Dosemetry And Efficacy Of Focused Ultrasound Ablation For Different Types Of Adenomyosis Based On MRI Classification

Adenomyosis is a common gynecologic disease in women of reproductive age which is characterized by the presence and the growth of endometrial or endometrium-like structures in themyometrium.All kinds of uterine sparing treatments are prone to relapse,while hysterectomy destroys the fertility.The treatment of adenomyosis has always been a great challenge in the gynecology.As a non-invasive treatment,the fucused ultrasound surgery(FUS),also called high intensity focused ultrasound(HIFU)ablation has the advantages of reproducible and uterine preservation,which has been utilized in the treatment of adenomyosis widely.However,in the previous studies,some patients reported poor relief of the symptoms,while the reason of it is not clear.We speculated that the symptom improvement maybe related to NPV ratio of the adenomyotic lesion or/and related to the subtypes.Currently,the generally accepted classification of adenomyosis are diffuse and focal adenomyosis,this classification is instructive to traditional invasive surgical resection.HIFU,as the representative of non-invasive therapy in recent years,the classification of diffuse and focal adenomyosis can not reflect the complexity of adenomyosis and meet the needs of HIFU treatment.Recent years,the new classification have been proposed by researchers according to the lation of the lesions,while the accuracy need to be further verified due to the small sample and the clinical acceptance and clinical practical value need to be futher validated.The clinicians urgently need a simple,comprehensive and practical classification method to guide the personalized treatment of HIFU for adenomyosis.In this study,the characteristics of magnetic resonance imaging(MRI)of nearly 1,000 patients with adenomyosis were analyzed to optimize the existing MRI classification criterion.The aims of the study were to address the inadequacy of the optimized MRI classification of adenomyosis and objectively evaluate the value of MRI classification in HIFU treatment of adenomyosis.First,we compare the correlation between the results of preoperative MRI features and postoperative pathological characteristics and evaluate the feasibility and accuracy of MRI classification of adenomyosis;then we perform a retrospective study to compare the difference in the severtity of clinical symptoms,HIFU treatment results and midterm efficacy of patients with different types of adenomyosis.Thus,we further optimize the indications,and provide a theoretical basis for optimizing the treatment plan.Purpose1.To evaluate the feasibility and accuracy of optimized MRI classification of adenomyosis;2.To evaluate the predictive value of MRI classification of adenomyosis on the severity of clinical symptoms,HIFU ablation dosage and HIFU ablation results,midterm efficacy after HIFU treatment and help to guide the development of personalized plans;3.To provide theoretical basis for optimizing indications and clinical protocols for HIFU treatment in adenomyosis.Materials and methods1.16 patients who underwent hysterectomy for adenomyosis in the Affiliated Hospital of Zunyi Medical University,Suining Central Hospital,Shijiazhuang People’s Hospital of Hebei Province from January 2020 to December 2021 were include in this study.All patients have completed standared MRI examinations before surgery.Adenomyosis was classified into four types according to the location of lesions on preoperative T2 WI of MRI as internal adenomyosis,external adenomyosis,intramural adenomyosis and full thickness adenomyosis.The in vitro uterine speciman was made into pathological sections and observed by HE staining.Under the microscope,the histopathological features were observed at 2x10,4x10 and 10x10 magnifications as required,and the pathological features of the lesions were compared with MRI findings.2.A total of 682 patients with adenomyosis who were treated with HIFU at Chongqing Haifu Hospital between January 2016 and December2019 were retrospectively reviewed.Based on the the location of the lesion on preoperative T2 WI image of MRI,the adenomyotic lesions were classified into four subtypes,and the classification criteria was the same as part one.Then the four types of adenomyosis were futher classified as asymmetric and symmetric subtypes according to the extent of the lesion.Evaluation of clinical symptom before HIFU treatment.Dysmenorrhea was scored before in accordance with the standards of Visual Analogue Scale(VAS 1-10 points),menstrual volumes were scored according to patients’ description on a 5-point scale.The clinical symptom severity in the patients with different subtypes of adenomyosis on T2 WI were compared between groups.3.A total of 682 patients with adenomyosis were include in this study,which is the same as part two.According to the location and extent of the lesion on the preoperative T2 WI image of MRI,the adenomyotic lesions were classified into four subtypes.The classification criteria was the same as part two.HIFU treatment was performed by professional doctors with more than 5 years experience.All adverse effects during the procedure and treatment results were recorded.The reatment results and treatment dose of HIFU ablation in patients with different subtypes of adenomyosis were compared and analyzed.4.A total of 321 patients with adenomyosis who received HIFU treatment and completed 18-month follow-up in Chongqing Haifu Hospital from January 2016 to December 2019 were enrolled in this study.According to the location and extent of the lesion on the preoperative T2 WI image of MRI,the adenomyotic lesions were classified into four subtypes.The classification criteria was the same as part two.Evaluation of clinical symptom before and 18-month after HIFU treatment.Dysmenorrhea was scored before and after treatment in accordance with the standards of Visual Analogue Scale(VAS 1-10 points),menstrual volumes were scored according to patients’ description on a 5-point scale.The long-term symptom relief in the patients with different subtypes of adenomyosis on T2 WI were compared between groups.Results1.The results of large pathological section showed that different types of adenomyosis had different infiltration positions.The light microscope showed that the lesion infiltrated from the endometrium to the medial muscle layer in the internal adenomyotic lesions,and the outer muscle layer and serous layer were not involved.While the lesion connected to the serosal tissue,and the serosal layer is invaded by the lesion in external adenomyosis.A normal muscle layer can be seen between the lesion and the endometrium.In full-thickness adenomyosis,ectopic endometrium and glands can be seen in the whole muscle layer,which are diffusely distributed.The signal characteristics on T2 WI are correlated with pathological components of lesions.The number of small blood vessels,ectopic glands and interstitial cells in the lesions was relatively less in adenomyotic lesions with hypointensity on T2 WI.While the number of blood vessels,ectopic glands and stromal cells in the lesions were moderate or abundant in adenomyotic lesions with isointensty signal on T2 WI.2.There were significant differences in the severity of clinical symptoms and midterm efficacy in patients with different type of MRI adenomyosis.The patients with external adenomyosis are mainly complained of dysmenorrhea,and have a higher proportion of intestinal irritation symptoms.The menstrual volume of patients with intrinsic adenomyosis increased significantly,while the incidence of infertility in patients with intrinsic adenomyosis was significantly lower than that in other groups.3.There were significant differences in the therapeutic dose and treatment results in the patients with different type of MRI adenomyosis.The treatment time,ablation time and therapeutic dose of patients with asymmetric intrinsic adenomyosis lesions were significantly lower than patients with full-thickness adenomyosis lesions.The NPV ratio achieved in the patients with extrinsic adenomyosis was significantly lower than patients with intrinsic adenomyosis and patients with full thickness adenomyosis,while the NPV ratio in the patients with intrinsic adenomyosis was significant higher than the other types of adenomyosis.The energy efficiency factor(EEF)in the group of patients with extrinsic adenomyosis was significant higher than the patients with intrinsic adenomyosis and full thickness adenomyosis.A higher percentage of sacrococcyx pain was found in the group of patients with extrinsic adenomyosis when compared with the other two groups of patients.The patients with intrinsic adenomyosis were more likely to show endometrium damage,while the patients with extrinsic adenomyosis were found a greater proportion of serosal damage,and the patients with perforative had a higher percentage of both ndometrium and serosal damage after HIFU treatment.4.The patients who show varying degrees of dysmenorrhea and menorrhagia before treatment had the symptom scores decreased significantly at 18 months after HIFU treatment.The proportion of women with clinical relief of menorrhagia at the 18-month follow-up was significantly lower among women with external adenomyosis than the other subtypes.Conclusion1.Different MRI signal characteristics of adenomyosis correspond to different pathological tissue components,MRI has a high specificity and sensitivity in the diagnosis and classification of adenomyosis,and it can be used for the classification research of adenomyosis2.There are significant differences in the severity of clinical symptoms in patients with different types of adenomyosis.MRI classification has certain guiding significance for predicting the severity of clinical symptoms.3.High-intensity focused ultrasound can be used to ablate different types of adenomyosis safely and effectively.The MRI classification of adenomyosis has certain clinical significance in predicting the outcome of ablation,which can be used to screen patients before surgery.4.HIFU is a safe and effective treatment for different subtype of adenomyosis with long-term sustained symptom improvements.MRI classification of adenomyosis has a certain clinical significance in predicting the severity of clinical symptoms and midterm efficacy and can be used to guide the formulation of personalized clinical plan.