Clinical improvement and shrinkage of uterine fibroids after thermal ablation by magnetic resonance-guided focused ultrasound surgery

Magnetic resonance-guided focused ultrasound for uterine fibroids

INTRODUCTION

The uterine leiomyoma is a pelvic solid tumor more frequent in women. The Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) is a technique aimed at diminishing hypermenorrhagia and dysmenorrhea in symptomatic women.

OBJECTIVE

To show the effects subsequent to MRgFUS application on symptoms, quality of life, and myoma volume in symptomatic women.

METHODS

Fifty-two patients with symptomatic uterine myomas underwent MRgFUS followed by clinical evaluation, pelvis MRI, and administration of the UFS-QoL questionnaire at 6 months and 12 months to detect symptom improvements and decrease in myoma volume.

RESULTS

The mean myoma volume decreased 24 % after 6 months and 42 % after 12 months. The mean score on the UFS-QoL questionnaire increased 54 % after 6 months and 81 % after 12 months. There were no serious complications. Four patients had first-degree burns. No infection cases were reported. Two patients progressed to a myomectomy by surgical hysteroscopy and one of them underwent total hysterectomy 11 months after the MRgFUS treatment.

CONCLUSION

This case series suggests that MRgFUS therapy is viable and effective in reducing symptoms and improving the life quality of symptomatic patients.

Ultrasound-Guided High-Intensity Focused Ultrasound of Uterine Fibroids and Adenomyosis: An 11-Year Experience from a Single Center in Hong Kong

Introduction: This study evaluated the efficacy and safety of ultrasound-guided high-intensity focused ultrasound (HIFU) in treating symptomatic uterine fibroids and adenomyosis. Methods: HIFU treatments performed in premenopausal women with symptomatic uterine fibroids and adenomyosis were analyzed retrospectively. Lesion volume reduction, change in symptoms of menstrual pain, and quality of life were examined. Major and minor complications, together with re-intervention rates, were evaluated. Results: Eighty-one HIFU treatments were performed in seventy-nine premenopausal women. The follow-up period was up to 95 months. A total of 65 women underwent treatment for uterine fibroids and 14 were treated for adenomyosis. For patients with uterine fibroids, the baseline fibroid volume median was 190.1 cm3 (18.5-1729.4 cm3). Fibroid volume was reduced by 50.1% (-26.2-97.8, p < 0.0001) at 6 months and 66.9% (-33.7-98.3, p < 0.0001) at 12 months after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores had decreased by 43.5% (0-62.5%, p < 0.0001) at 6 months and 50% (0-73%, p < 0.0001) at 12 months after treatment. In the adenomyosis arm, the median baseline uterine volume was 97.7 cm3 (43.7-367.4 m3). Uterine volume was reduced by 19.6% (range: 1.2-42.0, p = 0.28) at 6 months and 41.9% (18.9-69.2, p = 0.04) at 12 months after treatment. UFS-QOL scores were reduced by 38.1% (6-66.7%, p < 0.0001) at 6 months and 40% (0-70%, p < 0.0001) at 12s month after treatment. Fourteen (21.5%) patients with uterine fibroid and five (35.7%) patients with adenomyosis required subsequent interventions. Conclusions: HIFU provides symptomatic relief to most patients with uterine fibroids and adenomyosis. It is a promising uterus-sparing treatment for patients with these conditions.

Application value of contrast-enhanced ultrasonography in the treatment of uterine fibroids by high-intensity focused ultrasound ablation: A retrospective study

PURPOSE

To determine efficacy and safety of contrast-enhanced ultrasonography (CEUS) in high-intensity focused ultrasound (HIFU) ablation of uterine fibroids (UFs).

METHODS

We retrospectively reviewed women undergoing HIFU ablation for UFs between June 2018 and January 2020. Before and after HIFU, patients underwent CEUS and magnetic resonance imaging (MRI) examinations. The relationship between CEUS features and ablation rate was analyzed. The time-intensity curves on CEUS were measured before and after HIFU ablation, and compared with those obtained using MRI. Adverse reactions were recorded.

RESULTS

A total of 64 patients were included. The immediate HIFU ablation rate significantly differed between low-, iso-, and high-enhancement UFs (87.2% ± 1.6%, 83.3% ± 2.1%, and 72.9% ± 3.1%, respectively; p < 0.05). On CEUS, the peak time of the time-intensity curve was significantly longer after treatment than before treatment (32.2 ± 9.7 and 26.7 ± 9.4 s, respectively; p < 0.05). Peak intensity was significantly lower after treatment than before treatment (13.7 ± 7.5 and 30.9 ± 11.2 dB, respectively; p < 0.05). All measurements were comparable between CEUS and MRI. The most common peri- and post-procedure adverse reaction was pain, which was temporary.

CONCLUSION

CEUS could dynamically and safely evaluate the immediate effects of the HIFU ablation of UFs.

Three-dimensional ultrasound VOCAL combined with contrast-enhanced ultrasound: an alternative to contrast-enhanced magnetic resonance imaging for evaluating ablation of benign uterine lesions

OBJECTIVE

This study explores the feasibility and value of three-dimensional ultrasound virtual organ computer-aided analysis (3D-VOCAL) combined with contrast-enhanced ultrasound (CEUS) for measuring the non-perfused volume (NPV) after microwave ablation (MWA) of benign uterine lesions.

METHODS

Fifty-six patients with uterine myoma (UM) and adenomyosis (AM) treated with MWA were enrolled. NPV measurements were obtained postoperatively using two-dimensional CEUS (2D-CEUS), 3D-VOCAL combined with CEUS and three-dimensional contrast-enhanced magnetic resonance imaging (3D-CEMRI). Bland-Altman analysis and intraclass correlation coefficient (ICC) values were used to analyze the agreement of NPV measurements obtained via 2D-CEUS and the combined method with 3D-CEMRI. The inter- and intra-observer agreements of the NPV values obtained with all three methods were also analyzed.

RESULTS

Considering 3D-CEMRI as the standard, 3D-VOCAL showed greater agreement than 2D-CEUS and higher ICCs (ICC, 0.999 vs. 0.891) than 2D-CEUS for different lesion types and sizes of non-perfusion areas (p < 0.001 for all comparisons). NPV measurements obtained via 2 D-CEUS and 3 D-CEMRI differed significantly for AM and non-perfusion areas with maximum diameter ≥5 cm (p < 0.05) and showed no significant differences (p > 0.05) for UM and non-perfusion areas with maximum diameter <5 cm. The NPV measurements obtained via 3D-VOCAL and 3D-CEMRI did not differ significantly (p > 0.05). The intra- and inter-observer agreements of 3D-VOCAL measurements were better than those of 2D-CEUS and slightly lower than those of 3D-CEMRI.

CONCLUSIONS

3D-VOCAL combined with CEUS provides accurate estimates of NPV after MWA of benign uterine lesions, and offers a reliable, simple and efficient alternative to CEMRI.

Comparison of two invasive non-surgical treatment options for uterine myomas: uterine artery embolization and magnetic resonance guided high intensity focused ultrasound-systematic review

BACKGROUND

Uterine Artery Embolization (UAE) and Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) are two noninvasive treatments for uterine leiomyoma.

METHODS

This systematic review, following PRISMA guidelines, analyzed the effectiveness of two treatments by comparing percent fibroid volume shrinkage immediately after the procedure and after 3, 6, 12 and 24 months of follow-up and also assessed and compared common complications following treatment. The search utilized Science Direct, PubMed, MEDLINE, Google Scholar and BioMed Central databases, selecting manuscripts published during the period 2000 and 2020. Studies with premenopausal patients with previous treatments for uterine leiomyoma and/or with other pelvic diseases were excluded.

RESULTS

Twenty-nine papers satisfied inclusion and exclusion criteria. Results were pooled and stratified by treatment and follow-up time. Weighted fibroid volume percent shrinkage after UAE was statistically significantly greater than MRgHIFU at 6, 12, and 24 months follow-up times. However, UAE had statistically significantly more complications, such as pain, nausea and vomiting. However, this study cannot conclude that UAE is more effective than MRgHIFU due to confounding factors.

MRI guided focused ultrasound (MRgFUS) treatment for uterine fibroids among women with and without abdominal scars

INTRODUCTION

MRI guided focused ultrasound (MRgFUS) is a noninvasive technique for treating uterine fibroids. The presence of abdominal scars can limit the number of women eligible for the procedure, due to absorbance of beam energy. The goals of this study were to assess the number of women that fit the procedure and to compare outcomes among women with or without abdominal scars.

MATERIAL AND METHODS

A prospective cohort study of all women that were interested in MRgFUS in a single University-Affiliated Hospital between November 2012 and December 2019. Rates of women that were referred to further screening, fulfilled selection criteria and underwent the procedure were compared between patients with or without abdominal scars. We evaluated the treatment parameters of the two groups and used linear regression model predict non-perfused volume (NPV) at the end of the process.

RESULTS

Out of 701 patients, 21.8% were suitable for MRgFUS. Women with scars had significant lower NPV compared with women without scars (60% versus 82.4%, p = 0.021). No serious adverse events were reported in both groups. Linear regression models showed that fibroids' volume, stopping the treatment due to severe pain and the presence of abdominal scars had a statistically significantly negative effect on NPV (betas: -11.51, -6.96, and -6.29, p-values: <0.001, 0.003, and 0.007 respectively), while number of sonication had a statistically significantly positive effect on NPV (beta = 5.98, p = 0.011).

CONCLUSION

Regardless of strict inclusion criteria, MRgFUS treatment is less efficient among women with abdominal scars, although still feasible for those who are interested in noninvasive option.

Secretome Profiling and Computational Biology of Human Leiomyoma Samples Unravel Molecular Signatures with Potential for Diagnostic and Therapeutic Interventions

In recent years, significant advancements have been made in the way the complex proteome samples are compared but the ultimate goal of routine biomarker discovery has yet to be achieved. Based on reverse genetic strategy, our study involved the spotting of genes showing expressional variability in uterine leiomyoma females. Serum samples were taken from uterine leiomyomas subjects (n=6) and healthy control subjects (n=6) for proteomic studies. Additionally, leiomyoma tissue samples (n=25) and normal myometrium samples (n=25) were taken for validation studies. In this study, we profiled the proteomes of uterine leiomyoma patient's serum and healthy control, along with relative quantification using Nano LC-MS/MS analysis. A total of 146 proteins were reported to be significantly differentially expressed (P value less than 0.05) in case and control sample. Statistical analysis identified a number of molecular signatures distinguishing healthy from diseased serum. Among these, five proteins lumican, ficolin, MASP2, EMSY, and kallistatin were further chosen according to their function for validation. Kallistatin was downregulated while ficolin, MASP2, lumican, and EMSY were found to be upregulated in the diseased sample. The expression modulations in the identified genes were further validated in twenty-five cases. Interactions among the differentially expressed proteins were identified followed with network analysis. Network analysis emphasized important pathways that are highly deregulated in myoma, and functional significance of these pathways in the pathology of the disease was discussed. Comparative expression analysis reveals distinct molecular signatures and their probable role in diagnosis of the disease.

Efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids: an observational single-center study

INTRODUCTION

To evaluate treatment response of uterine fibroids after ultrasound guided high-intensity focused ultrasound (USgHIFU) with a special focus on fibroid size and characterization based on Funaki classification scheme, as well as clinical response to treatment of leading fibroid-associated symptoms.

MATERIALS AND METHODS

Uterine fibroids treated by USgHIFU were assigned to Funaki type 1-3 based on T2-w-MRI. Differences in size, non-perfused volume ratio (NPVR) and volume reduction over time were determined using T1-/T2-w MRI sequences and contrast-enhanced sonography. Treatment effects on three leading fibroid-associated symptoms were also evaluated. Measurements were compared by mixed model, Bland-Altman's plot and Spearman's correlation.

RESULTS

In this prospective single-center study, 35 patients with 44 symptomatic uterine fibroids were treated by USgHIFU (n = 22, n = 12 and n = 10 assigned to Funaki type 1, 2 and 3, respectively). NPVRs of Funaki type 1 and 2 fibroids were significantly higher compared to type 3 (p = .0023). A significant fibroid shrinkage was observed independent of Funaki type compared to baseline: 38.8 ± 26.9%, 46.7 ± 30.3% and 54.5 ± 29.3% at 3, 6 and 12 months, respectively (each p < .05). Moreover, patients experienced a significant improvement of fibroid-associated hypermenorrhea (3.9 ± 1.3 vs. 2.3 ± 1.3), pressure in the pelvic area (3.5 ± 1.3 vs. 2.1 ± 0.9) and frequent urination (2.8 ± 1.5 vs. 1.9 ± 0.8) one year post-procedure (each p < .05), regardless of fibroid Funaki type.

CONCLUSION

Following USgHIFU, a significant shrinkage of uterine fibroids and improvement of leading fibroid-associated symptoms were demonstrated regardless of the Funaki type.

The efficacy and safety of MR-HIFU and US-HIFU in treating uterine fibroids with the volume <300 cm3: a meta-analysis

BACKGROUND

High-intensity focused ultrasound (HIFU) is a promising and non-invasive therapy for symptomatic uterine fibroids. Currently, the main image-guided methods for HIFU include magnetic resonance-guided (MR-HIFU) and ultrasound-guided (US-HIFU). However, there are few comparative studies on the therapeutic efficacy and safety of MR-HIFU and US-HIFU in treating symptomatic uterine fibroids with a volume <300 cm³.

OBJECTIVE

We performed this meta-analysis to evaluate the efficacy and safety of MR-HIFU and US-HIFU in treating symptomatic uterine fibroids with a volume <300 cm³.

METHODS

We searched relevant literature in PubMed, EMBASE, Cochrane Library CNKI from inception until 2021. The mean value, the proportion, and their 95% confidence intervals (CIs) were measured by random-effects models. Publication bias was assessed using funnel plots.

RESULTS

48 studies met our inclusion criteria-28 describing MR-HIFU and 20 describing US-HIFU. The mean non-perfused volume rate (NPVR) was 81.07% in the US-HIFU group and 58.92% in the MR-HIFU group, respectively. The mean volume reduction rates at month-3, month-6, and month-12 were 42.42, 58.72, and 65.55% in the US-HIFU group, while 34.79, 37.39, and 36.44% in the MR-HIFU group. The incidence of post-operative abdominal pain and abnormal vaginal discharge in the US-HIFU group was lower than that of MRI-HIFU. However, post-operative skin burn and sciatic nerve pain were more common in the US-HIFU group compared with MRI-HIFU. The one-year reintervention rate after MR-HIFU was 13.4%, which was higher than 5.2% in the US-HIFU group.

CONCLUSION

US-HIFU may show better efficiency and safety than MR-HIFU in treating symptomatic fibroids with a volume <300 cm³.

The effect of injected dose on localized tumor accumulation and cardiac uptake of doxorubicin in a Vx2 rabbit tumor model using MR-HIFU mild hyperthermia and thermosensitive liposomes

PURPOSE

When doxorubicin (DOX) is administered via lyso-thermosensitive liposomes (LTLD), mild hyperthermia enhances localized delivery to heated vs. unheated tumors. The optimal LTLD dose and the impact of different doses on systemic drug distribution are unknown.

Materials and methods: In this study, we evaluated local and systemic DOX delivery with three LTLD doses (0.1, 0.5, and 2.5 mg/kg) in a Vx2 rabbit tumor model. Temporally and spatially accurate controlled hyperthermia was achieved using a clinical MR-HIFU system for the intended heating duration (40 min).

Results: DOX concentration in tissues delivered from LTLD combined with MR-HIFU mild hyperthermia are dose-dependent, including heated/unheated tumor, heart, and other healthy organs. Higher DOX accumulation and tumor-to-heart drug concentration ratio, defined as the ratio of DOX delivered into the tumor vs the heart, were observed in heated tumors compared to unheated tumors in all three tested doses. The DOX uptake efficiency for each mg/kg of LTLD injected IV of heated tumor was significantly higher than that of unheated tumor and heart within the tested dose range (0.1-2.5 mg/kg). The DOX uptake for the heart linearly scaled up as a function of dose while that for the heated tumor showed some evidence of saturation at the high dose of 2.5 mg/kg.

Conclusions: These results provide guidance on clinical protocol design of hyperthermia-triggered drug delivery.

Tolerability and Feasibility of X-ray Guided Non-Invasive Ablation of the Medial Branch Nerve with Focused Ultrasound: Preliminary Proof of Concept in a Pre-clinical Model

Four to six million patients a year in the United States suffer from chronic pain caused by facet joint degeneration. Thermal ablation of the affected facet joint's sensory nerve using radiofrequency electrodes is the therapeutic standard of care. High-intensity focused ultrasound (HIFU) is a novel technology enabling image-guided non-invasive thermal ablation of tissue. Six pigs underwent fluoroscopy-guided HIFU of the medial branch nerve and were followed up for 1 wk (two pigs), 1 mo (two pigs) and 3 mo (two pigs). At the end of each follow-up period, the animals were sacrificed, and targeted tissue was excised and evaluated with computed tomography scans as well as by macro- and micropathology. No significant adverse events were recorded during the procedure or follow-up period. All targets were successfully ablated. X-Ray-guided HIFU is a feasible and promising alternative to radiofrequency ablation of the lumbar facet joint sensory nerve.

Percutaneous microwave ablation of uterine fibroids: correlation between shrinkage and trend symptoms

PURPOSE

To assess a correlation between the shrinkage of the fibroid and the course of the symptoms.

MATERIAL AND METHODS

Fourteen patients with symptomatic uterine leiomyomas (mean fibroid volume: 111.45 cm3) underwent percutaneous microwave ablation. Contrast-enhanced MRI follow-up was performed before and after treatment to evaluate the volume shrinkage. Two scores obtained from the Uterine Fibroids Symptom and Quality of Life questionnaire were used to perform a clinical follow-up to evaluate the symptoms and the quality of life at baseline, and at 3, 6 and 12 months after treatment.

RESULTS

All patients were treated, no complications occurred. During a mean MR follow-up of 8.1 months we observed shrinkage of the fibroids in all patients (mean 70.3 cm3). During 12 months clinical follow-up, we observed a significant improvement of symptoms and an excellent improvement of quality of life (p < .001).

CONCLUSION

Uterine fibroids percutaneous microwave ablation is a safe tool to obtain a significant improvement in quality of life for all the patients of our cohort.

Combined treatment for big submucosal myoma with High Intensity Focused Ultrasound and hysteroscopic resection

OBJECTIVE

Big submucosal myoma often causes heavy menstrual bleeding and are complicated in hysterscopic surgery. High Intensity Focused Ultrasound (HIFU), is a method for myoma ablation therapy, which may benefit on size reduction, and assist following hysterscopic myomectomy.

CASE REPORT

Two cases, case one,. 44-year-old female with 3.8 cm submucosal myoma, STEPW (Size, Topography, Extension, Penetration and Wall) score 6 and case 2. 48-year-old female, with 6.0 cm submucosal myoma, STEPW score 8, both received HIFU treatment before hysterscopic myomectomy was done. The myomas reduced after 5 months with improvement of anemia. The following hysterscopic myomectomy shows less operative time and fewer blood loss.

CONCLUSION

HIFU reduce size of submucosal myoma and may improve anemia after months. Less operating time and blood loss were demonstrated in the following hysterscopic myomectomy. For well selected patients, combined treatment with HIFU and hysteroscopic resection may decrease complication rate.

Non-contrast enhanced MRI for assessment of uterine fibroids' early response to ultrasound-guided high-intensity focused ultrasound thermal ablation

PURPOSE

To examine non-contrast enhanced MRI value to evaluate necrotic area and ablation rate of uterine fibroids after high-intensity focused ultrasound (HIFU) thermal ablation.

METHOD

In total, 508 patients with 598 fibroids who underwent HIFU treatment were enrolled. Contrast-enhanced MRI (CE-MRI) with diffusion-weighted imaging (DWI)were performed before treatment and within two days post-treatment. DWI signal performance of post-operative fibroids was observed; apparent diffusion coefficient (ADC) and DWI signal values pre- and post-operation were measured. The volume of post-operative DWI signal change area and post-contrast enhanced fibroid necrosis area were compared.

RESULTS

Average ADC and DWI signal values before HIFU treatment were higher than those post-operation; the difference was statistically significant before and after ablation (P < 0.05). After HIFU, 78.09 % (467 / 598) of DWI showed complete regular or irregular high-signal rings and 21.91 % (131 / 598) showed incomplete high-signal rings. No significant difference was noted between the complete high-signal ring volume on DWI and the non-enhanced volume (P > 0.05); however, this difference was statistically significant compared with the incomplete high-signal ring volume on DWI (P < 0.05). Two doctors had good agreements on evaluating the morphology of high-signal rings (κ > 0.75, P < 0.05).

CONCLUSIONS

Combined with pre-operative T2WI and post-operative DWI, non-contrast enhanced MRI can effectively evaluate ablation rate for most patients with uterine fibroids.

Long-term outcome of MR-guided focused ultrasound treatment and laparoscopic myomectomy for symptomatic uterine fibroid tumors

BACKGROUND

Fibroid tumors are the most common benign tumors in women of reproductive age. Treatment is usually indicated for those who are symptomatic, with different techniques being used.

OBJECTIVE

The purpose of this study was to compare the long-term outcome of laparoscopic myomectomy with magnetic resonance-guided focused ultrasound for symptomatic uterine fibroid tumors.

STUDY DESIGN

A cohort study was conducted on all patients with symptomatic uterine fibroid tumors who were admitted to a single tertiary care center and treated operatively with laparoscopic myomectomy or treated conservatively with magnetic resonance-guided focused ultrasound from January 2012 until January 2017. Assessment for further interventions and sustained fibroid-associated symptoms was performed, with the use of the Uterine Fibroid Symptom and Quality of Life symptom severity score.

RESULTS

One hundred fifty-four women met the inclusion criteria. Complete follow-up evaluation was achieved for 64 women who underwent laparoscopic myomectomy and for 68 women who were treated by magnetic resonance-guided focused ultrasound. Follow-up time was similar for the 2 groups (median, 31 months [interquartile range, 17-51 months] vs 36 months [interquartile range, 24-41]; P=.95). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (P=0.312). Similarly, the Uterine Fibroid Symptom and Quality of Life symptom severity score questionnaire score at follow-up interviews revealed comparable median scores of 17 (interquartile range, 12-21) vs 17 (interquartile range, 13-22) for laparoscopic myomectomy and magnetic resonance-guided focused ultrasound, respectively (P=.439). Analysis of each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue) did not change these findings, nor did a multivariate analysis.

CONCLUSION

Satisfaction with long-term outcome and rate of reinterventions after magnetic resonance-guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.

Focused ultrasound transducer spatial peak intensity estimation: a comparison of methods

Characterisation of the spatial peak intensity at the focus of high intensity focused ultrasound transducers is difficult because of the risk of damage to hydrophone sensors at the high focal pressures generated. Hill et al (1994 Ultrasound Med. Biol. 20 259-69) provided a simple equation for estimating spatial-peak intensity for solid spherical bowl transducers using measured acoustic power and focal beamwidth. This paper demonstrates theoretically and experimentally that this expression is only strictly valid for spherical bowl transducers without a central (imaging) aperture. A hole in the centre of the transducer results in over-estimation of the peak intensity. Improved strategies for determining focal peak intensity from a measurement of total acoustic power are proposed. Four methods are compared: (i) a solid spherical bowl approximation (after Hill et al 1994 Ultrasound Med. Biol. 20 259-69), (ii) a numerical method derived from theory, (iii) a method using measured sidelobe to focal peak pressure ratio, and (iv) a method for measuring the focal power fraction (FPF) experimentally. Spatial-peak intensities were estimated for 8 transducers at three drive powers levels: low (approximately 1 W), moderate (~10 W) and high (20-70 W). The calculated intensities were compared with those derived from focal peak pressure measurements made using a calibrated hydrophone. The FPF measurement method was found to provide focal peak intensity estimates that agreed most closely (within 15%) with the hydrophone measurements, followed by the pressure ratio method (within 20%). The numerical method was found to consistently over-estimate focal peak intensity (+40% on average), however, for transducers with a central hole it was more accurate than using the solid bowl assumption (+70% over-estimation). In conclusion, the ability to make use of an automated beam plotting system, and a hydrophone with good spatial resolution, greatly facilitates characterisation of the FPF, and consequently gives improved confidence in estimating spatial peak intensity from measurement of acoustic power.

Can magnetic resonance image-guided focused ultrasound surgery replace local oncology treatments? A review

Magnetic resonance image-guided focused ultrasound surgery (MRgFUS) is an innovative technology in the new panorama of treatment using ultrasound. It combines two well-known and distinct methodologies: high-intensity focused ultrasound (HIFU) and a magnetic resonance imaging system (MRI). This review on MRgFUS is focused on the technical aspects and the current clinical applications in oncology. More precisely, the advantages/disadvantages of MRgFUS compared to other local approaches such as surgery and radiotherapy are discussed in detail.

Outcome of magnetic resonance-Guided focused ultrasound surgery (MRgFUS) for FIGO class 1 fibroids

OBJECTIVE

Intracavitary uterine fibroids and fibroids that distort the uterine cavity are associated with excessive vaginal bleeding and infertility. While intracavitary fibroids smaller than 4 cm are usually treated safely by operative hysteroscopy, larger fibroids may require multiple surgeries or more extensive surgery with possible damage to the integrity of the uterine wall. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive approach for treating uterine fibroids, mainly the intramural type. We present the outcome of MRgFUS treatment for intracavitary fibroids (FIGO class 1) in cases that could not be treated by hysteroscopy due to either fibroid size or patient refusal. (Canadian Task Force II-1).

STUDY DESIGN

A retrospective cohort study from a single tertiary referral center. A total of 68 patients were treated by MRgFUS for symptomatic uterine fibroids from January 2013 to December 2016. Six of them had FIGO class 1 fibroids. Adverse effects and short- and long-term outcomes (quality of life issues and need for additional surgical intervention) were assessed during ambulatory clinic visits and by phone interviews.

RESULTS

The mean ± SD fibroid volume on MRI screening was 86.3 ± 60.9 cm³. Six of those patients underwent the procedure (mean age 40.5 ± 5.6 years, range 33-48). The follow-up duration was 24.1 ± 12.0 months. Four patients were not interested in future fertility and did not undergo additional treatment, while the two who planned to conceive underwent another surgical intervention (one underwent operative hysteroscopy after reduction of fibroid size and the other underwent laparoscopic myomectomy).

CONCLUSION

This preliminary study shows that MRgFUS can be a feasible treatment option for FIGO class 1 uterine fibroids. Shrinkage of fibroids by MRgFUS can obviate or facilitate subsequent surgical intervention in selected cases.

Review of magnetic resonance-guided focused ultrasound in the treatment of uterine fibroids

Uterine leiomyoma is the most frequently occurring solid pelvic tumor in women during the reproductive period. Magnetic resonance-guided high-intensity focused ultrasound is a promising technique for decreasing menorrhagia and dysmenorrhea in symptomatic women. The aim of this study is to review the role of Magnetic resonance-guided high-intensity focused ultrasound in the treatment of uterine fibroids in symptomatic patients. We performed a review of the MEDLINE and Cochrane databases up to April 2016. The analysis and data collection were performed using the following keywords: Leiomyoma, High-Intensity Focused Ultrasound Ablation, Ultrasonography, Magnetic Resonance Imaging, Menorrhagia. Two reviewers independently performed a quality assessment; when there was a disagreement, a third reviewer was consulted. Nineteen studies of Magnetic resonance-guided high-intensity focused ultrasound-treated fibroid patients were selected. The data indicated that tumor size was reduced and that symptoms were improved after treatment. There were few adverse effects, and they were not severe. Some studies have reported that in some cases, additional sessions of Magnetic resonance-guided high-intensity focused ultrasound or other interventions, such as myomectomy, uterine artery embolization or even hysterectomy, were necessary. This review suggests that Magnetic resonance-guided high-intensity focused ultrasound is a safe and effective technique. However, additional evidence from future studies will be required before the technique can be recommended as an alternative treatment for fibroids.

A clinical investigation treating different types of fibroids identified by MRI-T2WI imaging with ultrasound guided high intensity focused ultrasound

Clinical data from 172 cases of uterine fibroids with different appearances on MRI-T2WI and accepted ultrasound guided high intensity focused ultrasound (USgHIFU) treatment were retrospectively analyzed. This study aimed to evaluate the clinical safety and efficacy of ablating different types of fibroids, classified by T2-weighted magnetic resonance imaging (MRI-T2WI). Based on MRI-T2WI signal intensities, uterine fibroids were classified as three types: hypointensive (52 cases), isointensive (64 cases) and hyperintensive (56 cases). Evaluation parameters including treatment time, ablation efficiency, percentage non-perfused volume, fibroid reduction rate, adverse reactions, symptom severity scores (SSS) and re-intervention rate were assessed from 3 months to 1 year. The percentage non-perfused volume and ablation efficiency of hyperintensive uterine fibroids were lower than those of isointensive and hypointensive uterine fibroids. All fibroids shrunk and the SSS continued to reduce at 3 and 6 months after treatment respectively. At 12-month postoperative assessments, hypointensive fibroids continued to shrink, while the isointensive fibroids enlarged but remained smaller than pre-treatment. The incident rate of postoperative Society of Interventional Radiology B-class (SIRB-class) adverse events showed no significant differences. The re-interventional rate of hyperintensive fibroids was higher than in isointensive and hypointensive groups. USgHIFU ablation of all types of fibroids were safe and effective.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

Uterine fibroid therapy using interventional radiology mini-invasive treatments: current perspective

Uterine fibroids are common benign tumors of unclear etiopathology that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality, and may have a negative impact on the reproductive system as well. Besides surgery aided by uterus-saving techniques, several minimally invasive procedures are now available within the field of interventional radiology that represent a valid solution for women who desire pregnancy and relief from disease-specific symptomatology. The main advantages offered by these techniques are low grade of invasiveness and short times of hospitalization. The most diffuse techniques are uterine artery embolization (UAE) and magnetic resonance-guided high-intensity focused ultrasound (MRgFUS). UAE is an endovascular procedure whose goal is obtained by provoking ischemia of the uterine vessels. MRgFUS is a thermoablation procedure that selectively ablates the symptomatic fibroids. In this review study, both procedures will be described, including a description of technical details, indications, contraindications, complications, and outcomes.

The safety and effectiveness of volumetric magnetic resonance-guided high-intensity focused ultrasound treatment of symptomatic uterine fibroids: early clinical experience in China

BACKGROUND

Uterine fibroids are the most common benign tumor in women, and surgical intervention is still the main fibroid treatment. Patient demands have encouraged development of less-invasive methods such as high-intensity focused ultrasound (HIFU). This study aimed to evaluate the safety and effectiveness of magnetic resonance-guided high-intensity focused ultrasound therapy using a volumetric ablation technique in the treatment of symptomatic uterine fibroids in China.

METHODS

One hundred and seven patients were enrolled and treated with magnetic resonance-guided high-intensity focused ultrasound in this study. Clinical efficacy was based on the proportion of patients with fibroid shrinkage (10 % volume reduction or more compared to baseline) at 6 months post treatment as measured with magnetic resonance imaging. The quality of life and symptom outcome was assessed using the uterine fibroid symptom and quality of life questionnaire with symptom severity scoring. Safety was primarily assessed by evaluating the reported adverse events.

RESULTS

Ninety nine of the 107 treated patients had fibroid shrinkage at 6 months post treatment. Resulting in an overall 93 % (95 % confidence interval 86-97 %) treatment success rate, p value <0.001; the symptom severity scoring and health-related quality of life at 6 months was statistically different from the screening symptom severity scoring at 0.05 level. Of 366 adverse events reported, there were no study procedure-related or device-related serious adverse events were in the study.

CONCLUSIONS

This study demonstrated that the volumetric magnetic resonance-guided high-intensity focused ultrasound device is safe and technically effective and can be utilized in clinically efficient treatments of symptomatic uterine fibroids.

TRIAL REGISTRATION

NCT01588899.

Perfusion volume correlates, percentage of involution, and clinical efficacy at diverse follow-up survey times after MR-guided focused ultrasound surgery in uterine fibroids: first report in a Mexican mestizo population

OBJECTIVES

To evaluate the clinical efficacy of magnetic resonance-guided focused ultrasound surgery in a Mexican mestizo population.

METHODS

This retrospective study included 159 women (mean age 37 ± 6.4 years, range 22-53 years) from 2008 to 2010. Two hundred sixty-eight symptomatic uterine fibroids were treated using MR-guided focused ultrasound surgery. Parameters included initial perfused volume, final perfused volume, non-perfused volume (NPV), and treated volume ratio (TVR). Follow-up up to 15 months assessed treatment efficacy and symptomatic relief. Non-parametric statistics and the Kaplan-Meier method were performed.

RESULTS

T2-weighted hypointense fibroids showed a frequency of 93.6%; isointense and hyperintense fibroids had frequencies of 5.60 and 1.1%. There was a negative correlation between NPV and age (r = -0.083, p = 0.307) and treatment time (r = -0.253, p = 0.001). Median TVR was 96.0% in small fibroids and 76.5% in large fibroids. Involution of 50% and 80% was achieved at months 6-7 and month 11, respectively. Relief of symptoms was significant (p < 0.05).

CONCLUSIONS

Our data show that higher TVR attained immediately post-treatment of MRgFUS favours higher involution percentages at follow-up; however, careful patient selection and use of pretreatment imaging are important components for predicting success using MR-guided focused ultrasound surgery.

KEY POINTS

• Type 1 fibroids were the most common (93.2%). • Age and treated volume were not correlated (r s   = -0.215, p = 0.165). • Small fibroids achieved a higher treated volume than large (96.0% vs. 76.5%). • A 50% involution was achieved at 6-month follow-up for type-1 fibroid. • A decrease of 80% was reached at 11 months for type-1 fibroids.

Volumetric MR-Guided High-Intensity Focused Ultrasound with Direct Skin Cooling for the Treatment of Symptomatic Uterine Fibroids: Proof-of-Concept Study

Objective. To prospectively assess the safety and technical feasibility of volumetric magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation with direct skin cooling (DISC) during treatment of uterine fibroids. Methods. In this proof-of-concept study, eight patients were consecutively selected for clinical MR-HIFU ablation of uterine fibroids with the use of an additional DISC device to maintain a constant temperature (T ≈ 20°C) at the interface between the HIFU table top and the skin. Technical feasibility was verified by successful completion of MR-HIFU ablation. Contrast-enhanced T1-weighted MRI was used to measure the treatment effect (nonperfused volume (NPV) ratio). Safety was evaluated by recording of adverse events (AEs) within 30 days' follow-up. Results. All MR-HIFU treatments were successfully completed in an outpatient setting. The median NPV ratio was 0.56 (IQR [0.27–0.72]). Immediately after treatment, two patients experienced coldness related discomfort which resolved at the same day. No serious (device-related) AEs were reported. Specifically, no skin burns, cold injuries, or subcutaneous edema were observed. Conclusion. This study showed that it is safe and technically feasible to complete a volumetric MR-HIFU ablation with DISC. This technique may reduce the risk of thermal injury to the abdominal wall during MR-HIFU ablation of uterine fibroids. This trial is registered with NTR4189.

Improving thermal dose accuracy in magnetic resonance-guided focused ultrasound surgery: Long-term thermometry using a prior baseline as a reference

PURPOSE

To investigate thermal dose volume (TDV) and non-perfused volume (NPV) of magnetic resonance-guided focused ultrasound (MRgFUS) treatments in patients with soft tissue tumors, and describe a method for MR thermal dosimetry using a baseline reference.

MATERIALS AND METHODS

Agreement between TDV and immediate post treatment NPV was evaluated from MRgFUS treatments of five patients with biopsy-proven desmoid tumors. Thermometry data (gradient echo, 3T) were analyzed over the entire course of the treatments to discern temperature errors in the standard approach. The technique searches previously acquired baseline images for a match using 2D normalized cross-correlation and a weighted mean of phase difference images. Thermal dose maps and TDVs were recalculated using the matched baseline and compared to NPV.

RESULTS

TDV and NPV showed between 47%-91% disagreement, using the standard immediate baseline method for calculating TDV. Long-term thermometry showed a nonlinear local temperature accrual, where peak additional temperature varied between 4-13°C (mean = 7.8°C) across patients. The prior baseline method could be implemented by finding a previously acquired matching baseline 61% ± 8% (mean ± SD) of the time. We found 7%-42% of the disagreement between TDV and NPV was due to errors in thermometry caused by heat accrual. For all patients, the prior baseline method increased the estimated treatment volume and reduced the discrepancies between TDV and NPV (P = 0.023).

CONCLUSION

This study presents a mismatch between in-treatment and post treatment efficacy measures. The prior baseline approach accounts for local heating and improves the accuracy of thermal dose-predicted volume.

Intraprocedure contrast enhanced ultrasound: the value in assessing the effect of ultrasound-guided high intensity focused ultrasound ablation for uterine fibroids

PURPOSE

To investigate the value of microbubble contrast-enhanced ultrasound (CEUS) in evaluating the treatment response of uterine fibroids to HIFU ablation.

MATERIALS AND METHODS

Sixty-eight patients with a solitary uterine fibroid from the First Affiliated Hospital of Chongqing Medical University were included and analyzed. All patients underwent pre- and post-treatment magnetic resonance imaging (MRI) with a standardized protocol, as well as pre-evaluation, intraprocedure, and immediate post-treatment CEUS. CEUS and MRI were compared by different radiologists.

RESULTS

In comparison with MRI, CEUS showed that the size of fibroids, volume of fibroids, size of non-perfused regions, non-perfused volume (NPV) or fractional ablation (NPV ratio) was similar to that of MRI. In terms of CEUS examination results, the median volume of fibroids was 75.2 (interquartile range, 34.2-127.3) cm(3), the median non-perfused volume was 54.9 (interquartile range, 28.0-98.1) cm(3), the mean fractional ablation was 83.7±13.6 (range, 30.0-100.0)%. In terms of MRI examination results, the median volume of fibroids was 74.1 (interquartile range, 33.4-116.2) cm(3). On the basis of contrast-enhanced T1-weighted images immediately after HIFU treatment, the median non-perfused volume was 58.5 (interquartile range, 27.7-100.0) cm(3), the average fractional ablation was 84.2±14.2 (range, 40.0-100.0)%.

CONCLUSIONS

CEUS clearly showed the size of fibroids and the non-perfused areas of the fibroid. Results from CEUS correlated well with results obtained from MRI.

Ultrasound guided high intensity focused ultrasound (USgHIFU) ablation for uterine fibroids: Do we need the microbubbles?

PURPOSE

The aim of this study was to assess the safety and effectiveness of contrast-enhanced ultrasound (CEUS) on ultrasound guided high intensity focused ultrasound (USgHIFU) ablation of uterine fibroids.

METHODS

Thirty-three patients (37 fibroids) were randomly assigned to two groups: group A (17 patients, 20 fibroids) in which CEUS was used before, during and after HIFU treatment, and group B (16 patients, 17 fibroids) in which CEUS was not administered at all. Follow-up including contrast-enhanced magnetic resonance imaging (MRI) and a clinical questionnaire was performed, and technical success, ablation efficacy, volume reduction and complications were assessed.

RESULTS

Technical success was 100% in both groups. CEUS revealed residual enhancement in 40% of the patients in group A and the treatment was continued until the completion of ablation. MRI at 1 month after treatment revealed significant difference in the relative fibroid volume reduction rate between the two groups: 16.1% in group A versus 4.8%, in group B (p = 0.01). There was no statistically significant relative volume reduction rate for the results at 3, 6 and 12 months and no significant changes in the quality of life results or the complication rate.

CONCLUSIONS

CEUS was safe and effective in enhancing US guidance during HIFU ablation of uterine fibroids. Moreover, the use of CEUS during HIFU sonication increased the ablation efficacy, leading to a more relevant fibroid volume reduction at 1 and 3 months. This gap disappeared after 6 months, when there were no differences between the two groups of patients at MRI. However, in our experience, USgHIFU represented a very effective method for the treatment of uterine fibroids, and the use of CEUS during HIFU procedure reduced the treatment time and treatment repetitions for incomplete fibroid ablation.

A retrospective comparison of microwave ablation and high intensity focused ultrasound for treating symptomatic uterine fibroids

OBJECTIVES

To retrospectively compare the effectiveness and safety of percutaneous microwave ablation (PMWA) and ultrasound-guided high-intensity focused ultrasound (USgHIFU) for treating symptomatic uterine fibroids.

METHODS

Seventy-three women with symptomatic uterine fibroids who met the inclusion criteria were enrolled in our study from September 2012 to December 2013. Thirty-one patients with forty uterine fibroids underwent PMWA, and forty-two patients with fifty-one uterine fibroids underwent USgHIFU. A contrast-enhanced MRI was performed before and after treatment, and all patients were followed up for 6 months. Assessment endpoints included symptom severity scores (SSS), treatment time, ablation rate, fibroid regression rate and adverse events.

RESULTS

The mean age of the patients in our study was 35.4±6.2 years (range, 21-49 years), and the median volume of uterine fibroids was 95.7cm(3) (60.3-131.5cm(3)). The ablation rate of uterine fibroids was 79.8±18.2% and 77.1±14.9% in the PMWA group and the USgHIFU group, respectively, and showed no significant difference between the groups. Changes in SSS after PMWA were similar in the PMWA group (47.7 pre-treatment vs. 29.9 post-treatment) and USgHIFU group (42.1 pre-treatment vs. 24.6 post-treatment). The regression rate of uterine fibroids also showed no marked difference between the two groups (PMWA, 50.3%; USgHIFU, 52.4%). The median treatment time of the PMWA group was 46.2min, which was demonstrably superior to USgHIFU. Finally, the occurrence rate of adverse events was the same in the two groups.

CONCLUSIONS

The safety and effectiveness of PMWA and USgHIFU in the treatment of uterine fibroids were similar; however, the median treatment time of PMWA was shorter than that of USgHIFU.

High-Intensity Focused Ultrasound (HIFU) in Uterine Fibroid Treatment: Review Study

BACKGROUND

High-intensity focused ultrasound (HIFU) is a highly precise medical procedure used locally to heat and destroy diseased tissue through ablation. This study intended to review HIFU in uterine fibroid therapy, to evaluate the role of HIFU in the therapy of leiomyomas as well as to review the actual clinical activities in this field including efficacy and safety measures beside the published clinical literature.

MATERIAL/METHODS

An inclusive literature review was carried out in order to review the scientific foundation, and how it resulted in the development of extracorporeal distinct devices. Studies addressing HIFU in leiomyomas were identified from a search of the Internet scientific databases. The analysis of literature was limited to journal articles written in English and published between 2000 and 2013.

RESULTS

In current gynecologic oncology, HIFU is used clinically in the treatment of leiomyomas. Clinical research on HIFU therapy for leiomyomas began in the 1990s, and the majority of patients with leiomyomas were treated predominantly with HIFUNIT 9000 and prototype single focus ultrasound devices. HIFU is a non-invasive and highly effective standard treatment with a large indication range for all sizes of leiomyomas, associated with high efficacy, low operative morbidity and no systemic side effects.

CONCLUSIONS

Uterine fibroid treatment using HIFU was effective and safe in treating symptomatic uterine fibroids. Few studies are available in the literature regarding uterine artery embolization (UAE). HIFU provides an excellent option to treat uterine fibroids.

Safety and efficacy of sonographically guided high-intensity focused ultrasound for symptomatic uterine fibroids: preliminary study of a modified protocol

OBJECTIVES

We aimed to assess the safety and efficacy of sonographically guided high-intensity focused ultrasound for treating patients with symptomatic uterine fibroids using a modified protocol.

METHODS

This work was part of an ongoing prospective phase 1 study. Twenty patients with 22 symptomatic fibroids were treated with sonographically guided high-intensity focused ultrasound under no anesthesia. The modified protocol consisted of repeated and shortened (<25 minutes) treatment sessions of high-input acoustic intensity (1000-1500 W/cm(2)) and intensified sonication pulses (1500-2000) at each spot. The primary end points were periprocedural complications. The secondary end points were symptomatic improvement and radiologic evidence of treatment responses, including the degree of fibroid infarction and volume shrinkage 3 months after treatment. Symptomatic improvement was assessed by a pain score, a pictorial chart menstrual score, the Urogenital Distress Inventory short form, and the Incontinence Impact Questionnaire short form. The degree of fibroid infarction was assessed by the nonperfused ratio on contrast-enhanced magnetic resonance imaging, defined as the ratio of the nonperfused fibroid volume to the total fibroid volume.

RESULTS

Nineteen patients tolerated the treatment well, with no major adverse events. One patient who received treatment for a fibroid located within 6 cm from the skin had third-degree skin burns at 2 sites of 1 cm in diameter. Fibroid-related abdominal pain, pictorial chart, Urogenital Distress Inventory, and Incontinence Impact Questionnaire scores were significantly improved (P < .05). The median nonperfused ratio at 3 months was 20% (95% confidence interval, 5%-32.5%). Median volume shrinkage at 3 months was 17.2% (95% confidence interval, 4.3%-26.6%).

CONCLUSIONS

Sonographically guided high-intensity focused ultrasound using a modified protocol may be safe and effective for symptomatic uterine fibroids in selected patients to avoid skin burns.

Reproductive impact of MRI-guided focused ultrasound surgery for fibroids: a systematic review of the evidence

PURPOSE OF REVIEW

Magnetic-resonance-guided focused ultrasound surgery (MRgFUS) is a minimally invasive technique for the treatment of uterine fibroids. The purpose of this review is to highlight the impact of MRgFUS on fertility and reproductive outcomes.

RECENT FINDINGS

The role of MRgFUS in the treatment of fibroids has been evolving since its introduction in 2004. Several new devices and techniques including location-specific treatment, volumetric therapy, and vessel-targeted therapy have been introduced over the last few years. Several case series report uncomplicated pregnancy following MRgFUS; however, results of the ongoing studies will further elucidate the utility of MRgFUS in patients planning future fertility. A systematic review of the literature was completed and studies that reported quality of life at baseline and after 6 months were included in a meta-analysis.

SUMMARY

MRgFUS represents a minimally invasive treatment for uterine fibroids that is able to improve the quality of life and fibroid size with durability. It is possible that MRgFUS could be the treatment of choice for patients desiring future fertility; however, further investigation is needed.

Cost comparison between uterine-sparing fibroid treatments one year following treatment

Background

To compare one-year all-cause and uterine fibroid (UF)-related direct costs in patients treated with one of the following three uterine-sparing procedures: magnetic resonance-guided focused ultrasound (MRgFUS), uterine artery embolization (UAE) and myomectomy.

Methods

This retrospective observational cohort study used healthcare claims for several million individuals with healthcare coverage from employers in the MarketScan Database for the period 2003–2010. UF patients aged 25–54 on their first UF procedure (index) date with 366-day baseline experience, 366-day follow-up period, continuous health plan enrollment during baseline and follow-up, and absence of any baseline UF procedures were included in the final sample. Cost outcomes were measured by allowed charges (sum of insurer-paid and patient-paid amounts). UF-related cost was defined as difference in mean cost between study cohorts and propensity-score-matched control cohorts without UF. Multivariate adjustment of cost outcomes was conducted using generalized linear models.

Results

The study sample comprised 14,426 patients (MRgFUS = 14; UAE = 4,092; myomectomy = 10,320) with a higher percent of older patients in MRgFUS cohort (71% vs. 50% vs. 12% in age-group 45–54, P < 0.001). Adjusted all-cause mean cost was lowest for MRgFUS ($19,763; 95% CI: $10,425-$38,694) followed by myomectomy ($20,407; 95% CI: $19,483-$21,381) and UAE ($25,019; 95% CI: $23,738-$26,376) but without statistical significance. Adjusted UF-related costs were also not significantly different between the three procedures.

Conclusions

Adjusted all-cause and UF-related costs at one year were not significantly different between patients undergoing MRgFUS, myomectomy and UAE.

High-Intensity Focused Ultrasound Ablation of Uterine Fibroids - Potential Impact on Fertility and Pregnancy Outcome

Laparoscopic myomectomy is regarded as the gold standard for women with symptomatic fibroids who wish to become pregnant. High-intensity focused ultrasound (HIFU or MRgFUS) ablation of uterine fibroids is also being discussed as a non-surgical, minimally invasive, therapeutic option. This review examines the available data on the impact of HIFU/MRgFUS on fertility and pregnancy, focusing particularly on potential direct side-effects of this type of intervention on ovaries, fallopian tubes and uterus and potential late effects on pregnancy and birth, based on the current literature. All pregnancies after HIFU/MRgFUS published to date (around 100 cases) were evaluated. The published case series suggest that HIFU/MRgFUS ablation has no impact on the rate of miscarriages or other obstetrical outcome parameters. Because no prospective studies exist which permit firm conclusions to be drawn on the impact of HIFU/MRgFUS on fertility and pregnancy outcome in women with symptomatic fibroids, this approach is currently only recommended for women with suspected fertility problems due to uterine fibroids who either decline surgery or who have an unacceptably high surgical risk.

[Focused ultrasound therapy: current status and potential applications in neurosurgery]

High Intensity Focused Ultrasound (HIFU) therapy is an innovative approach for tissue ablation, based on high intensity focused ultrasound beams. At the focus, HIFU induces a temperature elevation and the tissue can be thermally destroyed. In fact, this approach has been tested in a number of clinical studies for the treatment of several tumors, primarily the prostate, uterine, breast, bone, liver, kidney and pancreas. For transcranial brain therapy, the skull bone is a major limitation, however, new adaptive techniques of phase correction for focusing ultrasound through the skull have recently been implemented by research systems, paving the way for HIFU therapy to become an interesting alternative to brain surgery and radiotherapy.

Vaginal mifepristone for the treatment of symptomatic uterine leiomyomata: an open-label study

OBJECTIVE

To evaluate the efficacy and safety of 3 months of vaginal mifepristone treatment on leiomyoma volume and related symptoms.

DESIGN

Prospective, open-label, two tertiary centers, phase II clinical trial.

SETTING

Two tertiary medical centers in Israel.

PATIENT(S)

Thirty-three enrolled women, ages 30-53 years, diagnosed with symptomatic uterine fibroids.

INTERVENTION(S)

Patients received 10 mg mifepristone vaginally daily for 3 months.

MAIN OUTCOME MEASURE(S)

Reduction in uterine leiomyoma volume. Improvement in symptoms related to uterine fibroids was assessed with the use of the "Uterine Fibroid Symptoms Quality of Life Questionnaire" (UFS-QoL). The number of bleeding days, safety, and tolerability were secondary measures.

RESULT(S)

Mifepristone treatment significantly reduced leiomyoma volume from 135.3 ± 22.9 cc at enrollment to 101.2 ± 22.4 cc after 3 months of treatment. The UFS-QoL Score significantly decreased from 20.7 ± 0.7 at enrollment to 14.0 ± 0.8 after 3 months of treatment. The number of bleeding days significantly decreased by 3.5 days. Endometrial biopsies showed no evidence of endometrial hyperplasia or cellular atypia. There were no major side effects during the course of the study, and treatment was well tolerated.

CONCLUSION(S)

Vaginal mifepristone may offer an effective treatment option for women with symptomatic uterine leiomyoma and can improve the patients' quality of life.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00881140.

Ultrasound-guided high-intensity focused ultrasound vs laparoscopic myomectomy for symptomatic uterine myomas

STUDY OBJECTIVE

To assess the quality of life (QoL) of women at 1 and 12 months after ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment as compared with laparoscopic myomectomy for treatment of symptomatic uterine myomas.

DESIGN

Nonrandomized prospective clinical trial (Canadian Task Force classification II-2).

SETTING

Urban university-based hospital in China.

INTERVENTIONS

One hundred thirty premenopausal women underwent USgHIFU (n = 89) or laparoscopic myomectomy (n = 41) for treatment of symptomatic uterine myomas.

MEASUREMENTS AND MAIN RESULTS

Eighty-three patients in the HIFU group and 39 in the surgical group were followed up at 1 and 12 months. QoL was assessed using the Medical Outcomes Study 36-Item Short-Form General Health Survey, which showed no significant differences between groups in any of the 8 subscales at the 12-month follow-up visit. Symptom score, willingness to recommend the treatment to a friend, hospital stay, and recovery period were compared between the 2 groups. In the HIFU group, hospital stay was shorter (mean [SD] 2.9 [1.5] days vs 6.2 [2.7] days; p <.001) and patients resumed normal activities sooner (4.5 [1.5] days vs 10.9 [3.8] days; p <.001). Significant clinical complications and adverse events after each treatment were documented and compared, and HIFU yielded significantly better results.

CONCLUSIONS

Compared with laparoscopic myomectomy, HIFU treatment of symptomatic uterine myomas leads to comparable QoL and symptom improvement, fewer significant clinical complications and adverse events, shorter hospital stay, and faster recovery. Randomized studies with long-term follow-up are needed to reach definitive conclusions insofar as HIFU treatment of uterine myomas.

Sonographically guided high-intensity focused ultrasound for the management of uterine fibroids

High-intensity focused ultrasound therapy has received increasing interest in the management of solid malignancies and benign tumors. Magnetic resonance imaging has always been used to define the target for controlling and monitoring the ablation. Recently, sonographically guided high-intensity focused ultrasound has been introduced to monitor the ablation process. This article provides an overview of the background, clinical use, and treatment outcomes of sonographically guided high-intensity focused ultrasound in the treatment of uterine fibroids.

Mid-term clinical efficacy of a volumetric magnetic resonance-guided high-intensity focused ultrasound technique for treatment of symptomatic uterine fibroids

OBJECTIVE

To assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) using a volumetric ablation technique for treating uterine fibroids.

METHODS

Forty-six premenopausal women with 58 symptomatic uterine fibroids were prospectively included for MR-HIFU. After treatment, CE-MRI allowed measurement of the non-perfused volume (NPV) ratio, defined as the non-enhancing part of the fibroid divided by fibroid volume. Clinical symptoms and fibroid size on T2W-MRI were quantified at 3 and 6 months' follow-up. The primary endpoint was a clinically relevant improvement in the transformed Symptom Severity Score (tSSS) of the Uterine Fibroid Symptom and Quality of Life questionnaire, defined as a 10-point reduction.

RESULTS

Volumetric ablation resulted in a mean NPV ratio of 0.40 ± 0.22, with a mean NPV of 141 ± 135 cm(3). Mean fibroid volume was 353 ± 269 cm(3) at baseline, which decreased to 271 ± 225 cm(3) at 6 months (P < 0.001), corresponding to a mean volume reduction of 29 % ± 20 %. Clinical follow-up showed that 54 % (25/46) of the patients reported a more than 10-point reduction in the tSSS. Mean tSSS improved from 50.9 ± 18.4 at baseline to 34.7 ± 20.2 after 6 months (P < 0.001).

CONCLUSION

Volumetric MR-HIFU is effective for patients with symptomatic uterine fibroids. At 6 months, significant symptom improvement was observed in 54 % of patients.

KEY POINTS

• Volumetric MR-guided high-intensity focused ultrasound is a novel ablation technique for leiomyomatosis. • We prospectively evaluated the outcome of volumetric MR-HIFU ablation for symptomatic fibroids. • This study showed that volumetric MR-HIFU results in an effective treatment. • A randomised controlled trial would set this technique in an appropriate context.

Cranial nerve threshold for thermal injury induced by MRI-guided high-intensity focused ultrasound (MRgHIFU): preliminary results on an optic nerve model

Future clinical applications of magnetic resonance imaging-guided high-intensity focused ultrasound (MRgHIFU) are moving toward the management of different intracranial pathologies. We sought to validate the production, safety, and efficacy of thermal injury to cranial nerves generated by MRgHIFU. In this study, five female domestic pigs underwent a standard bifrontal craniectomy under general anesthesia. Treatment was then given using an MRgHIFU system to induce hyperthermic ablative sonication (6 to 10 s; 50 to 2000 J.) Histological analyses were done to confirm nerve damage; temperature measured on the optic nerve was approximately 53.4°C (range: 39°C to 70°C.) Histology demonstrated a clear definition between a necrotic, transitional zone, and normal tissue. MRgHIFU induces targeted thermal injury to nervous tissue within a specific threshold of 50°C to 60°C with the tissue near the sonication center yielding the greatest effect; adjacent tissue showed minimal changes. Additional studies utilizing this technology are required to further establish accurate threshold parameters for optic nerve thermo-ablation.

MR-guided focused ultrasound (MRgFUS) is effective for the distinct pattern of uterine fibroids seen in African-American women: data from phase III/IV, non-randomized, multicenter clinical trials

Background

Uterine fibroids are common among women at the reproductive age. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a novel and a conservative treatment for symptomatic cases. The aim of the study was to evaluate the efficacy of MRgFUS in African-American (AA) women compared with that in non-African-Americans (non-AA).

Methods

A single-armed phase IV study was conducted to establish the efficacy of treatment in AA women. Comparison of patient, fibroid, and treatment characteristics from this trial was compared with that of the previously published phase III trial. Both studies were approved by the IRB of each medical center.

Results

Sixty-three AA and 59 non-AA women were treated with MRgFUS. Although AA women had a different pattern of disease, outcomes were similar in both groups. AA patients had a significant higher total number of fibroids compared with non-AA (median 6.0, interquartile range (IQR) 3.0–10.0 vs. 2.0, IQR 1.0–4.0, respectively, p < 0.001), although their total fibroid volume was significantly smaller (median 196.9 cm³, IQR 112.8–415.3 cm³ vs. 394.8 cm³, IQR 189.8–674.4 cm³, respectively, p < 0.001). AA women were younger compared with non-AA (mean ± SD 43.4 ± 5.1 vs. 46.3 ± 4.1 years of age, respectively, p = 0.001) when they presented for treatment. The rate of alternative treatments as well as fibroid-associated symptoms at follow-up time points (3, 6, 12, 24, and 36 months, period following MRgFUS treatment) did not differ according to race (p ≥ 0.62).

Conclusion

Despite differences in the pattern of fibroid disease, MRgFUS for uterine fibroids has a similar efficacy for AA women compared with non-AA women.