Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure

M J Harmsen, T Van den Bosch, R A de Leeuw, M Dueholm, C Exacoustos, L Valentin, W J K Hehenkamp, F Groenman, C De Bruyn, C Rasmussen, L Lazzeri, L Jokubkiene, D Jurkovic, J Naftalin, T Tellum, T Bourne, D Timmerman, J A F Huirne, M J Harmsen, T Van den Bosch, R A de Leeuw, M Dueholm, C Exacoustos, L Valentin, W J K Hehenkamp, F Groenman, C De Bruyn, C Rasmussen, L Lazzeri, L Jokubkiene, D Jurkovic, J Naftalin, T Tellum, T Bourne, D Timmerman, J A F Huirne

Abstract

Objectives: To evaluate whether the Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis need to be better defined and, if deemed necessary, to reach consensus on the updated definitions.

Methods: A modified Delphi procedure was performed among European gynecologists with expertise in ultrasound diagnosis of adenomyosis. To identify MUSA features that might need revision, 15 two-dimensional (2D) video recordings (four recordings also included three-dimensional (3D) still images) of transvaginal ultrasound (TVS) examinations of the uterus were presented in the first Delphi round (online questionnaire). Experts were asked to confirm or refute the presence of each of the nine MUSA features of adenomyosis (described in the original MUSA consensus statement) in each of the 15 videoclips and to provide comments. In the second Delphi round (online questionnaire), the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVS examinations and to provide feedback on the proposed revisions. A third Delphi round (virtual group meeting) was conducted to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts.

Results: Of 18 invited experts, 16 agreed to participate in the Delphi procedure. Eleven experts completed and four experts partly finished the first round. The experts identified a need for more detailed definitions of some MUSA features. They recommended use of 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts participated in the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most of the still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the online meeting, in which they discussed and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features of adenomyosis, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and echogenic subendometrial lines and buds were classified unanimously as direct features of adenomyosis. Globular uterus, asymmetrical myometrial thickening, fan-shaped shadowing, translesional vascularity, irregular junctional zone and interrupted junctional zone were classified as indirect features of adenomyosis.

Conclusion: Consensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect signs of adenomyosis. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: Delphi technique; adenomyosis; consensus; ultrasonography.

© 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Figures

Figure 1
Figure 1
Transvaginal two‐dimensional and three‐dimensional ultrasound images of a uterus affected by adenomyosis depicting all Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: 1, interrupted junctional zone; 2, irregular junctional zone; 3, asymmetrical myometrial thickening; 4, globular uterus; 5, echogenic subendometrial lines and buds; 6, myometrial cysts; 7, hyperechogenic islands; 8, translesional vascularity; 9, fan‐shaped shadowing. , endometrium.
Figure 2
Figure 2
Example of a question in Round 1 (online survey) of the modified Delphi procedure on definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis, depicting a videoclip of a three‐dimensional transvaginal ultrasound examination and the question to the participant.
Figure 3
Figure 3
Example of a question in Round 2 (online survey) of the modified Delphi procedure on definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis, depicting a two‐dimensional still image of a transvaginal ultrasound examination.
Figure 4
Figure 4
Example of a question in Round 2 (online survey) of the modified Delphi procedure on definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis, showing proposed definition of globular uterus.
Figure 5
Figure 5
Schematic representation of direct and indirect Morphological Uterus Sonographic Assessment (MUSA) features of uterine adenomyosis (not endometriosis), according to modified Delphi procedure. Adapted from Van den Bosch et al..
Figure 6
Figure 6
Transvaginal ultrasound image showing typical spherical shape of a globular uterus.

References

    1. Ferenczy A. Pathophysiology of adenomyosis. Hum Reprod Update 1998; 4: 312–322.
    1. Munro MG. Classification and Reporting Systems for Adenomyosis. J Minim Invasive Gynecol 2020; 27: 296–308.
    1. Naftalin J, Hoo W, Pateman K, Mavrelos D, Holland T, Jurkovic D. How common is adenomyosis? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic. Hum Reprod 2012; 27: 3432–3439.
    1. Pinzauti S, Lazzeri L, Tosti C, Centini G, Orlandini C, Luisi S, Zupi E, Exacoustos C, Petraglia F. Transvaginal sonographic features of diffuse adenomyosis in 18–30‐year‐old nulligravid women without endometriosis: association with symptoms. Ultrasound Obstet Gynecol 2015; 46: 730–736.
    1. Tellum T, Nygaard S, Lieng M. Noninvasive Diagnosis of Adenomyosis: A Structured Review and Meta‐analysis of Diagnostic Accuracy in Imaging. J Minim Invasive Gynecol 2020; 27: 408–418e3.
    1. Van den Bosch T, Dueholm M, Leone FP, Valentin L, Rasmussen CK, Votino A, Van Schoubroeck D, Landolfo C, Installe AJ, Guerriero S, Exacoustos C, Gordts S, Benacerraf B, D'Hooghe T, De Moor B, Brolmann H, Goldstein S, Epstein E, Bourne T, Timmerman D. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol 2015; 46: 284–298.
    1. Van den Bosch T, de Bruijn AM, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, Bourne T, Timmerman D, Huirne JAF. Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound Obstet Gynecol 2019; 53: 576–582.
    1. Rasmussen CK, Van den Bosch T, Exacoustos C, Manegold‐Brauer G, Benacerraf BR, Froyman W, Landolfo C, Condorelli M, Egekvist AG, Josefsson H, Leone FPG, Jokubkiene L, Zannoni L, Epstein E, Installe A, Dueholm M. Intra‐ and Inter‐Rater Agreement Describing Myometrial Lesions Using Morphologic Uterus Sonographic Assessment: A Pilot Study. J Ultrasound Med 2019; 38: 2673–2683.
    1. Rasmussen CK, Hansen ES, Dueholm M. Inter‐rater agreement in the diagnosis of adenomyosis by 2‐ and 3‐dimensional transvaginal ultrasonography. J Ultrasound Med 2019; 38: 657–666.
    1. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs 2000; 32: 1008–1015.
    1. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, Wales PW. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol 2014; 67: 401–409.
    1. de Villiers MR, de Villiers PJ, Kent AP. The Delphi technique in health sciences education research. Med Teach 2005; 27: 639–643.
    1. Vogel C, Zwolinsky S, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obes (Lond) 2019; 43: 2573–2586.
    1. Novellas S, Chassang M, Delotte J, Toullalan O, Chevallier A, Bouaziz J, Chevallier P. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. AJR Am J Roentgenol 2011; 196: 1206–1213.
    1. Bazot M, Darai E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertil Steril 2018; 109: 389–397.
    1. Bluhm M, Dueholm M. Imaging for Adenomyosis: Making the Diagnosis by Sonography. J Minim Invasive Gynecol 2020; 27: 267.
    1. Exacoustos C, Brienza L, Di Giovanni A, Szabolcs B, Romanini ME, Zupi E, Arduini D. Adenomyosis: three‐dimensional sonographic findings of the junctional zone and correlation with histology. Ultrasound Obstet Gynecol 2011; 37: 471–479.
    1. Rasmussen CK, Hansen ES, Ernst E, Dueholm M. Two‐ and three‐dimensional transvaginal ultrasonography for diagnosis of adenomyosis of the inner myometrium. Reprod Biomed Online 2019; 38: 750–760.
    1. Tellum T, Nygaard S, Skovholt EK, Qvigstad E, Lieng M. Development of a clinical prediction model for diagnosing adenomyosis. Fertil Steril 2018; 110: 957–964e3.
    1. Kepkep K, Tuncay YA, Goynumer G, Tutal E. Transvaginal sonography in the diagnosis of adenomyosis: which findings are most accurate? Ultrasound Obstet Gynecol 2007; 30: 341–345.
    1. Luciano DE, Exacoustos C, Albrecht L, LaMonica R, Proffer A, Zupi E, Luciano AA. Three‐dimensional ultrasound in diagnosis of adenomyosis: histologic correlation with ultrasound targeted biopsies of the uterus. J Minim Invasive Gynecol 2013; 20: 803–810.
    1. Lazzeri L, Morosetti G, Centini G, Monti G, Zupi E, Piccione E, Exacoustos C. A sonographic classification of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement. Fertil Steril 2018; 110: 1154–1161e3.
    1. Bazot M, Darai E, Rouger J, Detchev R, Cortez A, Uzan S. Limitations of transvaginal sonography for the diagnosis of adenomyosis, with histopathological correlation. Ultrasound Obstet Gynecol 2002; 20: 605–611.
    1. Sun YL, Wang CB, Lee CY, Wun TH, Lin P, Lin YH, Tseng CC, Chen CH, Tseng CJ. Transvaginal sonographic criteria for the diagnosis of adenomyosis based on histopathologic correlation. Taiwan J Obstet Gynecol 2010; 49: 40–44.
    1. Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, Marteau T. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998; 2: i–iv, 1–88.
    1. Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manag 2004; 42: 15–29.
    1. Kottner J, Audige L, Brorson S, Donner A, Gajewski BJ, Hrobjartsson A, Roberts C, Shoukri M, Streiner DL. Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. J Clin Epidemiol 2011; 64: 96–106.
    1. Naftalin J, Hoo W, Pateman K, Mavrelos D, Foo X, Jurkovic D. Is adenomyosis associated with menorrhagia? Hum Reprod 2014; 29: 473–479.
    1. Naftalin J, Hoo W, Nunes N, Holland T, Mavrelos D, Jurkovic D. Association between ultrasound features of adenomyosis and severity of menstrual pain. Ultrasound Obstet Gynecol 2016; 47: 779–783.
    1. Chapron C, Vannuccini S, Santulli P, Abrao MS, Carmona F, Fraser IS, Gordts S, Guo SW, Just PA, Noel JC, Pistofidis G, Van den Bosch T, Petraglia F. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update 2020; 26: 392–411.

Source: PubMed

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