Comparison of high-intensity focused ultrasound for the treatment of internal and external adenomyosis based on magnetic resonance imaging classification

Figures & data

Figure 1. Flowchart of patient selection.

Figure 2. MRI features of internal and external adenomyosis. (A) Internal adenomyosis: a lesion with ill-defined margin located in the anterior wall of the uterus had developed in the thickened junctional zone (red arrow) and the myometrium outside the adenomyotic lesion was preserved. The thickness of the intact myometrium was 6 mm (white arrow). (B) External adenomyosis: a lesion with ill-defined margin (red arrow) located in the outer myometrium of the posterior wall of the uterus, the inner myometrium (the thickness was 8 mm, white arrow) between the adenomyotic lesion and the junctional zone was preserved, and the junctional zone was kept intact without aberrancy.

Figure 3. HIFU treatment for internal and external adenomyosis. (A) Pre-HIFU enhanced MRI showed an internal adenomyotic lesion located at the anterior wall of the uterus(arrow); (B) A contrast enhanced MR image obtained 1 day after HIFU showed the internal adenomyotic lesion was ablated(arrow). The NPV ratio was 89.5 %. (C) Pre-HIFU enhanced MRI showed an external adenomyotic lesion located at the posterior wall of the uterus(arrow); (D) A contrast enhanced MR image obtained 1 day after HIFU showed the external adenomyotic lesion was ablated without damaging to the serosa of the uterus(arrow). The NPV ratio was 44.1%.

Table 1. Comparison of baseline characteristics of patients with internal and external adenomyosis.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 238)	(n = 167)
Age (years)	42.3 ± 6.3	39.3 ± 5.7	0.000
BMI (kg/m^2)	24.1 ± 3.3	23.5 ± 3.3	0.043
Rectus abdominis thickness(mm)	9.7 ± 3.6	10.1 ± 3.7	0.326
Subcutaneous fat thickness(mm)	18.7 ± 7.6	19.4 ± 8.3	0.379
Location of the lesions(A/P/F)	88/131/19	16/140/11	0.000
Volume of the uterus (cm^3)	223.9 (155.2, 302.5)	197.3 (135.8, 274.0)	0.038
Volume of lesion (cm^3)	86.2 (55.9, 148.7)	70.7 (33.4, 121.2)	0.001
Endometriosis cyst of ovary (%)	12 (5.0)	69 (41.3)	0.000

Notes. A: anterior wall of the uterus; P: posterior wall of the uterus; F: fundus.

Table 2. Comparison of HIFU treatment results between patients with internal and external adenomyosis.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 238)	(n = 167)
Power (W)	357.0 ± 48.8	360.7 ± 51.0	0.462
Treatment time(min)	58.5 ± 31.1	70.9 ± 43.9	0.001
Sonication time(s)	526.8 ± 321.8	597.4 ± 396.2	0.049
Treatment intensity(s/h)	545.5 (428.6, 664.1)	534.0 (398.0, 623.5)	0.361
Total energy(KJ)	190.5 ± 124.6	224.4 ± 159.2	0.017
NPV ratio (%)	48.0 (29.0, 69.0)	43.0 (26.0, 59.0)	0.054
EEF(J/mm^3)	2.9 (1.5, 6.9)	5.2 (2.5, 11.5)	<0.001

Table 3. Comparison of baseline characteristics and HIFU treatment results between patients with internal and external adenomyosis in the posterior wall of the uterus.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 131)	(n = 140)
Age (years)	42.1 ± 6.7	39.2 ± 5.6	0.000
BMI (kg/m^2)	24.1 ± 3.0	23.4 ± 3.4	0.079
Rectus abdominis thickness(mm)	9.8 ± 3.7	9.9 ± 3.7	0.737
Subcutaneous fat thickness(mm)	18.2 ± 7.1	18.8 ± 8.2	0.471
Volume of the uterus (cm^3)	220.4 (154.7, 299.1)	193.8 (132.4, 268.6)	0.038
Volume of lesion (cm^3)	81.7 (55.7, 121.1)	72.0 (33.5, 123.4)	0.024
Power (W)	362.6 ± 29.3	360.2 ± 49.8	0.685
Treatment time(min)	60.1 ± 34.9	66.8 ± 42.6	0.162
Sonication time(s)	532.9 ± 350.4	540.9 ± 338.7	0.849
Treatment intensity(s/h)	545.5 (429.0, 649.5)	526.0 (391.3, 606.0)	0.328
Total energy(KJ)	198.0 ± 138.0	204.3 ± 136.5	0.705
NPV ratio (%)	49.0 (30.0, 71.0)	42.0 (25.0, 58.8)	0.008
EEF(J/mm^3)	2.9 (1.4, 8.0)	5.2 (2.4, 11.1)	0.003

Table 4. Comparison of adverse effects between patients with internal and external adenomyosis during HIFU treatment.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 238)	(n = 167)
Leg pain	33 (13.9%)	26 (15.6%)	0.737
Sciatic or buttock pain (n, %)	97 (40.8%)	94 (56.3%)	0.003
Skin burning sensation (n, %)	93 (39.1%)	48 (28.7%)	0.041
Treated area pain	138 (58.0%)	104 (62.3%)	0.445
Groin pain	6 (2.5%)	4 (2.4%)	1

Table 5. Comparison of dysmenorrhea before and 18 month after HIFU between the two groups.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 205)	(n = 161)
Pre-HIFU pain score	5.0 (3.0, 7.0)	8.0 (7.0, 9.0)	0.000
Post-HIFU pain score	1.0 (0.0, 3.0)	3.0 (2.0, 5.0)	0.000
P	0.000	0.000

Table 6. Comparison of symptom improvement in patients with dysmenorrhea 18 month after HIFU between the two groups.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 205)	(n = 161)
Partial relief (n, %)	23 (11.2)	22 (13.7)	0.496
Obvious relief (n, %)	86 (42.0)	95 (59.0)	0.148
Complete relief (n, %)	54 (26.3)	13 (8.1)	0.003
Clinical effective rate (n, %)	163 (79.5)	130 (80.8)	0.086

Table 7. Comparison of menorrhagia scores before and 18 month after HIFU between the two groups.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 209)	(n = 140)
Pre-HIFU menstruation volume score	4.0 (3.0, 5.0)	3.0 (2.0, 4.0)	0.000
18-month post-HIFU score	1.0 (1.0, 2.0)	1.0 (1.0, 2.0)	0.856
P	0.000	0.000

Table 8. Comparison of treatment efficacy in patients with menorrhagia 18 month after HIFU between the two groups.

Variables	Internal adenomyosis	External adenomyosis	p
	(n = 209)	(n = 140)
Partial relief (n, %)	32 (15.3)	28 (20.0)	0.524
Obvious relief (n, %)	90 (43.1)	18 (12.8)	0.000
Complete relief (n, %)	58 (27.8)	62 (44.3)	0.920
Clinical effective rate (n, %)	180 (86.2)	108 (77.1)	0.030