Radiologic Management of Uterine Leiomyomas-ACR Appropriateness Criteria

American College of Radiology has released ACR Appropriateness Criteria® Radiologic Management of Uterine Leiomyomas. These are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel.

Uterine fibroids, also known as leiomyomas, are the most common benign tumour in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy

Following are the Major Recommendations

Variant 1. The middle-aged woman with multiple uterine fibroids resulting in a 20-week-sized uterus on physical examination and menorrhagia. Bulk symptoms of urinary frequency and bloating are present. The patient has a recent negative serum pregnancy test and has no desire for future fertility.

Procedure	Appropriateness Category
Medical management	Usually Not Appropriate
MR-guided high-frequency focused ultrasound ablation	Usually Not Appropriate
Endometrial ablation	Usually Not Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Not Appropriate
Hysterectomy	Usually Appropriate

Variant 2. Childbearing-age woman with multiple submucosal and intramural fibroids presents with menorrhagia and pelvic pain. Most of the fibroids measure <4 cm, with two dominant fibroids measuring >6 cm. Uterus is 12 cm on MRI. The patient states that she does not desire future pregnancies and is concerned about the loss of femininity with hysterectomy.

Procedure	Appropriateness Category
Medical management	Usually Not Appropriate
MR-guided high-frequency focused ultrasound ablation	Usually Not Appropriate
Endometrial ablation	Usually Not Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Not Appropriate
Hysterectomy	May Be Appropriate

Variant 3. Childbearing age woman with menometrorrhagia. On MRI, she has three dominant leiomyomas, ranging in size from 6 to 8 cm and intramural in location. She states that she does not have plans for future pregnancy but would like to have the option in the future.

Procedure	Appropriateness Category
Medical management	Usually Not Appropriate
MR-guided high-frequency focused ultrasound ablation	May Be Appropriate
Endometrial ablation	Usually Not Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Appropriate
Hysterectomy	Usually Not Appropriate

Variant 4. Middle-aged woman with menorrhagia. MRI reveals a single 3 cm intramural fibroid and diffuse adenomyosis.

Procedure	Appropriateness Category
Medical management	Usually Not Appropriate
MR-guided high-frequency focused ultrasound ablation	Usually Not Appropriate
Endometrial ablation	May Be Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Not Appropriate
Hysterectomy	Usually Appropriate

Variant 5. A middle-aged woman with pelvic discomfort and 8 cm pedunculated subserosal fibroid on MRI.

Procedure	Appropriateness Category
Medical management	May Be Appropriate
MR-guided high-frequency focused ultrasound ablation	Usually Not Appropriate
Endometrial ablation	Usually Not Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Appropriate
Hysterectomy	Usually Appropriate

Variant 6. Middle-aged woman with constipation. MRI reveals a 12 cm subserosal leiomyoma compressing the rectum.

Procedure	Appropriateness Category
Medical management	Usually Not Appropriate
MR-guided high-frequency focused ultrasound ablation	Usually Not Appropriate
Endometrial ablation	Usually Not Appropriate
Uterine artery embolization	Usually Appropriate
Laparoscopic uterine artery occlusion	Usually Not Appropriate
Myomectomy	Usually Appropriate
Hysterectomy	Usually Appropriate

Summary of Recommendations

For more details click on the link: DOI: https://doi.org/10.1016/j.jacr.2018.03.010