1
|
do Amaral Coutinho C, Castro PT, Lopes FP, de Freitas Lima LAC, Araujo Júnior E, Aranda OL, de Araújo LFB, Marchiori E, Werner H. Elastographic and vascular findings of uterine myomas assessed by ultrasound. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 39150480 DOI: 10.1002/jcu.23784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/21/2024] [Accepted: 08/04/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVE The objectives of this study were to evaluate the vascularization pattern of uterine myoma (UM) by ultrasonography using Superb Microvascular Imaging (SMI) and tissue stiffness elastography. METHOD A prospective and cross-sectional study was carried out between March 2020 and December 2022 among women with clinical and ultrasound diagnosis of UM who would subsequently undergo radiofrequency ablation. Ultrasound examination was performed using both transvaginal and transabdominal routes. UM vascularization pattern was assessed by power Doppler (PD) and SMI, while elastographic pattern was assessed by shear wave (SWE) and strain (STE). FIGO classification, location, and measurement of the largest UM were also described. RESULTS A total of 21 women diagnosed with UM were evaluated. There was a predominance of nulliparous women and 20 women (95.2%) reported desire for pregnancy. Of the 18 women with abnormal uterine bleeding, 15 (83.3%) had abdominal cramping. As far as previous treatment, 7 (33.3%) had undergone myomectomy for other UM. The mean uterine and UM volumes were 341.9 cm3 (90-730) and 126.52 cm3 (6.0-430), respectively. There was a predominance of hypoechogenic lesions (90.5%). There was also preponderance of UM in the FIGO 2-5 classification (n = 9; 42.9%). Vascularization patter was mostly moderate (score 2) in 9 cases (42.9%). The majority of UM were considered to have intermediate stiffness (n = 10; 47.6%). CONCLUSION The majority of UM showed vascularization and moderate stiffness. A relationship was observed between the stiffness of the UM assessed by elastography and its FIGO classification.
Collapse
Affiliation(s)
- Cristiana do Amaral Coutinho
- Department of Radiology, Clínica Alta (DASA), Rio de Janeiro, Brazil
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | - Flávia Paiva Lopes
- Department of Radiology, Clínica Alta (DASA), Rio de Janeiro, Brazil
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, Brazil
| | | | | | - Edson Marchiori
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Heron Werner
- Department of Radiology, Clínica Alta (DASA), Rio de Janeiro, Brazil
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| |
Collapse
|
2
|
Wang Z, Ma Y, Zhou J, Jiang F, Chen JY, Chen WZ. Comparing the effect of FUAS and myomectomy on the elasticity of myometrium around targeted uterine fibroid. Int J Hyperthermia 2024; 41:2362998. [PMID: 39128847 DOI: 10.1080/02656736.2024.2362998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/09/2024] [Accepted: 05/28/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Focused ultrasound ablation surgery (FUAS) has been widely employed to treat patients with uterine fibroid (UF). This study aimed to estimate myometrial stiffness changes in patients who received FUAS for UFs or myomectomy (ME) and compare the recovery of surrounding myometrium between FUAS and ME groups. Our results may provide more evidence for guiding the proper conception timing in patients with UF. METHODS This study enrolled 173 patients from May 2022 to August 2023. Shear wave elastography (SWE) was used to dynamically monitor myometrial elasticity changes in patients before and after surgery. Moreover, our study monitored and analyzed the stiffness changes in the targeted fibroid after FUAS, as well as in the myometrium around after FUAS or ME. RESULTS The stiffness of the myometrium around the resected fibroid was significantly higher than at the preoperative level until 6 months. Conversely, the stiffness of the surrounding myometrium was only temporarily increased 1 day after FUAS. The comparison between FUAS and ME groups regarding the stiffness of the surrounding myometrium showed that nonsignificant differences were detected between the two groups before the treatment. The stiffness of the surrounding myometrium in the ME group was statistically significantly higher than that of the FUAS group 1 day as well as 1, 3, and 6 months after the treatment, respectively. CONCLUSION The FUAS had less impact on the surrounding myometrium than the ME, which may be more conducive to the recovery of myometrial elasticity in patients with UF.
Collapse
Affiliation(s)
- Ziyao Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Ultrasound Medicine, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Yan Ma
- Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jia Zhou
- Department of Ultrasound Medicine, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Feng Jiang
- Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jin-Yun Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Wen-Zhi Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| |
Collapse
|
3
|
Horwood G, Flaxman T, McInnes M, McLean L, Singh SS. Ultrasound Elastography in Benign Gynecology: A Scoping Review. Reprod Sci 2024; 31:2508-2522. [PMID: 38664357 DOI: 10.1007/s43032-024-01535-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/29/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations. METHODS A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations. RESULTS The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer. CONCLUSION Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions.
Collapse
Affiliation(s)
- Genevieve Horwood
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Teresa Flaxman
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew McInnes
- Department of Radiology, The Ottawa Hospital, Ottawa, ON, Canada
- School of Rehabilitation Sciences, The University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Linda McLean
- School of Rehabilitation Sciences, The University of Ottawa, Ottawa, ON, Canada
| | - Sukhbir Sony Singh
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada
- School of Rehabilitation Sciences, The University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
4
|
Stader JM, Recker F, Tonguc T, Ramig O, Thudium M, Matlac D, Mutschler N, Egger EK, Mustea A, Küppers J, Essler M, Jenne J, Strunk HM, Conrad R, Marinova M. Clinical experience with shear wave elastography (SWE) for assessing healthy uterus in a transabdominal approach. Sci Rep 2024; 14:14473. [PMID: 38914622 PMCID: PMC11196258 DOI: 10.1038/s41598-024-65238-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024] Open
Abstract
Aim of the study was to evaluate the diagnostic performance and feasibility of transabdominal ultrasound shear wave elastography (SWE) in assessing sonoelastographic features of the uterus. Twenty-seven premenopausal women were enrolled between 2021 and 2022. Transabdominal SWE measured myometrial stiffness in various uterine segments. Additionally, tissue stiffness of the quadriceps femoris muscle and autochthonous back muscle was measured. Statistical analysis employed non-parametric tests, t test, and a robust mixed linear model. Stiffness values of the uterus and the two investigated muscle types exhibited a similar spectrum: 6.38 ± 2.59 kPa (median 5.61 kPa; range 2.76-11.31 kPa) for the uterine myometrium, 7.22 ± 1.24 kPa (6.82 kPa; 5.11-9.39 kPa) for the quadriceps femoris musle, and 7.43 ± 2.73 kPa (7.41 kPa; 3.10-13.73 kPa) for the autochthonous back muscle. A tendency for significant differences in myometrial stiffness was observed concerning the type of labor mode (mean stiffness of 9.17 ± 1.35 kPa after vaginal birth vs. 3.83 ± 1.35 kPa after Caesarian section, p = 0.01). No significant differences in myometrial stiffness were observed concerning age, BMI, previous pregnancies, uterine flexion and menstrual cycle phase. Transabdominal SWE of uterine stiffness seems to be a fast and practicable method in a clinical setting. Uterine stiffness appears to be largely independent of various factors, except for the mode of delivery. However, further studies are needed to validate these results.
Collapse
Affiliation(s)
- Judith M Stader
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Florian Recker
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Tolga Tonguc
- Department of Diagnostic and Interventional Radiology, Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Olga Ramig
- Department of Diagnostic and Interventional Radiology, Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Marcus Thudium
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Dieter Matlac
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Nikola Mutschler
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Eva K Egger
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Jim Küppers
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jürgen Jenne
- Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany
| | | | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Muenster, Münster, Germany
| | - Milka Marinova
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| |
Collapse
|
5
|
Zaniker EJ, Zhang M, Hughes L, La Follette L, Atazhanova T, Trofimchuk A, Babayev E, Duncan FE. Shear wave elastography to assess stiffness of the human ovary and other reproductive tissues across the reproductive lifespan in health and disease†. Biol Reprod 2024; 110:1100-1114. [PMID: 38609185 PMCID: PMC11180622 DOI: 10.1093/biolre/ioae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
The ovary is one of the first organs to show overt signs of aging in the human body, and ovarian aging is associated with a loss of gamete quality and quantity. The age-dependent decline in ovarian function contributes to infertility and an altered endocrine milieu, which has ramifications for overall health. The aging ovarian microenvironment becomes fibro-inflammatory and stiff with age, and this has implications for ovarian physiology and pathology, including follicle growth, gamete quality, ovulation dynamics, and ovarian cancer. Thus, developing a non-invasive tool to measure and monitor the stiffness of the human ovary would represent a major advance for female reproductive health and longevity. Shear wave elastography is a quantitative ultrasound imaging method for evaluation of soft tissue stiffness. Shear wave elastography has been used clinically in assessment of liver fibrosis and characterization of tendinopathies and various neoplasms in thyroid, breast, prostate, and lymph nodes as a non-invasive diagnostic and prognostic tool. In this study, we review the underlying principles of shear wave elastography and its current clinical uses outside the reproductive tract as well as its successful application of shear wave elastography to reproductive tissues, including the uterus and cervix. We also describe an emerging use of this technology in evaluation of human ovarian stiffness via transvaginal ultrasound. Establishing ovarian stiffness as a clinical biomarker of ovarian aging may have implications for predicting the ovarian reserve and outcomes of Assisted Reproductive Technologies as well as for the assessment of the efficacy of emerging therapeutics to extend reproductive longevity. This parameter may also have broad relevance in other conditions where ovarian stiffness and fibrosis may be implicated, such as polycystic ovarian syndrome, late off target effects of chemotherapy and radiation, premature ovarian insufficiency, conditions of differences of sexual development, and ovarian cancer. Summary sentence: Shear Wave Elastography is a non-invasive technique to study human tissue stiffness, and here we review its clinical applications and implications for reproductive health and disease.
Collapse
Affiliation(s)
- Emily J Zaniker
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Man Zhang
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lydia Hughes
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Tomiris Atazhanova
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexis Trofimchuk
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Elnur Babayev
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Francesca E Duncan
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Center for Reproductive Longevity and Equality, Buck Institute for Research on Aging, Novato, CA, USA
| |
Collapse
|
6
|
Haimovich Segal S, Moratalla Bartolome E, Ross Cerro C, Vidal Mazo C, Pérez Sagaseta C. Conceptos actuales en cirugía histeroscópica: superando barreras y ampliando límites. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2023.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
|
7
|
Ali M, Bariani MV, Vafaei S, Omran MM, Yang Q, Madueke-Laveaux OS, Al-Hendy A. Prevention of Uterine Fibroids: molecular mechanisms and potential clinical application. JOURNAL OF ENDOMETRIOSIS AND UTERINE DISORDERS 2023; 1:100018. [PMID: 37637856 PMCID: PMC10451784 DOI: 10.1016/j.jeud.2023.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Uterine fibroids (UFs; leiomyoma) are the most common benign neoplastic threat to women worldwide, exacting an immense personal burden on female health and a monetary expense to the healthcare system estimated in the hundreds of billions of dollars every year globally. With no long-term non-invasive treatment option currently available to treat UFs, deeper insights regarding tumor etiology are the key for developing newer therapies. Accordingly, in this review, we discuss new mechanistic paradigm to explain UF tumor development through an exquisite model involving developmental reprogramming of myometrial stem cells due to early life endocrine disruptors exposure, inflammation, fibrosis, DNA damage, and eventually tissue stiffness. Further, we propose to utilize shear wave elastography as a potential screening tool for the early identification of women at risk for developing UFs who can benefit from several simple preventive strategies, including the consumption of natural compounds such as vitamin D and green tea as a safe fertility friendly non-hormonal modality to delay or even arrest or reverse UF progression.
Collapse
Affiliation(s)
- Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Maria Victoria Bariani
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
| | - Somayeh Vafaei
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
| | - Mervat M. Omran
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
- Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Qiwei Yang
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
| | - Obianuju Sandra Madueke-Laveaux
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA Chicago, IL 60637, USA
| |
Collapse
|
8
|
Brunelli AC, Brito LGO, Moro FAS, Jales RM, Yela DA, Benetti-Pinto CL. Ultrasound Elastography for the Diagnosis of Endometriosis and Adenomyosis: A Systematic Review with Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:699-709. [PMID: 36528440 DOI: 10.1016/j.ultrasmedbio.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/05/2022] [Accepted: 11/10/2022] [Indexed: 06/17/2023]
Abstract
Elastography is capable of measuring tissue mechanical properties and elasticity. It is used to help diagnose various diseases, although its use in pelvic endometriosis remains to be established. A systematic review and meta-analysis were conducted to assess transvaginal ultrasound elastography for the diagnosis of different manifestations of endometriosis and adenomyosis. PRISMA guidelines were used for a Medline, PubMed, Embase, BVS/Bireme, Scopus, Cochrane Library and Escudos database search. Studies indexed until March 2021 that evaluated elastography compared with histopathological results (gold standard), ultrasound or magnetic resonance imaging for diagnosis of pelvic endometriosis and adenomyosis were eligible. The Rayyan platform was used to select studies. Sensitivity (S), specificity (Ps), positive and negative predictive values and receiver operating characteristic curves were calculated for elastographic diagnosis of endometriosis. A meta-analysis using Review Manager 5 and Open Meta Analyst was performed. Bias risk in the studies was analyzed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. This systematic review was prospectively registered in the PROSPERO database: CRD42021244555. Among the 163 identified citations, 10 studies were eligible for review (5 for diagnosis of adenomyosis, 2 for endometrioma, 3 for deep intestinal endometriosis and rectovaginal septum [deep pelvic endometriosis], N = 744 women). In deep pelvic endometriosis, lesions diagnosed by elastography were found to correlate with histopathology results. Increased "stiffness" (elastography) was associated with a higher fibrotic component, with S = 78%-100% and Ps = 100%, according to the authors. On elastography, endometriomas were stiffer than hemorrhagic cysts (S = 82%, Ps = 79%) and malignant tumors (S = 86%, Ps = 100%). For these lesions, a meta-analysis could not be performed because the small number of studies and insufficient data. In adenomyosis, meta-analysis and receiver operating characteristic curve analysis revealed that elastography had good sensitivity and specificity. Studies indicated a low bias risk by QUADAS-2. Elastography had high sensitivity and specificity for deep pelvic endometriosis diagnosis, and its findings correlated with histopathology results. For adenomyosis, the meta-analysis confirmed the sensitivity and specificity results of the studies. Given these results, elastography may be a promising imaging test, contributing to non-invasive diagnosis of endometriosis and adenomyosis.
Collapse
Affiliation(s)
- Ana Claudia Brunelli
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Flavia Assad Salum Moro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Rodrigo Menezes Jales
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Daniela Angerame Yela
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | |
Collapse
|
9
|
Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study. J Clin Med 2022; 11:jcm11226707. [PMID: 36431184 PMCID: PMC9693154 DOI: 10.3390/jcm11226707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/30/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study aimed to examine the clinical characteristics of 11 patients undergoing laparoscopic adenomyomectomy guided by intraoperative ultrasound elastography and this technique's feasibility. PATIENTS AND METHODS Eleven patients undergoing laparoscopic adenomyomectomy using ultrasound elastography for adenomyosis at Kawasaki Medical School Hospital in Okayama, Japan between March 2020 and February 2021 were enrolled. Operative outcomes included operative time, operative bleeding, resected weight, operation complications, percent change in hemoglobin (Hb) values, and uterine volume pre- and postoperatively. Dysmenorrhea improvement was evaluated by changes in visual analog scale (VAS) scores pre- and 6- and 12-months postoperatively. RESULTS The median operative time and bleeding volume was 125 min (range, 88-188 min) and 150 mL (10-450 mL), respectively. The median resected weight was 5.0 g (1.5-180 g). No intraoperative or postoperative blood transfusions or perioperative complications were observed. The median changes in uterine volume, Hb value, and VAS score were -49% (-65 to -28%), -3% (-11 to 35%), and -80% (-100 to -50%), respectively. The median follow-up period post-surgery was 14 months (7-30 months). Adenomyosis recurrence was not observed in the patients during the follow-up period. CONCLUSIONS Laparoscopic adenomyomectomy using ultrasound elastography guidance is minimally invasive and resects as many adenomyotic lesions as possible.
Collapse
|
10
|
Ascher SM, Wasnik AP, Robbins JB, Adelman M, Brook OR, Feldman MK, Jones LP, Knavel Koepsel EM, Patel-Lippmann KK, Patlas MN, VanBuren W, Maturen KE. ACR Appropriateness Criteria® Fibroids. J Am Coll Radiol 2022; 19:S319-S328. [PMID: 36436959 DOI: 10.1016/j.jacr.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
- Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia.
| | - Ashish P Wasnik
- Panel Vice-Chair, University of Michigan, Ann Arbor, Michigan; Director, Division of Abdominal Radiology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan
| | - Jessica B Robbins
- Panel Chair; Vice Chair, Faculty Development and Enrichment, University of Wisconsin, Madison, Wisconsin
| | - Marisa Adelman
- Technology Assessment Committee, University of Utah, Salt Lake City, Utah; American College of Obstetricians and Gynecologists
| | - Olga R Brook
- Section Chief, Abdominal Imaging; Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Krupa K Patel-Lippmann
- Abdominal Imaging Fellowship Director, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael N Patlas
- McMaster University, Hamilton, Ontario, Canada; Editor-in-Chief, Canadian Association of Radiologists
| | - Wendaline VanBuren
- Section Chair, Gynecological Imaging, Department of Radiology Mayo Clinic, Rochester, Minnesota; Chair, Endometriosis Disease-Focused Panel, Society of Abdominal Radiology
| | - Katherine E Maturen
- Specialty Chair; Associate Chair, Ambulatory Care and Strategy, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
11
|
Transvaginal Ultrasound Combined with Strain-Ratio Elastography for the Concomitant Diagnosis of Uterine Fibroids and Adenomyosis: A Pilot Study. J Clin Med 2022; 11:jcm11133757. [PMID: 35807043 PMCID: PMC9267844 DOI: 10.3390/jcm11133757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
Uterine fibroids (UFs) and adenomyosis (AM) represent two benign uterine conditions that can affect fertility and are most frequently commonly responsible for abnormal uterine bleeding and chronic pelvic pain. Their differential diagnosis still represents a challenge, and several authors advise the addition of elastography to transvaginal ultrasound (TVUS) for a more accurate imagistic recognition. Through this study, we aimed to assess the diagnostic accuracy of TVUS combined with strain-ratio elastography (SRE) in concomitant AM and UFs. We conducted a study on 17 patients diagnosed with concomitant UFs and AM undergoing hysterectomy and 46 healthy patients. TVUS combined with SRE was conducted in each patient, focusing on identifying rigidity patterns of the lesions. Significantly higher mean SR and maximum SR values were identified among both AM and UF lesions as opposed to controls (p < 0.01), with the highest tissue stiffness being encountered among AM lesions, which allows for the differentiation of UF (p < 0.01) and concomitant identification of both lesions. These results are reflected by higher cut-off values obtained for AM, both for mean SR (5.42 vs. 2.85) and maximum SR (5.80 vs. 3.30). TVUS combined with SRE showed good diagnostic performance in identifying coexisting UFs and AM within the same uterine specimen. Future studies on wider populations are required to validate our findings.
Collapse
|
12
|
Contribution of UltraFast™ Ultrasound and Shear Wave Elastography in the Imaging of Carotid Artery Disease. Diagnostics (Basel) 2022; 12:diagnostics12051168. [PMID: 35626326 PMCID: PMC9140890 DOI: 10.3390/diagnostics12051168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/12/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023] Open
Abstract
Carotid artery disease is one of the main global causes of disability and premature mortality in the spectrum of cardiovascular diseases. One of its main consequences, stroke, is the second biggest global contributor to disability and burden via Disability Adjusted Life Years after ischemic heart disease. In the last decades, B-mode and Doppler-based ultrasound imaging techniques have become an indispensable part of modern medical imaging of carotid artery disease. However, they have limited abilities in carotid artery plaque and wall characterization and are unable to provide simultaneous quantitative and qualitative flow information while the images are burdened by low framerates. UltraFast™ ultrasound is able to overcome these obstacles by providing simultaneous quantitative and qualitative flow analysis information in high frame rates via UltraFast™ Doppler. Another newly developed ultrasound technique, shear wave elastography, is based on the visualization of induced shear waves and the measurement of the shear wave propagation speed in the examined tissues which enables real-time carotid plaque and wall analysis. These newly developed ultrasound modalities have potential to significantly improve workflow efficiency and are able to provide a plethora of additional imaging information of carotid artery disease in comparison to conventional ultrasound techniques.
Collapse
|
13
|
Current Trends in the Evaluation and Management of Uterine Fibroids. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00331-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
14
|
A Call-to-Action for Clinicians to Implement Evidence-Based Best Practices When Caring for Women with Uterine Fibroids. Reprod Sci 2022; 29:1188-1196. [PMID: 35178678 PMCID: PMC8853611 DOI: 10.1007/s43032-022-00877-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/06/2022] [Indexed: 11/12/2022]
Abstract
Uterine fibroids are common benign tumors that occur in up to 80% of women. Approximately half of the women affected experience considerable physical, psychological, and economic burdens and impact on quality of life due to symptoms such as heavy menstrual bleeding, pelvic pain, and infertility. Several medical and surgical options are available to treat uterine fibroids; however, healthcare providers may benefit from practical guidance in the development of individualized treatment plans based on a personalized approach. Medical treatments and minimally invasive procedures are generally preferred by most patients before considering more invasive, higher risk surgical interventions. In general, patient-centered, uterine-preserving procedures may be prioritized based on the patient’s goals and the clinical scenario. Occasionally, hysterectomy may be the preferred treatment option for some patients who require definitive treatment. This call-to-action highlights recent challenges to patient care, including radical shifts in physician–patient interactions due to the COVID-19 pandemic and recent changes to evidence-based, clinically approved therapies. This report also reviews contemporary recommendations for women’s health providers in the diagnosis and medical and surgical management of uterine fibroids. This call-to-action aims to empower healthcare providers to optimize the quality of care for women with uterine fibroids utilizing the best available evidence and best practices.
Collapse
|
15
|
Vora Z, Manchanda S, Sharma R, Das CJ, Hari S, Mathur S, Kumar S, Kachhawa G, Khan MA. Transvaginal Shear Wave Elastography for Assessment of Endometrial and Subendometrial Pathologies: A Prospective Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:61-70. [PMID: 33645765 DOI: 10.1002/jum.15679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To assess the role of shear wave elastography (SWE) in characterizing different endometrial and subendometrial pathologies. METHODS Seventy-three women with pathologically proven endometrial and subendometrial pathologies were enrolled in this prospective study and assessed with transvaginal SWE. The elasticity values (in kiloPascals), and the ratio of mean elasticity of the endometrial lesion to myometrial elasticity (E/M ratio) were compared in different pathologies. RESULTS There was a statistically significant difference (P <.001) in the mean, minimum, and maximum elasticity of the pathologies as well as the E/M ratio (P <.00001). In the analysis of the subgroups, the mean elasticity of endometrial polyp was statistically significantly lower than other subgroups (P <.01), while submucosal leiomyoma and focal adenomyoma had significantly higher values than other subgroups (P <.01). No statistically significant difference was noted in the mean elasticity of carcinoma and hyperplasia (P-.19). CONCLUSION SWE is a potential adjunct to ultrasound that provides an additional paradigm to characterize endometrial and subendometrial masses.
Collapse
Affiliation(s)
- Zainab Vora
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Smita Manchanda
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Chandan Jyoti Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Hari
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mathur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sunesh Kumar
- Department of Gynaecology-Obstetrics, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Kachhawa
- Department of Gynaecology-Obstetrics, All India Institute of Medical Sciences, New Delhi, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
16
|
Pongpunprut S, Panburana P, Wibulpolprasert P, Waiyaput W, Sroyraya M, Chansoon T, Sophonsritsuk A. A Comparison of Shear Wave Elastography between Normal Myometrium, Uterine Fibroids, and Adenomyosis: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2022; 16:49-54. [PMID: 35103432 PMCID: PMC8808257 DOI: 10.22074/ijfs.2021.523075.1074] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/17/2021] [Indexed: 02/04/2023]
Abstract
Background The differential diagnosis between uterine fibroid and adenomyosis is sometimes difficult; a precise diagnosis is required in women with infertility
because of the different choice of treatments. Ultrasound elastography (UE) is a novel technique to evaluate the elasticity or the stiffness of the tissue
of interest. The present study aims to compare UE shear wave velocity (SWV) among normal uterine myometrium, uterine fibroid, and adenomyosis, and assess
the accuracy of shear wave elastography in the diagnosis of adenomyosis. Materials and Methods This cross-sectional study recruited 25 subjects for each group (control, adenomyosis, and fibroid) from April 2019 to April 2020.
Transvaginal UE using an Aplio 500 (Toshiba Medical Systems, Japan) with ultrasound mapping for point of tissue biopsy was performed for all subjects.
The diagnosis was confirmed by histology. Masson’s trichrome staining for collagen was performed and quantified Results The mean ± standard deviation (SD) for SWV was 3.44 ± 0.95 m/seconds (control group), 4.63 ± 1.45 m/seconds (adenomyosis group), and 4.53 ± 1.07 m/seconds
(fibroid group). The mean SWV differed when comparing normal myometrium and adenomyosis after adjustments for age and endometrial pathology (P=0.019).
The cut-off point of SWV at 3.465 m/seconds could differentiate adenomyosis from the normal uterus with an 80% sensitivity, 80% specificity,
and an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.68-0.93) (P<0.001).
No significant difference in SWV between the adenomyosis and fibroid groups was detected. Conclusion Shear wave elastography could be an alternative tool to distinguish between normal myometrium and adenomyosis; however, it could not differentiate
adenomyosis from uterine fibroid or uterine fibroid from normal myometrium.
Collapse
Affiliation(s)
- Sutee Pongpunprut
- Department of Obstetrics and Gynaecology, Panyananthaphikkhu Chonprathan Medical Centre, Srinakharinwirot University, Nontaburi, Thailand
| | - Panyu Panburana
- Foetal and Maternal Medicine Division, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornphan Wibulpolprasert
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic, Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wanwisa Waiyaput
- Office of Research Academic and Innovation, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Morakot Sroyraya
- Department of Anatomy, Faculty of Science, Mahidol University, Bangkok, Thailand
| | - Tharintorn Chansoon
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Areepan Sophonsritsuk
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
17
|
Săsăran V, Turdean S, Gliga M, Ilyes L, Grama O, Muntean M, Pușcașiu L. Value of Strain-Ratio Elastography in the Diagnosis and Differentiation of Uterine Fibroids and Adenomyosis. J Pers Med 2021; 11:jpm11080824. [PMID: 34442468 PMCID: PMC8399978 DOI: 10.3390/jpm11080824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 12/26/2022] Open
Abstract
Benign uterine disorders, including uterine fibroids (UF) and adenomyosis (AM), can impact the life quality and fertility of women of reproductive age. Transvaginal ultrasound (TVUS) has long been used for their early identification, but its combined use with elastography seems to improve diagnostic accuracy of UF and AM. Thus, a prospective pilot study was conducted on 79 patients who underwent hysterectomy (25 microscopically diagnosed with AM and 53 with UF), with the aim of assessing the ability of TVUS combined with strain ratio elastography (SE) to accurately diagnose and distinguish UF and AM. Significantly higher mean and maximal strain ratio (SR) values were identified for patients with histologically confirmed AM as opposed to those with UF (p < 0.001). Diagnostic sensitivity and specificity, calculated in comparison with histology results, were higher for UF than AM. Receiver operating characteristic (ROC) analysis was applied between the two study groups, revealing cutoff values of 7.71 for mean SR and 8.91 for maximal SR, respectively, with good sensitivity and specificity parameters (100% and 96.23%; 96% and 96.23%). Our results support the use of TVUS in combination with SE for the positive and differential diagnosis of UF and AM, through identification of their particular tissue stiffness features.
Collapse
Affiliation(s)
- Vladut Săsăran
- Department of Obstetrics and Gynecology 2, Faculty of Medicine in English, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania;
| | - Sabin Turdean
- Department of Morphopathology, Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania
- Correspondence:
| | - Marius Gliga
- Department of Obstetrics and Gynecology 2, Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania; (M.G.); (L.I.); (O.G.)
| | - Levente Ilyes
- Department of Obstetrics and Gynecology 2, Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania; (M.G.); (L.I.); (O.G.)
| | - Ovidiu Grama
- Department of Obstetrics and Gynecology 2, Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania; (M.G.); (L.I.); (O.G.)
| | - Mihai Muntean
- Department of Obstetrics and Gynecology, Clinical County Hospital Mures, Samuel Koteles Street No. 29, 540057 Târgu Mureș, Romania;
| | - Lucian Pușcașiu
- Department of Obstetrics and Gynecology 1, Faculty of Medicine in English, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania;
| |
Collapse
|
18
|
Aninye IO, Laitner MH. Uterine Fibroids: Assessing Unmet Needs from Bench to Bedside. J Womens Health (Larchmt) 2021; 30:1060-1067. [PMID: 34410867 PMCID: PMC8432600 DOI: 10.1089/jwh.2021.0280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Uterine fibroids (leiomyomas) are noncancerous growths that can have deleterious effects on the health and quality of life for millions of women. Attempts to better understand the factors that influence prevalence and disparities associated with fibroids have been made; however, significant knowledge gaps continue to persist, which hinder care for individuals living with fibroids. The Society for Women's Health Research convened an interdisciplinary Uterine Fibroids Working Group to review the current state of knowledge about uterine fibroids and recommend areas in which to prioritize efforts to address research gaps and improve diagnosis, treatment, and access to care for patients with this chronic disease. Throughout a 2-day roundtable meeting, participants discussed updates on key literature, research, clinical practice, and public health data on uterine fibroids. Overarching themes and recommendations were identified and determined by consensus agreement of the participants at the conclusion of the meeting. Systematic studies of the etiology and pathology of uterine fibroids are needed to address important knowledge gaps and unmet clinical needs regarding the multifaceted management of fibroids and their effects on overall health and quality of life. The Working Group recommends addressing key deficits within the spheres of research, clinical care, and federal policy. Immediate needs include increasing research investment, improving fibroid assessment using pelvic imaging, implementing longitudinal study designs, addressing factors that contribute to disease disparities (especially among women of color), developing fertility-friendly treatment options, expanding awareness and education beyond gynecologic specialists, and advancing personalized patient care through shared decision-making approaches.
Collapse
Affiliation(s)
- Irene O Aninye
- Society for Women's Health Research, Washington, District of Columbia, USA
| | - Melissa H Laitner
- Society for Women's Health Research, Washington, District of Columbia, USA
| |
Collapse
|
19
|
The importance of compression sonoelastography in improving the diagnostics of the pathology of myometrium. EUREKA: HEALTH SCIENCES 2021. [DOI: 10.21303/2504-5679.2021.001908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The diversity of the clinical picture and the asymptomatic nature of the clinical manifestations of myometrial pathology cause difficulties in diagnosis. There is a lack of reliable diagnostic criteria for this pathology, in particular, imaging, especially with the simultaneous combination of adenomyosis and leiomyoma.
The aim of the research. Determination of the possibility of compression sonoelastography in the diagnosis of myometrial pathology and determination of its sonoelastography characteristics in leiomyoma and adenomyosis, as well as comparison of sonoelastography results with histological data.
Materials and methods. Elastography images of 155 patients with adenomyosis and leiomyoma, as well as combined pathology, were analyzed, the elastography diagnosis of which was confirmed by histological examination.
Results. Leiomyoma and adenomyosis had different elastography characteristics (strain ratios) with different color mapping; their specific characteristics and main differences are determined. Based on sonoelastography, the majority of patients (n=30) were suspected of having uterine fibroids, 14 had adenomyosis, and 42 had adenomyosis and fibroids. Sonoelastography revealed histological signs of adenomyosis in 3 patients with uterine leiomyoma.
Conclusions. Ultrasound examination using compression sonoelastography in such pathological conditions of the myometrium as adenomyosis and leiomyoma, as well as unchanged myometrium, makes it possible to determine changes in the degree of elasticity of the myometrium in the corresponding pathology. Sonoelastography allows the identification of clear distinguishing features of fibroids and adenomyosis. The unchanged myometrium has a certain elasticity, which can be equated to a specific numerical value – the coefficient of deformation. This indicator has different meanings in myoma and adenomyosis, which makes it possible to differentiate these pathological conditions of the myometrium. Compression sonoelastography is able to identify clear distinguishing features of leiomyoma and adenomyosis, and consistency of diagnoses based on sonoelastography and histology is significant but not optimal.
Collapse
|
20
|
Zhang M, Townsel CD, Akers LB, Kiros L, Treadwell MC, Maturen KE. Biomechanical Cervical Assessment Using 2-Dimentional Transvaginal Shear Wave Elastography in Nonpregnant and Pregnant Women: A Prospective Pilot Study. Ultrasound Q 2021; 37:183-190. [PMID: 34057917 DOI: 10.1097/ruq.0000000000000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
ABSTRACT This study evaluated the technical feasibility of 2-dimensional transvaginal shear wave elastography to quantify cervical stiffness in nonpregnant and pregnant women and established normal values in each group. With institutional review board approval, we performed a prospective study with an age-matched historical control design. Sixteen premenopausal nonpregnant women without cervical pathology and 17 low-risk pregnant women (gestational age 17-33 weeks) were enrolled. Cervical shear wave speeds were measured on a SuperSonic Aixplorer machine. The mean shear wave speeds of anterior cervix were 4.96 ± 1.96 m/s in nonpregnant women and 1.92 ± 0.31 m/s in pregnant women. No significant stiffness difference was found between the anterior and posterior cervix (P = 0.15). The upper cervix was stiffer than the lower cervix in the pregnant women (P = 0.00012). Transvaginal shear wave elastography reveals that cervix at a midterm gestation is significantly softer than nonpregnant cervix (P < 0.0001) and suggests a spatial stiffness gradient along the length of the cervix, consistent with histopathology and limited elastography literature. Our results indicate the potential of transvaginal shear wave elastography to provide objective and quantitative estimates of cervical stiffness, especially during pregnancy.
Collapse
Affiliation(s)
| | | | | | - Leah Kiros
- Psychology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | | |
Collapse
|
21
|
Vaginal elasticity is significantly decreased in vaginal atrophy: a strain elastography study. ACTA ACUST UNITED AC 2021; 27:1420-1424. [PMID: 33079743 DOI: 10.1097/gme.0000000000001673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Strain elastography is a novel method to assess the elasticity of tissues. We aimed to evaluate the value of vaginal strain elastography in women with vulvovaginal atrophy (VVA). METHODS Women with or without VVA were enrolled in this prospective study. Participants underwent vaginal cytology and vaginal wall elastography. Vaginal Health Index (VHI) was calculated. Based on Vaginal Maturation Value (VMV), participants were divided into atrophic and nonatrophic groups. Elastography parameters of the vaginal walls were measured in nine regions of interest (ROI). Elastography Index (EI) was defined by the average color score of nine ROIs. Groups were compared with unpaired t test or Mann-Whitney U test. Pearson correlation was used to determine the strength of association between EI and selected parameters. Multiple regression was used to evaluate the association between EI and age, VMV, and vaginal atrophy. RESULTS Ten women were diagnosed with VVA, and twenty had no cytological signs of vaginal atrophy (age-range 38-79 y). VHI score was significantly lower in the atrophic group (mean ± SD, 9.4 ± 2.011 vs 16.6 ± 4.22, P < 0.0001). In the atrophic group, EI was significantly lower than in nonatrophic group (mean ± SD, 20 ± 21 vs 47 ± 4, P < 0.01). We found a strong negative correlation between EI and vaginal atrophy (r = -0.706, P < 0.0001; 95% CI: 0.8501 to -0.4639). In the multiple regression model, only atrophy remained statistically significant for the prediction of EI (P = 0.004). CONCLUSIONS Vaginal elasticity is significantly decreased in women with vaginal atrophy, measured by EI. Our results suggest that strain elastography might be useful in the diagnosis of vaginal atrophy.
Collapse
|
22
|
Xholli A, Simoncini G, Vujosevic S, Trombetta G, Chiodini A, Ferraro MF, Cagnacci A. Menstrual Pain and Elasticity of Uterine Cervix. J Clin Med 2021; 10:jcm10051110. [PMID: 33799937 PMCID: PMC7961784 DOI: 10.3390/jcm10051110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/25/2022] Open
Abstract
Menstrual pain is consequent to intense uterine contraction aimed to expel menstrual flow through downstream uterine cervix. Herein it was evaluated whether characteristics of uterine cervix are associated with intensity of menstrual pain. Ultrasound elastography was used to analyze cervix elasticity of 75 consecutive outpatient women. Elasticity was related to intensity of menstrual pain defined by a Visual Analogue Scale (VAS). Four regions of interest (ROI) were considered: internal uterine orifice (IUO), anterior (ACC) and posterior cervical (PCC) compartment and middle cervical canal (MCC). Tissue elasticity, evaluated by color score (from 0.5 = blue/violet (low elasticity) to 3.0 = red (high elasticity), and percent tissue deformation was analyzed. Elasticity of IUO was lower (p = 0.0001) than that of MCC or ACC, and it was negatively related (R2 = 0.428; p = 0.0001) to menstrual VAS (CR −2.17; 95%CI −3.80, −0.54; p = 0.01). Presence of adenomyosis (CR 3.24; 95% CI 1.94, 4.54; p = 0.0001) and cervix tenderness at clinical examination (CR 2.74; 95% CI 1.29, 4.20; p = 0.0004), were also independently related to menstrual VAS. At post hoc analysis, women with vs. without menstrual pain had lower IUO elasticity, expressed as color score (0.72 ± 0.40 vs. 0.92 ± 0.42; p = 0.059), lower percent tissue deformation at IUO (0.09 ± 0.05 vs. 0.13 ± 0.08; p = 0.025), a higher prevalence of cervical tenderness at bimanual examination (36.2% vs. 9.5%; p = 0.022) and a higher prevalence of adenomyosis (46.5% vs. 19.9%; p = 0.04). These preliminary data indicate that IUO elasticity is associated with the presence and the intensity of menstrual pain. Mechanisms determining IUO elasticity are useful to be explored.
Collapse
Affiliation(s)
- Anjeza Xholli
- Academic Unit of Obstetrics and Gynecology, Maternal and Child Health (DiNOGMI), IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (A.X.); (A.C.); (M.F.F.)
| | - Gianluca Simoncini
- Academic Unit of Obstetrics and Gynecology, Azienda Sanitaria Universitaria di Udine, 33100 Udine, Italy; (G.S.); (S.V.); (G.T.)
| | - Sonja Vujosevic
- Academic Unit of Obstetrics and Gynecology, Azienda Sanitaria Universitaria di Udine, 33100 Udine, Italy; (G.S.); (S.V.); (G.T.)
| | - Giulia Trombetta
- Academic Unit of Obstetrics and Gynecology, Azienda Sanitaria Universitaria di Udine, 33100 Udine, Italy; (G.S.); (S.V.); (G.T.)
| | - Alessandra Chiodini
- Academic Unit of Obstetrics and Gynecology, Maternal and Child Health (DiNOGMI), IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (A.X.); (A.C.); (M.F.F.)
| | - Mattia Francesco Ferraro
- Academic Unit of Obstetrics and Gynecology, Maternal and Child Health (DiNOGMI), IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (A.X.); (A.C.); (M.F.F.)
| | - Angelo Cagnacci
- Academic Unit of Obstetrics and Gynecology, Maternal and Child Health (DiNOGMI), IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (A.X.); (A.C.); (M.F.F.)
- Correspondence:
| |
Collapse
|
23
|
Song M, Park SB, Yoon JW, Park HJ, Lee ES. Sonoelastography for pelvic metastatic malignant pheochromocytoma: A case report. Curr Med Imaging 2021; 17:1167-1170. [PMID: 33480348 DOI: 10.2174/1573405617666210122085839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 11/22/2022]
Abstract
Pheochromocytoma are tumors arising from the chromaffin tissue located in the adrenal medulla and are associated with typical symptoms and signs. Occasionally, metastasis, defined as the presence of tumor cells at sites other than the original site, secondary to pheochromocytoma have been reported. Pelvic metastatic malignant pheochromocytoma has rarely been reported in the English literature. Here, we have reported a very rare case of pelvic metastatic malignant pheochromocytoma, with particular focus on sonoelastographic features.
Collapse
Affiliation(s)
- Minkyo Song
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973. Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973. Korea
| | - Jin Woo Yoon
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973. Korea
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973. Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973. Korea
| |
Collapse
|
24
|
Görgülü FF, Okçu NT. Which imaging method is better for the differentiation of adenomyosis and uterine fibroids? J Gynecol Obstet Hum Reprod 2020; 50:102002. [PMID: 33242677 DOI: 10.1016/j.jogoh.2020.102002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The paper compares shear wave elastography (SWE), strain elastography (SE) and magnetic resonance imaging apparent diffusion coefficient (MRI ADC) values, to evaluate their efficacy for differentiating between adenomyosis (AM) and uterine fibroids (UF). METHODS Patients who were scheduled for hysterectomy for AM or UFs, with a preliminary diagnosis, were additionally evaluated before surgery by transabdominal and transvaginal ultrasound elastography. SE of patients were evaluated by transvaginal ultrasound, and SWE of patients and control subjects were evaluated by transabdominal ultrasound. Then, the patients with a definitive histopathological diagnosis as AM or UFs were evaluated retrospectively and compared to the control group without myometrial pathology. In addition, MRI images of patients with UFs and AM were examined for ADC values. RESULTS The results of 98 patients in the UF group, 37 patients in the AM group, and 40 volunteers with a healthy myometrium in the control group were compared. There were no statistically significant differences in age and body mass index between the groups (P > 0.05). Uterine size was significantly higher in the UF and AM group than the control group (P < 0.001). A statistically significant difference was found between strain ratio (mean), strain ratio (max), and ADC values between the UF and AM groups (P < 0.001 for all three). There was a statistically significant difference in elastography scores distribution between the groups (P < 0.001). There was a statistically significant difference between the UF and control (P < 0.001) and between the UF and AM (P < 0.001) groups in terms of SWE (kilopascal (kPa)) averages (P < 0.001). We found that none of these discrimination methods were statistically superior to each other in differentiating the UFs from the AM. CONCLUSION In the differentiation of myometrial pathologies in gynecological imaging, both SE and SWE are cheaper, provide faster results, are non-invasive and easy to apply, and hence are as promising as the more expensive MRI ADC. Our study is the first to use both modalities of elastography and MRI ADC values together, compare these methods with each other and confirm the results pathologically.
Collapse
Affiliation(s)
- Feride Fatma Görgülü
- Department of Radiology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey.
| | - Nefise Tanrıdan Okçu
- Department of Obstetrics and Gynecology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
| |
Collapse
|
25
|
A critical review of recent advances in the diagnosis, classification, and management of uterine adenomyosis. Curr Opin Obstet Gynecol 2020; 31:212-221. [PMID: 31192829 DOI: 10.1097/gco.0000000000000555] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize and highlight recent critical advances in the diagnosis, classification, and management of adenomyosis. RECENT FINDINGS Recent studies have clarified the specific mechanism through which adenomyotic lesions invade the underlying myometrium by epithelial-mesenchymal transition. Correlation studies using diagnostic MRI also strongly support the hypothesis of a different pathogenesis between the inner and outer myometrium forms of adenomyosis. Given advances in diagnostic imaging, several international organizations have also highlighted the importance of classification systems for adenomyosis. Finally, selective progesterone receptor modulators and gonadotropin-releasing hormone antagonists have demonstrated significant promise for treating pelvic pain and bleeding associated with adenomyosis, whereas novel fertility-preserving surgical techniques have been introduced to excise diffuse adenomyotic pathology while maintaining adequate uterine integrity. SUMMARY Recent attempts at a uniform and reproducible classification system likely represent the first step for the development of a staging system for adenomyosis that can be correlated with the severity of clinical symptoms and promote an individualized therapeutic approach. Simultaneously, further insights into the etiology and pathogenesis as outlined in this review may also help in the development of targeted medical therapies.
Collapse
|
26
|
New surgical technique of laparoscopic resection of adenomyosis under real-time intraoperative ultrasound elastography guidance: A case report. Heliyon 2020; 6:e04628. [PMID: 32793836 PMCID: PMC7408330 DOI: 10.1016/j.heliyon.2020.e04628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/11/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023] Open
Abstract
Detecting adenomyosis in the myometrium is a challenge since it is infiltrative with ill-defined margins and can be often confused with uterine fibroids. However, recent advances, such as ultrasound elastography, have enabled its detection in the myometrium, thereby facilitating its accurate diagnosis. We report our experience of performing complete laparoscopic resection of adenomyosis under real-time ultrasound elastography guidance in a 32-year-old woman who underwent laparoscopic adenomyomectomy following severe dysmenorrhea and heavy menstrual bleeding. Real-time ultrasound elastography was also utilized intraoperatively to detect residual adenomyosis. Complete adenomyosis resection and uterine reconstruction were achieved. Follow-up magnetic resonance imaging was conducted to confirm successful uterine reconstruction. The patient recovered rapidly with no complications. Intraoperative elastography-guided laparoscopic adenomyomectomy was feasible and effective in completely removing adenomyotic lesions.
Collapse
|
27
|
Jiao Y, Xue N, Zou C, Shui X, Wang H, Hu C. Assessment of early damage of endometrium after artificial abortion by shear wave elastography. Insights Imaging 2020; 11:28. [PMID: 32128718 PMCID: PMC7054526 DOI: 10.1186/s13244-020-0841-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/30/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the application of shear wave elastography (SWE) in the early damage detection through assessing the endometrial elasticity after artificial abortion. METHODS A total of nulliparous women (20-30 years) who received ultrasonography in our hospital were recruited between January 2017 and December 2017. These women were divided into normal control group (NC; n = 65), after once artificial abortion group (AOAA; n = 68), after twice artificial abortion group (ATAA; n = 61), and after three times or more (range, 3-6) artificial abortion group (ATTMAA; n = 60). SWE was performed to evaluate the endometrium; Young's modulus of the endometrium was determined and then the endometrial thickness was measured. RESULTS Young's modulus of the endometrium increased in the order of NC group, AOAA group, ATAA group, and ATTMAA group, and Young's modulus increased with the increase in the number of artificial abortions (p < 0.05). The endometrial thickness in the ATTMAA group was significantly lower than in the NC group, AOAA group, and ATAA group (p < 0.05), but there was no marked difference among the NC group, AOAA group, and ATAA group (p > 0.05). CONCLUSIONS SWE increases with increasing number of abortions, which may indicate the damage that is done to the endometrium earlier than measurement of the endometrial thickness do.
Collapse
Affiliation(s)
- Yan Jiao
- Department of Radiology, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, China
- Obstetrics and Gynecology Ultrasonic Department, Wenzhou Peoples' Hospital, Wenzhou, 325000, China
| | - Nianyu Xue
- Department of Diagnostic Ultrasonography, Ningbo First Hospital, Ningbo, 315010, China
| | - Chunpeng Zou
- Department of Diagnostic Ultrasonography, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Xujuan Shui
- Obstetrics and Gynecology Ultrasonic Department, Wenzhou Peoples' Hospital, Wenzhou, 325000, China
| | - Hongqing Wang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, China.
| |
Collapse
|
28
|
Simões APR, Maronezi MC, Uscategui RAR, Avante ML, Gasser B, Silva P, Pavan L, Maciel GS, Pelógia MES, Vicente WRR, Feliciano MAR. Quantitative ultrasound elastography and biometry of the bitch uterus in the early puerperium after vaginal delivery and caesarean section. Reprod Domest Anim 2020; 55:364-373. [PMID: 31945229 DOI: 10.1111/rda.13633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/30/2019] [Indexed: 11/30/2022]
Abstract
Elastography is an actual imaging method used to qualitatively and quantitatively evaluate the elastic properties of tissues. The aim of this study was to evaluate and compare uterine tissue biometry and stiffness during post-partum period in brachycephalic bitches (n = 12) after c-section (GCS; n = 8) or normal delivery (GNB; n = 4). These animals were evaluated daily by abdominal ultrasound from the day of delivery until the 10th day post-partum; measuring uterine diameter, myometrial and endometrial thickness (mm) and shear wave velocity (SWV; m/s), by B-mode and ARFI (acoustic radiation force impulse) elastography, respectively. Uterine diameter was higher (p = .012) in animals submitted to c-section (15.26 ± 4.73 mm) than in normal birth (12.53 ± 2.64 mm) during the first 7 days post-partum. Uterine thickness gradually involuted in both groups (p < .0001), the myometrium during the first 9 days (p = .005) and the endometrium during the first 6 days (p = .003). The myometrial and endometrial SWVs were similar between types of delivery (p = .7846 and .8273) and presented a gradual increase (p = .411; .0043, respectively), during the first 10 days post-partum. It was concluded that bitches with normal delivery had smaller uterine thickness and faster puerperal involution than submitted to c-section, while uterine tissue stiffness was similar between delivery types and increased gradually during post-partum.
Collapse
Affiliation(s)
- Ana Paula Rodrigues Simões
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | - Marjury Cristina Maronezi
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | | | - Michelle Lopes Avante
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | - Beatriz Gasser
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | - Priscila Silva
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | - Letícia Pavan
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | - Giovanna Serpa Maciel
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil
| | | | | | - Marcus Antonio Rossi Feliciano
- Faculty of Agricultural and Veterinary Sciences, Univ. Estadual Paulista "Júlio de Mesquita Filho", Jaboticabal, Brazil.,Department of Large Animals Clinic and Surgery, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| |
Collapse
|