MRI-based pictorial review of the FIGO classification system for uterine fibroids

The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon

Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.

Achieving NPVR ≥ 80% as technical success of high-intensity focused ultrasound ablation for uterine fibroids: a cohort study

OBJECTIVE

To report the long-term re-intervention of patients with uterine fibroids after ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and to analyse the influencing factors of re-intervention in patients in the NPVR ≥ 80% group.

MATERIALS AND METHODS

Patients with a single uterine fibroid who underwent USgHIFU at our hospital from January 2012 to December 2019 were enrolled. The patients were divided into four groups according to different nonperfusion volume ratio (NPVR). Kaplan-Meier survival curve was used to analyse long-term re-intervention in different NPVR groups, and Cox regression was used to analyse the influencing factors of re-intervention in the NPVR ≥ 80% group.

MAIN RESULTS

A total of 1,257 patients were enrolled, of whom 920 were successfully followed up. The median follow-up time was 88 months, and the median NPVR was 85.0%. The cumulative re-intervention rates at 1, 3, 5, 8 and 10 years after USgHIFU were 3.4%, 11.8%, 16.8%, 22.6% and 24.1%, respectively. The 10-year cumulative re-intervention rate was 37.3% in the NPVR < 70% group, 31.0% in the NPVR 70-79% group, 18.2% in the NPVR 80-89% group and 17.8% in the NPVR ≥ 90% group (P < 0.05). However, no difference was found between the group of NPVR 80-89% and the group of NPVR ≥ 90% (P = 0.499). Age of patients and signal intensity on T2-weighted imaging (T2WI) of tumours were found to be independent risk factors for long-term re-intervention in the NPVR ≥ 80% group. A younger age and greater signal intensity on T2W images corresponded to a greater risk of re-intervention.

CONCLUSION

USgHIFU, an alternative treatment for uterine fibroids, has reliable long-term efficacy. NPVR ≥ 80% can be used as a sign of technical success, which can reduce re-intervention rates. However, an important step is to communicate with patients in combination with the age of patients and the signal intensity on T2WI of fibroids.

TRIAL REGISTRATION

This retrospective study was approved by the ethics committee at our institution (Registration No. HF2023001; Date: 06/04/2023). The Chinese Clinical Trial Registry provided full approval for the study protocol (Registration No. CHiCTR2300074797; Date: 16/08/2023).

Uterine Fibroid Embolization Survey in Canada: Challenges, Opportunities, and Differences in Practices Across the Country

Purpose: To assess the current practices surrounding Uterine Fibroid Embolization (UFE) in Canada. Methods: An online survey was sent to Canadian Association for Interventional Radiology (CAIR) members. It included questions on symptoms prompting UFE, patient awareness, investigation, UFE settings, the number of UFE procedures, and post-UFE care. The findings were discussed at CAIR's 2023 annual meeting by an expert panel. Results: Out of 792 surveys sent, 87 were filled (11%). Menorrhagia is the most common indication for UFE (87%). Women's awareness of UFE as a treatment option for fibroids is viewed as poor or average by 94% of our survey respondents. Most respondents see patients in clinics (92%) before the procedure and evaluate fibroids with MRI pre-UFE (76%). There is variability in care post-UFE, with 33% of procedures being performed as day surgery while 67% lead to overnight stay. For pain management, intravenous analgesia (including patient-controlled analgesia) is used in 76% (63/83) of cases while 19% (16/83) of respondents mentioned using epidural analgesia. Finally, there is an even split between embolic agent used; non-spherical polyvinyl alcohol (50%) and spherical particles (50%). Conclusion: Respondents believe patients in Canada still have limited awareness of UFE. Interventional radiologists are increasingly involved in the entire patient care trajectory, overseeing pre-and post-procedure care and hospitalizing patients. For pain management after UFE, it is observed that while epidural analgesia has been demonstrated more effective than alternatives, it is not widely used as the primary method.

'That's just the Ovary!' and other cases of mistaken identity on CT of the female pelvis

CT is often the first imaging test in female patients with lower abdominal and pelvic pain because of the wide availability of CT and differential diagnoses that span both gynecologic and gastrointestinal disease. Pathology within the female pelvis may be difficult to diagnose on CT owing to suboptimal delineation of anatomy in comparison to MRI and ultrasound. These challenges are confounded by overlapping imaging features of a wide range of gynecologic entities and can lead to diagnostic dilemmas. High value CT interpretation will direct the clinician to the best next diagnostic step as ultrasound and MRI provide superior soft tissue delineation. Other imaging modalities, laboratory investigations, or tissue sampling may be necessary to definitively characterize indeterminate lesions. In this review, we illustrate various cases of mistaken identity on CT of the female pelvis involving the ovaries, uterus, and peritoneal cavity while highlighting clinical pearls that may aid the radiologist in arriving at the correct diagnosis and avoiding potential pitfalls.

Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization

PURPOSE

Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization.

METHODS

The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports.

RESULTS

199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),.

CONCLUSIONS

When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.

Long-term re-intervention after USgHIFU and prediction of NPVR in different ages of patients with uterine fibroids

OBJECTIVE

Long-term re-intervention after ultrasound-guided high intensity focused ultrasound (USgHIFU) ablation was reported, and the prediction of non-perfusion volume ratio (NPVR) in differently aged patients with uterine fibroids (UFs) was explored.

MATERIALS AND METHODS

Patients with UFs who underwent USgHIFU ablation from January 2012 to December 2019 were enrolled and divided into < 40-year-old and ≥ 40-year-old groups. Cox regression was used to analyze the influencing factors of re-intervention rate, and receiver operating characteristic (ROC) curve was used to analyze the correlation between NPVR and re-intervention rate.

RESULTS

A total of 2141 patients were enrolled, and 1558 patients were successfully followed up. The 10-year cumulative re-intervention rate was 21.9%, and the < 40-year-old group had a significantly higher rate than the ≥ 40-year-old group (30.8% vs. 19.1%, p < 0.001). NPVR was an independent risk factor in both two groups. When the NPVR reached 80.5% in the < 40-year-old group and 75.5% in the ≥ 40-year-old group, the risk of long-term re-intervention was satisfactory.

CONCLUSION

The long-term outcome of USgHIFU is promising. The re-intervention rate is related to NPVR in differently aged patients. Young patients need a high NPVR to reduce re-intervention risk.

Surgical treatment of a very rare case of a huge intraligamental leiomyoma of the uterus: A case report and mini‑review of the literature

Intraligamental leiomyomas of the uterus are rare. Extremely rare are the huge intraligamental fibroids (>20 cm), whose pre-operative diagnosis and surgical management poses a challenge to everyday clinical practice. The present study describes the case of patient who was subjected to surgical treatment for a huge intraligamental leiomyoma of the uterus, which weighed 3,370 g. A 48-year-old patient, without menstrual disorders and with a medical history of atypical symptoms from the digestive tract, was referred for a gynecological examination. Upon a physical examination, the abdomen was found to be bloated and distended, with no signs of peritoneal irritation. An intra-abdominal mass was suspected, the upper margin of which was palpable at about the level of the xiphoid process. The findings of computed tomography and magnetic resonance imaging confirmed the presence of a huge intra-abdominal mass, which probably originated from the internal genital organs. Following consultation with the patient, surgical treatment with laparotomy was decided. Intraoperatively, a large pedunculated subserosal leiomyoma was found, arising from the right lateral wall of the uterus with retroperitoneal extension within the leaves of broad ligament. Following the resection of the intraligamental leiomyoma, which had significant surgical challenges, a total hysterectomy with bilateral adnexectomy was performed. The post-operative course was smooth. In addition, in the present study, a brief review of intraligamental leiomyomas of the uterus is presented, emphasizing the significant diagnostic and surgical challenges and potential intraoperative complications that may arise in the management of patients with this condition.

Smooth Muscle Tumors of the Uterus at MRI: Focus on Leiomyomas and FIGO Classification

Leiomyomas are smooth muscle tumors of the uterus and are the most common uterine neoplasm. Although leiomyomas are usually asymptomatic, they can manifest with symptoms such as pain or uterine bleeding. Leiomyomas are classified on the basis of their anatomic location and morphology. Localization of leiomyomas relative to the endometrium, myometrium, and uterine serosa with use of the International Federation of Gynecology and Obstetrics (FIGO) classification system is helpful for guiding management in symptomatic patients. The FIGO system is a practical and universally accepted approach for classifying leiomyomas to guide radiologists and clinicians in deciding management. The MRI appearance of conventional leiomyomas is related to their tissue contents of smooth muscle and fibrous tissue and is well established. The MRI features of some leiomyoma subtypes and forms of degeneration also have been described. Other smooth muscle tumors of the uterus recognized in the 2020 World Health Organization classification system include intravenous leiomyomatosis, smooth muscle tumors of uncertain malignant potential, and metastasizing leiomyoma. At the far end of the spectrum are leiomyosarcomas, which are frankly malignant and therefore must be managed accordingly. Although MRI features that suggest a diagnosis of leiomyosarcoma have been proposed, these features overlap with those of some leiomyoma subtypes and degeneration. ^© RSNA, 2023 See the invited commentary by Fennessy and Gargiulo in this issue. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning

Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Uterine Myoma Position-based Radiofrequency Ablation (UMP-b RFA): 36 months follow-up clinical outcomes

OBJECTIVE

To assess the efficacy of Uterine Myoma Position-based Radiofrequency Ablation (UMP-b RFA) at 36 months. An analysis of a new uterine fibroid ablation technique that allows personalized access of delivering radiofrequency energy (transvaginal, hysteroscopic or laparoscopic) based on myoma localization.

STUDY DESIGN

Prospective observational cohort study in a community-based secondary care medical center enrolled 61 premenopausal women with 112 symptomatic uterine myomas. 112 fibroids were ablated in 5 ways with single or combined accesses: 82 Vaginal Ultrasound (VU)-guided RFA, 19 Laparoscopic (L)-RFA, 5 Hysteroscopic (H)-RFA, 5 VU+H-RFA, and 1 VU+L-RFA. The primary endpoint of this study was to evaluate the 3-year clinical outcome of UMP-b RFA. The secondary endpoint was the possible identification of predictors of its success. The outcomes evaluated at 12, 24, and 36 months after UMP-b RFA were myoma size, type of symptomatology suffered, quality of life based on the "Uterine Fibroid Symptom and Quality of Life" questionnaire, and interviews on the degree of satisfaction with this surgery. The reintervention and complication rates were also recorded and analyzed.

RESULTS

Fibroids volume and diameter were significantly reduced by -90.2 % / -55.7 % at 36 months post-intervention (p < 0.001) and the reduction of Symptom Severity scores was -71.8 % three years after UMP-b RA (p < 0.001). The overall improvement in the quality of life was demonstrated by an increase in the Quality-of-Life score of + 26.0 % at the third follow-up (p < 0.001). 88.5 % of the patients interviewed would have the surgery done again if they went back in time. The reintervention rate was 10/61 (16.4 %): 3 hysterectomies, 3 myomectomies, 3 operative hysteroscopies and 1 VU-RFA reoperation. In this group of unsuccessful surgeries, the mean diameter of the dominant myomas was found to be greater than that of the successes (5.3 vs 4.4 cm.). Out of the 61 cases, no major complications occurred, and the 2 minor complications observed were self-limiting.

CONCLUSION

Uterine Myoma Position-based Radiofrequency Ablation is a safe, effective, and minimally invasive solution for the treatment of symptomatic fibroids. Indeed, these clinical outcome data at 36 months shows how UMP-b RFA can treat the symptomatology of uterine fibromatosis. Hysterectomies or myomectomies were successfully avoided in more than 80 % of women bearing myomas with an average diameter of less than 5 cm.

Uterine fibroids - Causes, impact, treatment, and lens to the African perspective

Leiomyomas, or uterine fibroids as they are commonly known, are mostly seen in women of reproductive age. However, they can go undetected in most women, and approximately 25% of women show clinical symptoms. Although fibroids are a global burden impacting 80% of premenopausal women, they are more prevalent among Black women than among women of other races. Based on clinical diagnosis, the estimated cumulative incidence of fibroids in women ≤50 years old is significantly higher for black (>80%) versus white women (∼70%). The cause of leiomyomas is not clearly known, but studies have shown evidence of factors that drive the development or exacerbation of the disease. Evidence has linked risk factors such as lifestyle, age, environment, family history of uterine fibroids, and vitamin D deficiencies to an increased risk of uterine fibroids, which impact women of African descent at higher rates. Treatments may be invasive, such as hysterectomy and myomectomy, or non-invasive, such as hormonal or non-hormonal therapies. These treatments are costly and tend to burden women who have the disease. Sub-Saharan Africa is known to have the largest population of black women, yet the majority of uterine fibroid studies do not include populations from the continent. Furthermore, the prevalence of the disease on the continent is not well determined. To effectively treat the disease, its drivers need to be understood, especially with regard to racial preferences. This paper aims to review the existing literature and build a case for conducting future research on African women.

Long term follow-up of uterine fibroids treated with microwave ablation: an up to 3-year observational study of volume, regrowth, and symptoms

OBJECTIVE

To study long-term effects in patients treated with microwave ablation (MWA) for symptomatic uterine fibroids and investigate fibroid characteristics predictive of successful treatment.

METHOD

Women who received MWA treatment for uterine fibroids in a previous study were included. A total of 16 patients underwent contrast enhanced MRI before treatment, postoperatively at 6 months and at long-term follow-up, to assess volumes of treated fibroids (n = 42). Long-term MRI was performed between 16 and 36 months after treatment [median 22 months, interquartile range (IQR) 18.5-27]. Validated questionnaires for evaluation of uterine fibroid symptoms and menstrual bleeding (UFS-QoL and PBAC) were used to assess long-term effects on symptoms. The degree of shrinkage was correlated to vascularization and T2 signal intensity (SI) at preoperative MRI and location of fibroids according to the FIGO classification, using the Mann-Whitney U test.

RESULTS

Most patients (82%) reported improvement up to 3 years after treatment. Out of 42 treated fibroids, 35 (83%) continued to shrink over time with median relative volume reduction of 77% (IQR 39-95). For eight fibroids (19%) which showed low vascularization on the pretreatment MRI, there was less shrinkage compared to well-vascularized fibroids (p = 0.01). Most fibroids (79%) showed iso- to hyperintense T2 signal on preoperative MRI and showed a higher grade of shrinkage than hypointense fibroids (p = 0.02).

CONCLUSION

After microwave treatment improvement is maintained for most patients up to 36 months and most fibroids showed continuous shrinkage. Preoperative vascularization, high T2 SI and submucosal location predicted continuous volume reduction. However, to confirm this, larger studies are needed.

Metabolomic profiling of peripheral plasma by GC-MS and correlation with size of uterine leiomyomas

Background

Uterine leiomyomas are benign monoclonal tumors originating from the myometrium. Little information exists concerning metabolomics and the presence of leiomyomas.

Objective

The present study evaluated circulating metabolites in the plasma and their correlation with the presence and size of leiomyomas.

Study Design

Cross-sectional observational study, including women divided into 3 groups: 37 with leiomyomas and uterus >500 cm³, 17 with leiomyomas and uterus ≤150 cm³, and 21 leiomyoma-free. Patients underwent peripheral blood collection using untargeted metabolic assessment by gas chromatography coupled to mass spectrometer.

Results

There was no statistical difference between patients’ anthropometric and demographic features and laboratory tests. Statistical differences in uterus volume (P < 0.0001) were found. Forty-six metabolites were identified (35% amino acids and derivatives, 22% fatty acids, and 18% carbohydrates). Statistically significant metabolic distinction (P < 0.05, false discovery rate< 0.05) was observed for 14 metabolites. Most amino acids (L-isoleucine, L-valine, and pyroglutamic acid) were significantly reduced in plasma levels of patients with large leiomyomas. The only exception was L-glutamine, with a significant increase. Fatty acids (arachidonic acid, alfa-tocopherol, palmitic acid, and stearic acid) were similarly reduced in large leiomyomas patients, except for alpha-linolenic acid, which increased. For carbohydrates (myo-inositol, D-threitol, and D-ribose), there was a decrease in the plasma of patients with leiomyomas.

Conclusion

There are different plasma metabolites levels of amino acids, fatty acids, and carbohydrates among patients with leiomyomas, most of them reduced, but some significantly increased in large leiomyomas, compared to leiomyoma-free patients.

Uterine extension determined by MRI: a useful parameter for differentiating subserosal leiomyomas from ovarian tumors

PURPOSE

This study aimed to evaluate the utility of uterine extension determined via MRI for the differentiation of large subserosal leiomyomas from ovarian tumors.

METHODS

In total, 55 patients with subserosal leiomyomas and 127 patients with ovarian tumors were included in this study. These patients were selected from a cohort of female patients whose pelvic masses were larger than 10 cm and who underwent preoperative MRI. We retrospectively reviewed the MRI and compared the diagnostic ability of uterine extension measurements and bridging vascular signs for differentiating subserosal leiomyomas from ovarian tumors.

RESULTS

The vertical height of the uterus (107.2 ± 36.4 mm vs. 59.9 ± 24.9 mm, p < 0.01), the uterine length (114.4 ± 34.9 mm vs. 80.4 ± 23.8 mm, p < 0.01), and the frequency of the bridging vascular sign (78% vs. 6%, p < 0.01) were significantly higher in subserosal leiomyomas than in ovarian tumors. For diagnosing subserosal leiomyoma, the area under the curve, sensitivity, and specificity of vertical height of the uterus, using cutoff threshold > 81 mm, were 0.89, 89%, and 80% and those of the uterine length, using cutoff threshold > 84 mm, were 0.85, 69%, and 93%, respectively. Alternatively, the sensitivity and specificity of bridging vascular sign were 78% and 94%, respectively.

CONCLUSION

Uterine extension determined via MRI is a useful parameter for differentiating large subserosal leiomyomas from ovarian tumors.