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Learn more@mrionline.com . Today we are honored to welcome Dr.

1:17

Aaron Gomez.

1:18

For a lecture on the FIGO classification

1:20

system for uterine fibroids: review of MRI

1:24

findings and reporting best practices.

1:27

Dr. Aaron Gomez is an assistant professor of

1:29

radiology in the Russell H. Morgan Department of

1:31

Radiology and Radiological Science at Johns Hopkins.

1:35

She also serves as the director of the

1:37

Diagnostic Radiology Residency Program and is

1:40

the co-director of the Johns Hopkins University

1:43

School of Medicine's Diagnostic Radiology course.

1:47

At the end of the lecture, join Dr. Gomez

1:49

in a Q&A session where she will address

1:52

questions you may have on today's topic.

1:54

Please remember to use a Q&A feature

1:56

to submit your questions so we can get to

1:58

as many as we can before our time is up.

2:01

And with that, we're ready to begin today's lecture.

2:03

Dr. Gomez, please take it from here.

2:06

Thank you so much for having me.

2:07

I'm excited to be here.

2:09

Hi, everyone.

2:10

Thank you so much for, um, coming to this talk.

2:13

I am very excited to speak with you about the

2:16

FIGO classification system for uterine fibroids.

2:19

We're going to go over each one of the different fibroid

2:23

classifications according to this system, looking in depth

2:26

at the MRI findings, and then I'll also share with you

2:29

some tips and recommendations for reporting best practices.

2:34

So let's get started.

2:37

Here are the objectives for this talk.

2:39

Um, so I would like for you to understand the 2011 FIGO

2:43

fibroid classification system that's utilized by clinicians.

2:47

We will practice together classifying, um,

2:50

submucosal, intramural, and subserosal fibroids

2:53

according to the FIGO categories, which is

2:56

really important for treatment planning.

2:58

And we'll get into the details of that in just a moment.

3:02

I'll also share with you a suggested template for reporting.

3:05

We'll talk about some reporting best practices, and

3:08

then the overall thing that's important to take away

3:11

is that consistent, standardized reporting of MRI of

3:15

fibroids really provides us with the opportunity to

3:18

reduce mischaracterization, improve care communication

3:22

with referring clinicians, and also provide the

3:24

highest possible quality care to these patients.

3:29

Okay, here are the things that we'll talk about.

3:31

We'll start with an anatomy review.

3:33

I'll go over the classic system that was utilized

3:36

for classifying fibroids and its pitfalls.

3:39

Then we will review the FIGO fibroid classification

3:43

system, and in addition to the MRI findings,

3:46

we'll talk about treatment options by FIGO type.

3:49

I will give you lots of different examples

3:51

of the different FIGO classifications on MRI.

3:54

We'll talk about the template and also a case review.

3:59

Let's start with a review of uterine anatomy.

4:02

Um, so this is a sagittal T2-weighted

4:04

MRI of the pelvis, and the uterus is here.

4:07

It's a pear-shaped organ that's interposed

4:10

between the bladder, which is here anteriorly,

4:12

and the rectum, which is here posteriorly.

4:15

When we're talking about the anatomy of the uterus, it's

4:18

important to know, um, sort of the regional landmarks.

4:21

So here, uh, is the fundus of the

4:24

uterus, or the top of the uterus.

4:26

This is the uterine body, and it's important

4:29

to note that aside from the fundus, all of

4:30

the uterus is referred to as the uterine body.

4:33

The lower uterine segment is a term that should

4:35

only be used in the context of pregnancy.

4:39

This is the cervix.

4:40

This is the anterior lip of the cervix

4:42

and the posterior lip of the cervix.

4:43

We see the cervical canal here as well.

4:46

This thin T2, bright stripe is a

4:48

small amount of fluid in the vagina.

4:51

Um, when we are looking at the uterus on MRI, it's important

4:56

to note the distinct layers of the uterus that are present.

5:00

And so the endometrial stripe will appear as this T2

5:04

bright structure in the central aspect of the uterus.

5:08

The junctional zone is a darker band of tissue that's

5:12

interposed between the endometrium and the myometrium

5:16

of the uterus, which is this muscular layer out here.

5:19

The myometrium will have a very distinct T2

5:22

heterogeneous, um, or T2 isointense appearance to it.

5:27

It's important to note that the junctional zone of the

5:29

uterus is also a muscular layer, but at this point in the

5:33

uterus, the myocytes are packed more densely, so

5:37

there's less water content here, and that is the reason why

5:40

the junctional zone looks so dark on T2-weighted imaging.

5:44

Finally, this thin black line along the outside of the

5:48

uterus is the uterine serosa, and that'll be an important

5:51

landmark for us as we look at, um, uterine fibroids.

5:57

Next, we'll talk about the ovaries.

5:58

Here they are.

6:00

Um, so the ovaries can be classically identified on

6:03

T2-weighted imaging in premenopausal patients,

6:07

um, by their T2 hyperintense follicles.

6:10

We can also see the broad ligament, um,

6:13

which is here at these short arrows.

6:16

And then you can see the round ligament as well on MRI.

6:19

You'll see it kind of heading out along

6:20

the course of the iliac vessels, and that's

6:23

represented by these purple arrows here.

6:25

So this is our review of uterine anatomy

6:27

and also identification of the ovaries

6:30

and, uh, corresponding ligaments.

6:34

Uterine fibroids are benign tumors, but they

6:37

can certainly result in a lot of discomfort

6:40

and, um, really difficult symptoms for patients.

6:45

They are monoclonal tumors that arise

6:47

from smooth muscle of the uterus.

6:48

So, the myometrial layer that we just identified.

6:52

They're benign.

6:53

And when we look at them, uh, on histology, um,

6:56

they are made up of disordered myofibroblasts.

7:00

They have variable amounts of fibrous

7:02

connective tissue within them.

7:04

And the growth of fibroids really depends on hormonal

7:07

influence, so the influence of estrogen and progesterone.

7:10

And so most premenopausal patients will have the most

7:14

significant symptoms related to fibroids. After menopause,

7:18

fibroids will decrease in size.

7:20

They'll degenerate and calcify.

7:23

Conversely, fibroids may increase in size during

7:26

pregnancy or in the setting of external hormone

7:31

stimuli like oral contraceptive pills.

7:35

Patients will come in with a wide variety of symptoms,

7:38

um, but they can include abnormal uterine bleeding,

7:42

infertility, pregnancy loss, or bulk-related symptoms.

7:45

And what I mean by that is symptoms related to an enlarged

7:49

fibroid uterus, so mass effect on the surrounding organs in

7:53

the pelvis, pelvic pressure, and then rarely pelvic pain.

8:00

There are two primary imaging modalities that are used in

8:04

the evaluation and characterization of uterine fibroids.

8:07

Ultrasound is really the initial diagnostic exam in

8:11

patients who are symptomatic, and it's helpful for just

8:15

identifying the presence overall of fibroids if you have

8:20

a small amount of fibroid burden within the uterus.

8:23

Ultrasound can also be helpful in monitoring fibroid growth.

8:28

Patients who aren't going to have surgery or

8:31

more advanced treatment for their fibroids,

8:33

um, often do not go on to have other imaging.

8:37

Ultrasound is sufficient in this patient

8:38

population and in terms of troubleshooting.

8:42

Saline hysteroscopy can also be helpful in determining

8:44

if a fibroid is submucosal or intramural, and

8:48

I'll show you some examples of that later on.

8:51

MRI is a more advanced imaging technique that

8:54

we use, particularly in patients who are going

8:56

to have surgery for their uterine fibroids.

8:59

And so MRI is helpful in, um, accurately characterizing

9:03

fibroid size, location, the overall number of fibroids,

9:07

and their tissue characteristics, and it's superior to

9:10

ultrasound in evaluating patients with a very large uterus.

9:14

Um, as well as for the assessment of submucosal

9:16

fibroids, and that's because we can acquire a

9:18

larger field of view at one time with MRI versus

9:22

the small field of view that we get with either a

9:23

transabdominal or endocavitary probe on ultrasound.

9:28

In patients who are undergoing uterine salvage

9:30

therapy, and by that I mean either surgery

9:33

or a procedure to eliminate the presence of

9:35

fibroids while leaving the uterus in the body.

9:38

Um, MRI is very helpful in those cases as well.

9:41

And then, of course, um, as it is with sort of all

9:43

lesions, MRI is a great problem-solving tool to

9:46

differentiate between fibroids and their mimics.

9:51

This is our standard MRI protocol for

9:54

evaluating fibroids at Johns Hopkins.

9:57

And so we acquire a three-plane scout.

9:59

We do a sagittal and axial T2 as well as an axial T1.

10:04

Um, then we end up doing diffusion-weighted

10:06

imaging, and we do sagittal and axial pre-

10:09

and post-contrast T1-weighted imaging.

10:15

So what are some features of fibroids on MRI?

10:18

I'd like for you to just think about it for a moment.

10:21

Um, what do you expect to see in terms of

10:23

the T1 and T2 signal of fibroids?

10:26

Um, do you expect them to restrict diffusion?

10:29

And what about the corresponding ADC map?

10:31

What do you expect in terms of enhancement

10:34

when you're thinking about fibroids?

10:36

What's their relationship to the myometrium,

10:38

and can you think of any variants?

10:41

So hold on to that thought for a moment.

10:46

So on MRI, fibroids are typically very well circumscribed.

10:51

They're rounded, discrete lesions.

10:53

Typically low signal on T2-weighted imaging

10:56

compared to the surrounding myometrium.

10:59

Fibroids that are really cellular may have

11:02

a relatively high signal intensity on T2

11:04

weighted imaging, but that is more rare.

11:07

The enhancement pattern of fibroids is extremely variable,

11:11

and it's an important descriptor to include

11:13

when you're reporting, especially when the patient

11:16

is being considered for uterine artery embolization.

11:20

Fibroids will often have flow voids within them,

11:22

so T2 dark flow voids on T2-weighted imaging

11:25

because of their prominent vascular supply.

11:28

Um, and then there are a bunch of different

11:30

ways that fibroids can degenerate when they

11:32

involute, either because of a vascular insult

11:35

or, um, change in the hormonal environment.

11:39

Hyaline degeneration, um, and calcification

11:43

causes the T2 signal to decrease.

11:45

So this is kind of the classic

11:46

degeneration that we think of for fibroids.

11:49

They, um, atrophy, they become more hyalinized and calcified.

11:54

Cystic and myxoid degeneration will produce the opposite effect.

11:57

So a cystic lesion or cystic degeneration of a fibroid

12:00

is going to look bright on T2, and it'll be nonenhancing.

12:05

Uh, in cases of myxoid degeneration, you can get minimal

12:08

enhancement, and then hemorrhagic, or red, degeneration.

12:11

Uh, most folks also know, um, this is when you

12:13

have bleeding within a fibroid as it degenerates.

12:16

And so the distinct imaging feature that you'll see

12:19

here is high signal intensity on T1-weighted imaging

12:22

because of the blood products. The T2

12:24

weighted imaging will be variable because of,

12:27

um, depending on the age of the blood products.

12:30

A variant of leiomyoma, or fibroids, is lipoleiomyomas.

12:35

This is a variant of fibroids that can contain fat.

12:38

Um, and these will, um, also, uh, demonstrate, depending

12:43

on which fat saturation sequence you're doing, uh,

12:46

demonstrate characteristics of fat within the lesion.

12:50

So how did we traditionally look at uterine fibroids?

12:53

We used to use one of three terms to, uh, indicate

12:57

where a fibroid was located within the uterus.

13:01

Um, keeping in mind those landmarks

13:03

that we talked about earlier.

13:04

So we used to say whether a fibroid was submucosal,

13:07

meaning whether it protruded into the endometrial

13:11

cavity, uh, beneath the mucosal layer, whether it

13:14

was intramural or within the wall of the uterus.

13:17

And whether it was subserosal, meaning, um,

13:20

extending outward and being covered by a layer

13:22

of that uterine serosa, that thin black line

13:25

that we traced around the uterus earlier.

13:28

The pitfall for using this system is that

13:30

really the location is generalized and it doesn't

13:33

always lead to the best management for patients.

13:36

And so instead, it's better to use this

13:39

general framework, but then ask, but how

13:41

much, how much of the fibroid is submucosal?

13:43

What portion of this fibroid is taking

13:45

up space in each one of these areas?

13:49

So enter the 2011 FIGO classification,

13:54

um, of uterine fibroids.

13:55

And so we are still grouping fibroids according to

13:59

whether they are submucosal or intramural or subserosal.

14:03

But now we're asking the question,

14:05

how much of what and where.

14:08

So types zero to two.

14:11

Um, on the FIGO classification system includes all

14:14

fibroids that are submucosal, and we will go into

14:17

each of these in further detail in the coming slides.

14:21

Throughout this presentation, you will see this diagram, um,

14:24

of the uterus with the corresponding fibroid types included

14:28

so that you can, um, sort of follow along and have a global

14:32

overview of what this type of fibroid should look like.

14:37

The other classification according to the FIGO fibroid

14:40

system, um, includes intramural and subserosal fibroids,

14:45

as well as fibroids that are in a nonmyometrial location,

14:49

including cervical fibroids, broad ligament fibroids, and

14:52

parasitic fibroids, which are fibroids that have lost

14:56

their connection to the uterus and have established an

14:58

independent blood supply somewhere else in the pelvis.

15:02

Then the last FIGO classification that

15:04

we can use is a hybrid classification.

15:07

These numbers are stand-ins here.

15:09

Um, we'll talk about hybrid fibroids in further

15:12

detail, but it is a fibroid that has less than

15:15

50% of both submucosal and subserosal components.

15:19

And so the first number in the hybrid classification

15:22

designates the submucosal component, and the

15:25

second number designates the subserosal component.

15:31

Treatment options for fibroids are also

15:33

variable, and we will go into detail about each

15:36

of these lists according to the FIGO types.

15:39

But I want you to know that there's a lot

15:40

that we can do for patients with fibroids.

15:43

One of the first things that you

15:44

can try is medical management.

15:46

Um, it includes, um, pills to reduce the effects of

15:49

estrogen and attempt to reduce the size of fibroids.

15:52

There are a lot of different surgical options,

15:55

and it depends on a lot of different things.

15:57

And the number one thing you have to

15:59

consider is what the patient's preference is.

16:01

Is there a desire to keep the uterus to preserve fertility,

16:05

but it also depends on symptoms, the menopausal state of

16:08

the patient, and the location and size of the fibroids.

16:12

So we can do hysteroscopic myomectomy, which is where,

16:15

um, the uterus is cannulated via the cervix, and the

16:19

fibroids are removed directly from the endometrial cavity.

16:23

You can do laparoscopic myomectomy or a mini laparotomy,

16:26

which has a smaller incision, uh, than a regular laparotomy.

16:31

Morcellation is a technique where they use a small

16:33

machine to break the fibroid down into smaller pieces.

16:38

It has sort of fallen out of favor, um, because of the

16:41

potential to create parasitized or, uh, metastatic benign

16:45

leiomyomas, and we'll talk about that a bit more later.

16:49

Hysterectomy is certainly a treatment option, um, for

16:52

patients who, uh, no longer have a desire to preserve

16:55

fertility, um, or who are experiencing, um, really such

16:59

severe symptoms that it's the only treatment option.

17:02

There are also options including uterine

17:04

artery embolization or occlusion.

17:05

And then, um, sort of becoming more and more in vogue

17:09

are some ablative techniques, including MR-guided

17:12

focused ultrasound or, uh, radiofrequency ablation.

17:17

Okay.

17:17

Now the moment you've been waiting for, right.

17:20

Let's review each of the FIGO fibroid

17:22

classifications and the imaging features

17:25

and the way that these fibroids are treated.

17:29

So let's start out with FIGO

17:30

zero.

17:31

I think, uh, zero and seven are the easiest fibroid

17:36

types to remember, but this is a FIGO zero fibroid.

17:39

You can see it here.

17:41

Um, these are intracavitary

17:43

or pedunculated submucosal fibroids.

17:46

And so these will be attached to the endometrium by a stalk.

17:51

Um, it's a vascular stalk that's going to extend

17:54

out from the endometrium and connect to the fibroid.

17:57

It can be hard to appreciate the stalk in

17:59

a FIGO zero fibroid when it is, when the

18:01

fibroid is small or when the stalk is small.

18:03

So, for example, in this patient who has

18:05

a 100%, uh, intracavitary, FIGO zero

18:08

fibroid, we don't really see the stalk here.

18:11

Conversely, there is this rather large fibroid

18:15

that's prolapsing through the cervix in this

18:17

patient, and we see this very thick vascular stalk

18:20

extending all the way up to the fundal myometrium.

18:24

If you can see the stalk, it is important to measure

18:27

the stalk diameter so that when this is being removed

18:31

surgically, there's an understanding of how much bleeding

18:34

they can anticipate when the fibroid is resected.

18:38

FIGO zero fibroids will often present, um, with symptoms

18:41

related to the fibroid's effect on the endometrium.

18:45

So patients will come in with abnormal uterine bleeding.

18:48

They may come in with infertility or recurrent

18:51

pregnancy loss because these FIGO fibroids are

18:55

just attached to the endometrial cavity by a stalk.

18:57

They're ideal for hysteroscopic excision.

19:00

And so again, that's when you would take, um.

19:03

A surgical instrument come up through the cervix, into

19:05

the endometrial cavity, clip the stalk, and then deliver

19:08

the fibroid through the cervix and through the vagina.

19:11

So it's a minimally invasive procedure, and these

19:13

FIGO zero fibroids are ideal for this type of removal.

19:17

If a patient ends up undergoing uterine artery

19:20

embolization for a FIGO zero fibroid, these

19:22

can be spontaneously expelled.

19:25

But if they are not small enough to pass on their own

19:28

through the cervix, they can cause obstructive symptoms

19:30

including infection, and they may end up

19:33

having to go in and get them hysteroscopically anyway.

19:39

FIGO one fibroids, that's this type here on the diagram,

19:44

are less than 50% intramural and

19:46

therefore greater than 50% submucosal.

19:49

So these will protrude into the endometrial cavity.

19:53

The symptoms are the same as a FIGO zero fibroid, so

19:56

abnormal uterine bleeding, infertility, and pregnancy loss.

20:00

And what I'm trying to determine, how much of a fibroid.

20:05

If it is FIGO one, is intramural versus submucosal.

20:09

A trick that you can use is to trace the margin of

20:14

the endometrial cavity and just allow it to continue

20:18

through the fibroid to a point that you can see.

20:20

So if we're looking at this FIGO

20:22

one fibroid, if we're tracing the.

20:24

Endometrial junction zone margin.

20:27

Here, you can see that as we pass through the

20:29

fibroid, still greater than, greater than 50%

20:32

of the lesion is within the endometrial cavity.

20:35

Similarly here, this one is not pedunculated by

20:38

a stalk, but I can see that a significant portion

20:40

of it is protruding into the endometrial cavity.

20:43

Same thing here.

20:45

The treatment is the same as FIGO zero fibroids.

20:48

Usually with hysteroscopic myomectomy or uterine

20:51

artery embolization. Myomectomy can be difficult.

20:55

As I said, if these are large, if the fibroid is

20:57

greater than four to five centimeters, and similar

21:00

to FIGO zero, these can be spontaneously expelled

21:02

from the uterus after uterine artery embolization.

21:08

FIGO two fibroids.

21:09

This one here are greater than or equal to 50%

21:13

intramural, and therefore less than 50% submucosal.

21:17

So here are three examples of FIGO two fibroids.

21:21

We're going to use that same trick.

21:24

Tracing the, um, the endometrial junctional

21:28

zone margin to determine how much of our fibroid

21:32

is intramural and how much is submucosal.

21:34

So this one is probably the easiest one, right?

21:37

Um, because we can trace really clearly, and we can see

21:39

that the majority of this lesion is intramural, but a

21:42

small portion protrudes into the endometrial cavity.

21:45

This one is more difficult, but if you identify

21:48

the endometrial cavity.

21:48

Here, we can see that the bulk of

21:50

this lesion is again intramural.

21:52

Same thing with this lesion.

21:53

We see a small amount of the endometrial cavity

21:56

coming out to the sides, but if we cut across,

21:58

greater than 50% of this lesion is intramural.

22:02

The symptoms are the same as all of the

22:04

submucosal fibroid types, and the treatment,

22:07

um, is often hysteroscopic myomectomy.

22:11

For something like this, but when it's a big fibroid

22:14

like this one, you may end up having a two-step surgery.

22:18

So they may go in and remove a portion of the fibroid

22:21

hysteroscopically, um, and then reassess whether

22:24

they need to come back and do more hysteroscopic

22:26

resection or end up doing something like a lap or a

22:29

mini lap, um, to take out the remainder of the fibroid.

22:34

Uterine artery embolization is the most common

22:36

alternative because for a fibroid that is mostly

22:39

intramural, if you can shrink it with uterine

22:41

artery embolization, you may abate most of the

22:44

symptoms that are being experienced by the patient.

22:47

If they are doing a hysteroscopic myomectomy, one thing that

22:51

you have to be very careful of is the distance between the

22:57

furthest portion of the fibroid that's intramural and the

23:00

uterine serosa, if they're going in hysteroscopically

23:03

to resect this fibroid, and there's a very short

23:07

distance between the fibroid and the uterine serosa.

23:10

You risk perforating the uterus, um,

23:13

while doing a hysteroscopic myomectomy.

23:15

And so hysteroscopy is really suited

23:17

for these smaller FIGO two fibroids.

23:19

A larger one may require a more complex

23:21

or alternative surgical approach.

23:26

Let's move on to the intramural fibroids.

23:29

So now we're leaving that zero to two

23:31

classification, and we're moving into three to eight.

23:35

So a FIGO three fibroid is a patient that is

23:38

100% intramural and contacts the endometrium.

23:42

Notice the difference between a two and a three here, right?

23:45

So this is 100% below

23:49

the endometrial contour here. This one is

23:52

truly protruding into the endometrial cavity.

23:55

This one is intramural and just

23:56

contacting or deforming the endometrium.

24:00

So these can distort the endometrium,

24:02

but they don't protrude into the canal.

24:04

These can be really hard to tell apart from FIGO two.

24:08

And so one tip that I have for you, um, is if you

24:12

can visualize the junctional zone, it can help

24:15

you differentiate the fibroid from a FIGO two.

24:18

So in this patient, um, we have sagittal and axial T1

24:22

post images of this very large FIGO three type fibroid.

24:27

We can see this

24:28

thin strip of junctional zone here

24:30

along the margin of the lesion.

24:32

And so that, uh, will reassure us that this

24:35

is a FIGO three rather than a FIGO two.

24:39

These are often asymptomatic, but they

24:41

can cause menstrual irregularities, and

24:43

these have to be resected very carefully.

24:46

Um, so these are often resected, uh, laparoscopically.

24:51

They'll make an incision in the uterus.

24:53

If you have never been in the operating room when

24:55

a fibroid is being resected, one of the things

24:58

that makes these really easy to remove

25:01

surgically is that they're so well circumscribed.

25:04

Often all the surgeon has to do is make an incision along

25:07

the uterus and then apply some pressure to the rest of the

25:11

uterine body, and the fibroid will sort of deliver itself

25:14

as this well-encapsulated ball of smooth muscle tissue.

25:18

And so when they're doing laparoscopy, um, or laparoscopic

25:22

myomectomy for these rather large FIGO three fibroids,

25:25

they have to be careful that they are not extending

25:28

through to violate the endometrium, which can lead to

25:31

scarring and a whole host of other issues, um, that may

25:34

complicate things further down the line for the patient.

25:38

So the key point here, um, is to

25:41

differentiate between a FIGO two and three

25:43

because it can alter the management, right?

25:46

You would not try to come in and resect

25:48

this fibroid hysteroscopically because there

25:50

would be a violation of the endometrium here.

25:53

And so again, the tip is to find the junctional

25:55

zone, if at all possible, and that will help

25:58

you convince yourself that it is indeed, um, a

26:01

FIGO three fibroid.

26:08

And on this image, I'm sorry.

26:10

We can also see

26:11

the junctional zone here and a

26:13

little bit of the endometrial cavity.

26:14

Here's the endometrial cavity here, and

26:16

then this thin band of junctional zone.

26:20

FIGO four fibroids are the easiest ones to identify.

26:24

Aside from FIGO zero and FIGO seven, it is 100% intramural.

26:29

There's no submucosal component, no subserosal

26:33

component, no contact of the endometrium.

26:36

And so when you see these, um, the thing that you're going

26:39

to look for is a claw sign of surrounding myometrium.

26:42

You should see myometrium on

26:43

all sides of the fibroid, right?

26:46

Same thing here.

26:46

We can trace myometrium all the way around.

26:49

That's fibroid, myometrium all the

26:51

way around, all the way around.

26:54

In most cases of FIGO four fibroids, the

26:56

junctional zone is going to be maintained.

26:58

Again.

26:59

Here we see a tiny amount of distortion of the

27:00

junctional zone, but really it's fairly pristine.

27:03

We can see it all the way around.

27:04

Same thing here.

27:05

Junctional zone all the way around.

27:07

Junctional zone is here.

27:09

These are resected

27:11

laparoscopically or via laparotomy.

27:14

As long as there is enough distance between the fibroid

27:17

and the submucosa of the uterus to prevent a transmural

27:21

all-the-way-through-the-wall incision, there is a

27:24

higher risk of resecting these than with some of the

27:27

pedunculated fibroids, as we'll talk about in a bit.

27:32

FIGO five fibroids are

27:35

less than or equal to 50% intramural, or sorry, greater

27:38

than 50% intramural, less than 50% subserosal.

27:43

So the bulk of these fibroids will still be within the

27:46

wall of the uterus with a small subserosal component.

27:49

We can see it here on the diagram.

27:51

Again, you're going to want to trace the margin.

27:56

In this case, it's helpful to trace the serosal margin, and

27:59

so if we are following the quote-unquote normal contour of

28:02

the uterus here, we can see that this fibroid is less than

28:05

50% subserosal, with the majority of it being intramural.

28:10

Same thing here.

28:11

We're tracing that serosal line along

28:13

the normal contour of the uterus.

28:15

The majority of this one is intramural.

28:19

Same thing here with this fibroid.

28:20

If we're tracing all along that serosal

28:22

margin, the majority is intramural.

28:25

These will make an impression on the serosal

28:27

surface that has no intervening myometrium.

28:30

So you'll see here this serosal line is deformed,

28:32

and there is absolutely no myometrium

28:35

intervening between the fibroid and the serosa.

28:38

These are usually asymptomatic, but if they get large

28:42

enough, um, along with other fibroids, they can cause bulk

28:45

symptoms, particularly if they are pressing on another

28:48

organ in the pelvis, like the bladder or adjacent bowel.

28:53

These can be difficult to distinguish sometimes, especially

28:56

if you're sort of borderline in terms of the percentage,

28:59

uh, difficult to distinguish a five from a six, but it

29:03

doesn't really matter because the treatment is the same.

29:07

It includes uterine artery embolization or

29:09

laparoscopic or open myomectomy or targeted therapy.

29:12

It's really pretty easy, um, to

29:14

treat both of these FIGO types.

29:17

And so in these figures, again, um, as I've

29:20

shown you, uh, here are the FIGO five fibroids.

29:23

Same thing here.

29:24

This patient in the middle panel also has

29:26

a FIGO zero fibroid that is prolapsing

29:29

into the cervix via its tiny stalk.

29:35

FIGO six fibroids are less than 50%

29:39

intramural, greater than 50% subserosal.

29:43

So these are the ones that are just hanging on by a

29:45

small amount to the intramural, uh, portion of the

29:49

uterus, and they have a much larger subserosal component.

29:52

These, again, are usually asymptomatic.

29:55

It's difficult to distinguish a five from a six,

29:58

um, and the treatment is exactly the same as a five.

30:01

The only caveat for FIGO six fibroids is that if uterine

30:06

artery embolization is employed as the treatment, um,

30:11

these can potentially fall off of the uterus and be

30:15

expelled into the peritoneal cavity, which does place the

30:19

patient at risk for developing a parasitic fibroid.

30:23

And so again, what you're going to do is you're just

30:25

going to trace that normal serosal contour of the uterus.

30:28

And so we can see here that this one

30:30

has less than 50% intramural component.

30:33

This one has less than 50% intramural component.

30:35

This is the T1 post-contrast image for this same patient.

30:39

And we can see again that we have this thin covering

30:43

of serosa without any myometrium surrounding it.

30:47

So these are both nice examples of FIGO six

30:49

fibroids, which are majority subserosal.

30:52

And, um, of note, the patients who had both of the

30:56

fibroids that I'm looking at here and pointing

30:58

out in this figure, um, did not end up needing any

31:01

treatment for them because they were asymptomatic.

31:06

FIGO seven

31:06

fibroids.

31:07

Also very easy to identify.

31:09

These are the ones that are going to be hanging off of

31:11

the uterus rather than into the cavity by a stalk.

31:15

So these are subserosal and pedunculated.

31:17

They have zero intramural component whatsoever.

31:21

And just as we do with the FIGO zero fibroids, you will also

31:25

want to identify and measure the stalk, that vascular stalk.

31:30

You may see, in cases of large FIGO seven fibroids,

31:35

um, a vessel or flow voids within the stalk

31:38

that's called the bridging vessel sign.

31:42

These fibroids, um, are often large,

31:46

and so it's difficult to fully evaluate them by

31:49

ultrasound, which is why MRI can be so helpful.

31:54

The size really dictates also how

31:56

symptomatic these fibroids are.

31:58

Um, if they are small, um, they will go unnoticed

32:02

by most patients, but they can cause bulk symptoms.

32:05

They can also torsion, which is very painful.

32:08

And in the setting of torsion, a FIGO seven fibroid, just

32:13

as if it were embolized by uterine artery embolization,

32:16

may detach and become parasitized in the pelvis.

32:20

Because these are so exophytic and hang

32:23

off of the uterus, they also have the

32:25

potential to mimic a fibrous ovarian mass.

32:29

So let's look at these.

32:30

Um, so the yellow arrows, um, in these figures are

32:35

pointing out these pedunculated FIGO seven fibroids, and

32:39

then the green arrows are pointing to the vascular stalk.

32:42

This patient has a really thick,

32:43

broad-based vascular stalk here.

32:46

This one is smaller, it has a bridging vessel within it.

32:48

And then there are two stalks that we

32:50

can see here related to these fibroids.

32:55

FIGO eight fibroids, um, are fibroids

32:58

that are in a nonmyometrial location.

33:00

The most common location for a

33:02

FIGO eight fibroid is the cervix.

33:04

The second most common, um, is a broad ligament

33:07

fibroid or a parasitic fibroid, which is less common.

33:10

Again, I've alluded to this many times, but

33:13

parasitic fibroids are fibroids that occur after

33:16

um,

33:17

a fibroid either falls off related to torsion, uterine

33:21

artery embolization, or morcellation, in which they are sort

33:25

of breaking the fibroids down into smaller pieces, and a

33:29

portion of the fibroid falls into the peritoneal cavity.

33:32

These can establish their own blood supply,

33:34

end up, end up to grow up and become sort of

33:37

independent fibroids elsewhere in the pelvis.

33:40

And so the treatment for FIGO eight fibroids

33:43

is really variable.

33:44

It depends on the location, right?

33:46

So for, um, for this cervical fibroid, if this

33:50

patient was experiencing symptoms related to it,

33:53

hysteroscopic resection is probably the best

33:56

option for this cervical fibroid, excuse me.

33:59

Whereas if you had a fibroid that was parasitic out in

34:02

the broad ligament or elsewhere in the pelvis, laparoscopy

34:05

may be the best choice for resecting and treating it.

34:10

Finally, let's talk about hybrid FIGO fibroids.

34:13

So again, these are the ones, um, you have to

34:16

use this classification system when the fibroid

34:18

extends from the subserosa to the submucosa.

34:22

So it's spanning the entirety of the uterus

34:26

in terms of the wall, and it's encompassing

34:29

both the submucosal and subserosal components.

34:32

The most common hybrid FIGO classification that you will

34:36

have to use is a two-five, with a less than 50% submucosal

34:41

component and a less than 50% subserosal component.

34:45

So the first annotation is almost always

34:47

going to be a two or a three, and then the second

34:49

annotation is almost always going to be a five,

34:53

less frequently a six, and we can

34:55

imagine why that's true, right?

34:58

Most of the time we see the fibroid protruding into

35:00

the endometrial cavity with a distinct submucosal

35:03

component and a distinct subserosal component.

35:06

Sometimes more, sometimes less.

35:09

These are really difficult to treat.

35:11

It can be really challenging because you run the risk

35:14

of violating the endometrium, um, or making a transmural

35:18

incision, um, if you are trying to resect these surgically.

35:22

And so patients with hybrid fibroids

35:25

may go on requiring a hysterectomy.

35:28

If these are really vascular, you can attempt uterine

35:31

artery embolization to try to reduce the size and

35:34

then reassess with a follow-up MRI to see if perhaps

35:37

hysteroscopic or laparoscopic resection is then appropriate.

35:43

These are often really big.

35:45

And so another option is targeted resection.

35:49

So let's go ahead and look at

35:51

fibroids from a single patient.

35:52

These are all from the same person.

35:55

Um, and so we have an axial T2, a post-contrast T1,

36:00

and a sagittal T2-weighted image, and we see

36:03

this large, predominantly intramural fibroid here, right?

36:06

It's taking up the majority of the uterus.

36:09

And so we see here.

36:11

The fibroid is contacting the endometrium, right?

36:14

We see this thin sliver of endometrium here.

36:19

It's also contacting the serosa, right?

36:22

We see serosal contact out here.

36:23

We see serosal contact out here in the

36:25

sagittal, and so this is a three–five.

36:29

I also want to point out to you that we see this big

36:33

area of T2 hyperintensity that's non-enhancing

36:37

in the posterior aspect of the fibroid.

36:39

And so this is an area of cystic degeneration.

36:44

Miscategorization has

36:47

serious implications, right?

36:49

So as we've talked about, these fibroids have different

36:52

treatment strategies based on their classification.

36:55

And so classifying fibroids simply as

36:58

submucosal, intramural, or subserosal, right?

37:00

The old system does not work.

37:03

Um, because, for example, if you had a 100% intramural

37:05

fibroid that's contacting the endometrium, FIGO

37:08

three, you may miscategorize it as a FIGO two

37:12

with a submucosal component due to that abutment.

37:14

Similarly, a submucosal fibroid

37:17

that's a hybrid, right?

37:18

Extending from the submucosa to the subserosa.

37:21

A two–five could be misclassified as an intramural

37:25

fibroid depending on where it's centered.

37:29

So this is a case of a misclassified fibroid,

37:32

a 35-year-old patient with a solitary intramural fibroid.

37:35

This is a sagittal T2-weighted image, and we can

37:38

see this big fibroid in the anterior uterine body.

37:42

It is contacting and distorting the endometrium here.

37:46

Um, we can see

37:47

a thin layer of junctional zone traversing here, but

37:51

this was initially characterized as submucosal,

37:53

a fibroid, a FIGO two rather than a three.

37:56

And so they tried to resect this

38:01

hysteroscopically, and they were unsuccessful.

38:05

Troubleshooting for these patients

38:06

includes sonohysterography.

38:08

So what happens with the sonohysterogram is that you use a

38:11

catheter to distend the endometrial cavity with fluid.

38:15

It can sometimes clarify the location of fibroids.

38:18

And so this is, uh, an endovaginal ultrasound.

38:22

We see the endometrial stripe here in this patient.

38:24

There's a big fibroid.

38:26

We see that it certainly has an intramural component,

38:29

um, but may have a submucosal component as well.

38:32

And so on

38:33

this ultrasound, this fibroid was

38:35

classified as having a submucosal component.

38:38

The patient came back for, um, his sonohysterography,

38:44

and so this is the catheter and the distended

38:47

endometrial cavity with anechoic fluid.

38:51

Here's the fibroid out here, and we can now see, um, that

38:55

there is, in fact, just contact of the endometrial cavity.

38:58

So this is truly a FIGO three.

39:00

Um, and so that cannot be taken out hysteroscopically, and so

39:04

they ended up changing the treatment plan for this patient

39:06

from a hysteroscopic resection to a laparoscopic resection.

39:11

Finally, let's talk about mimics of fibroids.

39:14

So adenomyosis, um, can certainly mimic uterine

39:18

fibroids, and it can be very challenging.

39:21

Um, adenomyosis is the presence of ectopic

39:26

endometrial glandular tissue within the uterine myometrium.

39:31

It often looks like an indistinct thickening

39:34

or blurring of the junctional zone.

39:36

And the key feature to distinguish adenomyosis is

39:39

you'll have all of these T2 bright cystic spaces

39:42

throughout the area of ectopic glandular tissue.

39:47

Adenomyosis can look very focal. When that happens,

39:49

it's called an adenomyoma.

39:52

But the thing that you should know about adenomyosis

39:54

is it is not nearly as organized as a uterine fibroid.

39:59

It is not as easy to resect, and these are

40:02

very vascular lesions that tend to bleed.

40:05

And so attempting to resect an adenomyoma

40:08

laparoscopically would be likely unsuccessful and

40:12

also result in significant bleeding for the patient.

40:16

Other things that can mimic fibroids.

40:19

Um, just as fibroids can mimic adnexal masses, if you

40:23

have a fibrous adnexal mass, that could mimic a broad

40:26

ligament fibroid or a pedunculated subserosal fibroid.

40:30

Endometrial polyps can mimic FIGO zero

40:32

fibroids, and then intramural fibroids may be

40:35

mimicked by malignancy, including leiomyosarcoma.

40:39

In patients who are pregnant, focal myometrial.

40:41

Contractions can also mimic fibroids

40:44

because they are an area where the muscle

40:47

of the uterus is balled up temporarily.

40:49

And so typically these will resolve

40:51

during the course of the exam.

40:55

This is an example of leiomyosarcoma.

40:57

We can see how different this looks from the fibroids

41:00

that we've looked at so far in this presentation.

41:03

Right?

41:03

This thing is very heterogeneous.

41:05

So, um, this is a sagittal, uh, T2-weighted image.

41:10

Um, this is a post-contrast T1.

41:13

This is diffusion-weighted imaging

41:14

and the corresponding ADC map.

41:17

So leiomyosarcomas will have irregular margins.

41:20

They will be ill-defined.

41:22

Sometimes infiltrative.

41:23

These grow really quickly, so they may significantly

41:27

increase in size in a two- to three-month period.

41:30

They can have areas of internal necrosis, and the enhancement

41:33

looks just like this really heterogeneous early enhancement.

41:37

So that arterial phase enhancement

41:39

that makes us think about malignancy.

41:41

The T2 signal does not look like

41:43

the other fibroids we've seen, right?

41:45

It's more T2 intermediate as opposed to that really

41:48

discrete, well-defined T2 darkness, and these

41:51

will restrict diffusion on DWI and ADC mapping.

41:56

You may also see secondary signs of malignancy in patients

41:59

with leiomyosarcoma, including pelvic lymph nodes.

42:04

Now let's talk about reporting fibroids.

42:07

So one of the big things that I want to tell you is you

42:09

do not have to memorize this classification system,

42:12

and I encourage you to utilize templates that will

42:17

omit the need to memorize the classification system.

42:20

So at Johns Hopkins, we use a template

42:22

that incorporates pick lists, and I'll

42:24

show you what I mean by that in a second.

42:26

But basically it allows the radiologist to look

42:27

at the fibroid, determine what portion of it is

42:30

intramural, submucosal, and subserosal, and then

42:34

just go into a list, double click and pick, and

42:37

it populates the template with those findings.

42:41

It's also important to include the fibroid

42:45

location and degree of enhancement.

42:48

So this is our template that we use at Hopkins,

42:51

and, um, a few key things that we include.

42:54

So we include the overall size of the uterus,

42:57

the total number of uterine fibroids, and then

42:59

how many we see with some mucosal components.

43:03

Then we describe dominant fibroids without a

43:05

submucosal component up to three, and

43:08

fibroids with submucosal components up to two.

43:12

And so you can see here, um, we measure the fibroid and

43:16

then if we are saying that this is a fibroid without

43:20

a submucosal component, we just have a list here.

43:23

Um, and on the side of our PACS.

43:26

You just select, is it 100% intramural?

43:29

Um, is it contacting the endometrium?

43:31

Is it less than or greater than 50% subserosal?

43:35

And once you double click on that, it will

43:36

populate the FIGO type into the template.

43:39

And we keep this key down at the bottom, both

43:41

for ourselves and the referring clinicians.

43:45

We also describe the location of the fibroid,

43:49

um, and its degree of contrast enhancement

43:52

relative to the surrounding myometrium.

43:55

We also say whether there are any

43:57

aggressive or suspicious features present.

44:01

Okay, now that we've talked about reporting,

44:03

let's do a little bit of practice.

44:06

So here's case one.

44:08

I will show you this fibroid.

44:10

Um, we can see, uh, these are sagittal and

44:12

axial T2-weighted images of the pelvis.

44:15

We have this fibroid here, and I'll show you that this

44:19

is the endometrial cavity that we can trace all around.

44:23

Okay.

44:23

There's maybe a little something here,

44:26

um, connecting to the, uh, endometrium.

44:32

And so how would you classify this uterine fibroid?

44:36

Is it pedunculated intracavitary?

44:39

Is it less than 50% intramural?

44:42

Greater than 50% intramural or 100% intramural,

44:45

contacting the endometrium, again, noting that this is

44:48

probably a broad-based attachment to the endometrial cavity.

44:53

So this is a pedunculated intracavitary fibroid, right?

44:56

So this is the stalk of the fibroid here.

44:58

It's very broad-based.

45:02

Case two.

45:03

How would you describe this fibroid?

45:05

So these are, um, coronal, axial, and sagittal

45:09

T2-weighted images, all of the same patient.

45:11

This is the fibroid.

45:13

This is the fibroid.

45:14

This is the fibroid.

45:15

Again, let's trace the endometrial contour here to determine

45:20

how much of this is intramural and submucosal.

45:26

Intramural.

45:28

So what's your classification here?

45:34

So if you said.

45:35

Greater than 50% intramural, less than 50% submucosal.

45:39

You are correct.

45:42

Last one.

45:44

How would you describe this fibroid?

45:45

So sagittal, T2-weighted image, axial T2-weighted image,

45:48

and coronal T2-weighted image.

45:50

Again, let's trace that endometrial contour.

45:54

Tracing the endometrium.

45:56

Tracing the endometrium.

45:58

So what do you think here?

46:00

It's a little more challenging.

46:04

This one is less than 50% intramural,

46:07

greater than 50% submucosal.

46:10

A few pearls and practical tips to close

46:13

with if you are measuring fibroids.

46:16

Um, I encourage you to call out specific series and slices

46:20

when you are using a template and make key images of

46:23

your measurements so that either other radiologists or

46:25

referring clinicians can see what you are talking about.

46:29

When you are describing these fibroids, especially if

46:31

you're the one who's going to read a follow-up exam on these

46:35

patients, be your own best friend going forward, right?

46:38

If you have to come back and describe changes in

46:40

measurements for fibroids on a subsequent exam,

46:42

you may want to pay it forward for yourself as well

46:44

by making really high-quality key images and

46:47

writing a very specific and detailed report.

46:51

You can troubleshoot, um, the true nature

46:55

classification of a fibroid using multiple planes.

46:57

So use the coronal and sagittal planes to your advantage.

47:01

And then if you have it available to you,

47:03

here, we, um, have a T2 SPACE coronal,

47:06

but what a T2 SPACE is, is a 3D stack.

47:09

And so if you're able to acquire a coronal 3D T2-

47:12

weighted stack, you can make multiplanar reconstructions and

47:15

manipulate those images as you would at the intersection CT.

47:20

So in summary.

47:22

Submucosal is zero to two.

47:23

These patients are going to come in with bleeding,

47:25

infertility, pregnancy loss, and the resection of

47:28

these is going to be hysteroscopic; other three to eight.

47:32

These fibroids are going to cause bulk symptoms and mass

47:35

effect, and you have to take them out, um, via myomectomy

47:40

or hysterectomy, or do uterine artery embolization.

47:44

So characterization of fibroids according to the

47:47

FIGO classification system is really helpful in

47:50

allowing clinicians to plan treatment

47:52

accurately, and it has the potential to

47:54

reduce miscategorization of these lesions.

47:57

So being consistent when you're looking at

47:59

these, using a template for reporting and

48:02

using pick lists within those templates.

48:04

Sorry, I'm just stipulating here

48:06

and knocked something off my desk.

48:07

But consistently using a template, um, allows

48:11

you to be, um, consistent in your reporting and

48:15

avoiding the need to memorize all of the FIGO types.

48:18

Specifically, if you use pick lists and include the

48:20

types within your report, and practice makes perfect.

48:23

Keep trying, keep working with

48:24

these, um, and you will get better.

48:27

Here are my references.

48:28

I'm happy to take any questions that you may have, um, via

48:32

the Q and A. So let me pull up the Q and A. Um, so I have

48:38

a question from Elena that says, how do you differentiate

48:43

an intracavitary fibroid and an endometrial polyp?

48:48

So, um, an intracavitary fibroid, it can be really

48:52

challenging to differentiate from a polyp, um, on imaging.

48:56

On ultrasound, um, you may see

48:59

different features, right? On MRI,

49:01

you may not be able to tell.

49:02

Sometimes the shape is a little different.

49:04

You know, sometimes an endometrial polyp

49:06

will have more of an ovoid configuration.

49:08

On ultrasound, you'll certainly see a very vascular

49:12

stalk extending all the way out into the polyp, right?

49:15

They have that classic linear vascularity within them.

49:19

Uh, but sometimes it comes down to pathology.

49:22

Um, and these are resected in the same way.

49:27

We have another,

49:28

could you try again?

49:29

Sorry.

49:30

Um, we have another question from Mohamed.

49:33

It says, um, would these treatment options be

49:36

considered for fibroids with abnormal T2 signal also?

49:40

That's a good question.

49:41

And so I'm betting that what you are getting at here

49:45

is, um, would we still consider laparoscopy for a fibroid

49:50

that we thought may be suspicious for a leiomyosarcoma?

49:55

The answer is no.

49:56

Right?

49:56

Because you would not want to potentially,

49:59

um, seed the rest of the pelvis with tumor

50:02

if you were dealing with a malignancy.

50:04

And so you may end up, um, going on to do more

50:07

advanced imaging like PET-CT, um, or end up doing a, a

50:10

hysterectomy for a patient with a suspected sarcoma.

50:13

Great question.

50:16

We have a question from

50:17

Dr. Pasant says, are there imaging signs that can help to

50:20

identify early sarcomatous transformation of a fibroid

50:24

before it develops obviously infiltrative margins?

50:27

That's a great question, and I think the answer to it

50:30

would certainly, um, help us help a lot of patients.

50:33

I think initially still the T2

50:35

signal is very useful, right?

50:38

That,

50:39

um, heterogeneous or isointense T2 signal

50:44

can be very helpful in distinguishing an

50:47

early sarcomatous lesion from a true fibroid that's

50:50

just benign fibrous tissue. For us at Hopkins,

50:53

we also do diffusion-weighted

50:56

imaging with ADC mapping for every

50:58

fibroid patient that we see.

51:00

And so these are going to restrict way more

51:03

than the typical sort of low-level diffusion

51:05

restriction that you'll see in normal fibroids.

51:07

So I think T2 signal and doing DWI and an ADC map

51:11

could potentially help you detect leiomyosarcoma

51:14

very early on.

51:16

We have another question from Mohamed

51:18

that says, do you really measure all fibroids?

51:20

Is it practical?

51:22

And so the answer is,

51:24

sometimes. It depends on how many fibroids the patient has.

51:28

If the patient has 20 fibroids, no, I'm not going

51:31

to measure them all, but I am going to measure

51:34

the ones that are the largest or are potentially

51:38

contributing the most to the patient's symptoms.

51:41

So the ones with submucosal components, or the ones that

51:44

are probably responsible for the majority of mass effect.

51:47

Um, if the patient has

51:48

four fibroids total,

51:49

yes, I'll measure them all.

51:51

But if they have 20, no, you sort

51:52

of have to pick your battles.

51:55

We talked a little bit, there's a question

51:57

from Ali about the role of ADC.

51:58

We already sort of addressed that.

52:01

The next question says, should we give

52:03

contrast routinely in MRI pelvis for fibroids?

52:07

My answer is yes.

52:08

I think it's important to give contrast, um, to not only

52:12

see the degree of enhancement relative to the myometrium,

52:15

it allows you to further characterize or determine

52:20

the patient's candidacy for uterine artery embolization.

52:23

It would also allow you to see anything

52:26

unexpected in terms of the enhancement patterns,

52:29

you know, a focal nodularity or heterogeneity.

52:32

Um, so we do routinely administer contrast for our patients.

52:42

One question says.

52:45

From Vicky says, do you use the terminology STUMP or

52:49

do you say atypical fibroid, follow up in one year?

52:53

Um, I'm not sure.

52:54

Do you mean according, do you mean like a vascular stalk?

52:57

Um, we, I, we do not typically use the term

53:01

STUMP in our reports if we're talking about, uh,

53:05

a pedunculated fibroid. We would use the term vascular

53:08

stalk. If we have a fibroid that looks atypical,

53:11

um, typically we don't make recommendations in terms

53:15

of follow up, but we will reach out directly to the

53:18

referring OB or gynecologist and tell them,

53:22

you know, that we recommend, or, you know, that we'd

53:24

like to see short-interval follow up for the patient.

53:27

If we see something that looks weird or we're

53:28

suspicious, um, you know, we tell them it

53:30

should not go a year between follow up.

53:35

Someone's asking, can we get a copy

53:36

of the report template as a PDF?

53:38

Sure.

53:39

I'd be happy to share that with the MRI Online team

53:41

so that you can see the way that we report these.

53:44

I would love to help you come up with a template

53:48

so that you can implement structured reporting

53:50

in caring for your patients with fibroids.

53:52

Absolutely.

53:54

We have a question from Elizabeth says, um,

53:57

can a fibroid show restricted diffusion?

54:01

Um, they can. They will show

54:03

low-level diffusion restriction.

54:06

Um, and so, uh, similar to Ali's question was the

54:09

role of diffusion restriction, ADC, and fibroids.

54:12

So you'll see low-level diffusion

54:13

restriction in normal fibroids.

54:15

If you start to see really dramatic, meaning very, very dark

54:19

on the ADC map, um, degree of restriction, that's when you

54:22

have to become suspicious that perhaps there's, you know,

54:25

a malignant or early malignant lesion present here.

54:31

Oh, I see.

54:32

Um, Vicky is clarifying the term STUMP,

54:36

soft tissue tumor of unknown malignant potential.

54:39

We, um, we would not use that necessarily in our reporting.

54:44

But I think what we would say is, you know, in the

54:47

impression we would describe a uterine fibroid and we

54:50

would say with atypical or suspicious features, you

54:53

know, consider X, Y, Z for further characterization.

54:57

You know, or consider tissue sampling,

54:58

short-interval follow up, something like that.

55:00

But we don't specifically use the term STUMP when we are,

55:02

um, when we're characterizing.

55:07

Let's see.

55:07

Let me see if there's anything else from the chat that

55:14

I don't think there's anything else in the chat that

55:18

we're missing

55:19

here.

55:20

I

55:20

think you got through them all.

55:21

Dr. Gomez?

55:22

I think I did.

55:22

Oh, there's one more.

55:24

What's the difference between cystic and hyaline degeneration?

55:27

Let's go back to the beginning of the presentation and

55:30

I can show you the slide if you want to, um, jot it down.

55:35

One second.

55:37

Okay.

55:38

Uh, it's the enhancement.

55:40

The enhancement is going to allow you to potentially

55:43

differentiate between cystic and hyaline degeneration.

55:46

Um, so cystic degeneration, they're going to have

55:50

high signal intensity on T2-weighted imaging

55:52

without enhancement. Hyaline degeneration, sometimes not

55:55

as dramatic in terms of the T2 signal intensity,

55:59

and there may be minimal enhancement present.

56:02

There's another question.

56:03

Is there any indication for myomectomy before menopause?

56:06

Absolutely.

56:07

So in cases where the fibroid is impairing

56:11

the patient's ability to get pregnant or is causing

56:14

significant bleeding, you know, to the point of

56:16

anemia that has not been adequately

56:20

addressed with hormone therapy or uterine artery

56:23

embolization, you can absolutely do a premenopausal

56:25

myomectomy, and it can greatly reduce the symptoms,

56:28

particularly for patients who

56:30

want to preserve their fertility.

56:33

Yes, there is a question.

56:34

Is the FIGO fibroid classification

56:37

system consistent among radiologists?

56:39

Is there any interobserver variability?

56:41

We are doing a research study at our

56:43

institution right now to take a look at this.

56:45

I can tell you that among more experienced

56:48

radiologists who read these studies regularly,

56:50

there is less interobserver variability.

56:52

At academic institutions where you have

56:55

trainees more frequently reading these, or

56:57

radiologists who see these with less frequency,

56:59

um, there's certainly a lot of variability in reporting.

57:04

Um, let's see.

57:06

Uh, is it monoclonal per individual patient with

57:09

fibroids, or one clonal of for every patient?

57:13

For ev, for every fibroid in many patients.

57:15

Um.

57:17

I think you're referring to the, uh, like

57:19

the, the smooth muscle tumor lineages.

57:23

Um, I, I don't know that I have the answer to that question.

57:26

It may be out there in the pathology literature.

57:30

Let's see.

57:31

Another question says, what magnitude change

57:34

in fibroid size is considered concerning?

57:37

Yeah, so, um, if you see a fibroid that is growing, you

57:41

know, between a short interval, let's say, you know, within

57:44

a three- to six-month period, you see a fibroid that has grown

57:47

20 to 30%, um, within that interval, that's pretty rapid.

57:52

And so, at that point, you may

57:53

want to raise concern that there're.

57:55

Is something else going on here?

57:57

And so either there's, you know, some kind of degeneration

57:59

that's happening that's causing the fibroid to expand, um,

58:02

with edema or cystic change, or, you know, perhaps you're

58:04

dealing with something more sinister.

58:12

Um, there is a question.

58:14

Uh.

58:15

About how they may get the proposed

58:18

template, PDF, from MI, online staff.

58:20

Is that something that you're able to send

58:22

to them if, if they've registered for the

58:24

talk or if they're on the attendee list?

58:26

Absolutely, yes.

58:27

They'll get a follow-up email

58:28

after, after our session closes.

58:30

Yep.

58:31

Okay, wonderful.

58:32

Um, there's a question from Kai.

58:33

It says, do OID degeneration fibroids have T1

58:36

hyperintensity associated also? I don't

58:40

think of them as having T1 hyperintensity.

58:42

It may be more T1 isointense,

58:45

if I'm remembering correctly.

58:48

Okay.

58:48

I think that's it.

58:49

I think we, I think we got through it all.

58:50

Dr. Gomez, great job.

58:53

Thank you.

58:54

Thank you so much for your time.

58:55

It's really been a pleasure.

58:56

Um, I really appreciate the opportunity.

58:59

Um, I, I don't know if I have my, uh, my email

59:02

address here at the end, but, um, I'm eGomez8@jmi.edu.

59:07

I guess I can put it.

59:09

Uh, in the chat really quickly.

59:11

If anybody, perfect, email me, uh,

59:14

to, to talk more, I'm available.

59:16

Here's my email address in the chat.

59:18

Thank you again.

59:19

Dr. Gomez, thank you so much for your lecture

59:21

today, and thanks for everybody for the great

59:23

questions and participating in the Noon Conference.

59:26

And a special thanks to our co-sponsor, AAWR.

59:28

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59:31

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59:33

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59:37

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59:40

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59:44

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59:48

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59:53

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