TKIs beyond immunotherapy predict improved survival in advanced HCC.

PURPOSE: For patients with advanced HCC, predictors of immunotherapy response are scarce, and the benefits of tyrosine kinase inhibitor (TKI) treatment after immunotherapy are unclear. We explored whether clinical features, such as target lesion response, immune-mediated toxicity, or subsequent TKI therapy predict immunotherapy response. METHODS: We retrospectively studied 77 patients with advanced HCC receiving immunotherapy. Patient characteristics and outcomes were assessed using various statistical methods, including the log-rank test and Kaplan-Meier methods. Cox proportional hazard modeling was used for multivariable survival analysis. RESULTS: For all patients, median overall survival (mOS) was 13 months (95% CI 8-19), and median progression-free survival (mPFS) was 6 months (95% CI 4-10). Patients with partial response (PR) and stable disease (SD) compared to progressive disease (PD) had prolonged mPFS (27 vs. 5 vs. 1 month(s), p < 0.0001) and mOS (not met vs. 11 vs. 3 months, p < 0.0001). Patients with vs. without immune-mediated toxicities trended towards longer mPFS (9 vs. 4 months p = 0.133) and mOS (17 vs. 9 months; p = 0.095). Patients who did vs. did not receive a tyrosine kinase inhibitor (TKI) after immunotherapy had a significantly improved mOS (19 vs. 5 months, p = 0.0024)). Based on multivariate modeling, the hazard ratio (HR) of overall survival (OS) of patients receiving TKI vs. no TKI was 0.412 (p = 0.0043). CONCLUSION: We show that disease control predicts prolonged mOS and mPFS. Furthermore, TKI therapy administered after immunotherapy predicts prolonged mOS in patients with advanced HCC.

Homologous Recombination Repair in Biliary Tract Cancers: A Prime Target for PARP Inhibition?

Biliary tract cancers (BTCs) are a heterogeneous group of malignancies that make up ~7% of all gastrointestinal tumors. It is notably aggressive and difficult to treat; in fact, >70% of patients with BTC are diagnosed at an advanced, unresectable stage and are not amenable to curative therapy. For these patients, chemotherapy has been the mainstay treatment, providing an inadequate overall survival of less than one year. Despite the boom in targeted therapies over the past decade, only a few targeted agents have been approved in BTCs (i.e., IDH1 and FGFR inhibitors), perhaps in part due to its relatively low incidence. This review will explore current data on PARP inhibitors (PARPi) used in homologous recombination deficiency (HRD), particularly with respect to BTCs. Greater than 28% of BTC cases harbor mutations in genes involved in homologous recombination repair (HRR). We will summarize the mechanisms for PARPi and its role in synthetic lethality and describe select genes in the HRR pathway contributing to HRD. We will provide our rationale for expanding patient eligibility for PARPi use based on literature and anecdotal evidence pertaining to mutations in HRR genes, such as RAD51C, and the potential use of reliable surrogate markers of HRD.

Portal Vein Thrombosis: Imaging the Spectrum of Disease With an Emphasis on MRI Features.

OBJECTIVE: The purpose of this article is to review the classic and uncommon imaging findings of portal vein thrombosis (PVT) (acute, chronic, congenital, and septic thrombus) as visualized on multiple modalities, with an emphasis on MRI findings. Additional aims are to understand the imaging of obliterative portal venopathy and its clinical significance, appreciate morphologic changes of the biliary system that may accompany PVT, and recognize changes in liver enhancement patterns seen with PVT related to the hepatic arterial buffer response. The review also addresses morphologic changes of the liver that may occur after PVT, including nodular regenerative hyperplasia, central hepatic hypertrophy, and peripheral fibrosis that may stimulate cirrhosis, as well as the importance of portal vein mapping and the diagnostic findings and clinical significance of tumor within the portal vein in the liver transplant population. CONCLUSION: PVT may be a complication of liver cirrhosis, but it may also occur as a primary vascular disorder without liver disease. PVT can result in portal hypertension and may present with variceal bleeding or hypersplenism. Radiologists should be familiar with the imaging of PVT in patients of various ages and in different clinical scenarios. PVT can influence hepatic perfusion, the shape of the bile ducts, and liver architecture. Bland PVT and tumor-related PVT have major implications for hepatic transplant.

Evidence Supporting LI-RADS Major Features for CT- and MR Imaging-based Diagnosis of Hepatocellular Carcinoma: A Systematic Review.

The Liver Imaging Reporting and Data System (LI-RADS) standardizes the interpretation, reporting, and data collection for imaging examinations in patients at risk for hepatocellular carcinoma (HCC). It assigns category codes reflecting relative probability of HCC to imaging-detected liver observations based on major and ancillary imaging features. LI-RADS also includes imaging features suggesting malignancy other than HCC. Supported and endorsed by the American College of Radiology (ACR), the system has been developed by a committee of radiologists, hepatologists, pathologists, surgeons, lexicon experts, and ACR staff, with input from the American Association for the Study of Liver Diseases and the Organ Procurement Transplantation Network/United Network for Organ Sharing. Development of LI-RADS has been based on literature review, expert opinion, rounds of testing and iteration, and feedback from users. This article summarizes and assesses the quality of evidence supporting each LI-RADS major feature for diagnosis of HCC, as well as of the LI-RADS imaging features suggesting malignancy other than HCC. Based on the evidence, recommendations are provided for or against their continued inclusion in LI-RADS. © RSNA, 2017 Online supplemental material is available for this article.

MRI features of primary rare malignancies of the liver: A report from four university centres.

PURPOSE: To determine if rare primary malignancies of the liver may have consistent features on magnetic resonance imaging (MRI). MATERIALS AND METHODS: This IRB-compliant retrospective study reviewed the records from the pathology departments of four university centres over an 11-year period from 2005-2016 to identify rare primary malignant tumours, which were cross-referenced with MRI records. MRI studies of these patients were reviewed to determine if these tumours exhibited consistent and distinctive features. RESULTS: Sixty patients were identified with rare primary liver tumours. The following distinctive features and frequency of occurrence were observed: mixed hepatocellular carcinoma-cholangiocarcinoma showed regions of wash-out in 7/19 of patients; 6/6 of fibrolamellar carcinomas demonstrated large heterogeneous lesions with large heterogeneous central scars; epithelioid haemangioendothelioma larger than 2 cm showed target-like enhancement in late-phase enhancement in 9/13; sarcomas excluding angiosarcoma had central necrosis in 3/9 and haemorrhage in 5/9; angiosarcomas showed centripedal progressive nodular enhancement in 3/6 and showed regions of haemorrhage in 3/6; and 7/7 of primary hepatic lymphomas showed encasement of vessels. CONCLUSION: Although helpful features for the differentiation of rare primary malignancies of the liver are identified, no MRI features appear to be specific and therefore histopathological confirmation is usually required for definitive diagnosis. KEY POINTS: • No MRI features appear to be specific for rare primary liver malignancies. • Haemorrhage is a helpful sign in diagnosis of primary hepatic sarcomas. • Angiosarcomas may show progressive nodular enhancement towards the centre mimicking haemangioma. • Vessel encasement is a helpful sign in diagnosis of primary hepatic lymphoma.

Interreader Reliability of LI-RADS Version 2014 Algorithm and Imaging Features for Diagnosis of Hepatocellular Carcinoma: A Large International Multireader Study.

Purpose To determine in a large multicenter multireader setting the interreader reliability of Liver Imaging Reporting and Data System (LI-RADS) version 2014 categories, the major imaging features seen with computed tomography (CT) and magnetic resonance (MR) imaging, and the potential effect of reader demographics on agreement with a preselected nonconsecutive image set. Materials and Methods Institutional review board approval was obtained, and patient consent was waived for this retrospective study. Ten image sets, comprising 38-40 unique studies (equal number of CT and MR imaging studies, uniformly distributed LI-RADS categories), were randomly allocated to readers. Images were acquired in unenhanced and standard contrast material-enhanced phases, with observation diameter and growth data provided. Readers completed a demographic survey, assigned LI-RADS version 2014 categories, and assessed major features. Intraclass correlation coefficient (ICC) assessed with mixed-model regression analyses was the metric for interreader reliability of assigning categories and major features. Results A total of 113 readers evaluated 380 image sets. ICC of final LI-RADS category assignment was 0.67 (95% confidence interval [CI]: 0.61, 0.71) for CT and 0.73 (95% CI: 0.68, 0.77) for MR imaging. ICC was 0.87 (95% CI: 0.84, 0.90) for arterial phase hyperenhancement, 0.85 (95% CI: 0.81, 0.88) for washout appearance, and 0.84 (95% CI: 0.80, 0.87) for capsule appearance. ICC was not significantly affected by liver expertise, LI-RADS familiarity, or years of postresidency practice (ICC range, 0.69-0.70; ICC difference, 0.003-0.01 [95% CI: -0.003 to -0.01, 0.004-0.02]. ICC was borderline higher for private practice readers than for academic readers (ICC difference, 0.009; 95% CI: 0.000, 0.021). Conclusion ICC is good for final LI-RADS categorization and high for major feature characterization, with minimal reader demographic effect. Of note, our results using selected image sets from nonconsecutive examinations are not necessarily comparable with those of prior studies that used consecutive examination series. © RSNA, 2017.

Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation.

OBJECTIVE: This article describes, illustrates, and correlates imaging and pathologic features of primary vascular mesenchymal neoplasms of the liver, which arise from the vascular endothelium and perivascular epithelioid cells. CONCLUSION: Familiarity with the spectrum of benign, malignant-potential and malignant vascular neoplasms, and nonneoplastic mimickers allows consideration in the differential diagnosis of enhancing hepatic masses. Understanding relevant pathologic features facilitates recognition of key imaging features, specifically dynamic contrast enhancement patterns on CT and MRI, which provide a useful classification system.

Pseudolymphoma (reactive lymphoid hyperplasia) of the liver: A clinical challenge.

Reactive lymphoid hyperplasia (RLH), also known as pseudolymphoma or nodular lymphoid lesion of the liver is an extremely rare condition, and only 51 hepatic RLH cases have been described in the literature since the first case was described in 1981. The majority of these cases were asymptomatic and incidentally found through radiological imaging. The precise etiology of hepatic RLH is still unknown, but relative high prevalence of autoimmune disorder in these cases suggests an immune-based liver disorder. Imaging features of hepatic RLH often suggest malignant lesions such as hepatocellular carcinoma and cholangiocarcinoma. In this report, we discuss two cases of hepatic RLH in patients with autoimmune hepatitis. We also present pathologic and magnetic resonance imaging findings, including one case utilizing a hepatocellular contrast agent, Eovist. Definitive diagnosis of hepatic RLH often requires surgical excision.

Small hepatocellular carcinoma: MRI findings for predicting tumor growth rates.

RATIONALE AND OBJECTIVES: Current clinical practice favors imaging rather than biopsy to diagnose hepatocellular carcinoma (HCC). There is a need to better understand tumor biology and aggressiveness of HCC. Our goal is to investigate magnetic resonance imaging (MRI) features of HCC that are associated with faster growth rates (GRs). MATERIALS AND METHODS: After approval from institutional review board, a retrospective evaluation was performed of pre-liver transplant patients. Fifty-two patients who developed a >2 cm HCC on serial imaging were included in the study group, with a total of 60 HCCs seen. Precursor foci were identified on serial MRIs before the specific diagnostic features of >2 cm HCC could be made, and GRs and MRI features, including signal on T1- and T2-weighted images (WI), the presence of intralesional steatosis on chemical shift imaging, and enhancement pattern were analyzed. GRs were correlated with imaging features. RESULTS: The average GR of precursor lesions to >2 cm HCC was determined to be 0.23 cm/mo (standard deviation [SD], 0.32), with a doubling time of 5.26 months (SD, 5.44). The presence of increased signal intensity (SI) on T2-WI was associated with significantly higher growth (P = .0002), whereas increased intensity on T1-WI at the initial study was associated with a significantly lower GR (P = .0162). Furthermore, lesions with hypervascular enhancement with washout pattern had significantly higher GR (P = .0164). There is no evidence of differences in GRs seen in lesions with steatosis. CONCLUSIONS: Small precursor lesions with increased SI on T2-WI and a washout pattern of enhancement are associated with faster GRs, which may suggest more aggressive tumor biology. These features may be helpful in patient management and surveillance for HCC.

LI-RADS categorization of benign and likely benign findings in patients at risk of hepatocellular carcinoma: a pictorial atlas.

OBJECTIVE: The purpose of this article is to review the imaging features and Liver Imaging Reporting and Data System (LI-RADS) categorization of benign and likely benign entities, including typical cirrhotic nodules, distinctive nodular observations, and benign entities that may simulate hepatocellular carcinoma. CONCLUSION: LI-RADS is a system of standardized criteria for interpreting liver CT and MR images of patients at risk of hepatocellular carcinoma. Most of the observations in these patients are not malignant. With the development of fibrosis and cirrhosis, these benign entities may take on an altered appearance.

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.

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.

Liver allograft outcomes after laparoscopic-assisted and minimal access live donor hepatectomy for transplantation.

BACKGROUND: The critical shortage of deceased organ donors has led to live-donor hepatectomy as an alternative donor option for transplantation. Although laparoscopic hepatectomy has been well described for management of liver tumors and can be performed safely, few studies have examined early recipient allograft outcomes after laparoscopic live-donor hepatectomy. We describe our initial experience with laparoscopic-assisted and minimal-access donor hepatectomy and its potential as a safe alternative with graft function comparable with open resection in live-donor liver transplantation. METHODS: We performed a retrospective analysis of our past 30 successive live-donor transplants between 2005 and 2009. Fifteen allografts were procured by standard open live-donor (OLD) hepatectomy, and 15 by laparoscopic-assisted (LALD) or minimal-access (MA) live-donor hepatectomy. Left lateral segment grafts were subcategorized and analyzed further. RESULTS: Mean donor age, sex, and liver anatomy were comparable between donor groups. Early graft function as measured by peak total bilirubin level, aspartate aminotransferase level, alanine aminotransferase level, and international normalized ratio on postoperative days 2, 7, 30, and 90 were similar between groups, although the international normalized ratio was slightly more increased on postoperative day 7 in LALD grafts (1.75 ± .45 vs 1.28 ± .16; P = .02). Perioperative allograft biliary (2 of 15 vs 0 of 15; P = .48) and vascular (3 of 15 vs 1 of 15; P = .6) complication rates also were comparable between OLD and LALD/MA grafts. One-year graft and patient survival for LALD/MA was 100% compared with 93% for OLD. CONCLUSIONS: Our experience shows that LALD or MA live-donor hepatectomy is a safe procedure and produces early graft function comparable with standard OLD hepatectomy. Multicenter, larger-volume experience will determine the widespread application of this technique.

A pilot study of intensity modulated radiation therapy with hypofractionated stereotactic body radiation therapy (SBRT) boost in the treatment of intermediate- to high-risk prostate cancer.

Clinical data suggest that large radiation fractions are biologically superior to smaller fraction sizes in prostate cancer radiotherapy. The CyberKnife is an appealing delivery system for hypofractionated radiosurgery due to its ability to deliver highly conformal radiation and to track and adjust for prostate motion in real-time. We report our early experience using the CyberKnife to deliver a hypofractionated stereotactic body radiation therapy (SBRT) boost to patients with intermediate- to high-risk prostate cancer. Twenty-four patients were treated with hypofractionated SBRT and supplemental external radiation therapy plus or minus androgen deprivation therapy (ADT). Patients were treated with SBRT to a dose of 19.5 Gy in 3 fractions followed by intensity modulated radiation therapy (IMRT) to a dose of 50.4 Gy in 28 fractions. Quality of life data were collected with American Urological Association (AUA) symptom score and Expanded Prostate Cancer Index Composite (EPIC) questionnaires before and after treatment. PSA responses were monitored; acute urinary and rectal toxicities were assessed using Common Toxicity Criteria (CTC) v3. All 24 patients completed the planned treatment with an average follow-up of 9.3 months. For patients who did not receive ADT, the median pre-treatment PSA was 10.6 ng/ml and decreased in all patients to a median of 1.5 ng/ml by 6 months post-treatment. Acute effects associated with treatment included Grade 2 urinary and gastrointestinal toxicity but no patient experienced acute Grade 3 or greater toxicity. AUA and EPIC scores returned to baseline by six months post-treatment. Hypofractionated SBRT combined with IMRT offers radiobiological benefits of a large fraction boost for dose escalation and is a well tolerated treatment option for men with intermediate- to high-risk prostate cancer. Early results are encouraging with biochemical response and acceptable toxicity. These data provide a basis for the design of a phase II clinical trial.

Solid pseudopapillary tumor in a pancreatic rest of the jejunum.

Solid pseudopapillary tumors of the pancreas (SPTP) are very rare, and an SPTP arising in a pancreatic rest has been reported only 4 times previously and never in association with the jejunum. We report this unusual case of a 16 year old girl who presented with 4 days of intermittent, crampy abdominal pain and was found to have an SPTP arising in a pancreatic rest of the jejunum.

MRI of adenomyosis: changes with uterine artery embolization.

OBJECTIVE: Our objective was to describe the MRI features of patients with pure or dominant adenomyosis treated with uterine artery embolization (UAE) and to correlate imaging features with symptoms. SUBJECTS AND METHODS: Nineteen patients with symptomatic pure or dominant adenomyosis on MRI were referred for UAE. All 19 patients had repeat MRI 4 months after UAE. The MR images obtained before and after UAE were evaluated for maximal junctional zone thickness, junctional zone-myometrial ratio, uterine volume, and the presence of avascular regions. Patients were asked to complete a questionnaire about their symptoms before and 3 and 12 months after UAE. RESULTS: Uterine volume decreased significantly after UAE (p < 0.01). The mean uterine volume reduction was 25.1%. Junctional zone thickness decreased significantly (p < 0.001). The junctional zone-myometrial ratio did not decrease significantly (p = 0.526). Fourteen (73.7%) of the 19 patients showed devascularized change within the adenomyotic region. Eighteen patients completed a questionnaire at 3 months. Sixteen (88.9%) of the 18 reported an improvement in symptoms, whereas the two remaining patients (11.1%) reported no change (p < 0.001). Of the 16 patients with clinical improvement, 11 had devascularized areas after UAE and five did not. Eleven of the 18 patients who completed a questionnaire 3 months after UAE also completed a questionnaire 12 months after UAE. Ten of these 11 patients still reported continued improvement, and one patient reported a worsening of symptoms. CONCLUSION: UAE in patients with pure or dominant adenomyosis results in decreased uterine volume and regions of devascularization. Most patients reported an improvement in clinical symptoms within 3 months after UAE. Some patients reported benefit for at least 1 year; however, the long-term durability of symptomatic relief remains unknown.

Spherical polyvinyl alcohol versus tris-acryl gelatin microspheres for uterine artery embolization for leiomyomas: results of a limited randomized comparative study.

PURPOSE: To compare the outcomes of uterine artery embolization (UAE) for leiomyomas with use of tris-acryl gelatin microspheres (TAGM) versus spherical polyvinyl alcohol (PVA) particles. MATERIALS AND METHODS: Patients undergoing UAE were randomly assigned to receive TAGMs or PVA. Embolization was performed in a standardized manner. Outcome data were collected at 3 months after embolization, including assessment of clinical symptoms, scores from a fibroid tumor-specific symptom and quality of life (QOL) questionnaire, and findings on contrast material-enhanced magnetic resonance (MR) imaging, including the degree of tumor infarction and volume reduction. Data were analyzed with use of t tests, the Mann-Whitney U test, and chi2 tests as appropriate. RESULTS: Thirty-six patients were treated. There were no differences in the two treatment groups at baseline. Clinical follow-up was obtained in 35 patients. Among the clinical outcome measures, QOL score improvement was greater for UAE with TAGMs compared with PVA (49.0 vs 27.9; P = .02), but no other differences were noted. Of the 25 patients in whom 3-month MR imaging follow-up was completed, those treated with TAGM were significantly more likely to have complete infarction of all leiomyomas (six patients vs one patient; P = .02), were more likely to have at least 90% tumor infarction (eight patients vs four patients; P = .03), and had a lower mean percent of residual perfused fibroid tumor tissue (9.6% vs 44.3%; P = .004) compared with patients treated with PVA. Based on these differences between the embolic agents, enrollment in this study was terminated. CONCLUSION: The use of spherical PVA particles in the manner described herein results in an unacceptably high rate of failed tumor infarction in UAE.

Long-term outcome of uterine artery embolization of leiomyomata.

OBJECTIVE: To determine the long-term outcome from uterine artery embolization for leiomyomata. METHODS: In a prospective study, 200 consecutive patients treated with uterine embolization were each followed for 5 years. Outcome, including symptom status compared with baseline, reinterventions, menstrual status, and satisfaction were recorded. Summary statistics were used to report baseline characteristics and outcome at each interval. Predictors of subsequent interventions, failure, and satisfaction with treatment were analyzed using logistic regression and Cox proportional hazards models. Failure was defined as subsequent hysterectomy, definitive myomectomy, repeat embolization, or failure of symptom improvement at the patient's final follow-up interval. RESULTS: Of the 200 patients initially treated, 5-year follow-up was completed in 182 (91%), with 18 patients missing. At 5 years after treatment, 73% had continued symptom control, whereas 36 (20%) had failed or recurred. There had been 25 hysterectomies (13.7%), 8 myomectomies (4.4%), and 3 repeat embolizations (1.6%). Long-term failure was more likely in those not improved at 1 year (relative risk [RR] 5.73; 95% confidence interval [CI] 2.32-14.12, P < .001) and in those with baseline leiomyoma volumes greater than the median (RR 2.18; 95% CI 1.05-4.51, P = .036). After adjustment, patients in the first tertile of leiomyoma volume reduction (< or = 30.5%) were 3 times more likely to be dissatisfied with outcome compared with women in the third tertile (> or = 56.3% volume reduction) (RR 3.23; 95% CI 1 07-9.81, P = .037). CONCLUSION: Uterine embolization provides durable symptom relief for most patients, with a 25% chance of failure of symptom control or recurrence over the course of a 5-year follow-up. LEVEL OF EVIDENCE: II-3.

Imaging manifestations of complications associated with uterine artery embolization.

Uterine artery embolization (UAE) is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. A growing body of literature documents symptomatic improvement in the majority of women who undergo UAE. Although UAE is usually safe and effective, there are a number of known complications associated with the procedure. Major complications include fibroid passage, infectious disease (endometritis, pelvic inflammatory disease-tubo-ovarian abscess, pyomyoma), deep venous thrombosis, pulmonary embolism, inadvertent embolization of a malignant leiomyosarcoma, ovarian dysfunction, fibroid regrowth, uterine necrosis, and even death. Minor complications include hematoma, urinary tract infection, retention of urine, transient pain, and vessel or nerve injury at the puncture site. As UAE takes its place in the treatment arsenal for women with symptomatic fibroids, radiologists need to be familiar with UAE-associated complications, which may require further treatment and may even be life threatening in some cases. Knowledge of these complications and their imaging features should lead to prompt diagnosis and appropriate treatment.

Uterine fibroid tumors: long-term MR imaging outcome after embolization.

PURPOSE: To assess and report the long-term magnetic resonance (MR) imaging outcomes of fibroid tumors treated with uterine artery embolization (UAE). MATERIALS AND METHODS: Contrast material-enhanced pelvic MR imaging was performed in 20 patients before UAE, at 3 months after UAE, and then yearly for up to 3 years. Two readers compared the uterine fibroid, dominant (ie, largest) fibroid, and percentage of perfusion measurements from each of these examinations by using intraclass correlations. Seventeen patients underwent contrast-enhanced MR imaging at baseline and 3 months and 3 years after treatment. Among these patients, those with complete infarction were compared with those with incomplete infarction of the dominant fibroid at 3 years to determine extents of infarction, differences in baseline characteristics, degrees of volume reduction of the uterus and fibroid, and extents of symptom change. Comparisons were performed by using t and Pearson chi(2) tests. Differences in proportions, with 95% CIs, were calculated. Each follow-up MR image was also evaluated for the presence of myometrial perfusion defects and new fibroids. RESULTS: Intraclass correlation coefficients calculated for the two readers (range, 0.974-0.995) and with the MR imaging data (range, 0.966-0.988) were high. Of the 17 patients included in the outcome analysis, the 12 with complete fibroid infarction were more likely not to have enhancing lesions at 3-year follow-up (P =.002) than were those with incomplete infarction. No significant differences in volume or symptom changes between the two groups were detected, but growth of residual perfused portions of the incompletely infarcted fibroids was seen in three patients, two of whom had recurrent symptoms. Four patients developed new fibroids, none of which has caused symptoms. There were no instances of myometrial infarction. CONCLUSION: Although the small study population prevented the drawing of definitive conclusions, the data suggest that although incomplete fibroid infarction may not affect outcome immediately, regrowth of uninfarcted fibroid tissue may result in symptom recurrence.