65 DISCUSSION: Generally, adenomyosis can be diagnosed and quantified on MRI by looking at four characteristics: junctional zone thickness and (ir)regularity, adenomyosis lesion size, uterine morphology, and (relative) myometrial signal intensity. We are unable to suggest from our results which single MRI parameter is most accurate as a diagnostic criterion due a lack of data, however JZ thickness is the most widely used. Most reported diagnostic adenomyosis MRI parameters have in fact not been verified versus the gold standard of histopathology. Only a small number of studies investigated the correlation between MRI phenotype and clinical outcome, with conflicting results. This is the first review to specifically investigate how adenomyosis can be objectively quantified on MRI and which summarizes the diagnostic potential of individual MRI parameters up to now. Previous similar reviews have looked at the use of MRI in the diagnosis and classification of adenomyosis in general, or the JZ separately (16,32). Munro et al. (32) and Kobayashi et al. (16) reviewed the existing classification systems for adenomyosis on imaging and histology and attempted to correlate MRI findings to clinical outcomes. As with our review, the classification systems and diagnostic criteria were shown to vary widely, and few studies correlated clinical outcomes in adenomyosis to MRI phenotype. This was also noted by Gordts et al. (43), highlighting a need for standardized classification and diagnosis of adenomyosis. It has been postulated that adenomyosis phenotype may not be able to be reliably correlated to clinical outcomes (32), and it should be noted that imaging alone may not be the final answer in defining adenomyosis phenotypes. More knowledge of the (epi)genetic profile of adenomyosis, in combination with well-defined and detailed imaging, will likely provide a definitive characterization of the disease in future. Several studies have summarized the relationship of JZ thickness generally to various clinical outcomes (46,98). These studies reported a significant relationship between JZ thickness and outcomes such as infertility, or menstrual phase; however, it is unknown how this may translate to adenomyosis patients. Of the studies included in this review, it could be suggested that JZ thickness is correlated to symptom severity, treatment response, infertility and age.
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