-\nmyosis. Microscopically, multiple irregular islands \nof endometrial glands and stroma embedded in \nthe myometrium and the entire uterine wall was \nidentified.The myometrium surrounding were hy-\npertrophic. The glands in the endometrial islands \nwere of basalis-type endometrium in contrast to \nthe early secretory glands in the endometrium (ta-\nble I) (figure 1-7). \nDISCUSSION\nAdenomyosis causes gross abnormality in ad-\nvanced cases and the diagnosis is based upon mi-\ncroscopic findings. In Lev Gur’s series (3), adeno-\nmyosis was present alone in the uteri smaller than \n280 g. Reiter et al. reported six cases with a uterine \nweight of 320 g (4). A clinical diagnosis of adeno-\nmyosis can be confirmed by transvaginal ultraso-\nnography and MRI, but specificity of these meth-\nods decreases when the uterine volume exceeds \n400 ml (5,6). \nThe MUSA (Morphological Uterus Sonographic \nAssessment) statement is a consensus statement \non terms, definitions and measurements used to \ndescribe the sonographic features of the myome-\ntrium using gray-scale sonography, Doppler and \nthree-dimensional ultrasound imaging. This Mor -\nphological Uterus Sonographic Assessment con-\nsensus is based on the opinion of clinicians with \nexpertise including members from the IOTA (In-\nternational Ovarian Tumor Analysis) and IETA \ngroups (24). it describes criteria for diagnosing ad-\nTable I. Case Presentation.\nCase Age Complain Gravidity, parity Findings Operative finding Figure \n1 40 AUB inform of \nmenoraghia \nG3P3 Diffuse and Asymmetrical \nThickening of uterine wall, \nenlarged uterus in size and \nvolume, endometrial thickness \nis 8mm with ill defined \nendometrial myometrial \njunction \nDiffuse adenmyosis \nWith trabeculations and \nasymmetry between walls \nanterior and posterior\n1 ,7\n2 45 AUB inform of \nmenoraghia \nG1P1 Myometrial cyst, striation \nshadowing, heterogenous \nechogenicity, adenomyoma\nSubendometrial \nMyometrial cyst \n2, 3\n3 47 Chronic PELVIC\nPAIN and low back pain\nG2P1+1 thickened myometrium, \npolypi, myometrial cyst, \nasymmetrical diffuse \nwall thickening, thick \nendometrium and ill defined \nTrabeculation on external \nsurface of uterus,myometrial \ncyst bulging in cavity and \nmultiple endometrial polypi \n4, 5\n4 42 AUB inform of \nmenoraghia \nG3P2+1 Diffuse asymmetrical \nmyometrial thickening, \nendometrial polyp, \nmyometrial cyst and thick \nilldefined endometrium, \nechogenic spots \nTrabeculations on the \nexternal surface, hickened \nmyometrium with \npolypoidal adenomyosis and \nsmall myometrial cysts \n6\n\nJ.Gynecol. Obstet. 2020, 32, N.3 Role of Gross Examination of the specimen and ultrasound \nin Uterine Adenomyosis: case series with review of literature\n210\nFigure 1. Diffuse adenomyosis of the uterus (thickened walls with asym-\nmetry and trabecula-tion all through).\nFigure 2. Myometrial cyst on ultrasound, an active recent lesion with \nechoic wall (A), Ultrasound with illdefined endometrium with shadowing \n(B), Mottled heterogenous echogenicity of myometrium with subendlmetrial \nbuds and lines (C).\nA\nB\nC\nFigure 3. Ultrasound with adenomyoma in wall, (A) which is echogenic \nmass, ill defined considered as old lesion with fibrosis, shadowing fan shaped \nwith intralesional vascu-larity, illdefined endometrium and junctional zone.\nFigure 4. Subendometrial adenomyotic cyst with multiple adenomyotic polypi.\nA\nB\nC\n\nRole of Gross Examination of the specimen and ultrasound \nin Uterine Adenomyosis: case series with review of literature\nA. S. El-Agwany\n211\nFigure 7. Trabeculation over the external surface of uterus.\nFigure 5. Echogenic spots in the myometrium associated with adenomyo-\nsis of old fibrosis hemorrhagic lesions and hyperechoic islands. \nFigure 6. Enlarged uterus with small myometrial \ncyst with (B,C), thick wall of hyper-trophied myome-\ntrium and polypodal adenomyosiss (B).\nA\nB\nC\nA\nB\nC\n\nJ.Gynecol. Obstet. 2020, 32, N.3 Role of Gross Examination of the specimen and ultrasound \nin Uterine Adenomyosis: case series with review of literature\n212\nenomyosis and fibroids. Adenomyosis assessment \non ultrasound include the following criteria for \ndiagnosis as globally enlarged uterus, ill-defined \nlesion as  in diffuse adenomyosis (adenomyoma \nmay be well-defined) and Myometrial anteropos-\nterior asymmetry. The mass lesion is characterized \nby ill-defined, irregular mass with no rim, no edge \nshadows but fan-shaped shadowing and mixed \nechogenicity. Myometrial cysts, hyperechogenic \nislands, subendometrial lines and buds, transle-\nsional flow, and thickened irregular or ill-defined \ninterrupted JZ can be detected as shown on previ-\nous photos (7).\nPolypoid adenomyoma, known as an adenomyo-\nmatous polyp, is an endometrial polyp in which \nthe stroma is predominantly composed of smooth \nmuscle. they are accounting for only 1.3% of all en-\ndometrial polyps (8-10). These tumors are of mixed \nepithelial and mesenchymal origin with typical and \natypical variants (11-13). Most studies have focused \non the clinicopathologic features of atypical polyp-\noid adenomyomas because they are confused with \nmalignant tumors. the transvaginal sonographic \nappearance has been described as a  polypoid, hy-\npoechoic or hyperechoic submucosal mass in the \nendometrial cavity, a large solid mass with mul-\ntiple cystic areas, a mass with large  cysts, and a \npolyp with small cystic spaces (11-13). Nasu et al. \n(14). reported a case of polypoid adenomyoma as \na large solid mass with multiple cystic areas, simi-\nlar to submucous leiomyoma with cystic degenera-\ntion. Furuhashi et al. (15) described a case in which \na hyperechoic pattern changed to a vesicular one, \nsimilar to trophoblastic disease. Color Doppler has \nbeen used in the diagnosis of endometrial abnor -\nmalities by identifying vessels in the lesions. \nCystic lesions of the uterus are rare and are con-\nsidered to be benign (16). Adenomyotic cysts are \nobserved in parous women, and in association \nwith diffuse adenomyosis uteri (17) isolated ad-\nenomyotic cysts may be detected (18,19). Adeno-\nmyotic cysts are seen in older ages but they may \nbe in adolescents (20). Small adenomyotic cysts \nthat do not exceed 5 mm in diameter are found \nin 24% of hysterectomy specimens (21) but larg-\ner adenomyotic cysts are rare. Repeated surgical \nintervention might be a risk factor for adenomy-\notic cysts (22). Pelvic pain, dysmenorrhea, men-\norrhagia and large uterus are the most common \nfeatures of adenomyosis. Urine retention may \nbe the symptom (23). Pain or severe dysmenor -\nrhea may be the main symptom in adenomyotic \ncysts. The pain of the adenomyotic cyst may be \ndue to the increase in size of the mass, stretch-\ning of the endometrial cavity and cystic bleeding. \nMagnetic resonance imaging is important for the \ndiagnosis of cystic adenomyosis especially when \nother imaging modalities are nonspecific (24). \nMagnetic resonance imaging can differentiate \nmultiple cysts within the uterine myometrium, \nbut hysterosalpingography may be useful for the \ndifferential diagnosis when magnetic resonance \ncannot differentiate isolated adenomyotic cyst \nfrom cavitated noncommunicating rudimentary \nhorn. Imaging techniques are important in differ -\nential diagnosis of adenomyotic cysts and help us \nto choose the appropriate intervention. In young \npatients hormonal therapy is the first choice and \ncan be accomplished by combined oral contra-\nceptives or progesterone laden IUD as mirena. In \nthe presence of severe symptoms that do not re-\nspond to medical therapy, a surgical intervention \ncan be planned for excision (24). In older patients \nwith no desire to preserve their fertility, hysterec-\ntomy can be performed.\nCONCLUSIONS\nAdenomyosis cannot be diagnosed accurately \nnor be differentiated from leiomyoma before the \npathological assessment of the uterus. it could be \nsuspected from gross pathologies and ultrasound \nfindings.\n\nRole of Gross Examination of the specimen and ultrasound \nin Uterine Adenomyosis: case series with review of literature\nA. S. El-Agwany\n213\nREFERENCES\n1. Rosai J. Female reproductive system. In: Ack-\nerman’s Surgical Pathology, 8th ed., Mosby, St. \nLouis, 1996; 1401–03.\n2. Sternberg S.S. The uterine corpus. 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