MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement.

Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel.

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

Evaluation of the Viability of Untreated Leiomyomas Using Computed Tomography-Detected Calcification Patterns.

OBJECTIVE: To evaluate the relationship between computed tomography (CT)-detected calcification patterns and Magnetic Resonance Imaging (MRI) enhancement as a surrogate for viability in untreated uterine leiomyomas. METHODS: We queried 2 university hospital databases to identify patients with: (1) at least 1 calcified leiomyoma on CT greater than 1 cm (2) contrast-enhanced MRI of the pelvis performed within 5 years of the CT, and (3) no prior history of uterine fibroid embolization (UFE). Computed tomography was used to analyze calcification pattern and contrast-enhanced MRI to analyze size and viability. RESULTS: There were 12,862 reports that fit the criteria. After exclusion, 50 patients with 74 calcified untreated leiomyomas were analyzed. Three calcification patterns were identified: rim (n = 22), diffuse (n = 9), and coarse either less than or greater than 50% (n = 43). Four of 22 (18%) of leiomyomas with rim calcification were viable. Three of 9 (33%) of leiomyomas with diffuse calcification were viable. All leiomyomas with coarse calcifications were viable, 43 of 43 (100%). CONCLUSIONS: Leiomyomas with coarse calcifications are viable, whereas the majority with rim or diffuse calcification are not. This information may be helpful when triaging symptomatic women to treatment.

Radiology Reporting in the Era of Patient-Centered Care: How Can We Improve Readability?

Radiology reports are consumed not only by referring physicians and healthcare providers, but also by patients. We assessed report readability in our enterprise and implemented a two-part quality improvement intervention with the goal of improving report accessibility. A total of 491,813 radiology reports from ten hospitals within the enterprise from May to October, 2018 were collected. We excluded echocardiograms, rehabilitation reports, administrator reports, and reports with negative scores leaving 461,219 reports and report impressions for analysis. A grade level (GL) was calculated for each report and impression by averaging four readability metrics. Next, we conducted a readability workshop and distributed weekly emails with readability GLs over a period of 6 months to each attending radiologist at our primary institution. Following this intervention, we utilized the same exclusion criteria and analyzed 473,612 reports from May to October, 2019. The mean GL for all reports and report impressions was above 13 at every hospital in the enterprise. Following our intervention, a statistically significant drop in GL for reports and impressions was demonstrated at all locations, but a larger and significant improvement was observed in impressions at our primary site. Radiology reports across the enterprise are written at an advanced reading level making them difficult for patients and their families to understand. We observed a significantly larger drop in GL for impressions at our primary site than at all other sites following our intervention. Radiologists at our home institution improved their report readability after becoming more aware of their writing practices.

The Risk of Uterine Malignancy in a Population Being Evaluated for Uterine Fibroid Embolization.

OBJECTIVE: The aim of the study was to determine the frequency of uterine malignancy in patients evaluated for uterine fibroid embolization (UFE) and the role of magnetic resonance imaging in triage. METHODS: Records and imaging studies of 864 UFE consult patients were reviewed for MRI findings suggestive of fibroid malignancy. Pathology was obtained for cases with suspicious baseline MRI's, and the most atypical mass was reanalyzed by an experienced radiologist, blinded to the pathological findings. RESULTS: Twenty one of 864 patients had baseline MRI findings concerning for malignancy at consultation and 17 had complete records. Re-evaluation suggested that 5 were malignant. Three were confirmed malignant (0.35%). One malignancy among the 843 without suspicious baseline MRI findings was missed at consultation. CONCLUSIONS: In our UFE population, uterine malignancy is rare (4/864, 0.46%), and MRI detected the majority, 3 (75%) of 4 before UFE. The observed prevalence of any malignancy was 0.35%, congruent with current Federal Drug Administration estimates.

Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment?

OBJECTIVE: The purpose of this article is to provide background on the epidemiologic, clinical, and economic impact of uterine leiomyomas, summarize the concerns associated with treating women with potential occult leiomyosarcomas (LMSs), and review the known and emerging imaging features of typical and atypical leiomyomas and explain how to differentiate them from LMSs. CONCLUSION: Surgical management of presumed benign uterine leiomyomas received popular media attention when a case of disseminated LMS occurred after laparoscopic power morcellator-assisted hysterectomy. A subsequent U.S. Food and Drug Administration review found a higher prevalence of unsuspected uterine sarcoma and LMS among patients undergoing myomectomy or hysterectomy for presumed benign leiomyomas than was previously reported. This heightened concern has led to increased pressure on radiologists to distinguish LMSs from leiomyomas.

Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study.

OBJECTIVE: The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis during pregnancy in a multiinstitutional study. STUDY DESIGN: In this multicenter retrospective study, the cases of pregnant women who underwent MRI evaluation of abdominal or pelvic pain and who had clinical suspicion of acute appendicitis between June 1, 2009, and July 31, 2014, were reviewed. All MRI examinations with positive findings for acute appendicitis were confirmed with surgical pathologic information. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated. Receiver operating characteristic curves were generated, and area under the curve analysis was performed for each participating institution. RESULTS: Of the cases that were evaluated, 9.3% (66/709) had MRI findings of acute appendicitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively. There was no statistically significant difference between centers that were included in the study (pair-wise probability values ranged from 0.12-0.99). CONCLUSION: MRI is useful and reproducible in the diagnosis of suspected acute appendicitis during pregnancy.

Diffusion-weighted imaging (DWI) of adenomyosis and fibroids of the uterus.

PURPOSE: Although magnetic resonance imaging is often able to distinguish between adenomyosis and fibroids, occasionally the imaging features of focal adenomyosis and fibroids overlap. Diffusion-weighted imaging (DWI) may provide useful information in differentiating pathologies. Therefore, the purpose of our study was to evaluate differences, if any, in the apparent diffusion coefficient (ADC) values of fibroids and adenomyosis. MATERIAL AND METHODS: Patients (n = 50) with uterine fibroids and adenomyosis (n = 43), who underwent pelvic MR imaging including DWI, were included in this IRB approved HIPPA compliant retrospective study. DWI was performed with b factors of 50, 400, and 800 s/mm using a 1.5 T scanner. ADC ROI measurements were placed over a fibroid, an area of adenomyosis, unaffected normal myometrium, skeletal muscle, and urine. Histogram analysis of ADC maps in 20 cases each of adenomyosis and fibroids was evaluated to assess the degree of tissue heterogeneity. RESULTS: The ADC values of adenomyosis and fibroids were compared using Student's t test. The mean and the standard deviation of the ADC values of the control group were as follows: fibroid 0.64 ± 0.29, adenomyosis 0.86 ± 0.30, myometrium 1.39 ± 0.36, and urine 3.01 ± 0.2 × 10(-3) mm(2)/s. There was a statistically significant difference among the ADC values of normal myometrium and fibroids (p < 0.0001), normal myometrium and adenomyosis (p < 0.0001), and fibroids and adenomyosis (p < 0.001). Histogram analysis demonstrates less heterogeneity of adenomyosis as compared to fibroids. CONCLUSION: The present study shows that ADC measurements have the potential to quantitatively differentiate between fibroids and adenomyosis.

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update.

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

MR Imaging of the Ovaries: From Puberty to Menopause.

The ovary resides in the pelvic cavity and is a dynamic organ with physiologic changes from birth to menopause. The imaging features of the normal ovary depend on the physiologic changes through puberty, reproductive age, and menopause. It is important for radiologists to understand the imaging features of normal physiologic changes in the ovaries and differentiate them from disease states.

Current concepts in uterine fibroid embolization.

Uterine fibroid embolization (UFE) has become established as an accepted minimally invasive treatment for uterine fibroids and should be considered a treatment option for patients with symptomatic uterine fibroids. It is important for diagnostic radiologists to understand the procedure, since imaging is a key component in the evaluation and care of these patients. Both the interventional radiologist and the gynecologist must fully evaluate a patient before recommending UFE as a treatment for symptomatic fibroids. However, relatively few absolute contraindications exist (pregnancy, known or suspected gynecologic malignancy, and current uterine or adnexal infection). A thorough evaluation includes a medical history, menstrual history, physical examination, and discussion of fertility goals. In almost all cases, bilateral uterine artery catheterization and embolization are needed, since most uterine fibroids, whether single or multiple, receive blood supply from both uterine arteries. After UFE, patients can reasonably expect resolution of symptoms such as menorrhagia, pelvic pressure, and pelvic pain. Although infrequent, major adverse events can occur and include ovarian failure or amenorrhea, fibroid expulsion, and rarely venous thromboembolism. Hysterectomy remains the definitive and most common treatment for uterine fibroids, but less-invasive approaches such as UFE are becoming of greater interest to both patients and physicians.

ACR Appropriateness Criteria® Fibroids.

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality.

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Comparison of uterine peristalsis before and after uterine artery embolization at 3-T MRI.

OBJECTIVE: The purpose of this article is to compare uterine peristalsis before and after uterine artery embolization (UAE) on a 3-T MRI system. SUBJECTS AND METHODS: MRI scans were prospectively performed for 20 women with symptomatic uterine fibroids (age range, 39-53 years) before and after UAE in the periovulatory phase with a 3-T scanner. Sagittal T2 turbo spin-echo sequences and a HASTE sequence were obtained. Sixty HASTE images were obtained for 3 minutes to display on cine mode. Two radiologists independently evaluated the datasets for the presence of uterine peristalsis using a 5-point rating scale. When peristalsis was present, the direction and frequency were recorded. The images were also evaluated for index fibroid location before and after UAE, index fibroid volume, uterine volume, and fibroid burden estimate. RESULTS: The presence and frequency of uterine peristalsis increased after UAE for both readers, but was significant only for the presence of uterine peristalsis. The majority of patients had peristalsis in the cervix-to-fundus direction. In six cases, uterine peristalsis emerged after UAE. Uterine volumes before UAE were significantly smaller in these six cases compared with the remaining 14 cases, though no significant difference was found in the reduction rate of the uterus or fibroid volumes. The index fibroid was intramural in three of the six cases with interval appearance of peristalsis. The fibroid was solitary in four of the six cases. CONCLUSION: Cine MRI at 3 T may show recovery of uterine peristalsis in some women with symptomatic fibroids after successful UAE.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee.

The ACR Incidental Findings Committee (IFC) presents recommendations for managing adnexal masses incidentally detected on CT and MRI. These recommendations represent an update of those provided in our previous JACR 2013 white paper. The Adnexal Subcommittee, which included six radiologists with subspecialty expertise in abdominal imaging or ultrasound and one gynecologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by iterative consensus. Algorithm branches successively categorize adnexal masses based on patient characteristics (eg, pre- versus postmenopausal) and imaging features. They terminate with a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected adnexal masses.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding.

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Female Infertility.

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.