Sandra Allison

Polyvinyl Alcohol Particles and Tris-acryl Gelatin Microspheres for Uterine Artery Embolization for Leiomyomas: Results of a Randomized Comparative Study

PURPOSE To determine if the type of embolic material used for uterine artery embolization (UAE) for leiomyomas has an impact on short-term recovery or the effectiveness of embolization. MATERIALS AND METHODS One hundred patients were randomly assigned to undergo UAE with polyvinyl alcohol (PVA) particles or tris-acryl gelatin microspheres. Short-term, in-hospital medication use and pain levels were recorded. After discharge, symptom severity, temperature, and medications used were recorded daily for 1 week and symptom levels were measured for weeks 2-4. Three months after embolization, contrast material-enhanced magnetic resonance imaging examinations were evaluated blindly to determine the extent of leiomyoma infarction. Symptom and quality of life (QOL) status was determined with use of questionnaires. Analysis was completed with use of chi(2) analysis, Fisher exact tests, Student t tests, and analysis of variance as appropriate. Regression analysis was used to analyze the impact on outcome of baseline factors (other than type of embolic agent). RESULTS No significant differences were noted at baseline between the two treatment groups. On average, there were significantly higher volumes of tris-acryl microspheres used (9.0 mL vs 3.0 mL; P =.0001), whereas microcatheter occlusion was more common with PVA (28% vs 4%, P =.001). There were no differences in pain severity, other postprocedural symptoms, or medication use between the two treatment groups. There were also no differences in the frequency of incompletely infarcted leiomyomas, degree of improvement in symptom score, patient satisfaction, or QOL. CONCLUSION No substantive differences were detected between outcomes of embolization with PVA particles or tris-acryl gelatin microspheres.

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.

ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

ACR appropriateness criteria pretreatment evaluation and follow-up of endometrial cancer of the uterus

Endometrial cancer is one of the common malignancies in the female genital tract. Imaging in pretreatment evaluation may play an important role in an assessment of morphological prognostic factors including tumor size, depth of myometrial invasion, endocervical extent, and lymph node status. Imaging is also useful in posttreatment evaluation of patients with clinically suspected recurrence. Various modalities including MRI, CT ultrasound and FDG PET-CT-CT have been used for evaluation of the endometrial cancer in both before and after treatment settings. Literature on the indications and usefulness of these imaging studies for endometrial cancer is reviewed.

ACR appropriateness criteria(®) on abnormal vaginal bleeding

In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.

ACR Appropriateness Criteria® Multiple gestations.

Multiple gestations are high-risk compared with singleton pregnancies. Prematurity and intrauterine growth restrictions are the major sources of morbidity and mortality common to all twin gestations. Monochorionic twins are at a higher risk for twin-twin transfusion, fetal growth restriction, congenital anomalies, vasa previa, velamentous insertion of the umbilical cord and fetal death. Therefore, determination of multiple gestation, amnionicity and chorionicity in the first trimester is important. Follow up examinations to evaluate fetal well-being include assessment of fetal growth and amniotic fluid volume, umbilical artery Doppler, nonstress test and biophysical profile. To date, there is a paucity of literature regarding imaging schedules for follow-up. At the very least, antepartum testing in multiple gestations is recommended in all situations in which surveillance would ordinarily be performed in a singleton pregnancy.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed biennially by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging.

ACR appropriateness criteria© ovarian cancer screening.

The majority of women with ovarian cancer have advanced stage disease at the time of diagnosis and a poor 5 year survival rate. Hence, screening has been investigated in the hopes of improving survival by diagnosing ovarian cancer at an earlier stage. Most screening methods thus far have included ultrasound and/or serum tumor markers. However, low prevalence of the disease, high false positive rate of current screening methods, and the probable rapid growth of most ovarian carcinomas from no defined precursor lesion, all contribute to difficulty in screening for ovarian cancer. While screening may be able to detect ovarian cancer at an earlier stage, adequate data is presently lacking on whether screening improves survival. The results of ongoing large clinical trials will be available in a few years and should provide critical information regarding the usefulness of screening. Pending results of those large clinical trials, screening is not currently recommended for women at average risk for ovarian cancer. Screening is most likely to be performed in women with an increased familial risk of ovarian cancer, but patients should be aware that even with this risk factor, there is currently insufficient evidence to know if screening is effective. New screening methods, including new or multiple serum markers and proteomics, are also being investigated.

Acute Pelvic Pain: What We Have Learned From the Er

Acute pelvic pain, defined as the sudden onset of lower abdominal or pelvic pain lasting less than 3 months [1], is a common urgent clinical presentation. Women frequently present to the emergency department after hours. More than one third of women of reproductive age experience nonmenstrual pelvic pain [2]. Acute pelvic pain can pose a diagnostic challenge because the clinical history, symptoms, and physical examination findings are often nonspecific, and the clinical presentations of the underlying gynecologic, obstetric, urologic, and gastrointestinal conditions often vary widely and can frequently overlap. Although some of the common conditions, such as ruptured or hemorrhagic ovarian cysts, are self-limiting, it is imperative that urgent conditions that may necessitate intervention or surgery, such as ovarian torsion, pelvic inflammatory disease (PID), and appendicitis, be considered when a premenopausal woman has acute pelvic pain. The American College of Radiology Appropriateness Criteria list pelvic sonography as the preferred first-line imaging modality in the evaluation of acute pelvic pain in pregnant women and nonpregnant women of reproductive age when an obstetric or gynecologic condition is suspected and in the initial assessment of a suspected nongynecologic condition in a pregnant patient [3]. This can be attributed to its ready availability, cost-effectiveness, noninvasive nature, and lack of ionizing radiation. Sonography can also prove helpful in the assessment of suspected gastrointestinal or urinary tract abnormalities in a nonpregnant woman; however, CT is typically the preferred first-line imaging modality for those patients [3].