86 DISCUSSION: We assessed clinical and MRI parameters for their potential to predict histopathological adenomyosis diagnosis prior to hysterectomy. The resultant multivariate prediction model discriminates well between patients with and without adenomyosis (AUC 0.776). Five clinical characteristics: age at MRI, BMI, history of curettage, dysmenorrhoea, and AUB, and four primary MRI parameters: mean JZ thickness, JZ Diff ³5 mm, JZ/MYO >.40, and the presence of HSI foci are included. To the best of our knowledge, no comparable models for histopathological adenomyosis diagnosis based on MRI exist. Previous studies have investigated prediction of adenomyosis diagnosis based on ultrasound, with comparable accuracy (37,184,185). However, it is known that ultrasound diagnosis is highly operator dependent, with varying inter- and intra-observer variability (183,192,193). An MRI prediction model such as developed in our study thus has clinical value especially in cases where adenomyosis co-exists with other pathology (as was the case in the majority of our included patients), or is mild, or atypical. The parameters ultimately included in this model are unsurprising when considering reported adenomyosis clinical presentation and aetiology. Dysmenorrhoea and AUB are the most frequently reported symptoms of adenomyosis (19,194) and were thus logical (and statistically significant) additions to the model. Age at MRI was further included in the model due to the known physiological increase in JZ thickness with age (46,98,195). BMI was also manually entered into the model as, despite univariate analysis showing no significant association, increased body weight and obesity have been reported as strong risk factors for adenomyosis (196). History of curettage (after miscarriage) established itself to be an important predictor and was thus included in our model. It is debatable as to if curettage is a cause or a consequence of adenomyosis, as adenomyosis is often associated with risk of miscarriage (81). Conversely, curettage as a risk factor for the development of adenomyosis could potentially be explained by iatrogenic trauma leading to the mechanical transport of endometrial cells into the myometrium (8,10).
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