Stap 1 van 92 1% Dear participant, Welcome to the second round of the Delphi study on the MUSA characteristics for adenomyosis. In this round, we will present to you the results of the first round including the comments of the participating experts per characteristic. After that, we will ask you to rate a series of additional images that were collected from both new example cases and from the preceding round. In this round, we will only use stills in order to be able to clarify the exact definition of the individual characteristics. After each round of stills, we present a proposal for a new/revised definition of that MUSA characteristic and provide the opportunity to criticize this proposal. Per characteristic, there are 5-10 questions. This round will take approximately 60 minutes in total. We are using images from videos and from original stills, therefore we will use the word video and image interchangeable. There are NO actual videos in this Delphi. We have also added images from the VISUOG, hereby crediting them for the use ONLY in this Delphi. If you have any comments or questions regarding this project, please feel free to contact us. Please fill out the email address you used for the previous round: Globular uterus On this page we will summarize the results of the first round, concerning the characteristic "Globular Uterus". We found consensus on 12 videos and no consensus on 3 videos. The common remarks were: - not sure what the definition is - C-section scar can mimic globular uterus - the uterus does not seem globular enlarged, but the shape still seems globular. Below you will find an example of a video on which we reached consensus about the presence of a globular uterus (left), the absence of a globular uterus (right) and on which we did not reach consensus (middle). Following analysis of the videos on which we reached consensus, and taken the comments into account, we came to the following proposal for a definition of the presence of a globular uterus: A globular uterus is present were the anterior and posterior contour of the uterus diverge from the endometrium (non paralel). This results in the typical spherical curvature (see example of the outline below). Additionally we have two extra questions: G1. Should we say something about globally enlarged vs globally shaped? G2. Should both anterior and posterior wall diverge, or is one side enough? Next, we ask you to assess a set of additional images and decide whether the presented image shows a globular uterus or not. If not, please provide us with an argument supporting your judgement. 1a. Is this a globular uterus?* Yes No 1a. Do you have any remarks concerning this example? 1b. Is this a globular uterus?* Yes No 1b. Do you have any remarks concerning this example? 1c. Is this a globular uterus?* Yes No 1c. Do you have any remarks concerning this example? 1d. Is this a globular uterus?* Yes No 1d. Do you have any remarks concerning this example? 1e. Is this a globular uterus?* Yes No 1e. Do you have any remarks concerning this example? 1f. Is this a globular uterus?* Yes No 1f. Do you have any remarks concerning this example? 1g. Is this a globular uterus?* Yes No 1g. Do you have any remarks concerning this example? 1h. Is this a globular uterus?* Yes No 1h. Do you have any remarks concerning this example? A possible definition could be: A globular uterus is present were the anterior and posterior contour of the uterus diverge from the endometrium (non paralel). This results in the typical spherical curvature and should be evaluated in a mid-sagittal plane.1f. Could you agree with such a definition?* Yes, sure Yes, but with a modification: No, not like this, but... 1g. What would your suggestion for a definition be? Asymetrical thickening of myometrium On this page we will summarize the results of the first round, concerning the characteristic "Asymmetrical thickening". We found consensus on 12 videos and no consensus on 3 videos. The common remarks were: - no measurements done - only slightly Below you will find an example of images on which we reached consensus about the presence of asymmetrical thickening (left), the absence of asymmetrical thickening (right) and on which we did not reach consensus (middle). We ask you to assess a set of additional images and decide whether the presented image shows asymmetrical thickening of the myometrial walls or not. If not, please provide us with an argument supporting your judgment Depending on your judgment of what you regard as asymmetrical thickening, we hope to be able to specify the definition of asymmetrical thickening and add a minimum difference. 2a. Is this asymmetrical thickening of the myometrium?* Yes No 2a. Do you have any remarks concerning this example? 2b. Is this asymmetrical thickening of the myometrium?* Yes No 2b. Do you have any remarks concerning this example? 2c. Is this asymmetrical thickening of the myometrium?* Yes No 2c. Do you have any remarks concerning this example? 2d. Is this asymmetrical thickening of the myometrium?* Yes No 2d. Do you have any remarks concerning this example? 2e. Is this asymmetrical thickening of the myometrium?* Yes No 2e. Do you have any remarks concerning this example? This is a proposal for a definition of asymmetrical thickening. "Asymmetrical thickening occurs when the difference in thickness of the anterior and the posterior myometrial wall exceeds 5 mm"2f. Could you agree with such a definition?* Yes, sure Yes, but with a modification: No, not like this, but... 2g. What would your suggestion for a definition be? Cysts On this page, we will summarize the results of the first round, concerning the characteristic "Cysts". We found consensus on 14 examples and no consensus on 1 example video. The common remarks were: - What is the minimal size? - What is the definition? Below you will find an example images on which we reached consensus about the presence of cysts (left), the absence of cysts (right), and on which we did not reach consensus (middle). We ask you to assess a set of additional images and decide whether the presented image shows myometrial cysts or not. If not, please provide us with an argument supporting your judgment Depending on your judgment of what you regard as a cyst, we hope to be able to specify the definition of a cyst and add a minimum size. 3a. Is this a cyst in the myometrium?* Yes No 3a. Do you have any remarks concerning this example? 3b. Is this a cyst in the myometrium?* Yes No 3b. Do you have any remarks concerning this example? 3c. Is this a cyst in the myometrium?* Yes No 3c. Do you have any remarks concerning this example? The color doppler show NO color in this area3d. Is this a cyst in the myometrium?* Yes No 3d. Do you have any remarks concerning this example? 3e. Are these cysts in the myometrium?* Yes No 3e. Do you have any remarks concerning this example? 3f. Do you see any cysts in the myometrium?* Yes No 3f. Do you have any remarks concerning this example? 3g. Do you see any cysts in the myometrium?* Yes No 3g. Do you have any remarks concerning this example? A possible definition could be: "Rounded transone lesions in the myometrium, without flow, with a minimum size of 3mm or with a clear hyperechogenic rim" 3f. Could you agree with such a definition?* Yes, sure Yes, but with a modification: No, not like this, but... 3g. What would your suggestion for a definition be? Fans-haped shadowing On this page we will summarize the results of the first round, concerning the characteristic "Fan-shaped shadowing". We found consensus on 12 examples and no consensus on 3 example videos. The common remarks were: - Not clear - minimally visible - please provide pure black/white images (no doppler) Below you will find an example of images on which we reached consensus about the presence of fan-shaped shadowing (left), the absence of fan-shaped shadowing (right), and on which we did not reach consensus (middle). We ask you to assess a set of additional images and decide whether the presented image shows fan-shaped shadowing or not. If not, please provide us with an argument supporting your judgment. Depending on your judgment of what you regard fan-shaped shadowing, we hope to be able to specify the definition. 4a. Is this fan shaped shadowing?* Yes No 4a. Do you have any remarks concerning this example? 4b. Is this fan shaped shadowing?* Yes No 4b. Do you have any remarks concerning this example? 4c. Is this fan shaped shadowing?* Yes No 4c. Do you have any remarks concerning this example? 4d. Is this fan shaped shadowing?* Yes No 4d. Do you have any remarks concerning this example? 4e. Is this fan shaped shadowing?* Yes No 4e. Do you have any remarks concerning this example? 4f. Is this fan shaped shadowing?* Yes No 4f. Do you have any remarks concerning this example? 4g. Is this fan shaped shadowing?* Yes No 4g. Do you have any remarks concerning this example? 4h. Is this fan shaped shadowing?* Yes No 4h. Do you have any remarks concerning this example? 4i. Is this fan shaped shadowing?* Yes No 4i. Do you have any remarks concerning this example? This is a proposal for a definition fan-shaped shadowing: "Fan-shaped shadowing is present when linear hypo-echogenic stripes are present behind the myometrial lesion, sometimes alternating with linear hyper-echogenic stripes (slight/moderate/strong). This characteristic is best assessed without color Doppler on"4j. Could you agree with such a definition?* Yes, sure Yes, but with a modification: No, not like this, but... 4j. What would your suggestion for a definition be? Translaesional vascularity On this page we will summarize the results of the first round, concerning the characteristic "Translaesional vascularity". We found consensus on 13 examples and no consensus on 2 example video. The common remark was: - Doubt about lesion; hence no translesional vascularity Below you will find an example of a video on which we reached consensus about the presence of translesional vascularity (left), the absence of translesional vascularity (right) and on which we did not reach consensus (middle). We will now show you 5 examples of stills, asking you if you would classify this as translaesional vascularity or not. The current definition is: “Translesional vascularity is present when blood vessels are present crossing the lesion in the myometrium perpendicular to the endometrium.” At the end we will ask you if you agree to some additions to this definition: 5a. Is this Translaesional vascularity?* Yes No 5a. Do you have any remarks concerning this example? 5b. Is this translaesional vascularity?* Yes No 5b. Do you have any remarks concerning this example? 5c. Is this translaesional vascularity?* Yes No 5c. Do you have any remarks concerning this example? 5d. Is this translaesional vascularity?* Yes No 5d. Do you have any remarks concerning this example? 5e. Is this translaesional vascularity?* Yes No 5e. Do you have any remarks concerning this example? 5f. . This is a proposal for a definition of translesional vascularity. “Translesional vascularity is present when blood vessels are present crossing the lesion in the myometrium perpendicular to the endometrium.” We suggest making a distinction in what to expect with these additions: 5f. - Translesional vascularity in diffuse adenomyosis, where you expect to see translesional vascularity dispersed throughout the myometrium. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 5f. Circumferential vascularity can also be present in focal adenomyosis, with or without translesional vascularity, depending on the content of the adenomyoma (cystic/glandular/fibrotic)" Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 5g. What would your suggestion for a definition be? Hyperechogenic islands On this page, we will summarize the results of the first round, concerning the characteristic "Hyperechogenic islands". We found consensus on 13 examples and no consensus on 2 example videos. The common remarks were: - Doubt about echo enhancement - Poor resolution Below you will find an example of images on which we reached consensus about the presence of hyperechogenic islands (left), the absence of hyperechogenic islands (right) and on which we did not reach consensus (middle). We will now show you 9 examples of stills, asking you if you believe this is a Hyperechogenic islands or not. The current definition is: "Hyper echogenic areas lye within the myometrium and they may be regular, irregular or ill-defined". In the end, we will propose some additions to this definition. 6a. Is the blue arrow an hyperechogenic island?* Yes No 6a. Is the yellow arrow an hyperechogenic island?* Yes No 6a. Do you have any remarks concerning this example? 6b. Is this / are these hyperechogenic islands?* Yes No 6b. Do you have any remarks concerning this example? 6c. Is the blue arrow an hyperechogenic island?* Yes No 6c. Is the white arrow an hyperechogenic island?* Yes No 6c. Do you have any remarks concerning this example? 6d. Is this / are these hyperechogenic islands?* Yes No 6d. Do you have any remarks concerning this example? 6e. Is this / are these hyperechogenic islands?* Yes No 6e. Do you have any remarks concerning this example? 6f. Is the yellow arrow an hyperechogenic island?* Yes No 6f. Is the blue arrow an hyperechogenic island?* Yes No 6f. Is the green arrow an hyperechogenic island?* Yes No 6f. Do you have any remarks concerning this example? 6g. Is / are there hyperechogenic islands present?* Yes No 6g. Do you have any remarks concerning this example? 6h. Is / are there hyperechogenic islands present?* Yes No 6h. Do you have any remarks concerning this example? 6i. Is / are there hyperechogenic islands present?* Yes No 6i. Do you have any remarks concerning this example? 6f. The current definition is: "Hyper echogenic areas lye within the myometrium and they may be regular, irregular or ill-defined". We would like to propose the following additions:6j. We suggest no minimum diameter because it is too hard to measure (eyebolling?). Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 6g. We suggest to add that hyperechogenic islands need to have a minimum distance from the endometrium, for example 2mm. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 6g. We suggest that a minimum number of 3 hyperechogenic islands need to be present to score this item positive to prevent recording artefacts. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 6h. What would your suggestion for a definition be? Echogenic subendometrial lines and buds On this page we will summarize the results of the first round, concerning the characteristic "Echogenic subendometrial lines and buds". We found consensus on 13 examples and no consensus on 2 example videos. The common remarks were: - Endometrium hard to distinguish - 4x JZ not visible (to thin) - >50% said 3D is missing - Only slightly/little bit Below you will find an example of images on which we reached consensus about the presence of subendometrial lines and buds (left), the absence of subendometrial lines and buds (right) and on which we did not reach consensus (middle). We will now show you 6 examples of stills, asking you if you believe these are subendometrial lines and buds or not. The current definition is: "Subendometrial lines or buds may be observed disrupting the JZ. They are (almost) perpendicular to the endometrial cavity and are in a continuum with the endometrium." In the end, we will ask you about an addition to this definition. 7a. Is this / are these hyperechogenic lines and buds?* Yes No 7a. Do you have any remarks concerning this example? 7b. Is this / are these hyperechogenic lines and buds?* Yes No 7b. Do you have any remarks concerning this example? 7c. Is this / are these hyperechogenic lines and buds?* Yes No 7c. Do you have any remarks concerning this example? 7d. Is this / are these hyperechogenic lines and buds?* Yes No 7d. Do you have any remarks concerning this example? 7e. Is this / are these hyperechogenic lines and buds?* Yes No 7e. Do you have any remarks concerning this example? 7f. Is this / are these hyperechogenic lines and buds?* Yes No 7f. Do you have any remarks concerning this example? The definition is: "Subendometrial lines or buds may be observed disrupting the JZ. They are (almost) perpendicular to the endometrial cavity and are in continuum with the endometrium." We suggest that a 3D US is needed to correctly interpret lines and buds. 7g. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 7h. What would your suggestion for a definition be? Irregular junctional zone On this page we will summarize the results of the first round, concerning the characteristic "Irregular junctional zone". We found consensus on 13 examples and no consensus on 2 example videos. There is one video of which almost half of the experts "did not know". The common remarks were: - >50% remarks that 3D is missing - JZ difficult to see/distinguish Below you will find an example of images on which we reached consensus about the presence of an irregular junctional zone (left), the absence of an irregular junctional zone (right) and on which we did not reach consensus (middle). We will now show you 11 examples of stills, asking you if you believe this is an Irregular junctional zone or not. The current definition is: "The junctional zone can be irregular because of cystic areas, hyperechogenic islands, and hyperechogenic buds and lines. Measurement of irregularity: Jzmax-Jzmin=Jzdif. Extent of irregularity: % of JZ that is irregular (<50% or >50%) (=subjective)". In the end, we will ask you about some additions to this definition. 8a. Do you interpret this as an irregular junctional zone?* Yes No 8a. Do you have any remarks concerning this example? 8b. Do you interpret this as an irregular junctional zone?* Yes No 8b. Do you have any remarks concerning this example? 8c. Do you interpret this as an irregular junctional zone?* Yes No 8c. Do you have any remarks concerning this example? 8d. Do you interpret this as an irregular junctional zone?* Yes No 8d. Do you have any remarks concerning this example? 8e. Do you interpret this as an irregular junctional zone?* Yes No 8e. Do you have any remarks concerning this example? 8f. Do you interpret this as an irregular junctional zone?* Yes No 8f. Do you have any remarks concerning this example? 8g. Do you interpret this as an irregular junctional zone?* Yes No 8g. Do you have any remarks concerning this example? 8h. Do you interpret this as an irregular junctional zone?* Yes No 8h. Do you have any remarks concerning this example? 8i. Do you interpret this as an irregular junctional zone?* Yes No 8i. Do you have any remarks concerning this example? 8j. Do you interpret this as an irregular junctional zone?* Yes No 8j. Do you have any remarks concerning this example? 8k. Do you interpret this as an irregular junctional zone?* Yes No 8k. Do you have any remarks concerning this example? 8k. The definition is: "The junctional zone can be irregular because of cystic areas, hyperechogenic islands, and hyperechogenic buds and lines. Measurement of irregularity: Jzmax-Jzmin=Jzdif. Extent of irregularity: % of JZ that is irregular (<50% or >50%) (=subjective)". Experts find that the definition needs a 3D US to correctly interpret the junctional zone. We would like you opinion about the following additions: 8k. We suggest a high-quality snapshot of the area of interest is better than a movie to correctly assess irregularity of the JZ. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 8k. We suggest that a junctional zone of >12 mm is irregular per definition (to adhere to the definition of adenomyosis (>12mm) on MR imaging) Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 8l. What would your suggestion for a definition be? Interrupted junctional zone On this page we will summarize the results of the first round, concerning the characteristic "Interrupted junctional zone". We found consensus on 14 examples and no consensus on 1 example video. There are four videos of which half of the experts "did not know". The common remarks were: - >50% remarks that 3D is missing - JZ is not visible Below you will find an example of images on which we reached consensus about the presence of an interrupted junctional zone (left), the absence of an interrupted junctional zone (right) and on which we did not reach consensus (middle). We will now show you 12 examples of stills, asking you if you believe this is an Interrupted junctional zone or not. The current definition is: "There is interruption of the Junctional zone when a proportion (%) of JZ cannot be visualized (<50% or >50%)". In the end, we will ask your opinion about some additions to this definition. 9a. Do you interpret this as an interrupted junctional zone?* Yes No 9a. Do you have any remarks concerning this example? 9b. Do you interpret this as an interrupted junctional zone?* Yes No 9b. Do you have any remarks concerning this example? 9c. Do you interpret this as an interrupted junctional zone?* Yes No 9c. Do you have any remarks concerning this example? 9d. Do you interpret this as an interrupted junctional zone?* Yes No 9d. Do you have any remarks concerning this example? 9e. Do you interpret this as an interrupted junctional zone?* Yes No 9e. Do you have any remarks concerning this example? 9f. Do you interpret this as an interrupted junctional zone?* Yes No 9f. Do you have any remarks concerning this example? 9g. Do you interpret this as an interrupted junctional zone?* Yes No 9g. Do you have any remarks concerning this example? 9h. Do you interpret this as an interrupted junctional zone?* Yes No 9h. Do you have any remarks concerning this example? 9i. Do you interpret this as an interrupted junctional zone?* Yes No 9i. Do you have any remarks concerning this example? 9j. Do you interpret this as an interrupted junctional zone?* Yes No 9j. Do you have any remarks concerning this example? 9k. Do you interpret this as an interrupted junctional zone?* Yes No 9k. Do you have any remarks concerning this example? 9L. Do you interpret this as an interrupted junctional zone?* Yes No 9L. Do you have any remarks concerning this example? 9f. The current definition is: "There is interruption of the Junctional zone when a proportion (%) of JZ cannot be visualized (<50% or >50%)". Experts find that the definition needs a 3D US to correctly interpret these What is your opinion about the following additions? 9i. We suggest a high quality snapshot of the area of interest is better than a movie to correctly assess irregularity of the JZ. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 9i. We suggest that if you cannot visualize the JZ in sagital plane, then you could say it is not there (>50% interrupted). Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 9i. We suggest to only assess the JZ in the preluteal phase to obtain a good quality image and no false outcomes. Could you agree with such an addition?* Yes, sure Yes, but with a modification: No, not like this, but... 9j. What would your suggestion for a definition be? Thank you for filling out the second round of this Delphi. We will analyse the results as soon as we have all responses complete. We plan a final "face-to-face" round using Teams to finalize the revised definitions based upon your answers and after we have reached consensus.Do you have any final remarks?
