Letter to the editor |
Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging
1 Departments of Radiology and 2 Obstetrics and Gynecology, Hôpital Tenon, Paris, France
3 To whom correspondence should be addressed at: Service de Radiologie, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France. E-mail: marc.bazot{at}tnn.ap-hop-paris.fr
Sir,
We read with great interest the paper by Kunz et al. entitled ‘Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging’ (Kunz et al., 2005
). The authors found a higher incidence of uterine adenomyosis in women with endometriosis than in women without endometriosis and suggested that adenomyosis could be a determinant of infertility (Kunz et al., 2005). However, this article raises issues concerning the magnetic resonance (MR) imaging protocol used to diagnose adenomyosis.
Concerning the imaging technique itself, the authors directly adopted a protocol used in a study published five years previously (Kunz et al., 2000) that may not be optimal for the diagnosis of adenomyosis. First, a 1.5-T pelvic phased-array coil with a 256 x 512 matrix offers better spatial resolution than a 1-T body coil with a matrix of 154 x 256, particularly for the detection of hyperintense myometrial spots, which are the findings most specific to adenomyosis. Second, the usefulness of fat-saturated turbo-spin echo sequences for the detection of adenomyosis has never been demonstrated. Third, breath-hold T2-weighted sequences (true fast imaging with steady-state precession and turbo-inversion-recovery sequences) offer better differentiation between focal adenomyosis and uterine contraction, optimize the accuracy of MR imaging for the diagnosis of adenomyosis and reduce interobserver variability, while fast spin-echo T2-weighted images and breath-hold T2-weighted sequences appear to have similar accuracy (Bazot et al., 2003).
Concerning the MR imaging criteria, Kunz et al. considered that a junctional zone maximum of >11 mm (JZmax) was alone sufficient for the diagnosis of adenomyosis (Reinhold et al., 1996). In our experience, however, isolated JZmax >11 mm has a sensitivity and specificity of, respectively, 62% and 96% for the diagnosis of adenomyosis (Bazot et al., 2001). The combination of JZ thickness with high-signal-intensity myometrial spots, JZmax/entire myometrium >40% and regular homogeneous uterine enlargement increases the accuracy of MR imaging in women with adenomyosis who do not have associated leiomyomas, raising the sensitivity and specificity to 87% and 100%, respectively (Bazot et al., 2001). Regarding clinical implications, using a JZmax threshold of 10 mm as a criterion of adenomyosis, Kunz et al. found a very high prevalence of adenomyosis in the ‘total endometriotic’ group (79%) compared to both ‘healthy controls’ (9%) and ‘total controls’ (28%) (Kunz et al., 2005). These results contrast with those of a recent study in which only 44 (27%) of 163 women with pelvic endometriosis proven by laparoscopy and histology had adenomyosis on pre-operative MR imaging (Bazot et al., 2004).
Finally, like Kunz et al. we also found that uterine adenomyosis was the main determinant of infertility in a series of 34 women undergoing laparoscopic segmental colorectal resection for endometriosis, 22 of whom wished to conceive (Darai et al., 2005).
References
Bazot M, Cortez A, Darai E, Rouger J, Chopier J, Antoine JM and Uzan S (2001) Ultrasonography compared to magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Human Reprod 16,2427–2433.
Bazot M, Darai E, Clément de Givry S, Boudghène F, Uzan S and Le Blanche AF (2003) Fast breath-hold T2-weighted MR imaging reduces interobserver variability in the diagnosis of adenomyosis. Am J Roentgenol 185,1291–1296.
Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S and Buy JN (2004) Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology 232,379–389.
Darai E, Marpeau O, Thomassin I, Dubernard G, Poncelet C and Bazot M (2005) Fertility after laparoscopic colorectal resection for endometriosis: preliminary results. Fertil Steril 2005; 84, 945–950.
Kunz G, Beil D, Huppert P and Leyendecker G (2000) Structural abnormalities of the uterine wall in women with endometriosis and infertility visualized by vaginal sonography and magnetic resonance imaging. Hum Reprod 15,76–82.
Kunz G, Beil D, Huppert P, Noe M, Kissler S and Leyendecker G (2005) Adenomyosis in endometriosis-prevalence and impact on fertility. Evidence from magnetic resonance imaging. Hum Reprod 20,2309–2316.
Reinhold C, McCarthy S, Bret PM, Mehio A, Atri M, Zakarian R, Glaude Y and Liang 1 Seymour RJ (1996) Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology 199,151–158.
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