{"paper_id":"58d41908-ccda-449c-823c-81125be623dc","body_text":"R E S E A R C H Open Access\nWomen seeking second opinion for symptomatic\nuterine leiomyoma: role of comprehensive fibroid\ncenter\nNelly Tan1*†,T i m o t h yDM c C l u r e1†, Christopher Tarnay2†, Michael T Johnson2†, David SK Lu 1† and Steven S Raman1†\nAbstract\nObjective: The objective of the study was to describe our early experience with a comprehensive uterine fibroid\ncenter and report our results in women seeking a second opinion for management of symptomatic uterine\nleiomyoma.\nMethods: We performed a HIPAA-complaint, IRB-approved retrospective study of women seeking second opinion\nfor management of uterine fibroids at our multidisciplinary fibroid treatment center in a tertiary care facility from\nJuly 2008 to August 2011. After a review of patients ’ history, physical examination, and magnetic resonance imaging\n(MRI) findings, treatment options were discussed which included conservative management, uterine-preserving\noptions, and hysterectomy. We performed Fisher ’s exact test for categorical variables between the cohort that did\nor did not undergo a uterine-preserving treatment. Differences were considered significant at p < 0.05.\nResults: The mean age of the 205 patient study cohort was 43.8 years (SD 7.5). One hundred sixty-two (79.0%)\npatients had no prior therapy. Based on MRI, one or more fibroids were detected in 178/205 (86.8%), adenomyosis\nin 8/205 (3.9%), and a combination of fibroid and nonfibroid condition (i.e., adenomyosis, endometrial polyp) in\n18/205 (8.8%). In those who desired to transition their care to our institution ( n = 109), 85 patients underwent 90\ninterventions: 39 MRgFUS (magnetic resonance-guided high-intensity focused ultrasound surgery), 14 UAE (uterine\nartery embolization), 25 myomectomies, 8 hysterectomies, 3 polypectomies, and 1 endometrial ablation. Five\npatients had two procedures. Intramural and subserosal fibroids were most commonly treated with MRgFUS\nfollowed by myomectomy and then UAE; in contrast, pedunculated fibroids were frequently managed with\nmyomectomy.\nConclusions: Multidisciplinary fibroid evaluation may facilitate the increase use of less invasive options over\nhysterectomy for symptomatic fibroid treatment.\nKeywords: Fibroids, MRgFUS, Fibroid center, Multidisciplinary\nIntroduction\nUterine fibroids, or leiomyomas, are benign growths of\nthe uterine smooth muscle estimated to occur in up to\n20% to 35% of all reproductive-age women, and by 50 years\nof age, prevalence increases to 70% among white and 80%\namong African-American ancestry [1,2]. Up to 30% of\nwomen with uterine leiomyoma are symptomatic [3] with\nabnormal uterine bleeding and/or bulk symptoms such as\npressure, fullness, urinary symptoms, and increased ab-\ndominal girth. These symptoms can reduce quality of life\nin addition to impacting fertility and pregnancy [4,5].\nLeiomyoma-related signs and symptoms may be influ-\nenced by their location, size, and number [6,7].\nThe available treatment options for women with symp-\ntomatic uterine fibroids include surgical techniques such\nas hysteroscopic myomectomy, laparoscopic myomectomy,\nrobotic-assisted laparoscopy, minimally invasive options\nsuch as uterine artery embolization (UAE), laparoscopic or\npercutaneous radiofrequency ablation, and noninvasive ab-\nlative therapies such as magnetic resonance-guided high-\n* Correspondence: ntan@mednet.ucla.edu\n†Equal contributors\n1Department of Radiology, University of California, 757 Westwood Blvd, Los\nAngeles, CA 90095, USA\nFull list of author information is available at the end of the article\n© 2014 Tan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative\nCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and\nreproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication\nwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise\nstated.\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3\nhttp://www.jtultrasound.com/content/2/1/3\n\nintensity focused ultrasound surgery (MRgFUS). Numer-\nous factors including patient preference, desire for future\npregnancy, symptoms, and fibroid number, size, and loca-\ntion are carefully assessed in deciding treatment options.\nDespite the proliferation of uterine leiomyoma treat-\nment options in the USA, over 60% of symptomatic\nuterine leiomyomas are treated surgically with up to\n70% undergoing hysterectomy [5]. Over US$2 billion is\nspent annually for leiomyoma-related care, with the ma-\njority of the cost related to inpatient hospital stay after\nsurgery [8,9]. There is limited understanding to explain\nthe current treatment patterns of uterine fibroids [5]. It\nis likely that a complex set of sociodemographic, eco-\nnomic, referral pattern as well as availability of resources\ncontribute to these trends. In standard of care, women\nare unlikely to receive a comprehensive set of options\nregarding treatments for fibroid-related symptoms and\nare usually offered only a narrow range of treatments\nbased on single physician preference.\nIn a variety of diseases, a multidisciplinary approach\nimproves patient and disease outcomes with reduction\nin adverse events compared to traditional standard of\ncare [10-13]. These demonstrated improvements in pa-\ntient care led us to create a multidisciplinary center for\npatients with uterine fibroids in 2008. The aim of this\nstudy was to describe the clinical outcome of our multi-\ndisciplinary fibroid center as related to magnetic reson-\nance imaging (MRI) findings and treatment elected by\nwomen seeking a second option for prior diagnosis of\nsymptomatic uterine fibroids.\nMaterials and methods\nStudy setting\nThis study was approved by the UCLA Office of Human\nResearch Protection Program and is compliant with\nHIPAA. A single cohort observational study of all pa-\ntients consecutively evaluated at our multidisciplinary fi-\nbroid center at a major tertiary referral facility from 1\nJuly 2008 to 31 August 2011.\nMultidisciplinary fibroid center\nAt our multidisciplinary fibroid center, each patient with\nsuspected fibroid-related symptoms underwent consult-\nation by both a radiologist and gynecologist. A variety of\nother physicians including reproductive endocrinolo-\ngists, internists, and subspecialists acted as consultants\nto the multidisciplinary fibroid center as necessary. All\nphysicians were employees salaried by the university\nacademic medical group but billed separately for any\ngiven consultation. Women were either referred to the\nmultidisciplinary fibroid center by their gynecologists\nor primary care physicians or self-referred by online\nsearch for uterine fibroid treatment for second or third\nopinions. Other referrals were from friends, family, radio\nadvertisements, and fibroid treatment features on televi-\nsion talk shows. Women with prior imaging were encour-\naged to mail their studies to our center for review. In\npatients with prior documented ultrasound (US) imaging\npositive for uterine fibroids or if the consultation was for a\nsecond opinion, a contrast-enhanced pelvic MRI was per-\nformed to better characterize the number, size, and pos-\nition of the fibroids.\nClinic visits included sequential 30-min consultations\nwith a gynecologist specializing in fibroid-related prob-\nlems and a radiologist specializing in pelvic imaging and\nintervention. Each physician independently obtained a\ncomprehensive gynecological history. Fibroid-specific\nhistory obtained from the women included the present-\ning symptoms (bulk vs. bleeding), severity of the symp-\ntoms, prior treatments, and the women ’s desire for\nfuture fertility. A routine physical exam of the heart,\nlungs, and abdomen and pelvis was typically performed\nby the radiologist and was supplemented by an inde-\npendent formal pelvic examination performed by the\ngynecologist. The contrast-enhanced pelvic MR scan\nwas reviewed concomitantly by both the gynecologist\nand interventional radiologist to determine the number,\nsize, location of the fibroid, juxtaposition to the endo-\nmetrial cavity, and relationship to surrounding pelvic or-\ngans. The pelvic MR scan was also used to subtype each\nfibroid (classical, hypercellular, or degenerated) to help\nimprove the triage of these lesions. Classical fibroids\nwere of low signal intensity on T2-weighted imaging and\nenhanced avidly on dynamic contrast-enhanced T1-\nweighted imaging and were amenable to treatment by all\nmodalities. Hypercellular fibroids had high T2 signal and\nenhanced avidly on dynamic contrast-enhanced T1-\nweighted imaging and responded poorly to MRgFUS.\nLesions that lack enhancement are thought to have under-\ngone either red or cystic degeneration and would not\nbenefit from either uterine embolization or MRgFUS.\nInformation from the history and physical examin-\nation, MRI, and patients ’ treatment request were used to\noffer one or more treatment options to each woman.\nThe ultimate treatment decision was made in partner-\nship with the patient with respect to her preference. If a\nnonfibroid condition was diagnosed, further work-up\nwas then performed on a case-by-case basis by the gyne-\ncologists (see Figure 1).\nMagnetic resonance imaging\nMRI of the pelvis was performed in prone position with\nan external pelvic phased array coil for reception using\neither 1.5-T (Sonata, Avanto, Siemens Medical Solutions,\nErlangen, Germany or Horizon LX; GE Medical Systems,\nMilwaukee, WI, USA) or 3-T scanners (Trio, Vario,\nSiemens Medical Solutions, Erlangen, Germany). Women\nwere scanned in the prone position to most closely mimic\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 2 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\ntreatment position during MRgFUS. The MRI scans of\nthe pelvis include the following sequences: axial T1 2D\nspoiled gradient-recalled echo dual-echo (FMPSGPR,\nGE Healthcare, Milwaukee, WI, USA or FLASH 2D,\nSiemens Medical Systems, Erlangen, Germany), axial\n3D T1 with fat saturation (liver acquisition with volume\nacceleration (LAVA), gradient echo (GE), or volumetric\ninterpolated breath-hold examination (VIBE); Siemens),\naxial 2D single-shot T2 (SSFSE, GE, or HASTE; Siemens),\naxial, coronal, oblique axial, and coronal of uterus multi-\nshot T2 (FLARE, GE, or RESTORE; Siemens). After intra-\nvenous power injection of 0.1 mmol/kg of gadolinium\nDTPA (Magnevist, Bayer Healthcare, Berlin, Germany) at\n2c m3/s, dynamic sagittal 3D VIBE with fat saturation im-\naging was performed at 30, 60, 90, and 120 s. Coronal and\naxial 3D VIBEs with fat saturation were also obtained at\n180 and 300 s, respectively. One of two fellowship-trained\nabdominal imaging radiologists with 14 and 19 years of\nexperience in pelvic MR interpretation reviewed all the\nstudies on a commercially available workstation with\nhigh-resolution monitors (Centricity 2.0, GE Healthcare).\nFor each fibroid, the radiologists determine the size, num-\nber and location, T2 signal, presence of adenomyosis or\nendometrial polyps, relative enhancement after intraven-\nous gadolinium, and the dominant arterial supply to the\nuterus. The adnexa and cervix were evaluated to exclude\nincidental masses.\nTreatment algorithm\nIn the multidisciplinary fibroid center, treatment was\nstratified into medical therapy, MRgFUS, UAE, hystero-\nscopic resection, myomectomy (laparoscopic, robotic, or\nopen), and hysterectomy. Medical therapy, such as oral\ncontraceptive pills, were used as first-line treatment for\nwomen with abnormal uterine bleeding, but women who\nwere refractory to conservative treatment can elect to\nundergo any of the appropriate therapies. Gonadotropin-\nreleasing hormone (GnRH) was also used to manage ab-\nnormal uterine bleeding or to reduce the fibroid size prior\nto myomectomy or MRgFUS.\nMRgFUS is a noninvasive treatment option most indi-\ncated in women with a single dominant, classical, non-\npedunculated, nondegenerated fibroid less than 10 cm in\nsize and is offered to women who desired future fertility.\nOn a case-by-case scenario, women with more than one\nfibroid may be offered MRgFUS. Women with hypercel-\nlular or degenerated fibroids were considered poor can-\ndidates for MRgFUS.\nUAE was discussed as a treatment option primarily in\nwomen with intermediate-sized (8 –10 cm) to large-sized\n(>10 cm), nonpedunculated, classical or hypercellular,\nnondegenerated fibroids (>10 cm) or with multiple fi-\nbroids (>5). UAE was typically not offered to women\nwho desired future fertility.\nWith respect to women who chose surgery but desired\nfuture fertility or in women with large pedunculated fi-\nbroid, myomectomy (robotic-assisted laparoscopic ap-\nproach, hysteroscopic, or open) was the recommended\ntherapy. Desire for future fertility precluded UAE and\nhysterectomy, but not myomectomy or MRgFUS.\nHysteroscopic myomectomy was recommended for\nwomen with small (<4 cm) intracavitary leiomyomas, es-\npecially if they are pedunculated (type 0) or >50% of the\ncircumference is bulging into the endometrium (type 1).\nOpen or robotic-assisted laparoscopic or laparoscopic hys-\nterectomy was recommended when patients had symptom\nFigure 1 The flowchart of the process patients take. It is from the time point they learn about the center to the time when they are seen by\nthe center’s providers.\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 3 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nrecurrence after the first-line treatment failed. See\nTable 1 for the summary of inclusion and exclusion cri-\nteria for various treatment therapies.\nData\nPatient demographics, clinical history, MRI findings, treat-\nment eligibility, and follow-up management outcomes\nwere retrieved from the electronic medical records and re-\ncorded in a database by a single medical provider.\nStatistical analysis\nMean and standard deviation were determined for age\nand number of fibroids; median and range were mea-\nsured for fibroid size. We performed Fisher ’s exact test\nfor categorical variables between the cohort that did or\ndid not undergo uterine-preserving treatments. All ana-\nlyses were done using the statistical software STATA/SE\n11.2 (College Station, TX, USA), and statistics were con-\nsidered significant at p < 0.05.\nResults and discussion\nResults\nPatients\nThe study cohort consisted of 205 patients with a mean\nage of 43.8 years (standard deviation (SD) 7.5). Nearly all\npatients had received a diagnosis of uterine fibroids from\noutside clinics based on physical exam and/or ultra-\nsound, and most had been offered hysterectomy from\noutside facilities for treatment. The most common pre-\nsenting complaints were bleeding symptoms (41.9%),\nbulk symptoms (25.6%) or combination bulk and bleed-\ning symptoms (12.7%). The remainder of patients pre-\nsented with a variety of other symptoms unrelated to\neither bulk or bleeding (e.g., dyspareunia, abdominal pain,\nback pain, urinary incontinence, and infertility; 20.0%).\nOne hundred sixty-two (79.0%) patients had not had prior\ntherapy. In 43/205 (21.0%) patients with a history of prior\ntreatment, 27/43 (62.8%) had oral contraceptive pill or\ngonadotropin-releasing hormone agonist, 9/43 (20.9%)\nhad myomectomy, 2/43 (4.6%) had endometrial ablation,\nand 5/43 (11.6%) had prior UAE.\nTreatment recommendations\nTreatment recommendations were made jointly by the\nradiologist and gynecologist based on the patients ’ symp-\ntoms, physical exam findings, MRI findings, and prefer-\nences. Although all patients sought therapy for presumed\nuterine fibroids based on a previous diagnosis, up to\n13.2% had either a combination of fibroid and nonfibroid\nconditions (i.e., adenomyosis, endometrial polyp) in 18/\n205 (8.8%) or adenomyosis in 8/205 (3.9%) patients\n(Figure 2). Based on MRI, fibroids were detected on\nMRI in 178/205 (86.8%) patients. The majority of pa-\ntients were eligible for treatment with medical or\nuterine-preserving therapies to manage their symptoms\n(Figure 2). Hysterectomy was recommended for 9/205\n(4.4%) patients (Table 2).\nTreatment provided\nOf the 205 patients in the study cohort, 109 (53.2%)\nelected to transfer their care to our institution. Medical\ntherapy or no further treatment was recommended for\n24/109 patients (22.0%; Figure 3). A total of 85/109 pa-\ntients (77.9%) underwent 90 procedures, and 8/109 pa-\ntients (7.3%) underwent hysterectomy (Figure 3). The\ndistribution of the treatment type provided to the patients\nwho had follow-up care with our institution was based on\ncharacterization and localization of uterine pathology by\nMRI ( p ≤ 0.01; T able 3). The median size and number of\nfibroids among 85 patients who underwent 90 procedures\nwere reported in T able 4. Of the myomectomy cohort, 15/\n25 (60%) patients were managed with minimally invasive\nsurgical procedures (T able 4).\nTable 1 Summary of inclusion and exclusion criteria for various treatment therapies\nTreatment Inclusion criteria Exclusion criteria\nMRgFUS  Single, dominant if <10 cm  Degenerated or pedunculated\n Multiple (≤5 fibroids) if <5 cm  Hyperintense signal on T2-weighted\n(hypercellular) MRI\n Desires fertility\nUAE  Intermediate (5–10 cm) to large\n(>10 cm) fibroids\n Degenerated or pedunculated\n Multiple >5 fibroids  Desires fertility (relative contraindication)\nMyomectomy (robotic-assisted, hysteroscopic, or open)  Desires fertility  Poor surgical candidate (significant comorbidities)\n Small (<4 cm) intracavitary\n Pedunculated\nHysterectomy  Failed first-line treatment  Poor surgical candidate (significant comorbidities)\n Desires fertility\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 4 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nFive patients had two treatments (4.6%; Table 4). Pa-\ntient 1, with pressure symptoms and abnormal uterine\nbleeding who on MRI had an intracavitary lesion and\nmultiple intramural fibroids, had planned a combination\nof MRgFUS for the intramural lesions and hysteroscopic\nmyomectomy for the intracavitary fibroids. Patient 2 had\npressure symptoms and had a 10-cm pedunculated fi-\nbroid and a 5-cm intramural fibroid on MRI and under-\nwent a combination of MRgFUS for the intramural fibroid\nand robotic-assisted laparoscopic myomectomy for the pe-\ndunculated fibroid. Patient 3 who presented with pressure\nand bleeding symptoms had a 10-cm intramural fibroid\nabutting the endometrial stripe on MRI and underwent\nMRgFUS with bleeding symptom improvement but had\npersistent bulk symptoms and subsequently underwent\nopen myomectomy. Patient 4 presented with urinary fre-\nquency and had a 10-cm submucosal fibroid on MRI; she\nelected and underwent MRgFUS with transient symptom-\natic improvement. Subsequently, the patient underwent\nopen myomectomy due to symptom recurrence. Patient 5\nhad bulk symptoms and had multiple intramural fibroids.\nThough not ideal for MRgFUS, this patient was directive\nabout receiving this modality and after explicit risk/benefit\ncounseling underwent MRgFUS. She did not have suffi-\ncient improvement in her symptoms and subsequently\nhad UAE with symptom relief.\nFigure 2 General treatment algorithm and distribution of recommendations. General treatment algorithm for women presenting to the\ncomprehensive fibroid center and the distribution of recommendations made based on patients ’ symptoms and MRI findings. Asterisk denotes\nnonfibroid conditions existing concurrently with fibroids: adenomyosis ( n = 13), ovarian cyst endometrioma ( n = 2), endometrial polyp ( n = 3).\nSection sign denotes that one patient had urinary retention; the other patient had imaging findings that did not correspond to the patient ’s\npelvic pain. Dagger denotes that hysterosonogram was recommended to evaluate for a possible endometrial polyp. Recommendations to be\nevaluated at the fibroid center were made when feasible for the patient.\nTable 2 Reasons for the recommended hysterectomy in nine patients\nPatient Clinical and imaging findings Follow-up care\n1 17-cm fibroid Open supracervical hysterectomy. Patient had endometriosis\nseen intraoperatively which was cauterized\n2 >7 fibroids, 3 –5 cm which increase in size causing dyspareunia Open supracervical hysterectomy\n3 21-cm posterior exophytic fibroid Open supracervical hysterectomy\n4 Multiple fibroids; largest is 7 cm with concomitant adenomyosis Robotic-assisted laparoscopic supracervical hysterectomy\n5 Multiple fibroids; largest is 10 cm Robotic-assisted laparoscopic supracervical hysterectomy\n6 Multiple fibroids; largest is 4 cm with concomitant adenomyosis No follow-up\n7 Patient s/p UAE with peripherally calcified 6-cm fibroid No follow-up\n8 7-cm fibroid extending to the cervix No follow-up\n9 Multiple 6 –7-cm fibroids No follow-up\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 5 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nDiscussion\nIn this study, we have shown that a multidisciplinary fi-\nbroid center model is feasible and provides patients with\na full range of treatment options including alternative\ntherapy. On contrast-enhanced MRI, 13.2% of the pa-\ntients with prior outside diagnosis of uterine leiomyoma\nhad other pathologies on MRI (i.e., adenomyosis and\nendometrial polyp). The distribution of the procedure\ntype depended on the fibroid size, MR-based subtype\n(classical, hypercellular or degenerated), location, and\nconcomitant existing uterine pathologies. In our cohort,\nmost patients qualified for uterine-preserving treatment;\nwe suggested hysterectomy in 4.4% of our patients al-\nthough the majority had been offered hysterectomy at\nother facilities. Of patients who changed care to our in-\nstitution, 77.9% were treated with either an image-\nFigure 3 Treatment provided to women who changed to our institution. In women who changed their care to our institution after initial\nconsultation, the following describes the treatment provided to the patients based on their preferences, symptoms, and MRI findings.\nTable 3 Distribution of interventions provided based on characterization and localization of uterine pathology by MRI\nin 88 women\nDiagnosis MRgFUS ( n = 39) UAE ( n = 14) Myomectomy c\n(n = 25)\nHysterectomy\n(n =8 )\nEndometrial\nablation (n =1 )\np value\nFibroids (subtypes) Intramural/subserosal ( n = 60) 31 9 17 3 0 <0.01 d\nSubmucosal (n = 17) 7 3 3 3 1\nIntracavitary (n = 12) 4 3 5 0 0\nExophytic (n =7 ) 3 1 2 1 0\nPedunculateda (n = 11) 0 2 7 0 0\nCervical (n =1 ) 0 0 1 0 0\nOthers Adenomyosis ( n =9 ) 4 2 1 2 0 -\nEndometrial polyp ( n =3 )b 00 000 -\nThese women underwent nonmedical treatment, while women electing expectant management or medical therapy were not included in this table.\naThough UAE is not the standard treatment for pedunculated fibroids, each of the two patients who underwent uncomplicated UAE had multiple (>10) fibro ids.\nBoth patients had a nondominant small (<2 cm) pedunculated fibroid seen on MR.\nbAll three patients with endometrial polyps underwent polypectomy.\ncOpen/laparoscopic-assisted robotic myomectomy.\ndFisher’s exact test was used.\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 6 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nguided procedure or surgery. MR-guided focused ultra-\nsound was the most common procedure performed\nfollowed by myomectomy.\nPron [14] questioned why adoption of newer approaches\nfor treatment of uterine fibroids was lagging despite evi-\ndence supporting the safety and efficacy of minimally in-\nvasive therapies. She argued that the issue of low adoption\nwas due to the behavioral and practice patterns of clini-\ncians who may be uncomfortable or unfamiliar with non-\nsurgical options performed by other specialties. Even\namong gynecologists, adoption of newer, minimally inva-\nsive, uterine sparing techniques may be variable. In a\nstudy reviewing clinical experience from the UK [15], a\nsurvey of gynecologists reported that 11% performed lap-\naroscopic myomectomy and 43% performed hysteroscopic\nmyomectomy. The author argued that the low rate of\nadoption of the laparoscopic approach was likely due to\nlack of training, the nonavailability of instruments, as well\nas worries about prolonged operative time compared to a\nhysteroscopic approach. Further, although 51% of gynecol-\nogists had access to UAE, the median number of patients\nreferred to UAE was only five per year [15]. The results af-\nfirmed the underutilization of minimally invasive surgery\nand nonsurgical options for treatment of uterine fibroids.\nThe underutilization of minimally invasive options was\nalso reported in a study in the USA, where of the 42% of\nwomen with fibroids who underwent an intervention, 78%\nof these women underwent hysterectomy with only 10%\nundergoing myomectomy, 3% undergoing endometrial ab-\nlation, and 4% undergoing multiple therapies [5].\nWe have shown that gynecologists and interventional\nradiologists can successfully partner together to provide\nwomen with fibroid-related symptoms the widest variety\nof treatment options possible. In our multidisciplinary fi-\nbroid center, women seeking second opinion tended to\nchoose less invasive options for symptomatic fibroid\ntreatment favoring nonsurgical procedures followed by\nmyomectomy (T able 4). Among the myomectomy cohort,\n60% were also managed using a laparoscopic, robotic, or\nhysteroscopic approach over open myomectomy. The re-\nsults suggest that in the setting of a multidisciplinary cen-\nter in women seeking second opinion, a less invasive\nsurgical option is preferred even for large or multiple\nfibroids.\nThe discrepancy between distribution of treatments\namong this study ’s cohort and those reflecting the na-\ntional trends may be due to how patients and clinicians\nlearned about emerging fibroid therapies. Ankem [16]\nsurveyed radiologists in Michigan to understand the\nsources of information radiologists used to learn about\nUAE. The results demonstrated that while national and\nregional conferences were the initial source of informa-\ntion for the early adopters, colleagues ’ practice patterns\nwere the most important source of information for late\nadopters. The study argued that work relations and com-\nmunication among clinicians was the most conducive\nmeans for flow of information about UAE. An institution-\nbased practice as well as availability of appropriate\nresources may explain why newer modalities were widely\naccepted and used in our clinical practice.\nPatients usually uncover information about nontradi-\ntional and alternative fibroid therapies from internet\nsources, and this may also explain why our cohort of pa-\ntients elected the therapies they did. One study [17] in-\nvestigated the information-seeking behavior of patients\nwith symptomatic fibroids, specifically in those who\nlearned about and underwent UAE. In this study, 40%\nlearned about UAE from their gynecologist and 60% be-\ncame aware of UAE through mass media, friends, or\nfamily members. Our experience confirmed this result\nsince the vast majority of women were offered only hyster-\nectomy in the community. Additionally, women in this\nstudy were asked to rate the helpfulness of an information\nsource in providing information that they needed. The\nTable 4 Size and number of fibroids in 85 patients who underwent 90 procedures\nProcedures (total) Age Fibroid size (cm) Number of fibroids Miscellaneous\nMean (SD) Median (range) Mean (SD)\nMRgFUS (n = 39) 40.4 (9.5) 7.3 (5 –10) 2.6 (2.9) Two patients had MRgFUS adenomyosis\nUAE (n = 14) 47.1 (4.7) 7.8 (6.2 –8.5) 2.2 (1.1) Two patients had UAE for isolated adenomyoma\nTwo patients were with hypercellular intramural >8 cm fibroids\nFour patients were with >5 fibroids\nMyomectomy (n = 25) 43.2(6.6) 8.0 (5.4 –11) 2.9 (2.2) Approach: 11 hysteroscopic, 10 open, 2 robotic, 2 laparoscopic\nmyomectomies\nHysterectomy (n = 8) 46.0 (5.7) 9.5 (7.8 –14.0) 4 (3.7) Two patients were with isolated adenomyoma\nApproach: two laparoscopic hysterectomies\nPolypectomy (n =3 ) - - -\nEndometrial ablation ( n = 1) 2.2 cm 1 -\nFive patients had two procedures.\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 7 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nstudy found that the radiologists were viewed as the most\nhelpful in providing information, followed by the internet,\nthen by gynecologists and other primary care doctors.\nMRI is regarded as the definitive modality for uterine\nfibroid imaging. Although initially expensive, it is the\nmost accurate and reproducible imaging method for de-\ntecting, localizing, and characterizing leiomyoma [18,19]\nUnlike US or CT, MRI can also characterize fibroid sub-\ntypes, assess for fibroid degeneration, delineate the pres-\nence of gonadal arterial supply to individual fibroids (for\nUAE planning), and uncover a range of coexisting path-\nologies such as adenomyosis, polyps, urethral diverticula,\nand adnexal masses. [20] Thus, MRI enables a comprehen-\nsive and objective noninvasive gynecological evaluation to\ndetermine whether a patient undergoes laparoscopic myo-\nmectomy, UAE, or MRgFUS. It provides an immediate\nmethod of triage for a range of problems that often coexist\nlike adenomyosis and endometrial polyps, where in tandem\nwere detected in up to 13% of our cohort with outside US\ndiagnosis of fibroids. MRI has been proven superior to US\nin diagnosing adenomyosis [21-23]. Although adenomyosis\nmay be treated with UFE, its role was still evolving, and\npreoperative diagnosis was important for triage. Unlike\nwith US, MRI also enabled a confident diagnosis of de-\ngenerating fibroids, which would not benefit from UAE\nor MRgFUS. Similarly, MRI enabled a confident diag-\nnosis of hypercellular fibroids which respond very\npoorly to MRgFUS [24]. Thus, the European Society of\nHuman Reproduction and Embryology [25] endorsed\nMRI as a second-line technique examination for exam-\nining morphologic and vascular features of leiomyoma\nand for triaging treatment options as compared to US\nprimarily due to the higher expense of MRI.\nWe recognize that the use of MRI as the primary diag-\nnostic tool at our center is not the standard of practice.\nHowever, we feel that our practice is a specialized center\nand that the patient population is unique compared to a\ntypical gynecology or primary care practice. Most\nwomen came with known diagnosis of fibroids and came\nto us seeking specific treatments not available to all\npractices (i.e., MRgFUS). MRI allowed us to provide the\nmost comprehensive and accurate noninvasive diagnosis\nto guide appropriate treatment recommendations during\nmultidisciplinary consultation. There has not been a trial\nof cost-effectiveness of using MRI to triage women with\nleiomyoma over US as the primary imaging modality.\nHowever, Schwartz et al. [26] prospectively evaluated the\nimpact of MRI on treatment decisions for 69 consecu-\ntive women scheduled to undergo gynecologic surgery\nand effect on change in medical expense. The diagnosis\nwas changed in 53% of patients. Of this cohort, 81% had\na change in treatment; the most common change was\ncancellation of surgery. Use of MRI resulted in overall\nsavings per patient. Moreover, Lin et al. demonstrated\nthat people are willing to undergo diagnostic radiology\nexams—and are willing to pay more —to reduce un-\nnecessary, invasive medical procedures and overall\nhealth costs [27].\nThere were several limitations to our study. One sig-\nnificant potential source of bias was the self-referred na-\nture of our patient population. These women were\nsearching online for uterine-preserving options and\nwould likely choose uterine-preserving treatments, and\nthus, the results should not be generalized to all patients.\nPatients also likely came with a preconceived notion for\nspecific treatment, creating another source of selection\nbias for the study cohort, and thus, the results may not\nbe applicable to the general population. Another bias\nwas in the socioeconomic status of our patients. In gen-\neral, our patient population had health insurance, and as\na result, outcomes and conclusions may not be represen-\ntative of the general population across all socioeconomic\ngroups. Moreover, our medical center provided all com-\nprehensive treatments, and as such, our findings may\nnot be applicable to community-based practices, which\nmay have limited access to certain treatment such as\nMRgFUS, robotics, or UAE. We used MRI as the diag-\nnostic study of choice which was not the standard prac-\ntice. Therefore, we do not advocate MRI for initial\npresentation and evaluation. However, in women seeking\na second opinion for prior diagnosis of uterine leio-\nmyoma at a comprehensive fibroid center, MRI allowed\nus to provide efficient and definitive diagnosis to direct\nthe patient to appropriate treatments.\nDespite the limitations, our study supported the feasi-\nbility of establishing multidisciplinary fibroid centers to\naddress women with symptomatic fibroids. With in-\ncreasing access to the internet and utilization of social\nmedia, patients will likely be the driving force to the\nadoption of less invasive, less radical treatment alterna-\ntives across all surgical fields including gynecology as\nthey learn about new and evolving treatment options. In\nour patient population, most women were candidates for\nuterine-preserving options and chose to undergo a min-\nimally invasive uterine-preserving treatment.\nConclusions\nUterine fibroids had been managed by a single subspe-\ncialist effectively, typically gynecologists. However, with\nthe advent of multiple therapeutic options for treatment\nof symptomatic uterine fibroids which are performed by\ndifferent subspecialists, there is an increasing need for\ncrosstalk between multiple specialties to provide com-\nprehensive options for women. Patients can then decide\nfor themselves which treatment is best suited for their\nneeds and wishes. In the USA, most women are man-\naged with surgical therapy, most commonly hysterec-\ntomy. The reasons for this are likely multifactorial\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 8 of 9\nhttp://www.jtultrasound.com/content/2/1/3\n\nincluding social, economic, geographic, and access to\ncare. To overcome some of the barriers for patients, we\nstarted a comprehensive fibroid center in collaboration\nwith gynecology and radiology, and we reported our early\nexperience with the center. Our results demonstrate that\npatients undergo a wide range of therapy. However, there\nis a significant preference towards uterine-preserving op-\ntions. Of these, MR-guided focused ultrasound surgery\nwas the most commonly utilized procedure. Our findings\nsuggest that women desire minimally invasive therapies,\nand joint effort between gynecology and radiology maybe\none option for institutions to improve access to most, if\nnot all, of the therapeutic options available for symptom-\natic uterine fibroids.\nAbbreviations\nMRgFUS: MR-guided focused ultrasound surgery; MRI: magnetic resonance\nimaging; UAE: uterine artery embolization.\nCompeting interests\nNelly Tan was the Focused Ultrasound Surgery Foundation Clinical Fellow in\n2012. Timothy D. McClure was the Focused Ultrasound Surgery Foundation\nClinical Fellow in 2010. Christopher Tarnay, Michael T. Johnson, David SK Lu,\nand Steven S. Raman have no competing interests to declare.\nAuthors’ contributions\nNT participated in the design, data acquisition, analysis, interpretation, and\ndrafting of the manuscript. TDM participated in the design, interpretation,\nand drafting of the manuscript. CT participated in the design and drafting of\nthe manuscript. MTJ participated in the conception and drafting of the\nmanuscript. DSKL participated in the conception and design and drafting of\nthe manuscript. SSR participated in the conception and design and drafting\nof the manuscript. All authors read and approved the final manuscript.\nAcknowledgements\nNelly Tan would like to thank Focused Ultrasound Surgery Foundation for\nthe support on her clinical fellowship. We thank David Nelson and Steve Do\nfor the preparation of the figures and Zen Vuong for the critical review of\nthe manuscript. No additional sources of funding were used.\nAuthor details\n1Department of Radiology, University of California, 757 Westwood Blvd, Los\nAngeles, CA 90095, USA. 2Department of Obstetrics and Gynecology,\nUniversity of California, 757 Westwood Blvd, Los Angeles, CA 90095, USA.\nReceived: 1 November 2013 Accepted: 30 January 2014\nPublished: 15 April 2014\nReferences\n1. Wise LA, Palmer JR, Harlow BL, Spiegelman D, Stewart EA, Adams-Campbell\nLL, Rosenberg L. Reproductive factors, hormonal contraception, and risk\nof uterine leiomyomata in African-American women: a prospective\nstudy. Am J Epidemiol. 2004; 159(2):113–23.\n2. Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High\ncumulative incidence of uterine leiomyoma in black and white women:\nultrasound evidence. Am J Obstet Gynecol. 2003; 188(1):100–7.\n3. Buttram VC Jr, Reiter RC. 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Willingness to pay for\ndiagnostic technologies: a review of the contingent valuation literature.\nValue In Health. 2013; 16(5):797–805.\ndoi:10.1186/2050-5736-2-3\nCite this article as: Tan et al. : Women seeking second opinion for\nsymptomatic uterine leiomyoma: role of comprehensive fibroid center.\nJournal of Therapeutic Ultrasound 2014 2:3.\nTan et al. Journal of Therapeutic Ultrasound 2014, 2:3 Page 9 of 9\nhttp://www.jtultrasound.com/content/2/1/3","source_license":"CC0","license_restricted":false}