Benign myometrial conditions: leiomyomas and adenomyosis

PET/MR imaging in gynecologic cancer: tips for differentiating normal gynecologic anatomy and benign pathology versus cancer

Positron emission tomography/magnetic resonance imaging (PET/MR) is used in the pre-treatment and surveillance settings to evaluate women with gynecologic malignancies, including uterine, cervical, vaginal and vulvar cancers. PET/MR combines the excellent spatial and contrast resolution of MR imaging for gynecologic tissues, with the functional metabolic information of PET, to aid in a more accurate assessment of local disease extent and distant metastatic disease. In this review, the optimal protocol and utility of whole-body PET/MR imaging in patients with gynecologic malignancies will be discussed, with an emphasis on the advantages of PET/MR over PET/CT and how to differentiate normal or benign gynecologic tissues from cancer in the pelvis.

Uterine Artery Embolization for Adenomyosis

Adenomyosis is a benign gynecologic condition of the uterus similar to uterine leiomyoma (fibroids), but with different pathophysiology and prevalence. The treatment algorithms for symptomatic adenomyosis are not as established as for uterine fibroids and other gynecologic conditions. Uterine artery embolization (UAE) is a well-recognized treatment for symptomatic uterine fibroids. This minimally invasive therapy has been likewise effective for symptomatic adenomyosis but with nuances in UAE protocol and outcomes. There is also less quality evidence to garner support for generalized use of the procedure for symptomatic adenomyosis. Many factors contribute to this lack of data, and efforts to clarify the utility of UAE in adenomyosis will need to address a classification system and standardization of technique.

Intra- and Inter-Rater Agreement Describing Myometrial Lesions Using Morphologic Uterus Sonographic Assessment: A Pilot Study

OBJECTIVES

To evaluate the intra- and inter-rater agreement for myometrial lesions using Morphologic Uterus Sonographic Assessment terminology.

METHODS

Thirteen raters with high (n = 6) or medium experience (n = 7) assessed 30 3-dimensional ultrasound clips with (n = 20) and without (n = 10) benign myometrial lesions. Myometrial lesions were reported as poorly or well defined and then systematically evaluated for the presence of individual features. The clips were blindly assessed twice (at a 2-month interval). Intra- and inter-rater agreements were calculated with κ statistics.

RESULTS

The reporting of poorly defined lesions reached moderate intra-rater agreement (κ = 0.49 [high experience] and 0.47 [medium experience]) and poor inter-rater agreement (κ = 0.39 [high experience] and 0.25 [medium experience]). The reporting of well-defined lesions reached good to very good intra-rater agreement (κ = 0.73 [high experience] and 0.82 [medium experience]) and good inter-rater agreement (κ = 0.75 [high experience] and 0.63 [medium experience]). Most individual features associated with ill-defined lesions reached moderate intra- and inter-rater agreement among highly experienced raters (κ = 0.41-0.60). The least reproducible features were myometrial cysts, hyperechoic islands, subendometrial lines and buds, and translesional flow (κ = 0.11-0.34). Most individual features associated with well-defined lesions reached moderate to good intra- and inter-rater agreement among all observers (κ = 0.41-0.80). The least reproducible features were a serosal contour, asymmetry, a hyperechoic rim, and fan-shaped shadows (κ = 0.00-0.35).

CONCLUSIONS

The reporting of well-defined lesions showed excellent agreement, whereas the agreement for poorly defined lesions was low, even among highly experienced raters. The agreement on identifying individual features varied, especially for features associated with ill-defined lesions. Guidelines on minimum requirements for features associated with ill-defined lesions to be interpreted as poorly defined lesions may improve agreement.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

Fifteen cases clinical analysis of wedge-shaped resection of uterus treating adenomyosis-CONSORT

To investigate the improvement of dysmenorrhea and menorrhagia after wedge-shaped resection of uterus. The clinical data of 15 patients who experienced wedge-shaped resection of uterus for adenomyosis were retrospectively analyzed from September 2012 to October 2013. We use the amount of the completed soaked napkins to measure the menstrual blood volume, and the visual analog scale to evaluate the degree of dysmenorrhea. We used the 2 index to evaluate the improvement of dysmenorrhea and menorrhagia after operation. All operations were successful, no serious complication occurred. Before the operation, all 15 patients used more than 25 pieces of completed soaked napkins, after the operation, 13 patients had significantly decreased menstrual flow, the average amount of completed soaked napkins was 3.6. Meanwhile, 2 patients had no menstrual after surgery. Before the operation, among the 10 patients with severe dysmenorrhea, 9 patients had significant relief on pain, they only experienced slight pain after surgery, only 1 patient still experienced moderate pain. Two patients with slight pain had no pain after operation. Among the 3 patients with moderate pain, 2 patients experienced slight pain and 1 patient felt no pain after operation. The wedge-shaped resection of uterus is a safe and effective procedure to significantly reduce menorrhagia and alleviate the extent of dysmenorrhea, which is a promising alternative for patient who suffered from dysmenorrhea and menorrhagia for adenomyosis.

Heavy menstrual bleeding and dysmenorrhea are improved by Magnetic Resonance Guided Focused Ultrasound Surgery (MRgFUS) of adenomyosis

Background

To assess reduction in heavy menstrual bleeding and dysmenorrhea following MRI guided Focused Ultrasound Surgery (MRgFUS) of focal and diffuse adenomyosis up to 12 months post-treatment a retrospective cohort study was done at a tertiary care academic medical center for obstetrics, gynecology and infertility.

Methods

MRgFUS for adenomyosis uterus was done for thirty-seven patients presenting with symptoms of heavy menstrual bleeding and dysmenorrhea with MRI-suspected adenomyosis. The main outcome measure, was reduction in heavy menstrual bleeding, dysmenorrhea and Symptom Severity Scoring (SSS) over a 3, 6 and 12 month period. Secondary outcome was evidence of fertility preservation post procedure. D’Agostino & Pearson omnibus normality test, one-way Ananova, Pearson’s correlation coefficient analysis was performed on the data. Statistical significances, p-value and r-value were determined.

Results

Out of 37 patients who were treated by MRgFUS, 26 had sufficient follow-up to be included in the analysis. SSS calculated at 3, 6 and 12 months was significantly over the baseline. Both heavy menstrual bleeding and dysmenorrhea, which were assessed separately, were found to significantly improve over time with a positive correlation between the two. No other intervention was required.

Conclusion

MRgFUS provides immediate and sustained relief for patients with focal and diffuse adenomyosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s40738-016-0021-x) contains supplementary material, which is available to authorized users.

Healthcare utilization and costs among women diagnosed with uterine fibroids: a longitudinal evaluation for 5 years pre- and post-diagnosis

OBJECTIVE

To evaluate the healthcare utilization, treatments, and costs incurred by women with uterine fibroids (UF), compared to those without UF, for 5 years before and 5 years after diagnosis.

RESEARCH DESIGN AND METHODS

This is a longitudinal, retrospective case-control study. A total of 84,954 women with a diagnosis of UF, along with matched controls of women without UF, were selected from the Truven Health MarketScan claims database (2000-2010). The date of diagnosis of the UF patient was assigned as the index date for both the UF patient and her matched control.

MAIN OUTCOME MEASURES

Healthcare resource utilization, treatments, and costs (in 2010 USD) were evaluated annually for the 5 year periods before and after the index date.

RESULTS

UF patients had more outpatient and emergency room visits than controls before diagnosis, and more inpatient, outpatient, and emergency room visits than controls after diagnosis. Annual total healthcare costs were significantly higher for patients than controls during the last 3 years pre-index and all 5 years post-index. Overall, the difference was $12,623 over 10 years, with a difference of $1435 in the 5 years pre-diagnosis and a difference of $11,188 in the 5 years post-diagnosis. The cost difference between UF patients and controls was highest in the first year post-diagnosis, reaching $6131, and the difference was even larger when comparing clinically symptomatic UF patients to controls. The use of medications and surgical procedures related to UF peaked in the year post-diagnosis, with 39% of patients receiving a surgical treatment within the year.

KEY LIMITATIONS

UF patients included in the study did not include undiagnosed and potentially asymptomatic UF patients; the impact of disease severity on the costs of UF patients was not evaluated.

CONCLUSIONS

Patients with UF incurred significantly higher healthcare utilization and costs than those without UF, both pre- and post-diagnosis.

MRI appearances of benign uterine disease

Benign uterine disease is a common entity affecting women of all ages. Ultrasound has historically been the predominant imaging method used in the evaluation of benign gynaecological disease, magnetic resonance imaging (MRI) being reserved for use in the staging of malignant uterine and cervical disease. MRI is now increasingly used in the diagnosis of benign uterine disease as well as a tool for problem-solving in cases of diagnostic dilemma. It allows detailed assessment of benign conditions, such as endometrial lesions, leiomyomas, and adenomyosis, and can be helpful in the stratification of patients to different treatment modalities, including surgical resection, uterine artery embolization, and medical therapies. In this article, we review the MRI findings in the common benign uterine diseases.

Noninvasive treatment of focal adenomyosis with MR-guided focused ultrasound in two patients

Adenomyosis is a common benign gynecological disorder presenting with dysmenorrhea, menorrhagia, and pressure symptoms. Magnetic resonance imaging–guided focused ultrasound surgery (MRgFUS) utilizes precisely focused USG waves to generate and maintain high temperatures within the targeted tissue to achieve protein denaturation and coagulative necrosis. The heat generated is monitored using MRI images acquired in real-time in three planes. We present two cases of focal adenomyosis treated with MRgFUS showing good symptomatic relief at 3 and 6 months follow-up.

Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis

OBJECTIVE

The purpose of this study was to critically appraise the diagnostic accuracy of transvaginal sonography for diagnosing adenomyosis.

STUDY DESIGN

Computerized databases were used to identify relevant reports published between 1966 and 2007 reporting data on the accuracy of transvaginal sonography for diagnosing adenomyosis in women having hysterectomy. The presence or absence of adenomyosis was confirmed by histopathologic analysis of hysterectomy specimens. The total analysis included 14 trials with 1895 aggregate participants. Two authors independently assessed methodological quality and constructed tables for the assessment of diagnostic measures.

RESULTS

Transvaginal ultrasound predicted adenomyosis with a likelihood ratio of 4.67 (95% confidence interval [CI], 3.13-6.17). The overall prevalence of adenomyosis was 27.9% (95% CI, 25.5-30.3). The probability of adenomyosis with an abnormal transvaginal ultrasound was 66.2% (95% CI, 61.6- 70.6). The probability of adenomyosis with a normal transvaginal ultrasound was 9.1% (95% CI, 7.3-11.1).

CONCLUSION

Transvaginal sonography appears to be an accurate diagnostic test for adenomyosis.

Hormonal treatments for adenomyosis

Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. The medical treatment of adenomyosis is based on the hormonal dependency of the disease and its strongly debated similarities with endometriosis. Infact, despite the evident differences between the two conditions, the therapies that treat endometriosis effectively have also been successful for the treatment of adenomyosis. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis. Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.

Computed Tomographic and Magnetic Resonance Features of Gynecologic Abnormalities in Women Presenting With Acute or Chronic Abdominal Pain

Advances in technology and improved availability have led to increased use of computed tomography (CT) and magnetic resonance imaging (MRI) to evaluate women presenting to the emergency department or to their primary care provider with abdominal and/or pelvic pain. Computed tomographic examinations are often performed to evaluate the presence of appendicitis or renal stone disease. However, gynecologic abnormalities are frequently identified on these examinations. Although ultrasound remains the primary modality by which complaints specific to the pelvis are evaluated, in many instances, CT and MRI imaging occurs before sonographic evaluation.Historically, because of cost, radiation exposure, and relative ease of use, ultrasound examinations have preceded all other imaging modalities when evaluating pelvic disorders. However, as CT and MRI technology have improved, their use in diagnosing causes of pelvic pain has become equal to that of ultrasound. In some cases, primarily because of historic comfort with sonographic evaluation, gynecologic abnormalities originally diagnosed on CT or MRI may be immediately and unnecessarily reevaluated by ultrasound. For a woman in her reproductive years, the most common adnexal masses are physiological cysts, endometriomas, and cystic teratomas. Although lesions are often asymptomatic and incidentally detected, they can present with pain, and they increase the risk of ovarian torsion. Common causes of chronic pelvic pain in this population include leiomyomata and adenomyosis. In postmenopausal women, ovarian carcinoma, which often does not present clinically until a late stage, has to be included in the differential diagnosis of adnexal masses. If a gynecologic pathology is discovered on CT or MRI, an immediate follow-up ultrasound need not be pursued if the lesion can be characterized as benign, needing immediate surgical intervention, or a variant of normal anatomy. If, on the other hand, findings demonstrate a mass that either is uncharacteristic of a benign lesion, has an indeterminate risk for malignancy, or demonstrates suspicious characteristics for malignancy (such as enhancing mural nodules), further evaluation by serial ultrasound, biochemical marker, and/or CT or MRI is warranted. The purpose of this review is to present a series of commonly encountered gynecologic abnormalities with either CT or MR to make radiologists more familiar with gynecologic pathology on CT and MRI.

Artifacts and pitfalls in MR imaging of the pelvis

Artifacts are intimately intertwined with MRI. For the practicing radiologist, effective supervision, troubleshooting, and interpretation of diagnostic MR studies require a solid knowledge of the pertinent artifacts. This article seeks to familiarize the reader with commonly encountered artifacts and pitfalls in pelvic imaging, the mechanism behind their generation, and methods of minimizing their negative impact or maximizing their diagnostic yield. It also serves as an exciting tool to learn many aspects of basic and advanced MR physics. Artifacts are categorized into patient- and sequence-related artifacts. Various manifestations of motion and vascular artifacts, susceptibility, altered tissue contrast, blurring, chemical shift artifact, volume averaging, and gadolinium (Gd) pseudolayering are explained, along with their proposed remedies.

MR Imaging of Benign Uterine Disease

MR provides excellent depiction of the female pelvic anatomy and has become the imaging modality of choice for the accurate diagnosis of numerous benign gynecologic conditions. Detection and characterization of leiomyomata and adenomyosis is performed routinely at many centers, and MR plays an important role in stratifying patients into appropriate treatment options. MR imaging is also uniquely well suited to the evaluation of gynecologic conditions that occur during pregnancy and in the postpartum period. This article describes MR protocols and the typical findings of various benign conditions of the uterine corpus and cervix, including congenital anomalies, leiomyomas, adenomyosis, and complications related to pregnancy.

Frequency-dependent complex modulus of the uterus: preliminary results

The frequency-dependent complex moduli of human uterine tissue have been characterized. Quantification of the modulus is required for developing uterine ultrasound elastography as a viable imaging modality for diagnosing and monitoring causes for abnormal uterine bleeding and enlargement, as well assessing the integrity of uterine and cervical tissue. The complex modulus was measured in samples from hysterectomies of 24 patients ranging in age from 31 to 79 years. Measurements were done under small compressions of either 1 or 2%, at low pre-compression values (either 1 or 2%), and over a frequency range of 0.1-100 Hz. Modulus values of cervical tissue monotonically increased from approximately 30-90 kPa over the frequency range. Normal uterine tissue possessed modulus values over the same range, while leiomyomas, or uterine fibroids, exhibited values ranging from approximately 60-220 kPa.

New interventional techniques for adenomyosis

This chapter demonstrates that new interventional techniques have been introduced over recent years in order to find an adequate non-invasive therapy for adenomyosis. There is no evidence-based medicine to guide us in the treatment of adenomyosis with minimally invasive therapy. In fact, most data regarding adenomyosis and these evolving therapies comes from the inadvertent treatment of adenomyosis in studies designed to treat uterine leiomyomas. Essentially, all data are from case reports or small case series. The problem is compounded by the fact that there is no agreed imaging definition of adenomyosis, and so therapies that do not excise the uterus have no 'gold standard' for comparison. Nonetheless, there are some reports suggesting that there may be efficacy in techniques such as medicated intrauterine devices, uterine artery embolization, and MRI-guided focused ultrasound surgery. Larger studies specifically treating adenomyosis are clearly required. As with every new approach, the widespread success of these techniques will depend on the general adoption of adequate diagnostic solutions and improvements in the technical parameters of these new regimens. Since the techniques presented in this chapter are new, they have not yet undergone the necessary thorough scientific scrutiny and discussion that is needed for their general acceptance. In the past, adenomyosis was mainly a 'post-factum' pathological diagnosis after extensive surgery. Based on the evidence presented in this chapter it seems that adenomyosis has become an entity that might be treatable by new, minimally invasive or non-invasive treatments.

Pregnancy and live birth after focused ultrasound surgery for symptomatic focal adenomyosis: a case report

Adenomyosis is a benign disease whose symptoms mimic those of uterine leiomyoma. Hysterectomy is the treatment of choice; conservative surgery is difficult to perform and can damage the uterine structural integrity. We report the case of a 36-year-old woman who had difficulty conceiving because of profuse menometrorrhagia. An 84 cm3 uterine tumour was diagnosed on ultrasonography as leiomyoma, and conservative myomectomy was planned. Magnetic resonance imaging (MRI) corrected the diagnosis to focal adenomyosis. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) destroyed a significant part of the tumour. Following an uncomplicated MRgFUS treatment, a non-perfused volume of 33 cm3 was measured. At 6 weeks, the patient experienced a significant reduction in menometrorrhagia and a marked decrease in tumour size (about 50%). She conceived spontaneously and, after an uneventful pregnancy, gave birth at term to a healthy infant via normal vaginal delivery. No structural uterine abnormality was detected after her delivery. This report highlights the difficult diagnosis and new therapeutic considerations of adenomyosis. MRgFUS seems to have the potential to precisely and effectively treat focal adenomyosis without damage to surrounding healthy myometrium, allowing for normal reproduction. Further studies are needed to assess the overall safety and long-term effectiveness of MRgFUS for the non-invasive treatment of adenomyosis.

Magnetic resonance imaging in the characterization of pelvic masses

Female pelvic masses most commonly arise from the reproductive tract, although masses may arise from other structures in the pelvis, such as the gastrointestinal or urinary tracts. The evaluation of a pelvic mass often begins with the physical exam and proceeds to ultrasound, computed tomography, or magnetic resonance imaging. Each of these modalities has a role in the work-up of pelvic masses and each modality has inherent advantages and disadvantages. The focus of this article is to demonstrate the imaging features and role of MRI, in contrast to CT, for detecting, characterizing, and staging pelvic masses. The differential diagnosis for pelvic masses is extremely broad. Clinical history, precise anatomical localization, and MR imaging characterization can significantly narrow the differential diagnosis. With recent advances in therapeutic strategies, a non-invasive, preoperative diagnosis is highly desirable to suggest prognosis and to tailor the treatment approach.

Female Pelvis

MR is the diagnostic imaging modality of choice for many disorders of the female pelvis. Benign uterine disease is well-demonstrated using rapid sequences and minimal examination time,whereas evaluation of malignancy is best performed with high-resolution techniques. Wide-spread availability of ultrafast sequences has expanded MR imaging applications to include evaluation of pelvic floor relaxation and fetal anomalies. Promising developments, such as new contrast agents, MR-guided focused ultrasound,and 3 tesla imaging, suggest continued advancement of MR imaging in the care of patients who have gynecologic disease.