{"paper_id":"09cce439-daad-4e79-b072-d88695df60a2","body_text":"Uterine fibroids are the most common benign gynecological tumors in women of reproductive\nage ( 1 , 2 ) . Most women with fibroids are asymptomatic, and nearly a third of\npatients have significant symptoms such as dysmenorrhea, menorrhagia, abnormal uterine\nbleeding, secondary anemia, pelvic pain, and infertility ( 1 , 2 ) . The treatment of patients with\nuterine fibroids should be individualized on the basis of the symptoms, patient age, patient\ndesire to preserve fertility or the uterus, and the characteristics of the nodules (e.g.,\nsize and location), as well as the availability of therapy and the experience of the\nattending physician ( 2 , 3 ) . In this context, ultrasound is considered the initial test of\nchoice for the diagnosis of fibroids in symptomatic patients, mainly due to its broad\navailability, ease of use, cost-effectiveness, high sensitivity, and high\nspecificity ( 4 , 5 ) . The examination should be performed by specially trained physicians,\nwith the aim of accurately identifying and describing all fibroids ( 4 , 5 ) . Other\naspects that are crucial in the choice of treatment—the size and location of fibroids; the\npresence and size of the submucosal component; penetration of the myometrial component;\nproximity to the uterine serosa; relationship with and proximity to the endometrial cavity;\nvascular supply; and coexistence of adenomyosis or deep endometriosis—are easily determined\nand can be characterized by using transvaginal ultrasound ( 5 , 6 , 7 ) .\nIn 2011, the Fédération Internationale de Gynécologie et\nd’Obstétrique (FIGO) published a classification system for categorizing the location\nof uterine fibroids ( 8 ) . The Morphological\nUterus Sonographic Assessment (MUSA) group subsequently ratified the FIGO classification,\nadopting it to describe the location of fibroids ( 9 , 10 ) . Although the FIGO\nclassification system has provided gynecologists with a well-standardized framework for\ndescribing and characterizing uterine fibroids, significant variability has been observed\nacross ultrasound reports in terms of the FIGO classification ( 11 ) . Errors in the classification and description of fibroids in\nimaging reports can lead to inappropriate surgical planning ( 7 , 11 ) . However, it is well\nknown that the accuracy of ultrasound depends on the skill of the performing physician and\nthe quality of the description in the ultrasound report ( 12 , 13 ) . Therefore, the use of\nstructured reports, divided into ordered sections and with standardized language, could\nimprove the communication of the results of ultrasound examinations and the confidence of\nthe gynecologist in those results ( 14 ) .\nIn the present study, we illustrate the main findings to be reported in an ultrasound\nreport of fibroids. We also propose a structured template for transvaginal ultrasound\nreports, designed to facilitate the preoperative evaluation of patients with uterine\nfibroids.\n\nTraditionally, the classification of fibroids is based on their location in relation to two\nanatomical planes ( 15 ) : the endometrium and\nthe uterine serosa. Thus, uterine fibroids are classified as submucosal, intramural, or\nsub-serosal ( 16 ) . With advances in\ndiagnostic modalities, the need arose for a detailed, universally accepted classification\nsystem as a guide for choosing the most appropriate treatment ( 17 ) . Therefore, in 2011, the FIGO classification system for\ncauses of abnormal uterine bleeding was developed ( 17 , 18 ) . Currently, the FIGO\nclassification includes a total of nine types of fibroids ( 8 ) —types 0 through 8—as presented in  Table 1  and  Figure 1 .\nFIGO classification of fibroids.\nFigure 1 FIGO classification of fibroids: 0 = pedunculated intracavitary fibroid; 1 =\nsubmucosal fibroid that is < 50% intramural; 2 = submucosal fibroid that is\n≥ 50% intramural; 3 = fibroid that is 100% intramural but in contact with the\nendometrium; 4 = intramural fibroid; 5 = subserosal fibroid that is ≥ 50%\nintramural; 6 = subserosal fibroid that is < 50% intramural; 7 = sub-serosal\npedunculated fibroid; 8 = other (e.g., cervical and parasitic) fibroids; and 2-5 =\nhybrid fibroid that is < 50% submucosal and < 50% subserosal.\nFIGO classification of fibroids: 0 = pedunculated intracavitary fibroid; 1 =\nsubmucosal fibroid that is < 50% intramural; 2 = submucosal fibroid that is\n≥ 50% intramural; 3 = fibroid that is 100% intramural but in contact with the\nendometrium; 4 = intramural fibroid; 5 = subserosal fibroid that is ≥ 50%\nintramural; 6 = subserosal fibroid that is < 50% intramural; 7 = sub-serosal\npedunculated fibroid; 8 = other (e.g., cervical and parasitic) fibroids; and 2-5 =\nhybrid fibroid that is < 50% submucosal and < 50% subserosal.\nThe FIGO classification system was revised in 2018 ( 19 ) . The revised version suggests that an estimate of the total uterine\nvolume should be provided in the ultrasound report, as should the estimated total number of\nfibroids. In addition, the report should include the estimated volumes of up to four\nfibroids and their locations, described as anterior, posterior, right, left, or fundus.\nFurthermore, the relationship between the endometrium and fibroids should be recorded in\naccordance with the FIGO classification system ( 19 ) .\n\nOn ultrasound, a uterine fibroid is classically characterized as a solid, round,\nwell-defined, hypoechoic, heterogeneous lesion within the myometrium, often showing acoustic\nshadowing at the edge of the lesion, with or without internal fan-shaped shadowing ( Figure 2 ). On color Doppler ( Figure 3 ), the circumferential flow around the lesion is often visible ( 20 ) . In addition, Fleischer et al. ( 21 )  successfully used three-dimensional (3D)\ncolor Doppler to demonstrate that hypervascular fibroids show a greater reduction in size\nafter uterine artery embolization than do isovascular and hypovascular fibroids. Those\nauthors also found that, after the procedure, standard ultrasound showed decreased uterine\nsize and echogenicity and color Doppler imaging showed a marked decrease in blood flow to\nthe leiomyoma.\nFigure 2 Transvaginal ultrasound image showing a submucosal uterine fibroid.\nTransvaginal ultrasound image showing a submucosal uterine fibroid.\nFigure 3 Transvaginal color Doppler ultrasound image showing a submucosal fibroid with\ncircumferential vascularity.\nTransvaginal color Doppler ultrasound image showing a submucosal fibroid with\ncircumferential vascularity.\nThe 2015 MUSA consensus suggested using a systematic approach to assessing and reporting\nultrasound findings of the myometrium and associated fibroids ( 20 , 22 ) . The relevant\nparameters are presented in  Table 2 .\nThe MUSA consensus.\n\nDecisions regarding the treatment of fibroids should take into consideration the presence\nof symptoms (often pain, bleeding, or infertility); the age and reproductive aspirations of\nthe woman; and the number, size, and location of the fibroids. Most asymptomatic patients do\nnot need specific treatment, requiring only periodic monitoring with imaging\nexaminations ( 22 , 23 ) . Although the initial treatment for most patients with\nsymptoms of abnormal bleeding is clinical, the definitive treatment for fibroids is\nsurgical ( 23 ) . Typically, hysterectomy\nand myomectomy are the most effective treatments ( 24 ) . Alternatives to surgery include embolization of the uterine arteries\nand magnetic resonance imaging (MRI)-guided focused ultrasound ablation ( 25 ) . The key imaging aspects for the surgical\ntreatment of fibroids are outlined in the following items.\nIt is recommended that the longitudinal, anteroposterior, and transverse diameters of the\nuterus be measured, because that provides the uterine volume in cm 3 , as shown in  Figure 4 , which is extremely useful in the surgical planning ( 26 , 27 ) .\nWhen the uterine volume exceeds 375 mL, the efficiency of transvaginal ultrasound in\nfibroid mapping is significantly lower than is that of MRI ( 28 ) .\nFigure 4 Transvaginal ultrasound image, in transverse and longitudinal views, showing the\ndimensions of the uterus.\nTransvaginal ultrasound image, in transverse and longitudinal views, showing the\ndimensions of the uterus.\nThe number of fibroids will determine whether fibroid resection is feasible for symptom\ncontrol. When there are numerous fibroids, radiologists should consider reporting a range\nof 10–20. Although it is not necessary to describe all lesions, a minimum number should be\nchosen ( 27 ) . Most previous studies\nhave suggested that radiologists should describe no more than four non-submucosal fibroids\nand should describe all submucosal fibroids ( 25 , 26 , 27 ) , as depicted in  Figure 5 .\nFigure 5 Transvaginal ultrasound image, in a cross-sectional view, showing myomatosis in a\nlarge uterus.\nTransvaginal ultrasound image, in a cross-sectional view, showing myomatosis in a\nlarge uterus.\nIt is recommended that each fibroid described in the report be systematically measured in\nthree orthogonal planes, to obtain its volume in cm 3 , as illustrated in  Figure 6 .\nKnowledge of the size of each fibroid helps the gynecologist estimate the probability that\nthe fibroids are (collectively) the direct cause of the symptoms and determine the best\nsurgical approach in each case ( 28 ) .\nFigure 6 Transvaginal ultrasound image, in a longitudinal view, showing the dimensions of a\nfibroid.\nTransvaginal ultrasound image, in a longitudinal view, showing the dimensions of a\nfibroid.\nIt is essential to register the location of each fibroid as being in the wall of the\nuterus—anterior, posterior, or lateral (right or left)—in the uterine fundus, or global\n( Figure 7 ). For example, when the fibroid is\nlocated in the lateral wall or in the uterine fundus, there is a greater degree of\ncomplexity in the hysteroscopic surgical procedure ( 29 ) .\nFigure 7 Transvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO\n2) fibroid in the anterior wall of a retroverted uterine body.\nTransvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO\n2) fibroid in the anterior wall of a retroverted uterine body.\nSubmucosal (FIGO 0, 1, and 2) uterine fibroids constitute a common cause of menorrhagia\nand dysmenor-rhea because they project into the endometrial cavity. For women who wish to\nbecome pregnant, submucosal fibroids are especially worrisome because they can cause\ninfertility or miscarriage ( 30 ) .\nTherefore, such fibroids require surgical treatment, regardless of size. Treatment often\nincludes hysteroscopic resection. For symptomatic patients who have no desire to become\npregnant, hysterectomy can be an option. Hysteroscopic myomectomy of a bulky FIGO 2\nfibroid, as depicted in  Figure 8 , can be difficult\nand might require a two-stage surgical procedure or uterine artery embolization ( 31 ) .\nFigure 8 Transvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO\n2) fibroid with an intramural component > 50%.\nTransvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO\n2) fibroid with an intramural component > 50%.\nFibroids without a submucosal component (intramural and subserosal fibroids) that cause\nsymptoms of mass effect in the uterine cavity or adjacent structures such as the bladder\nand bowel can be treated with embolization, myomectomy, or hysterectomy if there is no\npossibility of or desire for pregnancy. Accurately differentiating FIGO 2 fibroids from\nFIGO 3 and 4 fibroids is critical, because the surgical approach differs ( 32 ) : FIGO 2 fibroids are resected by\nhysteroscopy; and FIGO 3 and 4 fibroids are resected by video-assisted laparoscopy or\nlaparotomy.  Figure 9  shows an intramural FIGO 4\nfibroid.\nFigure 9 Transvaginal ultrasound image, in a cross-sectional view, showing an intramural\n(FIGO 4) fibroid.\nTransvaginal ultrasound image, in a cross-sectional view, showing an intramural\n(FIGO 4) fibroid.\nTreatment of bulky symptomatic fibroids and of bulky subserosal (FIGO 5, 6, and 7)\nfibroids in adjacent structures includes embolization, video-assisted laparoscopic\nmyomectomy, and laparotomy. Due to their vascular pedicle, FIGO 7 fibroids are also at\nrisk of twisting, shedding, or becoming parasitized in the pelvis. For FIGO 5, 6, and 7\nfibroids, the treatment options include embolization, laparoscopic resection, laparotomy\nor hysterectomy ( 33 ) .  Figure 10  shows a FIGO 6 fibroid in the uterine\nfundus.\nFigure 10 Transvaginal ultrasound image, in a longitudinal view, showing a subserosal fibroid\nwith an intramural component < 50% (i.e., a FIGO 6 fibroid) in the posterior wall\nof the uterine fundus.\nTransvaginal ultrasound image, in a longitudinal view, showing a subserosal fibroid\nwith an intramural component < 50% (i.e., a FIGO 6 fibroid) in the posterior wall\nof the uterine fundus.\nA FIGO 2-5 fibroid, which is less than 50% submucosal and less than 50% subserosal ( Figure 11 ), is a commonly found hybrid type of fibroid.\nDue to the size and extent of such a fibroid, treatment includes targeted therapy such as\nMRI-guided focused ultrasound or embolization, although hysterectomy can be required if\nthe fibroid is extensive ( 34 , 35 ) .\nFigure 11 Transvaginal ultrasound image, in a longitudinal view, showing a hybrid (FIGO 2-5)\nfibroid in the uterine fundus.\nTransvaginal ultrasound image, in a longitudinal view, showing a hybrid (FIGO 2-5)\nfibroid in the uterine fundus.\nThe thickness of the myometrial mantle can be measured on transvaginal ultrasound ( Figure 12 ). Various authors consider the outer\nmyometrial mantle (distance from the fibroid margin to the serous surface) and the inner\nmyometrial mantle (distance from the fibroid margin to the endometrial surface) to be key\nfactors for hysteroscopic resection of submucosal fibroids. Some studies suggest that, in\nFIGO 2 fibroids, there is a greater chance of uterine rupture during resection if the\nouter myometrial mantle is smaller than 0.5 cm ( 36 ) .\nFigure 12 Transvaginal ultrasound image, in a cross-sectional view, showing an intramural\n(FIGO 4) fibroid, with the measurement of the outer mantle (distance from the serous\nsurface, white line) and of the inner mantle (distance from the endometrial surface,\nyellow line).\nTransvaginal ultrasound image, in a cross-sectional view, showing an intramural\n(FIGO 4) fibroid, with the measurement of the outer mantle (distance from the serous\nsurface, white line) and of the inner mantle (distance from the endometrial surface,\nyellow line).\nRecognition of adenomyosis is critical because it can change the treatment approach,\npatient counseling, and expectations. Adenomyosis, as shown in  Figure 13 , is defined as diffuse or focal invasion of the endometrial\nbasal layer into the myometrium, can cause fibroid-like symptoms, and is identified on\nultrasound as thickening or irregularity of the junctional zone, asymmetry of the\nmyometrial walls, acoustic bands in the myometrium (myometrial stratification into\nfan-shaped shadowing), subendometrial/myometrial echogenic linear striations, myometrial\ncysts, and increased vascularization on Doppler, with penetrating vessels in the affected\narea ( 37 ) .\nFigure 13 Transvaginal ultrasound image showing a retroverted uterus with adenomyosis\ninfiltrating the posterior wall (arrow).\nTransvaginal ultrasound image showing a retroverted uterus with adenomyosis\ninfiltrating the posterior wall (arrow).\nA preoperative diagnosis of endometriosis directly influences the planning of the\nsurgical treatment of fibroids and the composition of the multidisciplinary surgical team.\nTherefore, screening for endometriosis on routine transvaginal ultrasound, based on the\nInternational Deep Endometriosis Analysis group consensus ( 38 ) , should be encouraged and should be performed with a\npractical, dynamic, four-step ultrasound approach: routine evaluation of the uterus and\nadnexa with special attention to ultrasound signs of adenomyosis and the presence or\nabsence of endometriomas ( Figure 14 ); evaluation of\nindirect soft markers, such as site-specific sensitivity and ovarian mobility; assessment\nof the pouch of Douglas status by realtime ultrasound testing for the “sliding sign”; and\nidentification of deep infiltrating endometriotic nodules in the anterior and posterior\ncompartments, which necessitates evaluation of the bladder, vaginal vault, retrocervical\nregion, uterosacral ligaments, and bowel.\nFigure 14 Transvaginal ultrasound image showing an ovarian endometrioma.\nTransvaginal ultrasound image showing an ovarian endometrioma.\n\nSonohysterography consists of transvaginal ultrasound combined with the infusion of sterile\nsaline through a catheter into the uterine cavity. This minimally invasive 3D technique\nallows clear delineation of the uterine cavity. It is superior to two-dimensional ultrasound\nfor the diagnosis of intrauterine abnormalities such as polyps and submucosal fibroids. In a\npooled analysis using the gold standard (hysteroscopy) as the reference ( 39 ) , saline infusion ultrasound was found to have\na sensitivity of 92% and a specificity of 90%, compared with 64% and 90%, respectively, for\ntransvaginal ultrasound. Finally, 3D ultrasound can facilitate the spatial assessment,\nallowing more accurate characterization and localization of fibroids than what is achieved\nwith two-dimensional ultrasound. Multiplanar views, especially the coronal view, have\nimproved the description of fibroids on ultrasound ( 40 ) .\n\nAlthough the FIGO classification system has provided gynecologists with a well-standardized\nframework for characterizing uterine fibroids, there is still significant variability across\ntransvaginal ultrasound reports in terms of the quality of the descriptions of fibroids.\nIncomplete descriptions of fibroids or associated lesions such as adenomyosis and\nendometriosis can raise questions or lead to inappropriate surgical planning ( 40 ) . Consequently, a structured, illustrated\nmodel of an ultrasound report, standardizing the description of uterine fibroids—based on\nthe critical criteria for surgical management, the FIGO classification of uterine fibroid\nlocation, and the MUSA group descriptors—could be useful for sonographers and physician\nexaminers. A structured, accurately illustrated ultrasound report of fibroids allows\ngynecologists to choose the best treatment for the patient, be it hysteroscopy, laparoscopy,\nlaparotomy, or embolization ( 41 , 42 ) . The proposed report template is shown in the\n Appendix . In addition, bowel preparation can be\nadded if specifically requested by the attending physician. Another relevant topic when\nconsidering the imaging evaluation of patients with fibroids is illustrating the imaging\nfindings with drawings or sketches ( Figure 15 ), which\nis also strongly recommended and valued by surgeons and patients because it provides a\nroadmap for treatment ( 43 , 44 , 45 ) .\nFigure 15 Transvaginal ultrasound, in cross-sectional and longitudinal views (A and B images,\nrespectively), showing a uterine fibroid. Schematic drawings for reporting fibroids\n(C).\nTransvaginal ultrasound, in cross-sectional and longitudinal views (A and B images,\nrespectively), showing a uterine fibroid. Schematic drawings for reporting fibroids\n(C).\n\nThere are key points in the characterization of fibroids that help gynecologists plan the\nsurgical treatment and have the potential to allow complications and treatment failure to be\navoided. The structured, illustrated ultrasound report model proposed here, which is based\non those critical points, could improve patient counseling and treatment planning, as well\nas facilitating the selection of the most appropriate medical or surgical treatment\nstrategy.","source_license":"CC-BY-4.0","license_restricted":false}