NONINVASIVE IMAGING TECHNIQUES FOR QUANTIFICATION OF FIBROSIS IN BENIGN GYNECOLOGIC DISEASE: A SYSTEMATIC REVIEW

Objective: To systematically evaluate quantitative imaging modalities for non-invasive assessment of fibrosis in benign uterine pathology Design: Systematic literature review Materials and Methods: A PRISMA-guided search of PubMed, Embase, Scopus, Web of Science, and Cochrane Library identified original human studies evaluating quantitative imaging modalities against fibrosis reference standards including histology, hysteroscopy, treatment response, or healthy comparators. Modalities included ultrasound shear-wave elastography (SWE), strain elastography, magnetic resonance elastography (MRE), diffusion-weighted imaging (DWI/ADC), intravoxel incoherent motion (IVIM), diffusion kurtosis imaging (DKI), T2-weighted MRI, and atomic force microscopy (AFM). Diagnostic performance was summarized using area under the receiver operating characteristic curve (AUC), correlations, and group comparisons. Results: Twenty studies including 1,400 patients evaluated leiomyomas (n=13), adenomyosis (n=7), and endometrial fibrosis/intrauterine adhesions (IUA) (n=4), with overlap across conditions. Histologic correlation was available in 12 studies. Fibrotic tissue demonstrated increased stiffness and restricted diffusion compared with controls. SWE identified adenomyosis stiffness values ranging from 17–22 kPa versus 4.7–11 kPa in healthy myometrium. AFM-derived Young’s modulus correlated with collagen area fraction and α-smooth muscle actin expression. Leiomyoma stiffness on MRE (3.0–6.9 kPa) correlated with extracellular matrix content and predicted response to focused ultrasound and uterine artery embolization. In endometrial fibrosis, ADC, IVIM, and DKI differentiated fibrotic from healthy endometrium with AUCs ranging from 0.85–0.98. Across modalities, reported AUCs ranged from 0.70–0.99. Conclusions: Elastography and diffusion-based MRI techniques enable reproducible, non-invasive quantification of fibrosis in benign uterine disease, demonstrating correlation with histologic fibrosis markers and potential utility in predicting treatment response. Prospective validation against standardized histologic reference standards is needed before clinical implementation. Support: None