Consensus on revised definitions of morphological uterus sonographic assessment (MUSA) features of adenomyosis: results of a modified Delphi procedure

OBJECTIVE To update the Morphological Uterus Sonographic Assessment (MUSA) definitions of adenomyosis if deemed necessary, and to reach consensus on the updated definitions METHODS: A modified Delphi procedure among European gynecologists with expertise in ultrasound diagnosis of adenomyosis was performed. To identify MUSA features that might need revision, 15 two-dimensional (2D) video recordings (four recordings including also three-dimensional (3D) still images) of transvaginal ultrasound (TVUS) examinations of the uterus were presented in an online survey in the first Delphi round. Experts were asked to confirm or refute the presence of each of nine MUSA features of adenomyosis in each of the 15 videoclips and to give comments. In the second round, the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVUS examinations and to provide feedback on the proposed revisions. A third round, an on-line face-to-face meeting, was used to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts. RESULTS Sixteen of eighteen invited experts agreed to participate. Eleven experts completed and four experts partly finished the first assessment round. The experts identified a need for more detailed definitions of some MUSA features. They recommended to use 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts joined the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the on-line meeting, discussed, and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and subendometrial lines and buds were unanimously classified as direct features of adenomyosis, all others were classified as indirect features. CONCLUSIONS Consensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect features of adenomyosis. This article is protected by copyright. All rights reserved.