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Importance of Transvaginal Elastography in the Diagnosis of Uterine Fibroids

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DOI: 10.1055/s-0035-1553266 · Source: PubMed

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 Original Article 1

Importance of Transvaginal Elastography in the

Diagnosis of Uterine Fibroids and Adenomyosis
Stellenwert der transvaginalen Elastografie in der Diagnose
von uterinen Myomen und Adenomyose

Authors M. L. Frank1, S. D. Schäfer1, M. Möllers1, M. K. Falkenberg1, J. Braun1, U. Möllmann1, F. Strube1, A. Fruscalzo2, S. Amler3,
W. Klockenbusch1, R. Schmitz1

1
Affiliations Department of Obstetrics and Gynecology, University Hospital of Münster, Germany
2
Department of Obstetrics and Gynecology, St. Franziskus-Hospital, Münster, Germany
3
Institute of Biostatistics and Clinical Research, University of Münster, Germany

Key words Abstract Zusammenfassung

● elastography
"
! !
● uterus
"
Purpose: To evaluate normal uterine tissue with
● uterine fibroids
"
special regard to age and the presence of uterine
● adenomyosis
"
fibroids and adenomyosis with transvaginal elas-
tography.
Materials and Methods: In a prospective study
elastographic data of the uterus were obtained in
206 unselected women with transvaginal ultra-
sound. Women who presented without any uter-
ine pathology in ultrasonography were included
in a control group, women with uterine fibroids
in a uterine fibroid group, and women with ade-
nomyosis in an adenomyosis group. In the control
group strain values were measured at two regions
of interest (ROIs) placed one upon the other in the
anterior inferior uterine segment during a cycle of
compression. The maximum strain ratio (ROI1 /
ROI2) was stored as the “age index”. In all groups
strain values were measured at two ROIs placed
side by side in a uterine fibroid (uterine fibroid
group) or adenomyosis (adenomyosis group) or
received 26.1.2015
accepted 4.5.2015 healthy homogeneous tissue (control group) and
adjacent healthy tissue. Maximum strain ratios
Bibliography (ROI3 / ROI4) were stored as the “lesion index”.
DOI http://dx.doi.org/
Results: The “age index” was significantly negatively
10.1055/s-0035-1553266
correlated with the age of the women (r = –0.49,
Published online: 2015
Ultraschall in Med 2015; 36: 1–6 p < 0.001). The median “lesion indices” were signifi-
© Georg Thieme Verlag KG cantly (p < 0.001) different between the uterine fi-
Stuttgart · New York · broid, adenomyosis and control groups. Median “le-
ISSN 0172-4614 sion indices” were 2.65, 0.44 and 1.19, respectively.
Conclusion: The “age index” shows that normal
Correspondence
Mareike Lea Frank uterine tissue has a certain age-dependent stiff-
Department of Obstetrics and ness that increases with age. The “lesion index”
Gynecology, University Hospital allows for the assessment of the presence of a uter-
of Münster ine fibroid or adenomyosis and helps to differenti-
Albert-Schweitzer-Campus 1 ate between both focal findings. Thus the use of
Gebäude A1
elastography in addition to conventional ultra-
48149 Münster
sound could help to diagnose uterine focal lesions
Germany
Tel.: ++ 49/2 51/8 34 82 61 and may be useful in preoperative planning.
Fax: ++ 49■■■
m_fran30@uni-muenster.de
■ Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law.
Ziel: Evaluation von normalem Uterusgewebe mit
besonderem Hinblick auf das Alter und Beurtei-
lung des Vorliegens von Myomen und Adeno-
myose mittels transvaginaler Elastografie.
Material und Methoden: In einer prospektiven
Studie wurden bei 206 unselektierten Frauen
elastografische Daten des Uterus mit transva-
ginalem Ultraschall erhoben. Frauen ohne uterine
Pathologie im Ultraschall wurden einer Kontroll-
gruppe zugeteilt, Frauen mit Myom oder Ade-
nomyose einer Myom-bzw. Adenomyosegrup-
pe. In der Kontrollgruppe wurden Strain-Werte
an zwei übereinander liegenden Bildbereichen
(ROIs) im vorderen unteren Uterinsegment ge-
messen. Die während eines Kompressionszyklus-
ses ermittelte maximale Strain-Ratio (ROI1 /
ROI2) wurde als „Altersindex“ gesichert. In allen
Gruppen wurden Strain-Werte an zwei nebenei-
nander liegenden ROIs gemessen. Im Falle der
Myom- und Adenomyosegruppe befand sich jew-
eils ein ROI innerhalb des Herdbefundes und ei-
ner in benachbartem gesundem Gewebe. In der
Kontrollgruppe lagen beide ROIs in gesundem Ge-
webe. Die maximale Strain-Ratio (ROI3 / ROI4)
wurde als „Läsionsindex“ gesichert.
Ergebnisse: Der „Altersindex“ war signifikant
negativ mit dem Alter einer Frau korreliert
(r = – 0,49, p < 0,001). Die medianen „Läsionsindi-
ces“ der Myom-, Adenomyose- und Kontroll-
gruppe waren signifikant unterschiedlich (p <
0,001). Sie betrugen 2,65, 0,44 und 1,19.
Schlussfolgerung: Der „Altersindex“ zeigt, dass
normales Uterusgewebe eine gewisse Festigkeit
aufweist, die mit dem Alter zunimmt. Der „Läsion-
sindex“ erlaubt die Beurteilung des Vorliegens von
Myomen und Adenomyose und hilft bei deren Dif-
ferenzierung. Somit könnte die zusätzliche Anwen-
dung von Elastografie zum konventionellen Ultra-
schall bei der Diagnose uteriner Herdbefunde und
der präoperativen Planung helfen.
■

Frank ML et al. Importance of Transvaginal … Ultraschall in Med 2015; 36: 1–6

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2 Original Article
Introduction
! !
In the manual transvaginal examination, the normal uterus pre-
sents itself as a relatively soft and equally easy to deform organ in
younger women, whereas it appears as a stiffer and less deform-
able organ in older women.
Differences from these palpatory findings are suspicious of pa-
thology. For example, myomas can often be identified as stiff no-
dules or a uterus myomatosus as a non-specific solidification of
the uterus. The described tissue characteristics seem to be well
accepted. Nevertheless, to date, published data about the charac-
terization of normal uterine tissue are scarce [1].
Uterine fibroids and adenomyosis are frequent uterine patholo-
gies. Fibroids are the most common benign tumors of the female
genital tract [2], with a cumulative incidence that ranges about
70 – 80 % by age 50 [3].
Adenomyosis is defined as the presence of ectopic endometrial
mucosa within the myometrium. Its prevalence varies widely,
from 5 to 70 %, with a mean of 20 – 30 % in surgical findings [4].
Both pathologies can cause substantial morbidity. Fibroids, for
example, are shown to be associated with a morbidity of nearly
40 % of women during their reproductive years and sometimes
even after menopause [5]. As a consequence, uterine fibroids
and adenomyosis may require medical treatment or surgery.
Therefore, there is considerable interest in improving their diag-
nosis and achieving detailed information about their exact loca-
tion and extent, especially with regard to an upcoming surgical
intervention.
Transvaginal ultrasound is the most important imaging tech-
nique in the assessment of gynecological findings [6]. Its impor-
tance in the diagnosis, follow-up and delivery of pre-surgical in-
formation of gynecological pathologies is due to its accessibility
and relatively low cost.
Elastography is a new ultrasound tool that delivers information
about the elasticity of tissue. By its use, tissue stiffness can be
quantified [7].
The normal ultrasound allows for the application of elastography
within routine examination.
In the past few years a multitude of studies have been published
evaluating the application of elastography in different organs such
as the breast, liver, prostate and thyroid gland [8 – 11]. Recommen-
dations on its clinical use have been published recently [12].
The results are promising and it can be assumed that elastogra-
phy will be established as a diagnostic tool in the future.
Among others, elastography has been shown to improve the dif-
ferentiation of benign and malignant breast lesions [8, 13] and
nowadays 21 % of German breast ultrasound specialists are ap-
plying sonoelastography in the diagnosis of breast lesions [14].
The first studies have just been published on the assessment of
cervical stiffness in pregnancy and the related risk of preterm
birth [15, 16].
The aim of our study was to assess normal uterine tissue stiffness
with special regard to age with transvaginal elastography. Fur-
thermore, we evaluate the difference of stiffness between uterine
fibroids, adenomyosis and normal uterine tissue with transvagi-
nal elastography.
Assuming that elastography delivers additional information
about normal uterine tissue, uterine fibroids and adenomyosis,
it could be a helpful tool in the diagnosis of uterine pathologies
and in preoperative planning.
■ Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law.
Frank ML et al. Importance of Transvaginal … Ultraschall in Med 2015; 36: 1–6
Material and Methods
Study population
In a prospective and cross-sectional study, between March 2013
and August 2014, elastographic data of the uterus were collected
in 206 unselected women who underwent transvaginal ultra-
sound during routine examination in the department of obste-
trics and gynecology of the University Hospital Münster. Women
who presented without any uterine pathology, with uterine
fibroids or with adenomyosis in ultrasonography were included
in the study. Myomas were defined as concentric, round and
sharply defined lesions, whereas adenomyosis was defined as an
elliptical lesion, with poorly defined borders. These conventional
ultrasound diagnosis criteria served as the gold standard in our
study. Women with pregnancy, uterine infection, previous uter-
ine surgery or specific hormonal therapy were excluded. In-
formed consent was obtained from all patients and the study
was approved by the institutional ethics board.
Ultrasound examination
Transvaginal elastography was performed with an IU22 and
EPIQ7C Ultrasound System (Philips Medical Systems, Andover,
MA, USA) using the C10 – 3v PureWave 10 MHz vaginal probe.
Elastographic scanning (elastographic dual-mode scanning in
real-time) followed regular B-mode scanning of the uterus. Data
acquisition was performed independently of uterus position and
size. External compression was applied to the tissue by the ultra-
sound probe causing its deformation that was measured as
strain. One cycle of gentle compression and relaxation was per-
formed by an experienced gynecologist. The probe was gently
moved against the lower uterine segment followed by slow de-
compression. Movements were realized along the axis of the
transducer and the elastographic sample box was placed in the
same axis. The measured strain values were color coded and dis-
played as an elastogram.
The elastogram could be seen in real-time next to the regular
B-mode image on the screen.
Elastograms are colored with an ascending color scale that ranges
from blue over green and yellow to red. Blue indicates stiff tissue,
green moderately stiff tissue, yellow moderately soft tissue and
red soft tissue. They were superimposed on B-mode images to
permit better interpretation.
Tissue stiffness is assessed in comparison with the adjacent tis-
sue. In consequence, the calculated strain values and correspond-
ing colors are relative indicators for tissue stiffness.
Elastography data analysis
Elastographic raw data were analyzed offline with QLAB Ad-
vanced Quantification Software 9 and 10 (Philips Medical Sys-
tems, Andover, MA, USA). The operator was not involved in the
previous acquisition of the raw dataset and was previously su-
pervised in elastographic data analysis. Women who presented
without any uterine pathology were included in a control group,
women with uterine fibroids in a uterine fibroid group and wom-
en with adenomyosis in an adenomyosis group.
Color patterns and strain values were evaluated to collect semi-
quantitative and quantitative information.
First, elastographic data of the control group were studied to as-
sess normal uterine tissue.
A recurrent color phenomenon in younger uteri, a red sickle-
shaped form that was located in the anterior inferior uterine seg-
ment near the probe, was defined as the “sickle sign”.
■
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The “sickle sign” was assessed in the whole group on the basis of
a scale of 0 to 2 points. 0 points were given if no “sickle sign”
could be seen, 1 point if a thin red line was observed and 2 points
if a “sickle sign” as defined above was seen. The “sickle sign” was
approved by a second operator.
Motion compensation was activated and two quadratic 5 mm
ROIs were placed one upon the other in the anterior inferior uter-
ine segment at the moment of maximal relaxation. The first ROI
(ROI1) was placed close to the probe, and the second ROI (ROI2)
adjacent to the endometrium. In order to standardize the meas-
urement as much as possible, they were situated in extension of
the probe axis, with a maximum deviation of 20 degrees. Strain
values were measured at the two ROIs and their ratio was calcu-
lated during a cycle of tissue compression and relaxation (ROI1 /
ROI2). The maximum of the ratio was stored and named the “age
index”.
Second, elastographic data of all groups were analyzed to assess
the presence of a uterine fibroid or adenomyosis.
Again two quadratic 5 mm ROIs were chosen, and motion com-
pensation was activated. In the control group, ROIs were placed
side by side in the anterior inferior uterine segment between
the probe and the endometrium in homogeneous tissue. In the
uterine fibroid and adenomyosis group, the first (ROI3) was
placed in healthy homogeneous tissue, and the second (ROI4)
was placed on an equal level in a myoma or an area of adenomyo-
sis. The ROIs were placed at the same distance from the probe be-
cause a comparable amount of pressure reaches the same depth
of the tissue. Strain values were measured, and their ratio was
calculated during a cycle of tissue compression (ROI3 / ROI4).
The maximum ratio was stored as the “lesion index”.
All strain measurements were performed three times, and mean
values of the stored maxima were calculated to achieve more re-
liable data.
To assess intra- and interobserver reliability, 10 cases were selec-
ted and strain ratios were measured two times by the operator
and independently another time by a second operator.
Statistical analysis
Statistical analyses were performed using IBM SPSS® Statistics 22
for Windows (IBM Corporation, Somers, NY, USA).
Descriptive statistics were performed to characterize the study
population. The results are shown as mean ± standard deviation
(SD) or as median with interquartile range (IQR).
To compare the age between the three independent groups with
the “sickle sign”, with a thin red line, and without the “sickle
sign”, analysis of variance for normally distributed data was per-
formed.
The Spearman‘s rank correlation coefficient was chosen to assess
the correlation between age and “age index”.
To compare the “lesion indices” and the frame rates of the three
independent groups without abnormalities, with uterine fibroids
and with adenomyosis, the Kruskal-Wallis test for non-normally
distributed data was conducted.
To adjust for multiple testing, Bonferroni-post hoc tests were per-
formed.
The area under the receiver operating characteristic (ROC) curve
(AUC) analysis was performed to determine “lesion index” cut-off
values that predict with a high sensitivity and specificity the
presence of a uterine fibroid or adenomyosis.
Intra- and interobserver reliability of strain measurements was
determined using the intraclass correlation coefficient.
P-values were considered significant in case of p ≤ 0.05.
■ Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law.
Original Article 3
Results
!
206 women fulfilled the study criteria and were analyzed. 143
women presented without any uterine pathology, 41 with uter-
ine fibroids and 22 with adenomyosis. Elastographic data analy-
sis was feasible in all cases.
Patient age ranged from 16 to 81 years. The mean ±SD age of the
whole study population was 44.7 ± 16.1. The mean ages of the
group without abnormalities, the uterine fibroid group and the
adenomyosis group were 44.3 ± 16.8, 50.4 ± 14.8 and 36.9 ± 8.9,
respectively.
The mean ±SD frame rate of the records was 14.8 ± 0.7. The mean
frame rates in the control group, uterine fibroid group and ade-
nomyosis group were 14.9 ± 0.7, 14.7 ± 0.8 and 14.6 ± 0.8, respec-
tively. There was no significant difference between the frame
rates in the three groups (p = 0.227).
In the elastogram, the average uterus of a young woman was
mostly colored in blue, with smaller contents of green, at the mo-
ment of maximal relaxation. When compression began, the color
phenomenon that was previously defined as the “sickle sign” oc-
curred. The red sickle-shaped form in the anterior inferior uter-
ine segment near the ultrasound probe expanded with increas-
ing compression (● " Fig. 1a). The average uterus of an older
woman was also mostly colored in blue, with smaller contents
of green, before pressure was applied to it. The composition bare-
ly changed during the following cycle of compression (● " Fig. 1b).
A significant difference was found for the mean ages between the
group with the “sickle sign” and without the “sickle sign” and be-
tween the group with a thin red line and without the “sickle sign”
(p < 0.001). The group with a thin red line was older by trend than
the group with the “sickle sign”, but the difference was not signif-
icant (p = 0.058). The mean ages of the group with the “sickle
sign”, with a thin red line and without the “sickle sign” were
34.5 ± 12.9, 41.8 ± 14.5 and 56.6 ± 13.9 years, respectively.
A negative correlation was found between age and “age index”
(r = –0.49, p < 0.001). ●
" Fig. 2 shows how the maximum strain ra-
tio declines with age. The median “age index” was 2.4.
Uterine myomas could be identified as blue rounded areas. They
appear to be darker than the surrounding tissue and are often set
off from the surrounding tissue by a green border (● " Fig. 1c).
Areas of adenomyosis had a spotted, irregular color pattern and
appeared brighter than the adjacent normal myometrium. Often
foci of adenomyosis with a red center surrounded by a yellow and
a green irregular border could be seen (● " Fig. 1 d).
The median “lesion indices” of the uterine fibroid group, the ade-
nomyosis group and the control group were shown to be signifi-
cantly different (p < 0.001). The median “lesion index” indicative
for a myoma was 2.65 [2.12; 3.34] and the one indicative for ade-
nomyosis was 0.44 [0.36; 0.46]. Healthy homogeneous uterine
tissue had a median “lesion index” of 1.19 [1.07; 1.34] (● " Fig. 3).
A suitable cut-off value predictive for uterine fibroids was 1.785,
with a sensitivity of 88 % and a specificity of 95 %. The area under
the curve value was 0.955 (95 % confidence interval (CI): 0.919 –
0.992). A suitable cut-off value predictive for adenomyosis was
0.505, with a sensitivity and specificity of 86 % and 100 %, respec-
tively. The area under the curve value was 1. The ROC curves of
the “lesion indices” for uterine fibroids and adenomyosis are
shown in ● " Fig. 4, 5.
Intra- and interobserver reliability of strain measurements were
shown to be excellent [17]. The interobserver reliability was
0.983 (95 % CI: 0.933 – 0.996; p < 0.001) and the intraobserver re-
liability was 0.987 (95 % CI: 0.948 – 0.997; p < 0.001).
■
Frank ML et al. Importance of Transvaginal … Ultraschall in Med 2015; 36: 1–6
Ultraschall UNDI ∙ UiM-1729 ∙ 17.6.15 ∙ Reemers Publishing Services GmbH
4 Original Article
Fig. 1 Transvaginal elastography: The elastogram can be seen in real-time
next to the regular B-mode image on the screen. a Uterus of a 19-year-old
woman with “sickle sign”. The red sickle-shaped form that is located in the
anterior inferior uterine segment near to the probe is a recurrent color
phenomenon in younger uteri. b Uterus of a 73-year-old woman without
“sickle sign”. c Uterine fibroid. d Adenomyosis. Both focal findings (marked
with an *) are good to distinguish from the surrounding healthy tissue on
the color-coded elasticity image.
Fig. 2 Scatter plot showing the correlation of “age index” (y-axis) and
age of a woman in years (x-axis). The correlation is moderately negative
(r = –0.49, p < 0.001).
Abb. 2 Das Streudiagramm zeigt die Korrelation von „Altersindex“
(Y-Achse) und Alter in Jahren (X-Achse) an. Die Korrelation ist moderat
negativ (r = –0,49, p < 0,001).
Discussion
!
Our study has shown that uterine tissue can be evaluated with
transvaginal elastography. Uterine tissue stiffness was able to be
illustrated and was measurable using this new imaging tool.
The “age index” shows that the normal uterus has a certain age-
dependent stiffness and that this stiffness increases with age. The
“lesion index” allows for the assessment of the presence of a uter-
ine fibroid or adenomyosis.
In the control group two ROIs were first placed one above the
other, the first adjacent to the probe and the second adjacent
to the endometrium. As a result, in most cases of a “sickle sign”,
the first ROI was placed in it and the second above it. Because
strain values of soft tissue are high, whereas strain values of stiff
■ Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law.
Frank ML et al. Importance of Transvaginal … Ultraschall in Med 2015; 36: 1–6
Abb. 1 Transvaginale Elastografie: Das Elastogramm wird in Echtzeit ne-
ben dem regulären B-Mode-Bild abgebildet. a Uterus einer 19-jährigen Frau
mit „Sichel-Zeichen“. Die rote sichelförmige Figur, die sich im vorderen un-
teren Uterinsegment nahe des Ultraschallkopfes befindet, ist ein wieder-
kehrendes Farbphänomen in jüngeren Uteri. b Uterus einer 73-jährigen Frau
ohne „Sichel-Zeichen“. c Myom. d Adenomyose. Beide Herdbefunde (durch
ein * markiert) sind im farbkodierten Elastografie-Bild gut vom umgeben-
den gesunden Gewebe abzugrenzen.
Fig. 3 Box-and-whisker plot showing the distribution of the “lesion index”
in the control group, uterine fibroid group and adenomyosis group. The
median “lesion indices” are significantly different between the three
groups (p < 0.001).
Abb. 3 Der Box-Whisker-Plot zeigt die Verteilung des „Läsionsindex“ in
der Kontrollgruppe, Myomgruppe und Adenomyosegruppe. Die medianen
„Läsionsindices“ sind zwischen den drei Gruppen signifikant unterschied-
lich (p < 0,001).
tissue are low, the measured strain value at the first ROI was high
and the second low. In consequence, the ratio was high if a “sickle
sign” existed and low in case of its absence. According to the di-
minution of the “sickle sign” with age, the ratio between the two
measuring points declined with increasing age. In all groups two
ROIs were placed side by side in the uterine tissue. The first was
always placed in healthy tissue, the second was placed in a focal
finding or in homogeneous tissue.
The ratios of normal uterine tissue ranged around 1, emphasizing
that normal uterine tissue is relatively homogeneous. The mean
ratio of uterine fibroids was > 1 and the mean ratio of adenomyo-
■
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Fig. 4 ROC curve of the “lesion index” for uterine fibroids.
Abb. 4 ROC-Kurve des „Läsionsindex“ für Myome.
Fig. 5 ROC curve of the “lesion index” for adenomyosis.
Abb. 5 ROC-Kurve des „Läsionsindex“ für Adenomyose.
sis < 1, emphasizing that uterine fibroids are stiffer and adeno-
myosis is softer than the surrounding tissue.
The calculated ratios show that elastography is able to quantify
these focal findings.
To simplify, uterine fibroids are more than twice as stiff as heal-
thy uterine tissue and adenomyosis is about half as stiff or twice
as soft as healthy tissue.
To our knowledge, this is the first study showing that the elasto-
graphic calculation of strain ratios allows for the assessment of
■ Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law.
Original Article 5
the presence of uterine fibroids and adenomyosis and helps in
the differentiation between both focal findings.
A possible limitation of our study is that the applied force during
the elastographic examination could not be standardized. The
deformation of tissue depends on its characteristics but also on
the amount of the stress applied. In order to minimize its impact
as a possible confounder on the measured tissue elasticity, the ra-
tio between two ROIs was calculated. In addition, the QLAB soft-
ware calculates and displays the course of the ratio during the re-
cord. Strikingly, the course was regularly displayed as a curve
with a maximum. We stored that maximum as we suspect it to
be tissue-specific and relatively force-independent.
Moreover, standardization of the placement of ROIs was limited
as the position of the uterus in reference to the probe varies in
each woman. Nevertheless, following our standardized maxi-
mum strain ratio measurements, intra- and interobserver relia-
bility were shown to be excellent.
Another limitation could be that QLAB software 9 and 10 was not
specifically developed and not yet customized for gynecological
ultrasound.
Furthermore, conventional ultrasound diagnosis served as the
gold standard in our study, and the diagnosis was not verified by
histopathology. The assessed uterine pathologies can be hidden
due to untypical presentation.
Now there are a growing number of studies about the use of elas-
tography within the field of gynecology but data is still rare. Only
a few studies have been published about the assessment of uter-
ine myomas and adenomyosis with elastography.
In a feasibility study Ami et al. observed 10 women with uterine
fibroids with transvaginal elastosonography. They calculated
strain ratios and concluded that this technique offers comple-
mentary diagnostic information [18].
In a pilot study Tessarolo et al. evaluated 30 women with sus-
pected adenomyosis with standard B-mode and elastosonogra-
phy. Based on color evaluation, they found that adenomyotic
areas present more softness than the surrounding uterine tissue
and considered elastosonography as a possible useful tool in the
diagnosis of adenomyosis [19].
Stoelinga et al. defined specific sonoelastographic characteristics
of the myometrium, fibroids and adenomyosis. Their findings
were also based on color evaluation. Elastography-based diagno-
ses were compared with histology and/or MRI-based diagnoses
and showed excellent agreement [20].
Recently our group assessed deep infiltrating endometriosis
using transvaginal elastography. Schiffmann et al. showed that
the strain ratio between two ROIs in the Douglas’s cul-de-sac is
associated with the presence of an endometriotic lesion [21].
In conclusion, our study has shown that transvaginal elastogra-
phy can be used to evaluate uterine tissue. “Age index” and “le-
sion index” deliver information about uterine tissue stiffness.
Uteri with a stiffness differing from the mean stiffness at their
age could be associated with a manifest or developing pathology.
An untypically stiff young or soft old uterus could be further ex-
amined. For example cases of infection or cancer screening could
be investigated.
The use of elastography in addition to conventional ultrasound
could allow for easier identification of focal lesions and it may
also be possible to obtain more detailed information about their
exact location and extent which could be especially helpful in
preoperative planning.
The influence of the use of hormones on strain could also be an
interesting target for clinical research. Moreover in future studies
■
Frank ML et al. Importance of Transvaginal … Ultraschall in Med 2015; 36: 1–6
Ultraschall UNDI ∙ UiM-1729 ∙ 17.6.15 ∙ Reemers Publishing Services GmbH
6 Original Article
with a larger number of cases, a possible influence of the size and
location of uterine fibroids on measured strain values could be
investigated.
The nearer focal findings, especially myomas, were located close
to the probe and the more they were compressed in the direction
of the applied force, the better they could be depicted. Prospec-
tively it could be helpful to collect targeted elastographic data to
permit a further assessment of myomas. For example, gentle ab-
dominal pressure, manually applied by the gynecologist during
the elastographic recording, could be especially helpful if myo-
mas are located far away from the probe.
Further studies with a larger study population, histological con-
firmation and correlation and customized software are required
to evaluate the value of our findings.
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