Role of Gross picture and ultrasound in Uterine Adenomyosis: case series with review of literature

Background. In times, Adenomyosis cannot be diagnosed ac- curately and differentiated from leiomyoma before histologi- cal assessment in a hysterectomy specimen. it can be suspect- ed by gross pictures. Aim. We aim to provide an assistance to pathological exam- ination, proposing a role of ultrasound and gross examination of the specimen to be helpful. Case presentation. We presented different cases with adeno- myosis with different gross pathologies as trabeculation on external surface, small myometrial cysts, polypodial adeno- myosis and diffuse adenomyosis. Conclusions. Adenomyosis cannot be diagnosed accurately before the pathological assessment of the uterus. It could be suspected from gross pathologies and ultrasound findings. SOMMARIO L’adenomiosi non può essere diagnosticata accuratamente e differenziata dal leiomioma prima della valutazione istologica in un campione di isterectomia. può essere sospettato da im- magini grossolane. Scopo. Ci proponiamo di fornire assistenza per l’esame pa- tologico, proponendo alcune immagini grossolane ed ecogra- fiche come supporto alla diagnosi istologica finale. Presentazione del caso. Abbiamo presentato diversi casi di adenomiosi con differenti patologie lorde come trabecolazione sulla superficie esterna, piccole cisti miometriali, adenomiosi polipodiale e adenomiosi diffusa. La presentazione presenta diversi quadri grossolani di adenomiosi che possono sospet- tare l’adnomiosi. Conclusioni. L’adenomiosi non può essere diagnosticata ac- curatamente e differenziata dal leiomioma prima della valu- tazione patologica dell’utero. Potrebbe essere sospettato da patologie grossolane e risultati ecografici. Key words: Adenomyosis; cyst: uterus; polyp; hysterectomy. Corresponding Author: Ahmed S El-agwany E-mail: [email protected] Copyright 2020 DOI: 10.36129/jog.32.03.07 Role of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: case series with review of literature A. S. El-Agwany 209

Adenomyosis is the presence of endometrial glands and stroma in the myometrium (1). When adenomyosis is focal, it is similar to a leiomyoma in being an intramural, space-occupying mass. it differs from leiomyoma in which the mass cannot be shelled out easily (2). Adenomyosis cannot be diagnosed accurately nor differentiated from leio- myoma before the pathological assessment of the uterus, at times it could be suspected from gross pathological that are presented here. We aim to provide an assistance during surgery and before pathological examination as a guide and a preliminary diagnosis, proposing some gross pictures and ultrasound ones to be helpful as a support to the final histological diagnosis. All cases did not have chronic illness. BMI of pa- tients ranges between 25-30. The Second and third patient had history of one cesarean section while other patients surgical history is unremarkable. The complaints were not relieved by medical treatment combined of analgesics and hormonal treatment inform of pills and progesterone thera- py. Patients refused mirena and continuing medi- cation as they were putting on weight, they missed taking the pills and they developed unexpected bleeding. They were demanding a permanent cure - Patients underwent abdominal hysterecto- my with bilateral salpingectomy. On pathologic assessment, the abnormality in uterus was adeno- myosis. Microscopically, multiple irregular islands of endometrial glands and stroma embedded in the myometrium and the entire uterine wall was identified.The myometrium surrounding were hy- pertrophic. The glands in the endometrial islands were of basalis-type endometrium in contrast to the early secretory glands in the endometrium (ta- ble I) (figure 1-7).

Adenomyosis causes gross abnormality in ad- vanced cases and the diagnosis is based upon mi- croscopic findings. In Lev Gur’s series (3), adeno- myosis was present alone in the uteri smaller than 280 g. Reiter et al. reported six cases with a uterine weight of 320 g (4). A clinical diagnosis of adeno- myosis can be confirmed by transvaginal ultraso- nography and MRI, but specificity of these meth- ods decreases when the uterine volume exceeds 400 ml (5,6). The MUSA (Morphological Uterus Sonographic Assessment) statement is a consensus statement on terms, definitions and measurements used to describe the sonographic features of the myome- trium using gray-scale sonography, Doppler and three-dimensional ultrasound imaging. This Mor - phological Uterus Sonographic Assessment con- sensus is based on the opinion of clinicians with expertise including members from the IOTA (In- ternational Ovarian Tumor Analysis) and IETA groups (24). it describes criteria for diagnosing ad- Table I. Case Presentation. Case Age Complain Gravidity, parity Findings Operative finding Figure 1 40 AUB inform of menoraghia G3P3 Diffuse and Asymmetrical Thickening of uterine wall, enlarged uterus in size and volume, endometrial thickness is 8mm with ill defined endometrial myometrial junction Diffuse adenmyosis With trabeculations and asymmetry between walls anterior and posterior 1 ,7 2 45 AUB inform of menoraghia G1P1 Myometrial cyst, striation shadowing, heterogenous echogenicity, adenomyoma Subendometrial Myometrial cyst 2, 3 3 47 Chronic PELVIC PAIN and low back pain G2P1+1 thickened myometrium, polypi, myometrial cyst, asymmetrical diffuse wall thickening, thick endometrium and ill defined Trabeculation on external surface of uterus,myometrial cyst bulging in cavity and multiple endometrial polypi 4, 5 4 42 AUB inform of menoraghia G3P2+1 Diffuse asymmetrical myometrial thickening, endometrial polyp, myometrial cyst and thick illdefined endometrium, echogenic spots Trabeculations on the external surface, hickened myometrium with polypoidal adenomyosis and small myometrial cysts 6 J.Gynecol. Obstet. 2020, 32, N.3 Role of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: case series with review of literature 210 Figure 1. Diffuse adenomyosis of the uterus (thickened walls with asym- metry and trabecula-tion all through). Figure 2. Myometrial cyst on ultrasound, an active recent lesion with echoic wall (A), Ultrasound with illdefined endometrium with shadowing (B), Mottled heterogenous echogenicity of myometrium with subendlmetrial buds and lines (C). A B C Figure 3. Ultrasound with adenomyoma in wall, (A) which is echogenic mass, ill defined considered as old lesion with fibrosis, shadowing fan shaped with intralesional vascu-larity, illdefined endometrium and junctional zone. Figure 4. Subendometrial adenomyotic cyst with multiple adenomyotic polypi. A B C Role of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: case series with review of literature A. S. El-Agwany 211 Figure 7. Trabeculation over the external surface of uterus. Figure 5. Echogenic spots in the myometrium associated with adenomyo- sis of old fibrosis hemorrhagic lesions and hyperechoic islands. Figure 6. Enlarged uterus with small myometrial cyst with (B,C), thick wall of hyper-trophied myome- trium and polypodal adenomyosiss (B). A B C A B C J.Gynecol. Obstet. 2020, 32, N.3 Role of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: case series with review of literature 212 enomyosis and fibroids. Adenomyosis assessment on ultrasound include the following criteria for diagnosis as globally enlarged uterus, ill-defined lesion as in diffuse adenomyosis (adenomyoma may be well-defined) and Myometrial anteropos- terior asymmetry. The mass lesion is characterized by ill-defined, irregular mass with no rim, no edge shadows but fan-shaped shadowing and mixed echogenicity. Myometrial cysts, hyperechogenic islands, subendometrial lines and buds, transle- sional flow, and thickened irregular or ill-defined interrupted JZ can be detected as shown on previ- ous photos (7). Polypoid adenomyoma, known as an adenomyo- matous polyp, is an endometrial polyp in which the stroma is predominantly composed of smooth muscle. they are accounting for only 1.3% of all en- dometrial polyps (8-10). These tumors are of mixed epithelial and mesenchymal origin with typical and atypical variants (11-13). Most studies have focused on the clinicopathologic features of atypical polyp- oid adenomyomas because they are confused with malignant tumors. the transvaginal sonographic appearance has been described as a polypoid, hy- poechoic or hyperechoic submucosal mass in the endometrial cavity, a large solid mass with mul- tiple cystic areas, a mass with large cysts, and a polyp with small cystic spaces (11-13). Nasu et al. (14). reported a case of polypoid adenomyoma as a large solid mass with multiple cystic areas, simi- lar to submucous leiomyoma with cystic degenera- tion. Furuhashi et al. (15) described a case in which a hyperechoic pattern changed to a vesicular one, similar to trophoblastic disease. Color Doppler has been used in the diagnosis of endometrial abnor - malities by identifying vessels in the lesions. Cystic lesions of the uterus are rare and are con- sidered to be benign (16). Adenomyotic cysts are observed in parous women, and in association with diffuse adenomyosis uteri (17) isolated ad- enomyotic cysts may be detected (18,19). Adeno- myotic cysts are seen in older ages but they may be in adolescents (20). Small adenomyotic cysts that do not exceed 5 mm in diameter are found in 24% of hysterectomy specimens (21) but larg- er adenomyotic cysts are rare. Repeated surgical intervention might be a risk factor for adenomy- otic cysts (22). Pelvic pain, dysmenorrhea, men- orrhagia and large uterus are the most common features of adenomyosis. Urine retention may be the symptom (23). Pain or severe dysmenor - rhea may be the main symptom in adenomyotic cysts. The pain of the adenomyotic cyst may be due to the increase in size of the mass, stretch- ing of the endometrial cavity and cystic bleeding. Magnetic resonance imaging is important for the diagnosis of cystic adenomyosis especially when other imaging modalities are nonspecific (24). Magnetic resonance imaging can differentiate multiple cysts within the uterine myometrium, but hysterosalpingography may be useful for the differential diagnosis when magnetic resonance cannot differentiate isolated adenomyotic cyst from cavitated noncommunicating rudimentary horn. Imaging techniques are important in differ - ential diagnosis of adenomyotic cysts and help us to choose the appropriate intervention. In young patients hormonal therapy is the first choice and can be accomplished by combined oral contra- ceptives or progesterone laden IUD as mirena. In the presence of severe symptoms that do not re- spond to medical therapy, a surgical intervention can be planned for excision (24). In older patients with no desire to preserve their fertility, hysterec- tomy can be performed.

Adenomyosis cannot be diagnosed accurately nor be differentiated from leiomyoma before the pathological assessment of the uterus. it could be suspected from gross pathologies and ultrasound findings. Role of Gross Examination of the specimen and ultrasound in Uterine Adenomyosis: case series with review of literature A. S. El-Agwany 213

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