Introduction
Materials and methods
Questionnaire
Literature search
Consensus meeting
Results
Participating institutions
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Portugal: n=5
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France: n= 3
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Croatia: n=1
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Spain: n=1
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United Kingdom: n= 4
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Switzerland: n=3
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Germany: n=1
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Austria: n=2
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Sweden: n=1
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Italy: n=1
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Greece: n=1
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Serbia: n=1
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more than 50 exams: n=10
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20-50 exams: n=11
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10-20 exams: n=3
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less than 10 exams: n=1
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open surgery (hysterectomy, myomectomy): n= 24
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laparoscopic surgery: n=24
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medical/hormone therapy: n=22
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embolization of uterine leiomyomas: n=14
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Magnetic resonance guided focused ultrasound (MRgFUS): n=1
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assessment of pelvic pain or other clinical symptoms: n=22
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differential diagnosis of leiomyosarcoma: n=22
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treatment planning in symptomatic patients: n=22
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imaging of infertility: n=16
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therapy monitoring after treatment: n=16
Role of computed tomography
Patient preparation
MR equipment & MR protocol
Reporting
Imaging the pregnant patient
Discussion
MRI Imaging
Patient preparation
• Scheduling the exam according to the menstrual cycle is not necessary |
• Clinical questions should be asked before the exam (e.g., time of menstruation, clinical symptoms, hormonal medication, prior surgical procedures) |
• Fasting before the exam is recommended (3-6h) |
• The use of antiperistaltic agents is recommended (20 mg butyl scopolamine im/iv or 1 mg of glucagon iv), unless their use is contraindicated due to patient medical background |
• Patients should empty their bladder 1h prior to examination in order to achieve a moderately filled bladder |
MRI technical considerations (Table 2)
MR BASIC PROTOCOL |
• Axial T1W of the pelvis If high signal lesions are depicted, an axial FS T1W sequence should be performed |
• Sagittal and axial T2W of the pelvis or sagittal/oblique axial |
At least two T2W orthogonal oblique planes of the uterus, e.g. sagittal T2W sequence of the corpus of the uterus; Axial oblique T2W sequence of the corpus of the uterus |
SPECIFIC CLINICAL SETTINGS |
• Work-up of infertility - Add an oblique coronal T2W sequence along the long axis of the uterus to the basic protocol |
• Work-up of an adnexal mass of indeterminate origin - Add an oblique coronal T2W sequence along the long axis of the uterus to the basic protocol - Add dynamic contrast-enhanced study to the basic protocol in the oblique coronal plane along the long axis of the uterus. Alternatively select a plane across the maximum point of contact between the mass and the uterus - If the mass shows to be ovarian follow the ESUR guidelines for characterization of indeterminate adnexal masses. |
• Work-up of a rapid growing uterine mass - Add dynamic contrast-enhanced study to the basic protocol in the plane that best depicts the morphology of the lesion to be characterized - DWI study is optional |
• Work-up of an intermediate to high T2W leiomyoma - Add dynamic contrast-enhanced study to the basic protocol in the plane that best depicts the morphology of the lesion to be characterized - DWI study is optional |
• Pre- and post-embolization assessment - Add MR angiography or dynamic contrast-enhanced study to the basic protocol - Add DWI sequence to the basic protocol - MRA pre-embolization: evaluate the number, site of origin and size of uterine and ovarian arteries - MRA post-embolization is optional: useful in demonstrating eventual collateral supply to LM that where not fully devascularized |
Sequences/technique | Diagnostic value | Literature |
---|---|---|
Basic protocol
| 7,10,12,13,16 | |
Sag/Oblique axial T2W and T1W axial | Anatomy, characterisation and mapping of leiomyomas DDx adenomyosis Other findings | |
Fast T2W upper abdomen | Large tumors, renal obstruction, metastases | |
Optional sequences
| ||
T1W FS | DDx of fatty from hemorrhagic lesions of the uterus (e.g lipoleiomyomas, leiomyomas with haemorrhagic degeneration or haematometra) and the ovaries (teratoma, endometriomas) | 10,13,16,17 |
Oblique coronal T2W | Relationship to uterine cavity, DDx of uterine (claw sign) and ovarian origin | 3,10 |
Gadolinium T1W (optimally DCE) | Characterisation of leiomyomas DDx from leiomyosarcomas and adnexal masses (bridging feeding vessels); pre- and post embolisation therapy | 12,13, 17-23, |
DWI | Characterisation in atypical leiomyomas; treatment in leiomyoma embolisation | 11, 28-37 |
Leiomyoma | Leiomyosarcoma | |
---|---|---|
Age
| Premenopausal | Peri/postmenopausal |
Borders
| Well delineated | Often nodular* |
DWI
| Variable | Restricted diffusion, low ADC |
Invasiveness
| No | Adjacent tissues |
Number
| Commonly multiple | Solitary |
Size
| Variable | Large (>10cm) |
T2WI
| Mostly low, high in degeneration, whorled pattern | Inhomogenous with areas of hemorrhage*, intralesional vessels; T2 dark areas* |
Vascularity
| Variable; often parallels myometrium, cellular types with avid enhancement | Hypervascularization; peripheral early enhancement, central necrosis* |