Which is the role of enhancement curves in the differential diagnosis of uterine adenomyosis and myomatosis when comparing contrast-enhanced ultrasound (CEUS) and Color Doppler (CD)?

Purpose: To compare CEUS and CD findings in cases where a diagnosis of uterine adenomyosis was suspected on conventional transvaginal ultrasound (TVUS).

Methods and materials: In 74 patients uterine adenomyosis was suspected at TVUS, based on the following findings: asymmetrical thickening of the uterine wall, myometrial inhomogeneity with fluid-filled areas, broadening of the endo-myometrial junction. All cases were evaluated by CD and CEUS (4.8ml of SonoVue®, Bracco, Italy). CD was performed to assess the presence of diffuse intralesional or 'basket-like' vascularization of the lesions. Then, CEUS assessed the pattern of vascularization in the early (<1.5s) and late (>1.5s) arterial phase, as well as wash-in and wash-out times. Follow up was available in 66 cases where the final diagnosis was obtained with a combination of magnetic resonance imaging (60/66), hysterectomy (25/66) and/or surgical resection (18/66). There were 25 confirmed cases of adenomyosis, 43 confirmed cases of fibroids and 6 false positives.

Results: Fibroids had a 'basket-like' vascular pattern in all cases at CD and early CEUS and in 49/74 patients at late CEUS. Adenomyosis had a diffuse vascular pattern in all cases at CD, early and late CEUS. The wash-in time at CEUS was significantly shorter in adenomyosis than in fibroids, with a mean difference of 3.2 seconds but with a wide overlap between the two groups.

Conclusions: CEUS seems to be more effective in the diagnosis of adenomyosis suspected at conventional TVUS if compared to CD. The presence of 'basket-like' vascularization has a 100% negative predictive value and, if present, allows the differential diagnosis. Early phase, but not late phase, CEUS improves the detection of such finding.