Robert N. Troiano

Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids

Conservative surgical options for uterine myomata traditionally were abdominal myomectomy, laparoscopic myomectomy, and, more recently, myolysis. Each of these procedures has distinct advantages, but also apparent disadvantages. We attempted to introduce an additional option for conservative surgical treatment of fibroids by freezing the structures, a procedure termed cryomyolysis. In this pilot study, 14 women were pretreated with a gonadotropin-releasing hormone (GnRH) agonist for a minimum of 2 months preoperatively to minimize uterine and myoma size. Cryomyolysis was performed and the GnRH agonist was discontinued. Magnetic resonance imaging scans were performed in 10 of the 14 women after GnRH agonist treatment but before surgery, and 4 months postoperatively. Total uterine volume ranged from 41.3 to 1134.8 ml preoperatively, and 49.5 to 1320 ml postoperatively (mean increase 22% after discontinuation of GnRH agonist). Normal uterine volume ranged from 35.6 to 548.7 ml preoperatively and 45.1 to 729.6 ml postoperatively (mean increase 40%); however, myoma volume showed a mean decrease of 6% (range -87-28%). Analysis of only frozen myomata revealed a mean volume decrease of 10%. Cryomyolysis maintains at or slightly reduces these lesions to post-GnRH agonist size, and all other uterine tissue returns to pretreatment size. We believe cryomyolysis may be an effective conservative surgical approach to uterine fibroids.

Magnetic resonance imaging of mullerian duct anomalies of the uterus.

Congenital uterine anomalies (mullerian duct anomalies) comprise a spectrum of developmental malformations associated with varying degrees of adverse reproductive outcomes. Although traditionally diagnosed by hysterosalpingography or ultrasound, further elaboration of the findings frequently was performed with laparoscopy/laparotomy and hysteroscopy. The need for diagnostic surgical intervention has largely been eclipsed with the advent of magnetic resonance imaging, which has become the imaging modality of choice for characterization of congenital mullerian anomalies.

Endometrial cryoablation, a minimally invasive procedure for abnormal uterine bleeding

STUDY OBJECTIVE To evaluate the effectiveness of endometrial cyroablation for abnormal uterine bleeding. DESIGN Prospective study with 22 months follow-up (Canadian Task Force classification II-2). SETTING University Medical Center. PATIENTS Fifteen consecutive patients treated for metrorrhagia or menorrhagia refractory to medical or surgical therapy, and who were either not operative candidates or did not desire hysterectomy. INTERVENTION Cyroablation of the endometrium. MEASUREMENTS AND MAIN RESULTS Fifteen patients underwent 16 procedures for dysfunctional uterine bleeding. Uterine sounding depth was 6 to 15 cm. One patient had spinal anesthesia, seven had general anesthesia, and seven had intravenous conscious sedation with a cervical block. Eight patients underwent cryosurgery while fully anticoagulated. Posttreatment endometrial biopsies were performed on three patients and showed only granulation tissue. Life table calculations give amenorrhea rates of 75.5% at 6 months and 50.3% at 22 months. One woman underwent a repeat procedure, resulting in hypomenorrhea at 7-month follow-up. CONCLUSION This pilot study suggests that endometrial cryoablation may be performed simply and effectively. Future studies should be designed to optimize the technical aspects of the procedure, determine its relative efficacy, and investigate the indications.

Myometrial tissue in uterine septa

STUDY OBJECTIVE To assess the frequency of myometrial tissue in the septa of septate uteri. DESIGN Retrospective review (Canadian Task Force classification II-2). SETTING University-affiliated tertiary referral center. PATIENTS Twenty-nine consecutive women with uterine septa diagnosed by magnetic resonance imaging (MRI). INTERVENTIONS The MRI examination was performed with a 1.5 Tesla scanner using high-resolution phased array coils with multiplanar fast-spin echo and T1-weighted sequences. Of resected septa, tissue was available in four for histologic evaluation for the presence of myometrial tissue. MEASUREMENTS AND MAIN RESULTS In 17 women MRI showed a partial septum, all containing myometrium. The 12 patients with complete septum had evidence of myometrium in the upper part of the septum, with fibrous tissue constituting the lower part. Histology reviewed from four resected septa (2 partial, 2 complete) reported myometrial tissue. CONCLUSION Uterine septa are frequently composed of myometrial tissue.

Magnetic resonance imaging evaluation of adnexal masses

Anatomically, the adnexa encompasses the region within the pelvis that includes the ovary, fallopian tube, round ligament, and structures arising from associated embryologic rests. The scope and spectrum of gynecologic pathology seen in this area is enormously diverse, and specific diagnoses are often elusive to conventionally-used imaging techniques such as ultrasound and CT. MRI has become an important tool in the evaluation of the adnexal mass because of its multiplanar capability and undersurpassed soft tissue contrast. It is particularly effective in defining the origin of a pelvic mass. The recent development of fast spin-echo sequences along with new phased array coils have enabled higher resolution imaging in shortened imaging times. The result is improved characterization of adnexal masses, which often leads to specific diagnoses.

Emergent Complications of Assisted Reproduction: Expecting the Unexpected

With the increasing popularity of assisted reproductive technology (ART), radiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome (OHSS), ovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy. Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Heterotopic pregnancy refers to simultaneous intrauterine and ectopic pregnancies and has an incidence of 1%-3% in ART patients. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed. Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely diagnosis and help avert potentially fatal consequences.

Use of fetal magnetic resonance imaging in patients electing termination of pregnancy by dilation and evacuation

OBJECTIVE The purpose of this study was to determine whether magnetic resonance imaging of the fetal brain before dilation and evacuation enhances diagnosis when equivocal ultrasound findings and disrupted autopsy specimens exist. STUDY DESIGN Patients with equivocal fetal brain abnormalities on ultrasound examination who were considering termination of pregnancy were evaluated retrospectively. Abdominal and pelvic magnetic resonance imaging was performed for further evaluation, and orthogonal fetal brain images were obtained. A multidisciplinary team reviewed all cases and discussed the findings, possible causes, and recurrence risks with each patient. RESULTS Seven patients with fetal brain anomalies underwent magnetic resonance imaging before dilation and evacuation. Magnetic resonance imaging diagnoses included intracranial hemorrhages, semilobar holoprosencephaly, intracranial teratoma, multiple cerebral infarcts, and unilateral cerebellar hypoplasia. In all cases, magnetic resonance imaging provided valuable information and helped distinguish possible genetic syndromes from likely sporadic disorders of brain development. CONCLUSION Magnetic resonance imaging can provide insight into diagnosis, cause, and recurrence risks for patients who choose dilation and evacuation because of fetal brain abnormalities.

Utilizing two-dimensional ultrasound to develop normative curves for estimated placental volume.

OBJECTIVE The objective of this study was to use two-dimensional (2D) ultrasound (US) during routine prenatal surveillance to develop normative estimated placental volume (EPV) growth curves. STUDY DESIGN Patients ≥ 18 years old with singleton pregnancies were prospectively followed from 11 weeks gestational age (GA) until delivery. At routine US visits, placental width, height, and thickness were measured and EPV calculated using a validated mathematical model. RESULTS In this study, 423 patients were scanned between 9.7 and 39.3 weeks GA to generate a total of 627 EPV calculations. Readings were clustered at 12 and 20 weeks, times of routine scanning. The mean EPV was 73 ± 47 cc at 12.5 ± 1.5 weeks (n = 444) and 276 ± 106 cc at 20 ± 2 weeks (n = 151). The data best fit a parabolic function as follows: EPV = (0.384GA - 0.00366GA(2))(3). Tenth and 90th percentile lines were generated with ± 1.28 SE offset. EPV readings below the 10th or above the 90th percentiles tended to be associated with either small or large newborns, respectively. CONCLUSION Routine 2D US created EPV growth curves, which may be useful for stratifying patients into prenatal risk groups.

Chorionic Bump on First-Trimester Sonography Not Necessarily a Poor Prognostic Indicator for Pregnancy

The purpose of this study was to determine the live birth rate of pregnancies with a diagnosis of a chorionic bump, a convex bulge from the choriodecidual surface into the first‐trimester gestational sac.

Conspicuity of normal and pathologic female pelvic anatomy: comparison of gadolinium-enhanced T1-weighted images and fast spin echo T2-weighted images.

PURPOSE Our goal was to compare the conspicuity of normal and pathologic female pelvic anatomy between gadolinium-enhanced T1-weighted images and fast SE (FSE) T2-weighted images. METHOD In 48 consecutive female patients, pre- and postenhanced T1-weighted images were compared with FSE T2-weighted images acquired with a phased array coil. Normal zonal anatomy (ZA) and pathologic abnormalities in gadolinium-enhanced T1-weighted images were rated as increased, decreased, or without change in conspicuity as compared with FSE T2-weighted images. RESULTS The normal ZA of the uterine corpus on T1-weighted images showed a decrease in conspicuity in 93% of patients and an increase in 7% compared with FSE T2-weighted images. Conspicuity of cervical ZA on T1-weighted images was decreased in 86%, increased in 6%, and without change in 8% as compared with FSE T2-weighted images. ZA of the vagina on T1-weighted images was decreased in 94% and increased in 6% as compared with FSE T2-weighted images. On T1-weighted images, ovarian anatomy delineation was decreased in 95% and increased in 5% as compared with FSE T2-weighted images. Conspicuity of malignant pathologic abnormalities on T1-weighted images was decreased in 81%, increased in 11%, and without change in 8% as compared with FSE T2-weighted images. In patients with benign disease, conspicuity on T1-weighted images was decreased in 92%, increased in none, and without change in 8% as compared with FSE T2-weighted images. The p value for all categories was < 0.0001. CONCLUSION Conspicuity of both normal and pathologic anatomy was significantly decreased on enhanced T1-weighted images. The use of gadolinium cannot replace T2-weighted scans for delineation of anatomy and disease and should be reserved to cases in which standard imaging sequences are not sufficiently diagnostic.