Dr Mitusha Verma | MRI Fibroid Mapping & FIGO classification #mriteachingcourse

Duration: 4:02 615 transcript words EN summary

Video summary

Fibroids are now subject to a wide range of treatment options, spanning from non-invasive techniques like MR-guided focused ultrasound (MRgFUS) to invasive surgical procedures such as myomectomy or hysterectomy. In the context of MRI, the large field of view allows clinicians to precisely map the location, number, and proximity of fibroids to adjacent structures. Furthermore, analysis of T2-weighted images and post-contrast dynamic sequences provides critical information regarding vascularity, helping to determine whether a fibroid will respond to MRgFUS or if it requires uterine artery embolization. The most crucial aspect of this imaging is the ability to predict sarcomatous changes within the fibroid, which is essential for guiding management decisions. The FIGO classification system categorizes fibroids based strictly on their location relative to the uterine wall, a distinction that directly correlates with clinical symptoms. Submucosal fibroids, whether pedunculated or intracavitary, as well as those that are partly submucosal and partly intramural, tend to cause significant issues such as dysmenorrhea, menorrhagia, and infertility due to their pressure on the endometrial cavity. In contrast, purely intramural fibroids generally present fewer symptoms. The classification also includes subserosal types, which may be entirely serosal, partly serosal and intramural, or large enough to indent both the serosa and touch the endometrial cavity, known as type 2-5. Pedunculated subserosal fibroids are also categorized separately, though they can sometimes be confused with broad ligament or wandering fibroids, a confusion that MRI helps resolve by identifying the organ of origin and distinguishing them from ovarian lesions. On MRI, fibroids typically display a well-defined morphology with a whorled pattern and appear homogeneously iso- to hypointense on T2-weighted sequences. However, as they grow or undergo degeneration, such as hyaline or mixed degeneration, they become heterogeneous; while this heterogeneity is common, it does not necessarily indicate malignancy unless accompanied by other specific signs. The cellular nature of the fibroid influences its signal intensity, with more cellular tumors appearing hypointense on T2, and fat content can be identified using plain T1 sequences followed by fat-suppressed imaging to diagnose lipoleiomyoma. It is vital to differentiate these benign changes from true sarcomatous transformation, which requires careful evaluation beyond just the presence of heterogeneity. Finally, it is important to distinguish fibroids from adenomyosis, another condition within the endometriosis spectrum that can mimic a fibroid but presents with ill-defined margins rather than the sharp boundaries seen in leiomyomas. Adenomyosis manifests as an asymmetrically bulky uterus where either the anterior or posterior myometrium is thickened. Within this enlarged myometrium, one observes scattered T2 or T1 hyperintense foci representing ectopic endometrial tissue. These areas are relatively well-defined but lack the crisp demarcation of a typical fibroid, making accurate differentiation essential for proper diagnosis and treatment planning in patients presenting with uterine masses.

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[music] >> So, fibroids basically they are now amenable to a lot of treatment options from non-invasive like MRgFUS to practically invasive which is surgery itself, myomectomy or hysterectomy. So, what is important MRI wise is the field of view is very large and we can give them the exact idea of location of fibroids, number of fibroids, and their proximity to various other structures adjoining it. And the way the fibroid is appearing on T2, and post-contrast dynamic sequence, we can talk about the vascularity of fibroid, whether it will respond to MRgFUS or if it will require uterine artery embolization, or something like towards the management part part of it. And most important, if we can predict any sarcomatous change which has started within this fibroid, that is the most important point. So, basically this FIGO grading is also available and that is based on the location of fibroid, nothing else. And this is what you can put on your reports also, depending on whether it is a pedunculated intracavitary fibroid, it's intramural, that is one and part of it is submucosal, then part two is again it's more than 50% intramural and little bit submucosal, then three which is 100% intramural with just endometrial contact. So, as we know the fibroids which are submucosal or just pressing on the endometrial cavity are going to cause some symptoms as compared to those who are completely intramural. So, dysmenorrhea, menorrhagia, all those kinds of symptom are more prone and even infertility with these kind of submucosal fibroids. So, that is important. And then you have the subserosal fibroid, which is five and partly subserosal, partly intramural. When it's a very big fibroid which is touching the endometrial cavity also and indenting the serosa also, we call it two dash five. So, it is both. So, everything intramural, submucosal, subserosal. And then seven is pedunculated subserosal. These may be confusing sometime, and MRI definitely helps us to know the organ of origin because they may be kind of broad ligament fibroids or wandering fibroids and also getting confused with ovarian lesions. So, this is easy to pick up. These have like typical appearances, the world pattern, well-defined morphology. Most of them are homogeneously T2 iso to hypo intense, but with increase in size and starting of degeneration of various types, like hyaline degeneration and mixed degeneration, we'll see heterogeneity within these fibroids. But only heterogeneity is not anything of much concern. So, what is important is to look at other sequences. We'll see how do we see for the sarcomatous changes. So, basically, the degeneration will be either cystic, hyaline, or mixed. The most common ones are cystic or hyaline degeneration, and they start looking like heterogeneous on T2 weighted sequences with world pattern and T2 hyperintense areas within. The more these fibroids are cellular, they'll be more hypo intense on T2 weighted sequences. They can have fat content within, so your plain T1 will be important before you give contrast. And if that fat component is seen, you have fat suppressed sequences to prove that it is fat, and then it becomes a lipoleiomyoma. Another part is adenomyosis. We'll see in endometriosis spectrum also, but these are similar looking to a fibroid, but the margins are really ill-defined as compared to what we saw for fibroids. And you will have a adenomyotic uterus. So, asymmetrically bulky uterus where the anterior or posterior myometrium will be asymmetrically thick, and these typical T2 or T1 hyperintense foci will be seen scattered within the myometrium. And then a relatively well-defined area but less well-defined as compared to a fibroid which will be present in a adenomyotic uterus.