Pathologic features of uterine leiomyomas following uterine artery embolization

Reducing radicality in fertility-sparing surgery is associated with improved in vitro fertilization outcome in early-stage cervical cancer: A national retrospective study

OBJECTIVE

Fertility-sparing surgery (FSS) aims to achieve oncological outcomes that are non-inferior to radical treatment while preserving fertility and optimizing reproductive results. This study assesses in vitro fertilization (IVF) outcomes in early-stage cervical cancer survivors following FSS, comparing radical and non-radical approaches.

METHODS

This retrospective analysis used data from Hungary's National Health Insurance Fund (2004-2022) on patients who underwent IVF treatment following FSS for early-stage cervical cancer at ten Hungarian fertility clinics. Patients were classified into radical and non-radical surgical groups, with the uterine arteries being spared in the non-radical procedures. RStudio (R software version: 4.2.2) was used for statistical analysis. Student's t-test was used to compare group means, and Fisher's exact test was applied to assess independence and distributions between categorical variables, and to estimate odds.

RESULTS

The study analyzed data from 122 IVF treatment cycles involving 36 patients. The non-radical group had a significantly higher live birth rate (83%, 5/6 compared to the radical group (17%, 5/30). Additionally, the non-radical group had a significantly higher implantation rate and cumulative live birth rate per oocyte retrieval (37%, 7/19 and 55%, 6/11 respectively) compared to the radical group (8%, 12/148 and 6%, 5/80 respectively).

CONCLUSION

This is the largest study to evaluate IVF outcomes in young cervical cancer survivors who have undergone FSS. The findings suggest that less radical procedures are associated with significantly better IVF outcomes. These results emphasize the importance of considering oncological safety and reproductive outcomes together when choosing FSS for early-stage cervical cancer patients. It also highlights the reproductive benefits of performing less radical surgery.

Histological findings in resected leiomyomas following MR-HIFU treatment, single-institution data from seven patients with unfavorable focal therapy

PURPOSE

Magnetic resonance - high-intensity focused ultrasound (MR-HIFU) is a noninvasive treatment option for symptomatic uterine leiomyomas. Currently, pretreatment MRI is used to assess tissue characteristics and predict the most likely therapeutic response for individual patients. However, these predictions still entail significant uncertainties. The impact of tissue properties on therapeutic outcomes remains poorly understood and detailed knowledge of the histological effects of ultrasound ablation is lacking. Investigating these aspects could aid in optimizing patient selection, enhancing treatment effects and improving treatment outcomes.

METHODS AND MATERIALS

We present seven patients who underwent MR-HIFU treatment for leiomyoma followed by second-line surgical treatment. Tissue samples obtained during the surgery were stained with hematoxylin and eosin, Masson's trichrome and Herovici to evaluate general morphology, fibrosis and collagen deposition of leiomyomas. Immunohistochemical CD31, Ki-67 and MMP-2 stainings were performed to study vascularization, proliferation and matrix metalloproteinase-2 protein expression in leiomyomas, respectively.

RESULTS

The clinical characteristics and radiological findings of the leiomyomas prior to treatment as well as qualitative histological findings after the treatment are presented and discussed in the context of current literature. A tentative model for volume reduction is presented.

CONCLUSION

These findings provide insights into potential factors contributing to suboptimal therapeutic outcomes and the variability in histological changes following treatment.

Antitumor effect of the selective hypoxia-inducible factor-1 inhibitors echinomycin and PX-478 on uterine fibroids

OBJECTIVE

To investigate the antitumor effects of the selective hypoxia-inducible factor-1 (HIF-1) inhibitors echinomycin and PX-478 on uterine fibroids.

DESIGN

Experimental study using in vitro primary culture systems and an in vivo mouse xenograft model.

SETTING

Academic university center.

PATIENT(S)

Women with uterine fibroids who underwent hysterectomy or myomectomy.

INTERVENTION(S)

Administration of the selective HIF-1 inhibitors echinomycin and PX-478 to the media of the primary cultured uterine fibroid cells and to nonobese diabetic/severe combined immunodeficient mice bearing fibroid xenografts consisting of the primary cultured fibroid cells and type Ⅰ collagen gels beneath the kidney capsule.

MAIN OUTCOME MEASURE(S)

Cell proliferation was measured by Cell Counting Kit-8 assay. Apoptosis was evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay and by measuring caspase 3 and 7 activities. The xenografts were evaluated by gross appearance, surface area, and histology. The Ki-67 index was measured to evaluate proliferation of the xenografts.

RESULT(S)

Both echinomycin and PX-478 inhibited cell proliferation and induced apoptosis in fibroid cells cultured under hypoxia and normoxia. Enlargement of the fibroid xenografts was significantly attenuated. The Ki-67 index significantly decreased after the administration of the HIF-1 inhibitors in the xenograft model. Eight of 27 xenografts treated with the HIF-1 inhibitors contained calcification and hyalinizing components from 3 days after the grafting to 2 weeks, suggesting that the HIF-inhibitors induce degeneration of the fibroid xenografts.

CONCLUSION(S)

The selective HIF-1 inhibitors echinomycin and PX-478 show antitumor effects against uterine fibroids both in vitro and in vivo. These findings support the potential use of HIF-1 inhibitors for the treatment of uterine fibroids.

Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment?

OBJECTIVE

The purpose of this article is to provide background on the epidemiologic, clinical, and economic impact of uterine leiomyomas, summarize the concerns associated with treating women with potential occult leiomyosarcomas (LMSs), and review the known and emerging imaging features of typical and atypical leiomyomas and explain how to differentiate them from LMSs.

CONCLUSION

Surgical management of presumed benign uterine leiomyomas received popular media attention when a case of disseminated LMS occurred after laparoscopic power morcellator-assisted hysterectomy. A subsequent U.S. Food and Drug Administration review found a higher prevalence of unsuspected uterine sarcoma and LMS among patients undergoing myomectomy or hysterectomy for presumed benign leiomyomas than was previously reported. This heightened concern has led to increased pressure on radiologists to distinguish LMSs from leiomyomas.

Prostatic Artery Embolization with 250-μm Spherical Polyzene-Coated Hydrogel Microspheres for Lower Urinary Tract Symptoms with Follow-up MR Imaging

PURPOSE

To evaluate clinical outcomes and possible MR imaging predictors of clinical success after prostatic artery embolization (PAE) with 250-μm hydrogel particles.

MATERIALS AND METHODS

During a span of 1.5 years, 30 patients with moderate to severe lower urinary tract symptoms were included in a prospective, nonrandomized study. Embolization of at least one prostatic artery was considered as technical success. International Prostate Symptom Score (IPSS), quality of life (QOL), peak urinary flow rate (Q_max), residual urine volume, prostate volume, prostate-specific antigen level, and International Index of Erectile Function (IIEF) were recorded at baseline and at 1, 3, and 6 months after PAE. Multiparametric MR imaging was performed before PAE (n = 25) and 1 day (n = 25), 1 month (n = 7), 3 months (n = 7), and 6 months (n = 22) after intervention. A Wilcoxon-Mann-Whitney test was used to assess changes over time, and Spearman rank-correlation coefficient was used for outcome prediction.

RESULTS

PAE was technically successful in 90% of patients (n = 27). Clinical success (IPSS < 18 with decrease > 25% and QOL score < 4 with decrease ≥ 1 or Q_max ≥ 15 mL/s and increase of ≥ 3.0 mL/s) rates were 59% (16 of 27), 63% (17 of 27), and 74% (20 of 27) after 1, 3, and 6 mo, respectively. IIEF scores did not differ significantly during follow-up. The following adverse events occurred after PAE: urethral burning (5 of 27), fever (2 of 27), and urethral bleeding, rectal bleeding, cystitis, and penile burning sensation (1 of 27 each). No statistical correlations between initial multiparametric MR imaging changes and clinical parameters after 6 months were found (P values from .14 to .98).

CONCLUSIONS

PAE with 250-μm hydrogel microspheres led to good clinical success after 6 months with a low complication rate. Significant MR imaging predictors of clinical success were not identified.

Recent Developments in Surgical Pathology of the Uterine Corpus

There have been several updates recently on the classification of uterine tumors. Endometrial carcinomas have traditionally been divided into 2 types, but some are difficult to classify and do not fit readily into either of the currently recognized categories. The Cancer Genome Atlas Research Network has recently defined 4 new categories of endometrial cancer on the basis of mutational spectra, copy number alteration, and microsatellite instability, which might provide independent prognostic information beyond established risk factors. The Society of Gynecologic Oncology, moreover, now recommends systematic screening of every patient with endometrial cancer for Lynch syndrome. The new definition of high-grade endometrial stromal sarcoma disregards the number of mitotic figures as a primary diagnostic criterion and instead specifies moderate atypia still resembling stromal origin but lacking the pleomorphism of undifferentiated uterine sarcoma; these tumors also harbor a JAZF1-SUZ12 gene rearrangement. Mitotic count, atypia, and coagulative necrosis are the main histologic criteria that define leiomyosarcoma. Determining the type of necrosis can be very challenging in patients receiving various treatment modalities for symptomatic fibroids before myomectomy, since key histologic features of ischemic-type necrosis are often absent. Ancillary stains including p16, p53, MIB-1, trichrome, and reticulin may be helpful in tumors harboring necrosis that is difficult to classify. Minimally invasive gynecologic surgeries have introduced histologic artifacts that complicate the diagnosis. It is essential to recognize these as procedure-related artifacts to avoid upstaging tumors and triggering unnecessary adjuvant treatment.

Uterine artery embolization angiography and fertility related aspects

Purpose. Uterine artery embolization is a minimally invasive technique. It applies the principle of targeted anatomical structure devascularisation with utility in fibroid conservative therapy, including for future fertility preserving status. The objective of our paper represents a description and evaluation of angiography utility as a predictive method for fertility maintenance. Material and Methods. The angiography and ultrasound aspects obtained from a prospective study in which selected patients have undergone uterine artery embolization for fertility preservation are detailed. Results. The following angiography aspects have been detected: left- right shunt and utero-ovarian collaterals; these have been compared with the ultrasound aspects related to the fibroid evolution form a volumetric and Doppler ultrasound point of view. The angiographical description predicts the impact on post embolization fibroid evolution and upon fertility. An analysis is made in order to assess the way in which angiography can contribute to fertility alteration. Conclusions. The angiography aspects during embolization and the following ultrasound aspects can represent predictive factors as to fertility evolution after uterine artery embolization.

MRI findings after prostatic artery embolization for treatment of benign hyperplasia

OBJECTIVE

The purpose of this article is to assess and describe the MRI findings after prostatic artery embolization for treatment of benign prostatic hyperplasia.

MATERIALS AND METHODS

We retrospectively evaluated 17 patients who underwent prostatic artery embolization as part of different prospective studies to evaluate this alternative treatment of benign prostatic hyperplasia. Clinical results were evaluated by assessment of urinary catheterization and International Prostate Symptom Score (IPSS). Serial MRI examinations were performed, and the prostatic central gland and peripheral zone were evaluated for signal intensity changes and the presence and characteristics of infarcted areas. Statistical analysis was performed with ANOVA for repeated measures and Student t test.

RESULTS

All patients had clinical success, as defined by the removal of indwelling urinary catheter or decreased IPSS after embolization. Infarcts were seen in 70.6% of the subjects, exclusively in the central gland, were almost always characterized by hyperintensity on T1-weighted images and predominant hypointensity on T2-weighted images, and became smaller (mean reduction, p < 0.001) and isointense to the remaining of the central gland over time. Volume reduction of the prostate after embolization was significant (averaging 32.0% after 12-18 months; p < 0.001) only in patients with infarcts. No statistically significant association was seen between the development of infarcts and IPSS.

CONCLUSION

MRI can be used for assessing the development of infarcts and volume reduction in the prostate after embolization. Further studies are needed to correlate these findings to clinical outcome.

Uterine artery embolisation

PURPOSE OF STUDY

Fibroids are commonest benign tumour of the uterus. It presents with bleeding per vagina in most of the cases. Surgical treatment consists of myomectomy or hysterectomy with or without salpingo oophrectomy, with its inherent morbidity, prolonged hospital stay and psychosocial problems. Surgery is not the best option especially in unmarried and nullipara.

MATERIALS AND METHODS

Thirty-five patients were subjected to uterine artery embolisation (UAE). Mean age was 35.51 ± 7.36 years. Two patients were suffering from advanced carcinoma of cervix, 32 had fibroid of uterus, one had endometriosis. Three patients were unmarried, three did not have any issue, three had associated haemodynamically significant cardiac disorders, one had polycystic renal disease, and one had hypernephroma. Four patients had multiple fibroids. The UAE was done through contralateral femoral artery puncture, bilaterally, with the help of Judkin's right coronary catheter. Ultrasound was repeated after 3 months.

RESULTS

The UAE was successful in all patients. Mean procedural time was 75 minutes. Hospital stay was 1 day only. Bleeding stopped in all 35 patients. One patient had recurrence of bleeding after 2 months and underwent surgery. Fibroids disappeared in eight patients, decreased in size by > 75% in 11 patients, and by 50-75% in six patients. Five patients did not report back with ultrasound. Two patients had normal delivery after UAE.

CONCLUSION

Uterine artery embolisation is effective therapy to stop uterine bleeding. It is effective in controlling the symptoms in uterine fibroids and also decreases the size of fibroids. Hospital stay is only 1 day.

Comparison of clinical outcomes of tris-acryl microspheres versus polyvinyl alcohol microspheres for uterine artery embolization for leiomyomas: results of a randomized trial

PURPOSE

To compare tris-acryl microspheres and polyvinyl alcohol (PVA) microspheres as embolic agents in uterine artery embolization (UAE) for uterine leiomyomas in terms of clinical outcome, inflammatory response, and adverse reactions.

MATERIALS AND METHODS

A double-blinded randomized controlled trial was performed, with 27 patients in the tris-acryl microsphere group and 29 in the PVA microsphere group. The primary endpoint was clinical success, defined as a 2-year freedom from subsequent surgery as a result of persistent or deteriorated symptoms. Secondary endpoints included (i) posttreatment leiomyoma enlargement, (ii) leiomyoma volume reduction at 3 and 9 months, (iii) significant residual intratumoral perfusion, (iv) increase in inflammatory and stress markers, (v) incidence of complications, and (vi) duration of hospital stay.

RESULTS

There was no statistically significant difference between the two groups in patient demographics, clinical presentation, initial tumor findings, change in inflammatory and stress markers after treatment, incidence of complications, and duration of hospital stay. Tris-acryl microspheres were associated with a higher rate of clinical success than PVA microspheres (96.3% [26 of 27] vs 69% [20 of 29]; P = .012), a lower incidence of posttreatment leiomyoma enlargement (P = .030), and a lower incidence of significant residual intratumoral perfusion (P = .030).

CONCLUSIONS

In the treatment of uterine leiomyomas, UAE with tris-acryl microspheres was associated with a higher clinical success rate, a lower incidence of tumor enlargement, and no significant differences in adverse reactions and inflammatory response compared with the use of PVA microspheres. Tris-acryl microspheres therefore represent the preferred agent for UAE of uterine leiomyomas.

Uterine artery embolization with trisacryl gelatin microspheres in women treated for leiomyomas: a clinicopathologic analysis of alterations in gynecologic surgical specimens

To characterize the histologic range of alterations due to uterine artery embolization with trisacryl gelatin microspheres in gynecologic specimens containing leiomyomas in detail, we report our clinicopathologic experience with 26 cases (longest postuterine artery embolization interval, 1.9 yr). Microspheres were observed in 85% of cases and could be seen up to 1.9 years after embolization. They were mainly present in leiomyomas and nonneoplastic myometrium but could be found in other nontargeted sites, such as the cervix, endometrium, ovaries, and fallopian tubes; however, infarction (present in 96% of cases) was confined to leiomyomas and did not involve other nonneoplastic tissues. The appearance of the infarcts was correlated with time after embolization, and coagulative necrosis/necrosis of indeterminate type was restricted to the early period after uterine artery embolization (before 10 wk postuterine artery embolization) whereas hyaline necrosis was seen predominantly in the late period (mostly after 10 wk, up to 1.9 yr). Of the 14 hysterectomy specimens with microspheres in extravascular spaces (almost all of which were in close proximity to the arteries), pseudoaneurysms were also focally present in 8 (57%) specimens. Microspheres were usually associated with mild inflammatory reactions, which persisted >1 year after embolization but did not become more severe over time. Morphologic and histochemical features of trisacryl gelatin microspheres were compared with other embolization agents, which can also be encountered in surgical specimens [polyvinyl alcohol (PVA) particles and PVA microspheres]. Trisacryl gelatin microspheres were negative with periodic acid-Schiff and orange-pink with Movat stains whereas PVA was positive with periodic acid-Schiff and black with Movat. Our study, the largest histologic analysis to date, confirms and extends the observations of earlier studies of trisacryl gelatin microspheres. In addition, we conclude that, as expected, the histologic appearance of microsphere-induced infarcts is a function of time, similar to healing of infarcts in nongynecologic sites. Pseudoaneurysms are a likely mechanism for the production of microspheres in extravascular spaces. Inflammation associated with microspheres can persist in gynecologic tissues but does not seem to result in the destruction of nontargeted sites. Finally, trisacryl gelatin microspheres can be distinguished from PVA particles and PVA microspheres based on a combination of morphologic features and histochemical stains.

Uterine artery embolization for leiomyomas: percentage of infarction predicts clinical outcome

PURPOSE

To determine the effect of partial versus complete leiomyoma infarction on relief of leiomyoma-related symptoms and freedom from invasive reinterventions and to assess if patient age, location of the dominant leiomyoma, number of leiomyomas, or baseline uterine and dominant leiomyoma volume were associated with clinical failure.

MATERIALS AND METHODS

Study protocol was approved by the institutional review board, and informed consent was obtained. One hundred fifteen consecutive women (median age, 42 years; range, 34-61 years) with symptomatic uterine leiomyomas underwent contrast material-enhanced magnetic resonance (MR) imaging at baseline and 24-72 hours after uterine artery embolization (UAE) to determine the percentage of infarction of leiomyoma tissue (complete = 100%, almost complete = 90%-99%, and partial = 0%-89%). Clinical outcome and frequency of reinterventions were compared for up to 36 months.

RESULTS

One hundred thirteen patients completed at least one clinical follow-up. Twenty-four months after UAE, 50% +/- 15.2 (standard error) of the patients with partial infarction and 80% +/- 13.4 (standard error) of patients with almost complete infarction had undergone no reintervention. No patient with complete infarction needed a second treatment (P < .001). The hazard ratios for reintervention between the complete infarction group and the almost complete and partial infarction groups were 15.88 (95% confidence interval [CI]: 1.22, 2225.54; P = .034) and 73.08 (95% CI: 8.33, 9636.35; P < .001), respectively. There were significant differences in hazard ratios between patients with partial and those with complete infarction for persistence or recurrence of menorrhagia (hazard ratio, 7.45; 95% CI: 2.08, 28.31; P = .002) and bulk-related symptoms (hazard ratio, 5.90; 95% CI: 1.66, 21.92; P = .007). There was no significant correlation between patient age, number of leiomyomas, location of the dominant leiomyoma, or baseline uterine and dominant leiomyoma volume and clinical failure.

CONCLUSION

Women with leiomyoma infarction above 90% on contrast-enhanced MR images after UAE show significantly better symptom control and fewer reinterventions than do patients with a lower infarction rate.

[Therapeutic embolization of uterine leiomyomas: cases requiring surgery]

OBJECTIVE

To retrospectively analyze the clinical, radiolgical, and histological findings in patients with uterine leiomyomas (LU) that required surgical intervention after embolization.

MATERIAL AND METHODS

Between July 1999 and January 2006, we embolized 182 patients with LU. Eight of these patients subsequently required surgical resection of the tumor. We reviewed clinical data, imaging findings, embolization technique, and reasons for surgery, histological findings in the resected specimens, identification and location of the embolizing material, presence and type of necrosis in the LU, and associated pathology in adjacent organs.

RESULTS

The 8 patients that required surgery represented 4.3% of all patients embolized for LU. Surgery was necessary due to technical failure in two patients (1.02%), complications in three (1.64%) and failed treatment in the remaining three 3 (1.64%). The mean maximum diameter of the LU was 9.8 cm (range: 4-17 cm). The mean volume of the LU was 491.88 ml (range: 30-1.365 ml) The mean age of the patients was 37.7 years (range: 28-48 years). Global necrosis was evident in 6 LU; necrosis was hyaline type in 3 and inflammatory in the remaining 3. The embolizing material was detected in the LU in one case, in the uterine myometrium in two cases, and in the ovary in one.

CONCLUSION

Less than 5% of cases of LU required surgery after embolization; the risk of surgery after embolization was greater in large lesions. When the embolization technique was adequate, histological study confirmed global necrosis of the tumors, although this was not accompanied by clinical improvement.

Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study

To evaluate long-term effects of arterial embolization (AE) for postpartum hemorrhage (PPH) on menses recovery and subsequent pregnancies. One hundred thirteen consecutive patients, recruited from 1999 to 2006, who had undergone AE for severe PPH were evaluated in a retrospective monocentric study. As embolization agents, pledgets of absorbable gelatine sponge (Curaspon) were used in 106 cases, Curaspon powder in 3 cases, and inert microparticles in 4 cases. In 111/113 cases (98.1%), AE was successful in controlling PPH. In two cases (1.7%), the AE was unsuccessful and required a total abdominal postembolization hysterectomy. Concerning fertility, 6 patients were lost to follow-up and 107 were available. The average time to follow-up was 46.4+/-21.8 months. Of the 107 patients, 99 had recovery of menses (92.5%). Of the 107 (61%) patients, 66 reported regular menstruation with normal delay after the delivery. Thirty-three patients (31%) reported subjective changes in the frequency and amount of menses. Six patients (5.6%) had documented amenorrhea after AE and developed diffuse uterine synechiae at the hysteroscopic investigation. Out of 29 patients who desired and attempted conception, 18 patients (62%) reported a total of 19 pregnancies at the end of the follow-up. One miscarriage at 12 weeks of gestation was reported. The 18 pregnancies at term were uneventful until delivery, but 3 cases of further PPH (15%) occurred due to abnormal placentation requiring a further AE. All full-term newborns were healthy. AE is a feasible, safe, and reproducible technique to control PPH, allowing a very high resumption of menses and subsequent pregnancies; in these cases, considering the elevated incidence of further PPH due to abnormal placentation, an accurate ultrasonographic monitoring during pregnancy seems appropriate.

Fertility after bilateral uterine artery embolization in a sheep model

OBJECTIVE

To evaluate the impact of bilateral uterine artery embolization (UAE) upon fertility in sheep.

DESIGN

Prospective study.

SETTING

University-based interventional radiology, pathology, and reproductive physiology units.

ANIMAL(S)

Nineteen control ewes, 10 ewes embolized with polyvinyl alcohol particles (PVA group), and 10 ewes embolized with Tris-acryl gelatin microspheres (TGMS group).

INTERVENTION(S)

Bilateral UAE was performed with 600- to 1,000-mum PVA particles or 700- to 900-mum TGMS particles. Animals of three groups were synchronized and naturally inseminated.

MAIN OUTCOME MEASURE(S)

For each ewe, a hormonal follow-up was performed throughout the gestation. Gestation duration, number and weight of newborns, and fertility and gestation rates were recorded.

RESULT(S)

Mean number of estrus before insemination and gestation duration were not different between groups. There were 47 living newborns: 26 control, 9 PVA, and 12 TGMS. Overall birth weight of newborns was 3.7 +/- 0.9 kg for controls, 3.6 +/- 1.1 kg for TGMS, and 2.2 +/- 0.7 kg for PVA (which was statistically significant vs. control). In the PVA group, there was a statistically significant decrease of fertility rate and gestation rate vs. controls, but this was not the case in the TGMS group.

CONCLUSION(S)

Particles of PVA decrease fertility in sheep and lead to intrauterine growth retardation.

Recanalization and particle exclusion after embolization of uterine arteries in sheep: a long-term study

OBJECTIVE

To compare the long-term evolution of uterine arteries after embolization with the two most commonly used embolic agents for fibroid embolization: nonspherical polyvinyl alcohol (PVA) particles and trisacryl gelatin microspheres (TGMS).

DESIGN

Prospective study.

SETTING

University-based interventional radiology, pathology, and reproductive physiology units.

ANIMAL(S)

Two groups of 10 sheep embolized in the uterine artery.

INTERVENTION(S)

Embolization of the uterine artery with either 600-1000 microm nonspherical polyvinyl alcohol (PVA) particles or with 700-900 microm trisacryl gelatin microspheres (TGMS). Animals were synchronized and naturally inseminated. Animals were killed at 26 months.

MAIN OUTCOME MEASURE(S)

Uteri were examined pathologically for vessel size, site of occlusion, recanalization rate of vessels, and particle location within the vascular wall.

RESULT(S)

The PVA particles were more numerous in the vessels' lumen than the TGMS particles (13.3 +/- 20.8 vs. 2.5 +/- 2.7), were located more proximally than TGMS (97% vs. 68% in the trunk and first branches of the uterine artery), and were found almost exclusively in the intima (99.2%). In contrast, 54.4% of the TGMS particles were found in the intima, and 45.6% partially or totally excluded. The rate of recanalization was not statistically significantly different for PVA and TGMS (65.2% vs. 60.6%).

CONCLUSION(S)

The long-term evolution of uterine arteries was different after uterine artery embolization with PVA and TGMS because PVA particles formed large-sized aggregates that occluded proximal vessels and remained in the vessel intima. Microspheres occluded more distal vessels, and about 50% of them were partially or totally excluded from the vessel.

Tranexamic Acid-associated Necrosis and Intralesional Thrombosis of Uterine Leiomyomas

INTRODUCTION

Women with menorrhagia have increased levels of plasminogen activators in the endometrium. Tranexamic acid (cyklokapron), an antifibrinolytic agent, is commonly prescribed worldwide to women with menorrhagia, including those with fibroids. Necrosis in uterine leiomyomas may be associated with pregnancy, and progestogen or oral contraceptive use but its association with tranexamic acid has not been investigated. Four hundred ninety patients with uterine leiomyomas in 2004 and 2005 were reviewed. Their ages ranged from 22 to 86 (mean 47.2). One hundred forty-seven (30%) were treated with tranexamic acid.

RESULTS

Infarct-type necrosis was observed in the leiomyomas of 38 patients, 22 of whom had tranexamic acid (15%) whereas the remaining 16 had no drug exposure (4.7%) (odds ratio=3.60; 95% confidence interval: 1.83-6.07; P=0.0003). Two patients who took the drug less than 2 weeks before surgery had early infarcts with appearance resembled coagulative type necrosis. Eleven of the 22 cases of drug-induced necrotic leiomyoma (50%) also showed intralesional thrombus formation, and 4 showed organization of the thrombi.

CONCLUSIONS

Infarct-type necrosis and thrombosis of leiomyoma was more commonly observed in patients treated with tranexamic acid. Although the drug is effective for menorrhagia, clinicians should be aware of the possible complications associated with leiomyoma necrosis such as pain and fever. Distinguishing between types of necrosis may not always be straightforward particularly in early infarcts when the reparative connective tissue reaction between the viable and necrotic cells is not well-developed, resulting in an appearance similar to coagulative necrosis. When the overall gross and microscopic features of a leiomyoma with coagulative necrosis favor a benign lesion, the drug history should be reviewed so that this type of early and healing infarct-type necrosis is considered as the underlying cause of the apparent coagulative necrosis. This may otherwise result in a diagnosis of smooth muscle tumor of uncertain malignant potential, leading to prolonged follow-up and unnecessary further surgical intervention.

Uterine artery embolization and future fertility potential

The growing body of evidence concerning the safety and efficacy of uterine artery embolization (UAE) has led to increasing confidence amongst gynecologists and interventional radiologists that UAE can be used safely to treat women with symptomatic fibroids. UAE is clearly preferable for certain subgroups of patients, for example those with increased risks of complications of general anesthesia, those with religious objection to blood transfusion and those wishing to avoid surgical risk. This review of the available literature demonstrates the paucity of information concerning safety and efficacy of UAE for those wishing to conceive. Case reports and series are largely positive. However, there are continuing concerns over the effects of UAE on ovarian and uterine function, and on subsequent pregnancy outcome. More long-term data and randomized controlled trials are required to address these issues. Women who undergo embolization should be told that the effects on pregnancy and the resulting child are uncertain and that there may be long-term implications for the health and development of the offspring. Hence, it is inadvisable to try to conceive following the procedure. Given the available evidence, concern must remain that UAE may lead to significant damage to fertility, with higher risk of miscarriage and adverse pregnancy outcome when compared with open or laparoscopic myomectomy.

Nécrose utérine et ovarienne après embolisation des artères utérines pour hémorragie de la délivrance

We report here the case of a young woman who presented with pain, fever and apparent cutaneous sub ischaemia following embolisation of the uterine arteries for postpartum haemorrhagia. This embolisation was carried out by bilateral selective catheterism of the uterine arteries using 45 to 150 micron polyvinyl alcohol particles. Investigative laparotomy was decided in view of the persistence of the symptoms, and the patient underwent hysterectomy with ablation of the right adnexa to treat uterine necrosis and adnexal atrophy. Because of the information that we have actually, we can explain that this complication is linked with the use of polyvinyl alcohol small size particles. The migration of those embolisation agents might be responsible for obliteration of a large number of distal vessels. Those embolisation agents must, because of recommendation for good practice published in 2004, be reserved to exceptional cases to minimize the complication of embolisation.

Utero-Ovarian Anastomosis: Histopathologic Correlation after Uterine Artery Embolization with or without Ovarian Artery Embolization

PURPOSE

To study utero-ovarian anastomosis at angiography and its histologic effect on patients who were treated with uterine artery embolization (UAE) with or without ovarian artery embolization (OAE) for symptomatic uterine leiomyomata.

MATERIALS AND METHODS

Four hundred patients (mean age, 43.6 years +/- 6.34) underwent UAE at the authors' institution from June 1998 to May 2005. Eight of the 400 patients underwent hysterectomy with removal of at least one adnexae after UAE. Five patients received tris-acryl gelatin microspheres and three received polyvinyl alcohol particles. Two patients also underwent OAE with gelatin sponges. Specimens from 16 fallopian tubes and 12 ovaries were reviewed. Histologic slides were prepared and reviewed by two pathologists who were blinded to the angiographic findings. The presence of utero-ovarian anastomoses at angiography, the histologic features of adnexa, the presence of particles in the adnexa, and the size and location of the particles were studied.

RESULTS

Utero-ovarian anastomosis was present at angiography in three of the eight patients (38%) and five of the 16 adnexa (31%). Particles were present within the fallopian tube or ovary in all patients who demonstrated utero-ovarian anastomoses at angiography. When utero-ovarian anastomoses were identified bilaterally, particles were found in both adnexae. In cases with particles in the adnexa, the adnexal tissues were histologically viable without evidence of ischemic changes or infarction. Particles were not present in the ovary of patients without utero-ovarian anastomosis at angiography.

CONCLUSION

The angiographic finding of a utero-ovarian anastomosis during UAE appears to correlate with particle embolization in the fallopian tube or ovary. Histologically normal fallopian tubes and ovaries can be expected after UAE with microsphere particles with and without OAE with gelatin sponges.

Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolization with tris-acryl gelatin microspheres

PURPOSE

To assess the prevalence of anastomoses between uterine and ovarian arteries on angiography and their impact on changes in basal follicle-stimulating hormone (FSH) level after uterine artery embolization (UAE).

MATERIALS AND METHODS

Consecutive premenopausal women who underwent UAE for symptomatic uterine leiomyomata according to a uniform embolization technique with tris-acryl gelatin microspheres at a single institution were included in the study. Basal FSH levels before UAE and 6 months after UAE were compared for patients with and without anastomoses between uterine and ovarian arteries on angiography.

RESULTS

Among 124 patients included in the study (mean age, 43.1+/-5.7 years), patent anastomoses between the uterine and ovarian arteries were detected by angiography in 55 patients (44.4%). Overall, 11.3% of 124 patients showed an increase in basal serum FSH level of greater than 20 mIU/mL after UAE. In patients with utero-ovarian anastomoses, 18.2% showed an increase of greater than 20 mIU/mL after UAE, compared with 5.8% of patients without such anastomoses (P=.03). Mean basal FSH increase after UAE in patients with anastomoses was 8.4+/-20.2 mIU/mL, compared with 2.7+/-10.6 mIU/mL in patients without anastomoses (P=.047). Among patients with anastomoses, the 50- to 54-year age group had the highest percentage of patients with an FSH increase greater than 20 mIU/mL (50.0%) after UAE, followed by patients in the 45- to 49-year age group (15.4%).

CONCLUSIONS

Angiographically detected anastomoses between the uterine artery and the ovarian artery are not uncommon. UAE in patients with anastomoses is associated with a greater risk of significant increase of basal FSH level than in UAE in patients without anastomoses. The pathophysiologic processes resulting in change of FSH level may be a reflection of diminished ovarian function, but further study is warranted to delineate the precise mechanism.

Uterine Fibroids: Contrast-enhanced MR Angiography to Predict Ovarian Artery Supply—Initial Experience

PURPOSE

To prospectively evaluate the diagnostic performance of contrast material-enhanced magnetic resonance (MR) angiography in helping predict ovarian artery supply of uterine fibroids by using postembolization conventional aortography as the reference standard.

MATERIALS AND METHODS

The protocol for the study was approved by the institutional review board, and each patient gave informed consent. Ninety consecutive women (mean age, 42.5 years; range, 33-63 years) underwent MR angiography before uterine artery embolization (UAE). The number and origin of the ovarian arteries were determined. Ovarian artery supply of fibroids was graded as very unlikely, possible, or very likely by using a scoring system based on a combination of MR angiographic findings. MR angiographic results were compared with those of conventional aortography performed after UAE in all patients and followed by selective angiography in case of a suspected ovarian artery supply of fibroids. Analysis of the association between MR angiographic grading and conventional angiography as the standard of reference was performed with a chi(2) trend test. Sensitivity and specificity, including exact 95% confidence intervals (CIs), of MR angiography were determined.

RESULTS

MR angiography depicted 18 ovarian arteries (four bilateral, 10 unilateral), one with an atypical origin. Five ovarian arteries were classified as very likely; three, as possible; and 10, as very unlikely sources of arterial fibroid supply. Seven (39%) of 18 ovarian arteries detected at MR angiography were visible at conventional aortography. Fibroid supply was verified at selective angiography in five ovarian arteries in five (6%) of 90 patients. There was a strong association between MR angiographic grading and the results of conventional angiography (P = .002). Sensitivity of MR angiography in depicting ovarian artery supply (grade, possible or very likely) was 100% (five of five, 95% CI: 48%; 100%) and specificity was 77% (10 of 13, 95% CI: 46%; 95%).

CONCLUSION

Contrast-enhanced MR angiography can help predict ovarian artery supply of uterine fibroids.

Pathological findings of uterine leiomyomas and adenomyosis following uterine artery embolization

Uterine artery embolization (UAE) is an effective and accepted treatment option for symptomatic uterine leiomyoma. Between 2000 and 2005, 91 women were treated using this method, and were prospectively followed at our institution. Twenty of them subsequently underwent surgery. One of these patients was subjected to four surgical procedures. We describe the pathological findings of 23 surgical specimens obtained from these 20 patients. The embolic material used consisted of tris-acryl gelatin microspheres (TGMS) in 15 patients (18 surgical specimens), polyvinyl alcohol particles (PVA) in three patients, and a combination of PVA and TGMS in two patients. Histologically, of the 23 specimens examined, 20 were diagnosed as leiomyomas, and three as adenomyosis. Particles used for embolization were found in all but three specimens. Necrosis was present in 15 of 20 leiomyoma specimens. Hyaline necrosis was found in 12 specimens, coagulative necrosis in one case, and a combination of hyaline and coagulative or suppurative necrosis in two cases. The foci of adenomyosis remained unaltered.

Uterine Artery Embolization as a Treatment Option for Uterine Myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options. The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.

Successful spontaneous pregnancy following surgical removal of a post uterine artery embolized necrotic fibroid capsule: a case report

Uterine artery embolization has been shown to be an effective treatment in controlling symptomatic uterine fibroids. Reports suggest that significant complications associated with the procedure are rare. However, data pertaining to preservation of fertility after embolization are scarce, and some authors do not advocate this procedure for women considering future pregnancy. We present a case of a post-embolization uterine cavity abnormality which was repaired surgically, followed by successful pregnancy outcome.

Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization

Embolization has become a first-line treatment for symptomatic uterine fibroid tumors. Selective catheterization and embolization of both uterine arteries, which are the predominant source of blood flow to fibroid tumors in most cases, is the cornerstone of treatment. Although embolization for treatment of uterine fibroid tumors is widely accepted, great familiarity with the normal and variant pelvic arterial anatomy is needed to ensure the safety and success of the procedure. The uterine artery classically arises as a first or second branch of the anterior division of the internal iliac artery and is usually dilated in the presence of a uterine fibroid tumor. Angiography is used for comprehensive pretreatment assessment of the pelvic arterial anatomy; for noninvasive evaluation, Doppler ultrasonography, contrast material-enhanced magnetic resonance (MR) imaging, and MR angiography also may be used. After the uterine artery is identified, selective catheterization should be performed distal to its cervicovaginal branch. For targeted embolization of the perifibroid arterial plexus, injection of particles with diameters larger than 500 mum is generally recommended. Excessive embolization may injure normal myometrium, ovaries, or fallopian tubes and lead to uterine necrosis or infection or to ovarian failure. Incomplete treatment or additional blood supply to the tumor (eg, via an ovarian artery) may result in clinical failure. The common postembolization angiographic end point is occlusion of the uterine arterial branches to the fibroid tumor while antegrade flow is maintained in the main uterine artery.

Uterine Arterial Embolization With Tris-acryl Gelatin Microspheres

Uterine artery embolization (UAE) as an alternative to surgery for the treatment of uterine fibroids and adenomyosis uteri became increasingly popular. While the clinical success of this new treatment strategy is without doubt, there is still considerable uncertainty with respect to the morphologic changes induced by UAE. In this study, a total of 173 women were treated with UAE using tris-acryl gelatin microspheres (TGMS), a new particulate spherical embolic agent, for either symptomatic adenomyosis or leiomyoma. Surgical specimens of 8 women who underwent subsequent myomectomy or hysterectomy were evaluated by conventional histology and immunohistochemistry. TGMS were readily apparent in both macroscopy and routine histology. In patients with fibroids, TGMS accumulated in medium-sized vessels in the direct tumor vicinity, a minor fraction of particles was detected in the outer half of the myometrium and within leiomyomata. In patients with adenomyosis, a random distribution of TGMS was noted throughout the outer half of the myometrium. Freshly infused particles occluded the respective arteries without a significant tissue reaction. In the course of time, a granulomatous foreign body reaction in the vicinity of particles occurred, eventually followed by complete vessel destruction. Leiomyoma treated with UAE showed either hyaline necrosis, coagulative necrosis, or no change at all. Foci of adenomyosis remained unaltered. In conclusion, after UAE with TGMS, particles were identified predominately but not exclusively at the periphery of fibroids. Pathologists must be aware of the morphologic changes induced by UAE in leiomyoma to avoid misinterpretation of induced tissue alterations as signs of malignant tumor growth.

Uterine artery embolization: A pilot study in a rabbit model

Eight female adult ex-breeder New Zealand white rabbits underwent bilateral, unilateral, or superselective unilateral uterine artery embolization. The histopathologic changes after embolization in New Zealand white rabbits resemble those in humans, making rabbits an appropriate model for experimental uterine artery embolization.

Pregnancy After Uterine Artery Embolization for Leiomyomata:

OBJECTIVE

To report on pregnancies and deliveries occurring in a large cohort of women who underwent uterine artery embolization instead of surgery for symptomatic leiomyomata.

METHODS

A total of 555 women underwent uterine embolization in a multicenter clinical trial. The primary embolic agent was 355-500 microm polyvinyl alcohol particles with treatment end-point as bilateral stasis in the uterine arteries. Women desiring pregnancy were informed of the uncertain effect of embolization on fertility and pregnancy. Average age at embolization was 43 years (range 18-59 years). Thirty-one percent were younger than age 40 years. Women were followed up prospectively by telephone, and obstetric records of the women who conceived were reviewed.

RESULTS

Twenty-one women of average age 34 years (range 27-42 years) conceived, (3 of these twice), and 13 women were nulliparous. Twenty-three of the 24 pregnancies were conceived spontaneously (1 woman had in vitro fertilization). There were 4 spontaneous abortions (16.7%, 95% confidence interval 5.4-41.9%) and 2 elective pregnancy terminations. Fourteen of the 18 live births were full term and 4 were preterm. There were 9 vaginal deliveries and 9 cesarean deliveries, 4 of which were elective. Abnormal placentation occurred in 3 cases, all nulliparas (12.5% 95% confidence interval 3.1-36.3%). Two cases developed placenta previa (1 had a clinical partial accreta) and the third developed a placenta membranacea with accreta resulting in cesarean hysterectomy. Three postpartum hemorrhages all secondary to placental abnormalities occurred. Four newborns were small for gestational age (< or = 5th percentile); 2 of these pregnancies were complicated by gestational hypertension.

CONCLUSION

Women are able to achieve pregnancies after uterine artery embolization, and most resulted in term deliveries and appropriately grown newborns. Close monitoring of placental status, however, is recommended.

Uterine Artery Embolization of Leiomyomas With Trisacryl Gelatin Microspheres (TGM): Pathologic Features and Comparison With Polyvinyl Alcohol Emboli

In recent years, uterine artery embolization (UAE) has gained popularity as an alternative to surgery for the treatment of symptomatic uterine leiomyomas. Polyvinyl alcohol (PVA) particles have been the principal agent used for UAE. Recently, trisacryl gelatin microspheres (TGM) have been advocated as a preferable occlusive material for UAE. It is the first embolic agent to be cleared specifically by the United States Food and Drug Administration for this use. To date, information on the tissue effects, distribution, and morphology of UAE with TGM in resected human organs is very limited. Herein, we document the pathologic findings in a 46-year-old woman who underwent hysterectomy and bilateral salpingo-oophorectomy and omentectomy for metastatic colonic adenocarcinoma 19 months after UAE with TGM (microsphere size = 500-700 micron) for uterine leiomyomas. Histologically, a submucosal leiomyoma and an intramural uterine leiomyoma showed massive coagulative necrosis of the infarct-type with a peripheral zone of hyalinized fibrous tissue. Aggregates of TGM were within the necrotic leiomyomas and throughout the myometrium. Non-targeted extrauterine sites also contained TGM, including the paracervical soft tissue and the mesosalpinx as well as the ovaries and omentum where they were adjacent to metastatic colonic carcinoma. Other than the myomas, none of the embolized organs showed ischemic necrosis. Although some TGM were intravascular, most were extravascular. Typically, the microspheres were adjacent to muscular arteries from which they appeared to have been extruded following localized dissolution of the arterial wall. A thin rim of foreign body-type giant cells and mononuclear macrophages surrounded many of the TGM and focally involved the arterial wall. No vascular thrombosis was seen. TGM are believed to have advantages over PVA emboli for UAE. Hence, additional examples of surgical specimens following treatment of leiomyomas with TGM can be expected. Pathologists should be aware of the morphology of TGM in resected genital tract tissues. Although TGM are easily distinguished from embolic PVA particles, they may be mistaken for PVA microspheres if not carefully studied. Elastic stains are useful in the differential diagnosis of embolic agents.

Differentiation between completely hyalinized uterine leiomyomas and ordinary leiomyomas: three-phase dynamic magnetic resonance imaging (MRI) vs. diffusion-weighted MRI with very small b-factors

PURPOSE

To assess the possibility of differentiating between completely hyalinized leiomyomas and ordinary leiomyomas by using diffusion-weighted (DW) magnetic resonance imaging (MRI) (DWI) employing very small b-factors (b = 1.51 and 55.3 seconds/mm(2)) in comparison with three-phase dynamic MRI.

MATERIALS AND METHODS

The subjects were 25 patients with 52 histopathologically confirmed uterine leiomyomas. All leiomyomas were divided into two histopathologic subtypes (5 completely hyalinized leiomyomas and 47 ordinary leiomyomas). For each leiomyoma, the enhancement index (EI) at three-phase dynamic MRI and apparent diffusion coefficient (ADC) were obtained and then compared.

RESULTS

The EIs at second and third dynamic phases clearly differentiated the two types of leiomyomas without overlap of values. ADCs also clearly differentiated the two types of leiomyomas without overlap of values. Moreover, there were significant positive correlations between ADCs and EIs at all dynamic phases (r = 0.41-0.50, P < 0.01).

CONCLUSION

Not only three-phase dynamic MRI but also DWI with very small b-factors could be useful for differentiating completely hyalinized leiomyomas from ordinary leiomyomas.

Extensive psammomatous calcification of the uterus and cervix associated with a uterine serous carcinoma

This report describes a uterine serous carcinoma with bilateral ovarian metastasis, which was associated with widespread extensive psammomatous calcification of the uterine leiomyomata, the myometrium, and the cervical stroma. These psammoma bodies were not associated with tumour or epithelial elements. This psammomatous calcification is rare, with no previous reports of similar cases. The presence of psammoma bodies is probably related to the serous carcinoma, raising the possibility that psammoma body formation in serous carcinomas is the result of a factor secreted locally by the tumour, rather than the widely held theory that their formation is secondary to necrosis, with subsequent dystrophic calcification within a papillary neoplasm.

Childbirth and Myoma Treatment by Uterine Artery Occlusion: Do They Share a Common Biology?

When the uterine arteries are bilaterally occluded, either by uterine artery embolization or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. It is postulated that myomas are killed by the same process that kills trophoblasts: transient uterine ischemia. When the uterine arteries are bilaterally occluded, either by uterine artery embolization (UAE) or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. Over time, stagnant blood in these arteries and veins clots. Then, tiny collateral arteries in the broad ligament (including communicating arteries from the ovarian arteries) open, causing clot within myometrium to lyse and the uterus to reperfuse. Myomas, however, do not survive this period of ischemia. This is unique organ response to clot formation and ischemia. What allows the uterus to survive a relatively long period of ischemia while myomas perish? Childbirth appears to be the predicate biology. Following placental separation, the uteroplacental arteries and the draining veins of the placenta are torn apart at their bases in the junctional zone of the myometrium and bleed directly into the uterine cavity. Left unchecked, every woman would bleed to death in less than 10 minutes after placental delivery. Most women do not bleed to death because vessels in the uterus clot after placental delivery. During pregnancy, clotting and lytic factors in blood increase many fold. Following delivery, uterine contractions continue, intermittently, periodically slowing the velocity of flowing blood through myometrium. The combination of slowed blood flow, elevated clotting proteins, and torn placental vessels (known as Virchow's triad) causes blood in myometrial arteries and veins to clot. Fibrinolytic enzymes later lyse clot in arteries and veins not associated with placenta perfusion, and the uterus is reperfused. Remnant placental tissue - primarily uteroplacental arteries and veins - does not survive this period of ischemia. Placental tissue dies and over weeks is sloughed into the uterine cavity. At the same time, residual endometrial tissue grows under the sloughing placental tissue thus re-establishing the endometrial lining. It is postulated that myomas are killed by the same process that kills trophoblasts - transient uterine ischemia.

Uterine fibroid tumors: long-term MR imaging outcome after embolization

PURPOSE

To assess and report the long-term magnetic resonance (MR) imaging outcomes of fibroid tumors treated with uterine artery embolization (UAE).

MATERIALS AND METHODS

Contrast material-enhanced pelvic MR imaging was performed in 20 patients before UAE, at 3 months after UAE, and then yearly for up to 3 years. Two readers compared the uterine fibroid, dominant (ie, largest) fibroid, and percentage of perfusion measurements from each of these examinations by using intraclass correlations. Seventeen patients underwent contrast-enhanced MR imaging at baseline and 3 months and 3 years after treatment. Among these patients, those with complete infarction were compared with those with incomplete infarction of the dominant fibroid at 3 years to determine extents of infarction, differences in baseline characteristics, degrees of volume reduction of the uterus and fibroid, and extents of symptom change. Comparisons were performed by using t and Pearson chi(2) tests. Differences in proportions, with 95% CIs, were calculated. Each follow-up MR image was also evaluated for the presence of myometrial perfusion defects and new fibroids.

RESULTS

Intraclass correlation coefficients calculated for the two readers (range, 0.974-0.995) and with the MR imaging data (range, 0.966-0.988) were high. Of the 17 patients included in the outcome analysis, the 12 with complete fibroid infarction were more likely not to have enhancing lesions at 3-year follow-up (P =.002) than were those with incomplete infarction. No significant differences in volume or symptom changes between the two groups were detected, but growth of residual perfused portions of the incompletely infarcted fibroids was seen in three patients, two of whom had recurrent symptoms. Four patients developed new fibroids, none of which has caused symptoms. There were no instances of myometrial infarction.

CONCLUSION

Although the small study population prevented the drawing of definitive conclusions, the data suggest that although incomplete fibroid infarction may not affect outcome immediately, regrowth of uninfarcted fibroid tissue may result in symptom recurrence.

Leiomyoma Recurrence after Uterine Artery Embolization

PURPOSE

The purpose of this study was to evaluate the rate of leiomyoma recurrence after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

MATERIALS AND METHODS

A prospective study of UAE of uterine leiomyomas has been ongoing at the authors' hospital since 1997. The recurrence rate was assessed in June 2002. Vascular access was obtained via the right common femoral artery and free-flow embolization was performed with use of 150-250- micro m polyvinyl alcohol particles and an absorbable particle sponge. Follow-up included clinical and ultrasound (US) examinations at 3, 6, and 12 months, and once per year thereafter.

RESULTS

Eighty-five UAE procedures were performed between January 1997 and June 2000. Five patients were lost to follow-up. Median follow-up was 30 months (range, 2-57 months). There were six immediate failures: one technical failure, three cases of concomitant disease (one case of endometrial cancer and two cases of adenomyosis), and two cases of large subserosal leiomyomas. There were eight late failures or recurrences: one case of leiomyoma progression, seven cases of new leiomyomas. Mean time to recurrence was 27.4 months.

CONCLUSIONS

Although UAE is an effective primary treatment for leiomyomas, this study recorded a recurrence rate of 10% at just more than 2 years. Clinical and US examinations are needed before UAE to exclude pedunculated submucosal leiomyomas and cancers, and must be repeated for more than 2 years after UAE to monitor patients' progress. Longer follow-up and more events are needed to define risk factors for recurrence.

Adenomyosis: MRI of the uterus treated with uterine artery embolization

OBJECTIVE

The purpose of this study was to determine the MRI features seen after uterine artery embolization and to evaluate the clinical response in patients with adenomyosis.

MATERIALS AND METHODS

Thirty women with adenomyosis underwent uterine artery embolization and follow-up MRI for 1 year. Of the 30, 27 patients were diagnosed with uterine fibroids and adenomyosis on the basis of MRI before uterine artery embolization. In six of the 27 patients, the dominant disease was adenomyosis. Three of the 30 patients had adenomyosis alone. The distribution, thickness, and enhancement of adenomyosis were analyzed in each patient. Patients completed a symptom questionnaire.

RESULTS

After uterine artery embolization, the junctional zone-myometrial ratio did not change significantly. There were regions of devascularization of adenomyosis on contrast-enhanced images in 12 patients, all with a junctional zone thickness before uterine artery embolization of more than 20 mm (mean thickness, 39.2 mm). Eleven of the 12 patients had focal or asymmetric distribution patterns of adenomyosis. All three patients with pure adenomyosis and all six patients with dominant adenomyosis reported an improvement in symptoms.

CONCLUSION

In patients treated with uterine artery embolization, MRI shows changes in areas of adenomyosis with a decrease in junctional zone vascularity in patients with thickening of the junctional zone greater than 20 mm. Devascularization may be related to the distribution of adenomyosis. The presence of adenomyosis should not be used as a contraindication to uterine artery embolization because most patients show clinical improvement after undergoing this procedure.

Fatal sepsis after uterine artery embolization with microspheres

A case report of fatal sepsis after uterine artery embolization (UAE) with microspheres is presented. At autopsy, microspheres were found not only in arteries in the leiomyomata and myometrium but also in the parametria and the vagina, leading to a necrotic vaginal wall and uterine cervix. At present, polyvinyl alcohol particles are usually used in UAE. Recently, study results of the use of microspheres in embolization procedures have become available. The rationale for the choice of a specific embolization particle and the clinical implications of possible sepsis after UAE are discussed.

Hysterectomy for complications after uterine artery embolization for leiomyoma: results of a Canadian multicenter clinical trial

STUDY OBJECTIVE

To determine the complication-related hysterectomy rate after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

DESIGN

Prospective, multicenter, nonrandomized, single-arm clinical trial (Canadian Task Force classification II-2).

SETTING

Eight Ontario University-affiliated teaching and community hospitals.

PATIENTS

Five hundred fifty-five women.

INTERVENTION

Polyvinyl alcohol particles were delivered through a catheter into uterine arteries under fluoroscopic guidance.

MEASUREMENTS AND MAIN RESULTS

Prospective follow-up investigations consisted of telephone interviews, ultrasound examinations, and reviews of pathology and surgery reports. Median follow-up was 8.1 months, and all but five patients had complete 3-month follow-up. At 3 months, eight women (1.5%, 95% CI 0.6-2.8) underwent complication-related hysterectomy. Half of the surgeries were performed at institutions other than where UAE had been performed. Indications for hysterectomies were infections (2), postembolization pain (4), vaginal bleeding (1), and prolapsed leiomyoma (1).

CONCLUSIONS

The 3-month complication rate resulting in hysterectomy after UAE in a large cohort of women was low. Hysterectomy after UAE is an important measure of safety and a key outcome measure of this new therapy.

Pathologic features of uteri and leiomyomas following uterine artery embolization for leiomyomas

The objectives of this study were to identify the presence/absence and location of any embolic material and to describe the morphologic appearance of the leiomyoma and adjacent tissues of cases undergoing surgical intervention following uterine artery embolization (UAE) for leiomyomas. A total of 555 women underwent UAE using polyvinyl alcohol particles (PVA) in a multicenter clinical trial. The histopathologic slides from 17 of 18 women who subsequently underwent myomectomy or hysterectomy in the follow-up period (median 8.2 months) were reviewed without knowledge of the indication for surgery or time elapsed since UAE. The presence/absence and distribution of PVA emboli, associated inflammatory response, and necrosis were noted. Necrosis of leiomyoma(s) was classified as hyaline-type, coagulative tumor cell necrosis, and/or acute suppurative necrosis. In all cases PVA emboli were identified within smooth muscle tumors of the uterine body, its periphery, cervix, uterine body, myometrium, and/or the adnexa. A florid foreign body giant cell type of chronic inflammatory reaction was seen within 1 week of UAE and persisted with visible PVA for up to 14 months post-UAE. Typically, post-UAE leiomyomas showed hyaline-type, but rarely coagulative tumor cell necrosis and acute suppurative necrosis could be seen as well. Five of eight cases coming to surgery for complications showed necrotizing endomyometritis with tissue infarction. PVA particles are recognizable in post-UAE specimens. Leiomyoma necrosis is typically of the hyaline type; coagulative tumor cell necrosis was rarely seen. In some cases with complications, uterine and/or cervical necrosis occurred. The applicability of these findings for UAE patients who have been successfully treated and not resected is uncertain.