Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification

Retrospective case control study on the evaluation of the impact of augmented reality in gynecological laparoscopy on patients operated for myomectomy or adenomyomectomy

The objective of this study is to evaluate the safety of using augmented reality (AR) in laparoscopic (adeno)myomectomy, defined as an increase in operating time shorter than 15 min. A total of 17 AR cases underwent laparoscopic myomectomy or adenomyomectomy with the use of AR and 17 controls without AR for the resection of (adeno)myomas. The non-inferiority assumption was defined by an operative overtime not exceeding 15 min, representing 10% of the typical operative time. The 17 AR cases were matched to 17 controls. The criteria used in matching the two groups were the type of lesions, the size and the placement. The mean operative time was 135 ± 39 min for AR cases and 149 ± 62 min for controls. The margin of non-inferiority was expressed as a difference in operative time of 15 min between the case and control groups. The mean difference observed between AR cases and controls was -14 min with 90% CI [-38.3;11.3] and was significantly lower than the non-inferiority margin of 15 min (p = 0.03). This negative time difference means that the operative time is shorter for the AR cases group. Intraoperative data revealed a volume of bleeding ≤200 mL in 82.3% of AR cases and in 75% of controls (p = 0.62). No intra or postoperative complications were reported in the groups. The use of augmented reality in laparoscopic (adeno)myomectomy does not introduce additional constraints for the surgeon. It appears to be safe for the patients, with an absence of additional adverse events and of significantly prolonged operative time.

Establishment of a Predictive Model for the Efficacy of High-Intensity Focused Ultrasound in the Treatment of Uterine Fibroids

OBJECTIVES

High-intensity focused ultrasound (HIFU) has demonstrated efficacy as a non-invasive treatment for uterine fibroids, though individual variability exists. This study aims to develop a risk scoring model using clinical and biochemical features to predict HIFU treatment outcomes.

METHODS

This study collected clinical data from patients receiving HIFU treatment, including demographic characteristics, clinical symptoms, treatment information, and biochemical indicators. A risk scoring model was constructed using the random forest analysis method, and its performance was evaluated. Meanwhile, the impact of risk models and other factors on the efficacy of HIFU was evaluated. Furthermore, the interrelationships between the risk model and other factors were explored through interaction analysis. Finally, a nomogram was developed to evaluate its clinical utility.

RESULTS

The risk model, 4 or more treatments, age, and tumor necrosis factor levels were identified as independent influencing factors, with the risk model demonstrating the best performance (area under the curve (AUC) = 0.693). Interaction analysis revealed a significant synergistic effect between the risk model and receiving 4 or more treatments. The nomogram analysis indicated that lower risk scores and fewer treatment sessions were associated with better HIFU treatment outcomes. The receiver operating characteristic curves and calibration curves in both the training and validation sets demonstrated good performance of the nomogram.

CONCLUSIONS

This study successfully constructed a risk scoring model based on clinical features and biochemical indicators, which can effectively predict the efficacy of HIFU treatment for uterine fibroids. There is a significant interaction between the risk model and 4 or more treatments. The constructed nomogram provides strong support for individualized treatment.

Do MRI structured reports with FIGO classifications of leiomyomas contain adequate information for clinical decision making?

OBJECTIVE

To evaluate if structured reports (SR) of pelvic magnetic resonance imaging (MRI) scans using the PALM-COEIN FIGO (the International Federation of Gynecology & Obstetrics) uterine leiomyomas classification (SR-FIGO) contain adequate information for clinical decision making compared with narrative reports (NR).

METHODS

Three reporting templates for pelvic MRI scans were compared: NR, SR without the PALM-COEIN FIGO classification of leiomyomas, and SR-FIGO, for presence of 19 key-features (KF) deemed relevant for leiomyoma management. Kruskal-Wallis test was used to evaluate KF distribution across the report types. One gynecologist and one gynecologist-in-training evaluated the reports and MRI scans to assess the presence of sufficient information to decide on: (1) treatment type (observation/medical treatment/surgery/uterine artery embolization); (2) surgical approach (hysteroscopic/laparoscopic/robotic/open); (3) surgery type (myomectomy/hysterectomy); (4) necessity to review MRI scans; and (5) time spent reviewing MRI scans. The responses of the gynecologist and gynecologist-in-training to points 1 to 5 among report types were compared using χ2 test.

RESULTS

Twenty NR, 20 SR, and 20 SR-FIGO were reviewed. The number of KF was significantly different among reports (P < 0.001): SR-FIGO had the highest number of KF, followed by SR, and NR. In pairwise comparison, significant differences were observed between NR and SR (P = 0.001) and between NR and SR-FIGO (P = 0.001), but not between SR and SR-FIGO (P = 0.063). There were significant differences in answers to question 1 between the gynecologist and gynecologist-in-training for SR (P = 0.007) and SR-FIGO (P = 0.024), with the gynecologist deeming SR and SR-FIGO to provide enough information for treatment decisions more commonly than the gynecologist-in-training.

CONCLUSION

Although this investigation revealed that SR offers a greater wealth of information in contrast to NR, additional investigation is required to ascertain whether the integration of the PALM-COEIN FIGO classification in SR enhances the clinical decision making capacity of gynecologists.

Navigating diagnostic challenges: case reports on differentiating uterine fibroids from leiomyosarcoma through imaging and clinical evaluation

BACKGROUND

Differentiating between uterine fibroids and leiomyosarcoma poses significant challenges, particularly in cases of atypical fibroid degeneration. Accurate diagnosis is crucial for appropriate treatment and patient outcomes.

METHODS

We present two case reports to illustrate the complexities involved in distinguishing these conditions. Both cases involved patients with similar clinical presentations and imaging findings. The diagnostic process included trans-abdominal and trans-vaginal ultrasound, CT scans, and histopathological examination.

RESULTS

In Case 1, the patient presented with worsening abdominal pain and imaging revealed multiple myomas. Histological examination confirmed benign fibroids following surgery. Case 2 involved a patient with an abdominal mass and CT findings suggestive of a fibroid. However, ultrasound characteristics raised suspicion of malignancy, and subsequent histopathological analysis confirmed leiomyosarcoma.

CONCLUSION

These case reports underscore the importance of combining clinical evaluation with advanced imaging techniques for accurate differentiation between uterine fibroids and leiomyosarcoma. While ultrasound plays a critical role, its effectiveness is enhanced by the experience of the sonographer and the integration of other diagnostic modalities. Future multicenter studies should focus on refining these diagnostic approaches to improve accuracy and patient outcomes.

The feasibility of high-resolution organ-axial T2-weighted MRI when combined with federation of gynecology and obstetrics (FIGO) classification of uterine fibroid patients

PURPOSE

Correctly classifying uterine fibroids is essential for treatment planning. The objective of this study was to assess the accuracy and reliability of the FIGO classification system in categorizing uterine fibroids via organ-axial T2WI and to further investigate the factors associated with uterine compression.

METHODS

A total of 130 patients with ultrasound-confirmed fibroids were prospectively enrolled between March 2023 and May 2024. These patients underwent MR examinations, including body-axial T2W (sagittal and axial) and organ-axial T2W (high resolution with oblique coronal and double oblique axial). For postprocessing, the interobserver agreements between two radiologists and the interagreements between two MR examinations and operational descriptions were evaluated via kappa statistics. The accuracy of axial and organ-axial T2W assessments in the FIGO classification of uterine fibroids was compared when surgical outcomes were used as the gold standard. The Kruskal‒Wallis test was used to compare the differences in cavity deformation across various FIGO classifications. Spearman's rank correlation test was used to analyze the correlation between the FIGO classification and the parameters of uterine cavity deformation.

RESULTS

In total, 170 fibroids from 130 patients were included. Compared with body-axial T2WI, organ-axial T2WI showed better interobserver agreement and greater interagreements with operational descriptions, with kappa values of 0.877 (P = 0.04) and 0.932 (P = 0.037), respectively. The accuracy of the organ-axial T2WI assessment in determining the FIGO classification of uterine fibroids was greater than that of the body-axial T2WI assessment, with an accuracy of 92.9% (P < 0.01). Thirty-two (38.1%) fibroids showed cavity deformation according to organ-axial T2WI, including fibroids with FIGO types 0-7 and 2-5. Among these factors, the size of the fibroids (S), base width (B), depth of compression (D), D/B, D/S, and compression angle (A) significantly differed among the different FIGO types of fibroids (P < 0.05). Compression angle exhibited a linear correlation with the FIGO type (P < 0.001).

CONCLUSION

Compared with body-axial T2WI, organ-axial T2WI provides greater accuracy on the basis of the FIGO classification, which is more consistent with surgical outcomes. Given the excellent reliability and accuracy of the preoperative FIGO classification, organ-axial T2WI can contribute to treatment planning.

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.

Postmenopausal Shrinkage of Uterine Myomas: A Retrospective Study of 97 Cases Monitored Annually for 10 Years

Introduction and aim Both patients and gynecologists are concerned about how much and how quickly myomas shrink after menopause. This study aimed to elucidate clinical findings that may be associated with postmenopausal shrinkage of uterine myomas. Materials and methods This study included 97 patients who underwent menopause by August 2012, had myoma nodules with the longest diameter between 50 mm and 160 mm, and visited our specialized myoma clinic annually for at least 10 years after menopause. They underwent transabdominal ultrasonography at least once per year. An experienced gynecologist measured the longest diameter of myoma nodules with a maximum diameter between 50 mm and 160 mm. The shrinkage rate of myoma diameters after menopause compared to premenopausal diameters was calculated each year for 10 years. The shrinkage rate of the longest diameter of the largest nodule 10 years after menopause (10-year shrinkage rate) and its relationship with clinical findings (the age at menopause, parity, body mass index {BMI}, number of nodules, MRI findings on T2-weighted image, location of the nodule, and longest diameter of the largest nodule before menopause) were analyzed. Additionally, we examined annual changes in shrinkage rate of myomas over a 10-year period after menopause (annual trend), and the relationship between annual trends and factors such as BMI and the number of nodules. Results In this examination of 10-year shrinkage rate, the group with a BMI of less than 25 showed a significantly greater shrinkage rate compared to the group with a BMI of 25 or more (25.0% vs 15.7%, p=0.023). Additionally, the group with a single nodule showed a significantly greater 10-year shrinkage rate compared to the group with four or more nodules (26.3% vs 15.2%, p=0.036). For annual trends, the rate of change in the first two years after menopause was significantly faster compared to the trend from the third to the 10th year (difference in slope: 3.888 points per year, p<0.001). When divided into two groups based on the number of nodules (one or two nodules group and three or more nodules group), the group with one or two nodules showed a significant difference in the shrinkage rate between up to two years after menopause and from the period from the third to the 10th year (difference in slope: 4.590 points per year, p<0.001). However, for the group with three or more nodules, there was no significant difference in the annual trend between the first two years after menopause and the rate from the third to the 10th year (difference in slope: 1.626 points per year, p=0.107). Conclusion BMI and the number of myoma nodules were significantly related to the 10-year shrinkage rate. Although myomas shrank significantly faster within the first two years after menopause compared to the later period, the early annual trend did not differ significantly from the trend in the later period when there were multiple nodules with a maximum diameter of 50 mm or more.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Flares of Confusion: A Case Report of Uterine Leiomyoma and Angiomatosis Complexity on Imaging

Over the past decade, a series of rare and extraordinary uterine tumors have been discovered, with some featuring exceptionally uncommon tumor types. This highlights the growing recognition of these rare tumors due to evolutionary radiologic advancements. However, evaluating these patients requires adequate understanding to avoid misinterpretation and potential confusion with alternative differential diagnoses. This case is the first documented instance of two coexistent uterine benign tumors in a 45-year-old unmarried female patient. The patient's medical, gynecological, and surgical histories were unremarkable. Conventional abdominopelvic imaging via computed tomography (CT) and magnetic resonance imaging (MRI) revealed significant uterine expansion, indicating an atypical leiomyomatous or potentially leiomyosarcomatous mass. Subsequently, [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET)/CT revealed hypermetabolic uterine enlargement, suggesting further evaluation. The patient underwent radical hysterectomy, and histopathological analysis revealed multiple uterine fibroids concurrently existing against the uterine angiomatosis. This case is the first documented instance of intricate pathological interplay within the uterus.

Characteristic of Endometrial Stromal Sarcoma by Algorithm of Potential Biomarkers for Uterine Mesenchymal Tumor

The benign tumor uterine leiomyoma (UL) develops from the smooth muscle tissue that constitutes the uterus, whereas malignant tumor uterine sarcoma develops from either the smooth muscle tissue or stroma and is different from UL and endometrial cancer. Uterine sarcoma is broadly classified into three types: uterine leiomyosarcoma, endometrial stromal sarcoma (ESS), and carcinosarcoma. Although uterine leiomyosarcoma and ESS are both classified as uterine sarcoma, they significantly differ in terms of their sites of occurrence, symptoms, and treatment methods. Uterine leiomyosarcoma develops from the muscle tissue constituting the wall of the uterus and accounts for approximately 70% of all uterine sarcoma cases. In contrast, ESS develops from the stromal tissue beneath the endometrium and accounts for approximately 25% of all uterine sarcoma cases. ESS is classified as either low grade (LG) or high grade (HG). This case report aimed to highlight the importance of histopathologic examinations based on surgical specimens. Herein, we reported the case of a 45-year-old woman suspected of having submucosal leiomyoma of the uterus based on imaging results. Transvaginal ultrasonography and endometrial biopsy or partial dilation and curettage were performed. Contrast-enhanced magnetic resonance imaging (MRI) revealed a 32-mm mass projecting from the posterior wall of the uterus into the uterine cavity. T2-weighted imaging revealed a low signal within the mass; thus, submucosal UL was suspected. Histopathologic examination of surgical specimens obtained from a patient suspected of having submucosal UL after contrast-enhanced MRI indicated that the patient had ESS. Despite the remarkable advancements in medical imaging technology, the accuracy of contrast-enhanced MRI for detecting uterine mesenchymal tumors is limited. Therefore, histopathologic diagnosis based on surgical specimens should be performed when medical grounds for diagnosing a benign tumor on contrast-enhanced MRI are lacking.

Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids of Different Sizes: A Single Center Experience

The present study aimed to evaluate the clinical and radiological 1-year outcomes of uterine artery embolization (UAE) performed in a selected population of women with symptomatic myomas and who do not wish to conceive. Between January 2004 and January 2018, a total of 62 patients with pre-menopausal status and with no wish to conceive in the future underwent UAE for the treatment of symptomatic fibroids. All the patients underwent magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TV-US) before and after the procedure at 1-year follow-up. Clinical and radiological parameters were recorded, stratifying the population into 3 groups according to the size of the dominant myoma (group 1: <50 mm; group 2: ≥50 and ≤80 mm; group 3: >80 mm). Mean fibroid diameter was significantly reduced (42.6% ± 21.6%) at 1-year follow-up, with excellent improvements in terms of both symptoms and quality of life. No significant difference was observed regarding baseline dimension and the number of myomas. No major complications were reported (2.5%). The present study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids in pre-menopausal women with no desire to conceive.

Highly Cellular Leiomyoma Mixed With a Focus of Adenomyosis

The purpose of this case presentation was to highlight the importance of an adequate evaluation of images when suspicious of atypical leiomyoma and the importance of performing an extemporaneous biopsy during surgery to ensure the lesion is a benign muscular cell tumor.

Here, we present a case of a 34-year-old nulliparous woman who presented with a history of infertility and irregular menstrual cycles. A highly vascularized pelvic mass was visualized by Doppler ultrasound and a contrast MRI suggestive of uterine fibroid. Intraoperatively, the lesion was found adjacent to the uterus, with a second lesion deeper into the myometrium. The pathology reported a highly cellular leiomyoma with a focus of adenomyosis. Both lesions were extirpated without complications. The patient recuperated favorably within three months of follow-up. This case shows an example of a variety of the typical histology that can be found in uterine fibroids. Although the management of atypical leiomyomas could vary in different scenarios, conservative treatment is recommended if fertility wishes are present. In all cases, it is mandatory to exclude any possibilities of malignancy, like sarcoma, which would completely change the intraoperative management.