Fig. 5.1
A fibroid and adenomyosis in the same uterus. On the left an isoechogenic fibroid, surrounded by an echogenic rim causing edge shadows. On the right an ill-defined adenomyotic lesion with fan-shaped shadowing
Fig. 5.2
VCI 2 mm sonographic image compared to macroscopy. F fibroid. The circles show anechoic cysts surrounded by a hyperechogenic ring. The arrows indicate an irregular endometrial–myometrial border (From Van den Bosch et al. [7] with permission)
5.2 Fibroids
At ultrasound examination a fibroid is typically a well-defined, rounded lesion surrounded by or attached to the myometrium with circumferential blood flow at the outer border (Figs. 5.3 and 5.4). The echogenicity compared to the myometrium varies from hypo- to hyperechogenic. Shadows from the edge of the lesion or linear internal shadows with or without internal calcifications are often visible. Over time fibroids may become intensely calcified resulting in strong shadowing. At color imaging circumferential flow around the lesion is typically visible. The size of a fibroid as well as the minimal distance between the fibroid and the endometrium (inner lesion free margin) and the serosal surface of the uterus (outer lesion free margin) are relevant for clinical management (Fig. 5.5). The international federation of gynecology and obstetrics (FIGO) classification for fibroids specifies the location of the lesion: (1) completely within the cavity; (2) ≥50 % protruding into the cavity; (3) <50 % protruding into the cavity; (4) 100 % intramural, but contacts the endometrium; (5) subserosal ≥50 % intramural; (6) subserosal <50 % intramural; (7) subserosal pedunculated; and (8) others (e.g., cervical, parasitic) (Fig. 5.6) [1, 2].
Fig. 5.3
Coronal sonographic image of a FIGO 1 fibroid partially surrounded by hyperechogenic endometrium
Fig. 5.4
Grayscale (top) and power Doppler (bottom) image of a FIGO 7 fibroid. The vessels within the pedicle can been seen on power Doppler
Fig. 5.5
The outer and inner lesion free margins are measured in well-defined lesions (fibroids), while the penetration or ratio between the maximal diameter of the abnormal area and the total myometrial thickness is recorded in ill-defined lesions (adenomyosis) (From Van den Bosch et al. [1] with permission)
Fig. 5.6
The FIGO classification to report on the location of fibroids: (1) completely within the cavity; (2) ≥50 % protruding into the cavity; (3) <50 % protruding into the cavity; (4) 100 % intramural, but contacts the endometrium; (5) subserosal ≥50 % intramural; (6) subserosal <50 % intramural; (7) subserosal pedunculated; and (8) others (e.g., cervical, parasitic) (From Van den Bosch et al. [1] with permission)
5.3 Adenomyosis
Adenomyosis results in ill-defined lesions within the myometrium. The presence of endometrial glands and stroma within the myometrium and the associated muscular hypertrophy is called adenomyosis (Figs. 5.7 and 5.8) [3]. Characteristic ultrasound findings suggestive for adenomyosis are (asymmetric) thickening of the myometrium, myometrial cysts, hyperechogenic islands, fan-shaped shadowing, subendometrial echogenic lines and buds (linear striation), and an irregular endometrial–myometrial junction (Figs. 5.9, 5.10, 5.11, 5.12, 5.13, 5.14, and 5.15). The extent of the adenomyosis can be quantified as the percentage of total myometrium involved: localized if less than 25 % or global if at least 25 % of the myometrium is involved. The depth of penetration of the adenomyosis in the uterine wall can be measured. It is the distance from the outer endometrial lining to the most peripheral point of the lesion for lesions adjacent to the endometrium, the distance from the serosal surface to the most central point of the lesion for lesions adjacent to the uterine serosa, or the maximal diameter perpendicular to the serosal surface for central lesions distant (Fig. 5.5). The penetration is reported as the ratio between the depth of penetration and the total myometrial thickness.
Fig. 5.7
Histological slice of adenomyosis. The arrow shows invasion of endometrial tissue into the myometrium. Within the adenomyosis lesion, small cysts can be seen. E endometrium, C endometrial cavity, A adenomyosis, M myometrium (From Van den Bosch et al. [7] with permission)
Fig. 5.8
Histological slice of adenomyosis with myometrial cysts of various sizes
Fig. 5.9
Common sonographic features of adenomyosis (From Van den Bosch et al. [1] with permission)
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