Acoustic Radiation Force Impulse Elastography for Differentiating Adenomyosis and Uterine Leiomyoma: A Prospective Histopathology-Validated Study with Moderate Diagnostic Performance

Purpose To evaluate the diagnostic performance of Acoustic Radiation Force Impulse (ARFI) elastography in differentiating adenomyosis from uterine leiomyoma and to compare its diagnostic accuracy with magnetic resonance imaging (MRI). Methods This prospective study included 164 patients with histopathologically confirmed diagnoses after hysterectomy: adenomyosis (n = 53), leiomyoma (n = 56), and controls (n = 55). All participants underwent preoperative ARFI elastography and MRI. Shear wave elastography (SWE) values were compared among groups, and diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis. Results Mean SWE values were significantly higher in the leiomyoma group (3.09 ± 0.78 m/s) than in the adenomyosis (2.80 ± 0.83 m/s; p = 0.040) and control groups (2.57 ± 0.84 m/s; p < 0.001). No significant difference was observed between adenomyosis and controls (p = 0.158). For differentiating leiomyoma from controls, the area under the curve (AUC) was 0.677 (95% CI, 0.581–0.773), with 71.4% sensitivity and 62.8% specificity. For differentiating leiomyoma from adenomyosis, the AUC was 0.619 (95% CI, 0.508–0.730), with 67.1% sensitivity and 59.0% specificity. MRI showed high diagnostic accuracy for both conditions and enabled adenomyosis subtype classification, whereas SWE values did not differ significantly among adenomyosis subtypes. Conclusion ARFI elastography demonstrated only modest diagnostic accuracy (AUC 0.619–0.677) in differentiating uterine leiomyoma from normal myometrium and adenomyosis, and failed to distinguish adenomyosis from normal myometrium. Given its limited performance, ARFI elastography cannot be recommended as a standalone diagnostic tool. It may serve as an adjunctive method only in selected settings where MRI is unavailable, but further validation is required before clinical implementation.