Association Between 3D Transvaginal Ultrasound-Based XI VOCAL Counting Severity and Tissue MMP-9 Levels in Patients with Adenomyosis

Ni Luh Lany Christina,1 Hartanto Bayuaji,1 Mulyanusa Amarullah Ritonga,1 Ruswana Anwar,1 Anita Rachmawati,1 Dian Tjahyadi,1 Sri Ratna Dwiningsih21Department of Obstetrics and Gynecology, Hasan Sadikin General Teaching Hospital, Faculty of Medicine, Padjadjaran University, Bandung, West Java, Indonesia; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Airlangga University, Surabaya, East Java, IndonesiaCorrespondence: Ni Luh Lany Christina, Department of Obstetrics and Gynecology, Hasan Sadikin General Teaching Hospital, Faculty of Medicine, Padjadjaran University, Pasteur No. 38 Street, Pasteur, Bandung, West Java, 40161, Indonesia, Tel +6281353455466, Email [email protected]: Adenomyosis severity assessment remains challenging due to the lack of objective imaging parameters associated with underlying tissue characteristics. This study aimed to investigate the association between 3D transvaginal ultrasound-based XI VOCAL Counting severity and tissue MMP-9 levels in patients with adenomyosis.Patients and Methods: This study employed an analytical observational design with a cross-sectional approach, focusing on adenomyosis patients who underwent surgery at Dr. Hasan Sadikin and Bandung Kiwari Hospitals. Diagnosis and severity were assessed using 3D transvaginal ultrasound-based XI VOCAL Counting, which quantifies transverse uterine sections showing MUSA direct signs, including subendometrial lines and buds, hyperechoic islands, and intramyometrial cysts. Tissue MMP-9 levels were measured by ELISA, and statistical analysis evaluated group differences and variable correlations, with significance set at p ≤ 0.05.Results: A total of 54 patients were included. XI VOCAL Counting severity was positively associated with tissue MMP-9 levels. The correlation was moderate during the proliferative phase (r = 0.680) and stronger during the secretory phase (r = 0.814; p < 0.001).Conclusion: XI VOCAL Counting severity was positively associated with tissue MMP-9 levels in patients with adenomyosis, with a stronger association observed during the secretory phase. These findings suggest that XI VOCAL Counting may provide a potential imaging-based severity assessment associated with molecular characteristics related to extracellular matrix remodeling. Further prospective multicenter studies are required to validate its reproducibility, clinical utility, and association with clinical outcomes.Keywords: adenomyosis, MMP-9, XI vocal counting, 3D transvaginal ultrasound, direct signs