Tolerance, Hospital Stay, and Recovery after Uterine Artery Embolization for Fibroids: The Ontario Uterine Fibroid Embolization Trial

What predicts durable symptom relief of uterine fibroids treated with MRI-guided focused ultrasound? A multicenter trial in 8 academic centers

OBJECTIVE

To identify variables predictive of durable clinical success after MRI-guided focused ultrasound (MRgFUS) treatment of uterine fibroids.

MATERIALS AND METHODS

In this prospective, multicenter trial, 99 women with symptomatic uterine fibroids were treated using MRgFUS. Pelvic MRI was obtained at baseline and treatment day. The Uterine Fibroid Symptom-Quality of Life questionnaire was used to calculate a symptom severity score (SSS) at baseline and 6, 12, 24, and 36 months following treatment. Clinical, imaging, and treatment variables were correlated with symptom reduction sustained through the 12- and 24-month time points using univariable and multivariable logistic regression analyses. A novel parameter, the ratio of non-perfused volume to total fibroid load (NPV/TFL), was developed to determine association with durable outcomes.

RESULTS

Post-treatment, mean symptom severity decreased at the 6-, 12-, 24-, and 36-month follow-ups (p < 0.001, all time points). In univariable analysis, three variables predicted treatment success (defined by ≥ 30-point improvement in SSS) sustained at both the 12-month and 24-month time points: increasing ratio of NPV/TFL (p = 0.002), decreasing total fibroid load (p = 0.04), and the absence of T2-weighted Funaki type 2 fibroids (p = 0.02). In multivariable analysis, the NPV/TFL was the sole predictor of durable clinical success (p = 0.01). Patients with ratios below 30% had less improvement in SSS and lacked durable clinical response compared with those between 30-79 (p = 0.03) and ≥ 80% (p = 0.01).

CONCLUSION

Increased non-perfused volume relative to total fibroid volume was significantly associated with durable reduction of symptoms of abnormal uterine bleeding and bulk bother.

CLINICAL RELEVANCE STATEMENT

Patient selection for sustained clinical benefit should emphasize those with likelihood of achieving high ablation ratios, as determined by imaging (e.g., device access, Funaki type) and by considering the total fibroid load, not just the primary symptomatic fibroid.

TRIAL REGISTRATION

Clinical trial ID: NCT01285960.

KEY POINTS

• Patient selection/treatment approach associated with durable symptom relief in MRI-guided focused ultrasound ablation of uterine fibroids remains unclear. • The ablation ratio, non-perfused volume/total fibroid volume, was positively associated with sustained symptom relief in both bleeding and bulk bother at 1- and 2-year follow-ups. • Selecting patients with imaging features that favor a high ratio of ablation to total fibroid load (including non-targeted fibroids) is the main factor in predicting durability of symptom relief after uterine fibroid treatment.

Superior Hypogastric Nerve Blockade for Uterine Artery Embolization: A Systematic Review

Superior hypogastric nerve block (SHNB) has potential to reduce pain following uterine artery embolization (UAE). However, existing studies are limited by design, sample size, or conflicting results. A systematic review of the literature was performed. Outcomes included technical success, time to complete SHNB, time under fluoroscopy, procedure time, time to recovery, needle repositioning, same-day discharge, readmission, pain, analgesic consumption, and adverse events. Of 15 included studies, the same-day discharge rate was 98.8%, and readmission rate was 6.9%. The mean pain score was 3.4 in patients who received SHNB compared to 4.3 among controls. Of patients who received SHNB, 46.7% did not require further pain medication. Major adverse events occurred in 0.4% of patients. Early clinical studies suggest that SHNB appears to reduce pain and analgesic consumption in patients undergoing UAE. Additional randomized trials are needed to confirm these findings.

Comparison of Uterine Necrosis After Uterine Artery Embolization with Soluble Gelatin Sponge Particles or Tris-acryl Gelatin Microspheres in Swine

PURPOSE

To compare the recanalization of the uterine arteries and uterine necrosis after uterine artery embolization (UAE) using either soluble gelatin sponge particles (SGS), which dissolve in saline, or tris-acryl gelatin microspheres (MS), which are permanent embolic materials, in swine.

METHODS

Fourteen uteri in seven swine were divided into two groups for embolization with either 500-1000 µm SGS (SGS group) or 500-700 µm MS (MS group) (seven uteri per group). The uterine arteries were embolized using SGS or MS, and angiography was performed to evaluate recanalization of the uterine arteries immediately, 1, 2, 3, 4, 5, and 6 h, and 3 days after embolization. On day 3, the uteri were removed to determine the macroscopic necrosis rate and for histopathologic examination.

RESULTS

In the SGS group, four uterine arteries were completely recanalized, two were partially recanalized, and one was still occluded 5 h after embolization. In contrast, all seven uterine arteries in the MS group were still occluded 6 h after embolization. The complete recanalization rate at 3 days was significantly greater in the SGS group than in the MS group (100.0% vs. 14.3%, respectively; P = .0047). The mean uterine necrosis rate was not significantly different between the SGS and MS groups (15.0 ± 15.7% vs. 26.8 ± 13.3%, respectively; P = .096). The mean smallest arterial diameter containing embolic materials was 48.2 ± 22.0 μm (range 21-109 μm) for SGS and 446.7 ± 107.0 μm (range 352-742 μm) for MS (P < .0001).

CONCLUSION

The uterine arteries recanalized earlier in the SGS group than in the MS group and the uterine necrosis rates were similar in both groups. SGS have the potential for a more distal penetration in comparison with MS.

Workflow-Based Design and Evaluation of a Device for CBCT-Guided Biopsy

Biopsies for personalized cancer care can be performed with cone beam computed tomography (CBCT) guidance, but manual needle manipulation remains an issue due to X-ray exposure to physicians. Modern CBCT scanners integrate today real-time imaging and software assistance for needle planning. In this paper, these available features are exploited to design a novel device offering an intermediate level of assistance between simple passive mechanical devices of limited efficiency, and advanced robotic devices requiring adapted procedure workflows. Our resulting system is built to limit its impact on the current manual practice. It is patient-mounted and provides remote control of needle orientation and insertion. A multilayer phantom is specifically developed to reproduce interactions between the needle and soft abdominal tissues. It is used to experimentally evaluate the device added value by comparing assisted versus manual needle insertions. The device is shown to help reducing X-ray exposure by a factor 4, without impacting the accuracy obtained manually.

Efficacy of Intraprocedural Superior Hypogastric Nerve Block in Reduction of Postuterine Artery Embolization Narcotic Analgesia Use

PURPOSE

Uterine artery embolization (UAE) is an effective treatment for the management of symptomatic uterine fibroids. We aim to evaluate the efficacy of superior hypogastric nerve block (SHNB) in reducing narcotic analgesia use for postprocedural pain after UAE.

METHODS

A retrospective review of 88 consecutive patients with symptomatic fibroids who underwent UAE between August 2015 and August 2018 was performed. A total of 44 patients had intraprocedural SHNB and 44 patients had no SHNB. They were placed on a morphine patient-controlled anesthesia (PCA) pump after the procedure and were admitted for overnight observation. The total amount of PCA narcotic analgesia received was recorded for each patient. Additional factors including fibroid size, fibroid location, and patient age were evaluated to determine the predictors of narcotic use reduction after SHNB.

RESULTS

The mean amount of postprocedural morphine use was 51.7 mg in patients who did not receive an SHNB versus 35.9 mg in patients who did receive an SHNB (P = .008), resulting in a 47.2% reduction in narcotic analgesia use in the SHNB cohort. A significant reduction in morphine use with SHNB was associated with fibroid size greater than 5 cm (P = .009), intramural fibroid location (P = .04), and patients 45 years or younger (P = .006).

CONCLUSION

The use of SHNB could significantly reduce the amount of narcotic analgesia required for pain control after UAE with larger intramural fibroids and younger patients as predictors of increased efficacy.

Observations And Experiments For The Definition Of A New Robotic Device Dedicated To CT, CBCT And MRI-Guided Percutaneous Procedures

In this paper, we present the work achieved to define the robotic functionalities of interest for percutaneous procedures as performed in interventional radiology. Our contributions are twofold. First, a detailed task analysis is performed with workflow analysis of biopsies, one of the most frequent tasks, under three imaging modalities, namely CT, CBCT and MRI. Second, the functionalities of a robotic assistant are identified, and we analyze whether a single device can bring an added value during procedures in the three modalities while keeping the robotized workflow close to manual tasks, to minimize learning time and difficulty of use. Experimental analysis on CBCT is notably used to confirm the interest of the determined robotic functionalities.

Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center

OBJECTIVE

To evaluate effectiveness and safety of UFE as alternative to surgery, in treatment of uterine fibromatosis.

METHODS/MATERIALS

255 patients (aged 26-55) with symptomatic UF, indication for surgery, followed in our center (2000-2014), single or multiple fibroids, pain and/or functional/compressive disorders, underwent embolization: injection of PVA particles (150-900 μm) from distal portion of uterine arteries (ascending section). Primary end-point: flow-stop distally to injection site, disappearance of lesion design, preservation of flow in main trunk of UA. Secondary end-point: control of pain and functional/compressive disorders during follow-up (2-7 years).

RESULTS

Procedure was performed bilaterally in 250 patients (98%). Mean duration: 47 min (average fluoroscopy: 10:50 min). Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h). Follow-up at 2 years: resolution of menstrual disorders in 78% of patients and improvement in 14%; pain disappeared in 66%; significant improvement of menstrual flow and HCT/HB levels, decrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. Recurrence in 18 patients.

CONCLUSIONS

UFE represents an excellent alternative to surgical treatment: it is safe, tolerable and effective both in short and long term, with evident advantages in economic and social terms.

The management of peri- and postprocedural pain in interventional radiology: a narrative review

Interventional radiology encompasses a wide range of procedures and the degree of associated pain depends predominantly on the procedure being undertaken. Procedures may be painful during but not after the procedure, relatively painless during but painful after the procedure, or relatively painless during and after the procedure. However, there is a lack of good quality publications in interventional radiology that specifically address the subject of peri- and postprocedural pain management. Nevertheless, a variety of more or less complex protocols exist for intraprocedural sedation and for peri- and postprocedural analgesia. While weight-based protocols for procedural sedation have demonstrable benefit, protocols for postprocedural pain relief after major procedures have not been sufficiently rigorously evaluated.

Post-uterine artery embolization pain and clinical outcomes for symptomatic myomas using gelfoam pledgets alone versus embospheres plus gelfoam pledgets: a comparative pilot study

BACKGROUND

To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids.

METHOD

We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months.

RESULTS

A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal.

CONCLUSION

Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.

MRI predictors of clinical success in MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids: results from a single centre

OBJECTIVES

To assess the technical and clinical results of MRgFUS treatment and factors affecting clinical treatment success.

MATERIALS AND METHODS

A total of 252 women (mean age, 42.1 ± 6.9 years) with uterine fibroids underwent MRgFUS. All patients underwent MRI before treatment. Results were evaluated with respect to post-treatment nonperfused volume (NPV), symptom severity score (SSS), reintervention rate, pregnancy and safety data.

RESULTS

NPV ratio was significantly higher in fibroids characterized by low signal intensity in contrast-enhanced T1-weighted fat saturated MR images and in fibroids distant from the spine (>3 cm). NPV ratio was lower in fibroids with septations, with subserosal component and in skin-distant fibroids (p < 0.001). NPV ratio was highly correlated with clinical success: NPV of more than 80 % resulted in clinical success in more than 80 % of patients. Reintervention rate was 12.7 % (mean follow-up time, 19.4 ± 8 months; range, 3-38). Expulsion of fibroids (21 %) was significantly correlated with a high clinical success rate. No severe adverse events were reported.

CONCLUSIONS

Adequate patient selection and correct treatment techniques, based on the learning curve of this technology, combined with technical advances of the system, lead to higher clinical success rates with low complications rate, comparable to other uterine-sparing treatment options.

KEY POINTS

• MRgFUS appears to be a valid alternative to other uterus-preserving therapies • Patient selection is a significant factor in achieving high NPV ratios • MRI screening parameters correlate with the amount of fibroid ablation in MRgFUS • NPV results of more than 80 % correlate with higher clinical success rates.

A randomized, double-blind, placebo-controlled study of preemptive oral oxycodone with morphine patient-controlled anesthesia for postoperative pain management in patients undergoing uterine artery embolization for symptomatic uterine fibroids

PURPOSE

To evaluate the analgesic efficacy of oral premedication of oxycodone in a group of patients undergoing elective uterine artery embolization under sedation for fibroid disease.

METHODS

Thirty-nine patients (mean age 42.3 years) were prospectively randomized 1:1 to receive 20 mg oxycodone or placebo orally immediately before their procedure. At the commencement of the procedure, patients were provided with a patient-controlled analgesia device for 24 h, programmed to deliver 1 mg boluses of intravenous morphine with a 5 min lockout. Mean visual analog scale pain intensity ratings (0-100 mm) were measured from both groups and evaluated over 0 to 6 h as the primary end point. Other measured parameters included opioid-related side effects and eligibility for discharge (NCT00163930; September 12, 2005).

RESULTS

Early pain intensity did not vary significantly between the active and placebo groups [mean (standard deviation): 3.2 (2.5) vs. 3.1 (2.2), p = 0.89]. The oxycodone group, however, experienced significantly more nausea (p = 0.035) and a greater incidence of vomiting (p = 0.044). Overall opioid requirement over 24 h, measured as oral morphine equivalent, was greater in the oxycodone group (median [interquartile range]: 64.5 [45-90] mg vs. 22.5 [15-46.5] mg, p < 0.0001). The number of patients first eligible for discharge at 24 h in the oxycodone group was decreased but not significantly (p = 0.07).

CONCLUSION

The addition of preprocedural oral oxycodone to morphine patient-controlled analgesia does not offer any analgesic advantage to patients having uterine artery embolization and may cause a greater incidence of nausea and vomiting.

Uterine-sparing minimally invasive interventions in women with uterine fibroids: a systematic review and indirect treatment comparison meta-analysis

OBJECTIVE

To evaluate the effectiveness of uterine-sparing interventions for women with symptomatic uterine fibroids who wish to preserve their uterus.

DESIGN

Systematic review and indirect comparison meta-analysis.

METHODS

MEDLINE, EMBASE, CENTRAL, conference proceedings, trial registers and reference lists were searched up to October 2013 for randomized controlled trials.

MAIN OUTCOME MEASURES

Outcome measures were patient satisfaction, re-intervention and complications rates, reproductive outcomes, and hospitalization and recovery times.

RESULTS

Five trials, involving 436 women were included; two compared uterine artery embolization with myomectomy and three compared uterine artery embolization with laparoscopic uterine artery occlusion. Indirect treatment comparison showed that myomectomy and uterine artery embolization resulted in higher rates of patient satisfaction (odds ratio 2.56, 95% credible interval 0.56-11.75 and 2.7, 95% credible interval 1.1-7.14, respectively) and lower rates of clinical failure (odds ratio 0.29, 95% credible interval 0.06-1.46 and 0.37, 95% credible interval 0.13-0.93, respectively) than laparoscopic uterine artery occlusion. Myomectomy resulted in lower re-intervention rate than uterine artery embolization (odds ratio 0.08, 95% credible interval 0.02-0.27) and laparoscopic uterine artery occlusion (odds ratio 0.08, 95% credible interval 0.01-0.37) even though the latter techniques had an advantage over myomectomy because of shorter hospitalization and quicker recovery. There was no evidence of difference between the three techniques in ovarian failure and complications rates. The evidence for reproductive outcomes is poor.

CONCLUSION

Our study's results suggest that laparoscopic uterine artery occlusion is less effective than uterine artery embolization and myomectomy in treatment of symptomatic fibroids. The choice between uterine artery embolization and myomectomy should be based on individuals' expectations and fully informed discussion.

Uterine fibroids: current perspectives

Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman's menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.

Magnetic resonance imaging-guided focused ultrasound treatment of symptomatic uterine fibroids: impact of technology advancement on ablation volumes in 115 patients

OBJECTIVES

The aim of this study was to assess the impact of the advanced technology of the new ExAblate 2100 system (Insightec Ltd, Haifa, Israel) for magnetic resonance imaging (MRI)-guided focused ultrasound surgery on treatment outcomes in patients with symptomatic uterine fibroids, as measured by the nonperfused volume ratio.

MATERIALS AND METHODS

This is a retrospective analysis of 115 women (mean age, 42 years; range, 27-54 years) with symptomatic fibroids who consecutively underwent MRI-guided focused ultrasound treatment in a single center with the new generation ExAblate 2100 system from November 2010 to June 2011. Mean ± SD total volume and number of treated fibroids (per patient) were 89 ± 94 cm and 2.2 ± 1.7, respectively. Patient baseline characteristics were analyzed regarding their impact on the resulting nonperfused volume ratio.

RESULTS

Magnetic resonance imaging-guided focused ultrasound treatment was technically successful in 115 of 123 patients (93.5%). In 8 patients, treatment was not possible because of bowel loops in the beam pathway that could not be mitigated (n = 6), patient movement (n = 1), and system malfunction (n = 1). Mean nonperfused volume ratio was 88% ± 15% (range, 38%-100%). Mean applied energy level was 5400 ± 1200 J, and mean number of sonications was 74 ± 27. No major complications occurred. Two cases of first-degree skin burn resolved within 1 week after the intervention. Of the baseline characteristics analyzed, only the planned treatment volume had a statistically significant impact on nonperfused volume ratio.

CONCLUSIONS

With technological advancement, the outcome of MRI-guided focused ultrasound treatment in terms of the nonperfused volume ratio can be enhanced with a high safety profile, markedly exceeding results reported in previous clinical trials.

[Uterine artery embolization for myomas treatment]

Myoma treatment by uterine artery embolisation (UAE) using non-spherical PVA particles or calibrated tris-acryl microspheres>500μm is effective in more than 90 % of cases in the short-term. In the long-term, menorrhagia, bulk-related symptoms and pelvic pain are significantly improved or eliminated in 75 % of cases at 5 to 7 years. At 6 months, uterine volume reduction and larger myoma volume reduction varies between 30 to 60 % and 50 to 80 % respectively. During hospital stay the complication rate is very low, less than 3 % mostly urinary infection and pain. Secondary hysterectomy for complication is less than 2 % at 3 months. Definitive amenorrhea is reported in less than 5 % of cases in women of more than 45-year of age. No significant impact of embolization on hormonal function has been reported in women less than 45 years with normal baseline function. UAE is not indicated for submucous myomas. Randomized studies comparing embolization to hysterectomy demonstrate that reinterventions are more frequently performed after embolization. Secondary hysterectomy is performed in 13 to 24 % of cases at 2 years and in up to 28 % of cases at 5 years. Hospital stay, duration of recovery and time off work are shorter after embolization compared to hysterectomy. Embolization is cheaper than hysterectomy at 12 and 24 months even taking into consideration the additional costs of imaging and reinterventions. UAE is a good alternative treatment in women with unique myoma of less than 10cm and multiple myomas around 15cm. This treatment should be proposed to women each time possible. Randomized studies comparing embolization to myomectomy demonstrate that in the short and mid-term there is no difference in terms of control of menorrhagia and bulk-related symptoms. Uterine volume reduction and quality of life were not different at 6 months. Periprocedural and 30-day complication rates are not different. At 6 months, the rate of complications is higher after myomectomy. Reinterventions are more frequent after embolization compared to myomectomy. Hospital stay, duration of recovery and time off work are shorter after embolization compared to myomectomy. UAE is less aggressive than myomectomy and should be proposed as a conservative alternative treatment. Embolization should be considered with caution in pregnancy-seeking women since there is still a lack of good quality data available in the specific group of patients. FSH level is more frequently elevated after embolization compared to myomectomy. Pregnancy rate and term pregnancy rate are higher after myomectomy compared to embolization. Spontaneous abortion is more frequent after embolization than after myomectomy. At this time, UAE is not indicated excepted in studies or in specific cases when the woman want a pregnancy. Embolization performed before myomectomy (preoperative or combined procedures) can be discussed for an individual patient but there is not enough data to support its routine use.

Epidural analgesia versus patient-controlled analgesia for pain relief in uterine artery embolization for uterine fibroids: a decision analysis

PURPOSE

This study was designed to compare the costs and effects of epidural analgesia (EDA) to those of patient-controlled intravenous analgesia (PCA) for postintervention pain relief in women having uterine artery embolization (UAE) for systematic uterine fibroids.

METHODS

Cost-effectiveness analysis (CEA) based on data from the literature by constructing a decision tree to model the clinical pathways for estimating the effects and costs of treatment with EDA and PCA. Literature on EDA for pain-relief after UAE was missing, and therefore, data on EDA for abdominal surgery were used. Outcome measures were compared costs to reduce one point in visual analogue score (VAS) or numeric rating scale (NRS) for pain 6 and 24 h after UAE and risk for complications.

RESULTS

Six hours after the intervention, the VAS was 3.56 when using PCA and 2.0 when using EDA. The costs for pain relief in women undergoing UAE with PCA and EDA were <euro>191 and <euro>355, respectively. The costs for EDA to reduce the VAS score 6 h after the intervention with one point compared with PCA were <euro>105 and <euro>179 after 24 h. The risk of having a complication was 2.45 times higher when using EDA.

CONCLUSIONS

The results of this indirect comparison of EDA for abdominal surgery with PCA for UAE show that EDA would provide superior analgesia for post UAE pain at 6 and 24 h but with higher costs and an increased risk of complications.

MR-guided high-intensity focused ultrasound treatment for symptomatic uterine leiomyomata: long-term outcomes

RATIONALE AND OBJECTIVES

To evaluate the long-term clinical outcomes of magnetic resonance--guided high-intensity focused ultrasound (MR-g HIFU) treatments for symptomatic uterine leiomyomata.

MATERIALS AND METHODS

Patients were recruited for a prospective study for MR-g HIFU treatments of symptomatic leiomyomata, with up to 3-year follow-up. The study was approved by the institutional review board and was Health Insurance Portability and Accountability Act--compliant. Clinical assessments were obtained at 3 months, 6 months, and 1, 2, and 3 years after MR-g HIFU, as well as uterine fibroid symptom severity scores (SSS) and health-related quality of life questionnaires (UFS-QOL). MR imaging was performed at each follow-up to assess the efficacy of the treatment at 6 months, 1 year, 2 years, and 3 years.

RESULTS

Fifty-one leiomyomata in 40 patients were treated. All patients were treated within the US Food and Drug Administration guidelines with leiomyomata localized on MR and treated with sonication. The mean baseline volume of treated leiomyomata was 336.9 cm(3). The mean improvement scores for transformed SSS was 47.8 (P < .001) and for tUFS-QOL was 39.8 (P < .001) at 3 years. The mean volume decrease in treated leiomyomata was 32.0% (P < .001), and, in the uterus, the volume decrease was 27.7% (P < .001) at 3 years. There were no long-term complications.

CONCLUSIONS

Long-term follow-up data from MR-g HIFU treatments show sustained symptomatic relief among enrolled patients. Although the results are preliminary, MR-g HIFU for the treatment of uterine leiomyomata may result in acceptable long-term outcomes at 3 years.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Four-dimensional transcatheter intra-arterial perfusion MR imaging before and after uterine artery embolization in the rabbit VX2 tumor model

PURPOSE

To test the hypothesis that four-dimensional (4D) transcatheter intra-arterial perfusion (TRIP) MR imaging can measure uterine fibroid perfusion changes immediately before and after uterine artery embolization (UAE) in the rabbit VX2 tumor model.

MATERIALS AND METHODS

Eight VX2 uterine tumors were grown in six rabbits. After positioning a catheter within the uterine artery, we performed 4D TRIP-MRI measurements with 3-mL injections of 2.5% gadopentetate dimeglumine. We used a dynamic 3D spoiled-gradient echo sequence with in vivo B(1)-field correction for improved accuracy during perfusion quantification. We performed UAE using 1 mL of gelatin microspheres (2 x 10(6) particles; diameter 40-120 mum). Two regions-of-interest were drawn within each tumor upon perfusion maps. Functional embolic endpoints were reported as the mean percent reduction in fibroid tumor perfusion. Measurements before and after UAE were compared using paired t-tests (alpha = 0.05).

RESULTS

VX2 uterine tumor perfusion decreased significantly from 27.1 at baseline to 7.09 after UAE (mL/min/100 mL of tissue, P < 0.0001). Overall perfusion reduction was 76.3% (95% confidence interval: 66.3-86.3%).

CONCLUSION

Four-dimensional TRIP MRI can objectively quantify uterine fibroid perfusion reductions during UAE in VX2 rabbits. This technique could be used clinically to potentially determine an optimal embolic endpoint with the long-term goals of improving UAE success rates and minimizing procedure-related ischemic pain.

Complications of percutaneous procedures

Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures.

Hysterectomy-current methods and alternatives for benign indications

Hysterectomy is the commonest gynecologic operation performed not only for malignant disease but also for many benign conditions such as fibroids, endometrial hyperplasia, adenomyosis, uterine prolapse, dysfunctional uterine bleeding, and cervical intraepithelial neoplasia. There are many approaches to hysterectomy for benign disease: abdominal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, total laparoscopic hysterectomy (TLH) where the laparoscopic procedures include uterine artery ligation, and subtotal laparoscopic hysterectomy (STLH) where there is no vaginal component and the uterine body is removed using a morcelator. In the last decades, many new techniques, alternative to hysterectomy with conservation of the uterus have been developed. They use modern technologies and their results are promising and in many cases comparable with hysterectomy. This paper is a review of all the existing hysterectomy techniques and the alternative methods for benign indications.

Leiomyoma shrinkage after MRI-guided focused ultrasound treatment: report of 80 patients

OBJECTIVE

The purpose of this study was to assess the degree of leiomyoma ablation and shrinkage after MRI-guided focused ultrasound treatment performed according to U.S. Food and Drug Administration protocols for commercial trials.

MATERIALS AND METHODS

A total of 147 symptomatic leiomyomas in 80 women (average age, 46 years; range, 34-55 years) were managed with MRI-guided focused ultrasound. The average volume of treated fibroids was 175+/-201 (SD) cm3. Before treatment, T2-weighted MR images in three planes were obtained to measure leiomyoma volume. Immediately after treatment, T1-weighted contrast-enhanced fat-suppressed MR images in three planes were used to measure nonperfused volume ratio. Similar images obtained 6 months after treatment were used to determine leiomyoma shrinkage. Qualitative and quantitative relations between fibroid volume, nonperfused volume ratio at treatment, and 6-month shrinkage were measured.

RESULTS

The average nonperfused volume ratio was 55%+/-25% immediately after treatment. Six months after treatment, the average volume of treated fibroids had decreased to 112+/-141 cm3 (n=81) (p<0.0001) with an average volume reduction of 31%+/-28%. A linear regression model showed highly significant correlation between posttreatment nonperfused volume ratio and shrinkage at 6 months (p<0.0001).

CONCLUSION

MRI-guided focused ultrasound therapy for leiomyoma can result in nonperfused volume ratio and shrinkage that exceed those in previous clinical trials because the treatment guidelines have been relaxed to allow a greater amount of tissue ablation. The results suggest that a larger nonperfused volume ratio can be achieved, resulting in greater shrinkage and improved relief of symptoms.

Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study

OBJECTIVE

To determine whether uterine fibroid embolization may advance ovarian follicular depletion in reproductive-aged women with apparently normal baseline ovarian function.

DESIGN

Prospective cohort study.

SETTING

University tertiary care center.

PARTICIPANT(S)

Thirty-six patients aged 26 to 39 years with fibroids, regular menstrual cycles, and day 3 serum FSH levels<10 mIU/mL and 36 matched control women.

INTERVENTION(S)

Day 3 serum FSH and E2 levels and ultrasound-based antral follicle count and ovarian volume were determined before (baseline) and at 12, 24, 36, 48, and 60 months after embolization and compared with those of the control group. Menstrual status was determined annually on the basis of prospectively recorded menstrual calendars.

MAIN OUTCOME MEASURE(S)

Longitudinal changes in hormone levels, ultrasound measures, and bleeding patterns.

RESULT(S)

Although the FSH and E2 levels increased significantly and the antral follicle count and ovarian volume values declined significantly over time within the groups, no significant differences were found between the groups. The cycle remained regular in all but two women (one in the embolization group and one in the control group), who started having cycle irregularity after 24 months and 36 months follow-up, respectively.

CONCLUSION(S)

This long-term follow-up study suggests that fibroid embolization does not lead to an accelerated decline in ovarian reserve in younger patients.

Magnetic resonance-guided focused ultrasound (MRgFUS) compared with abdominal hysterectomy for treatment of uterine leiomyomas

OBJECTIVES

To compare women undergoing magnetic resonance-guided focused ultrasound (MRgFUS) to a group of contemporaneously recruited women undergoing total abdominal hysterectomy. Patient demographics, safety parameters, quality of life outcomes and disability measures are reported.

METHODS

One hundred and nine women were recruited in seven centers for MRgFUS treatment and 83 women who underwent abdominal hysterectomy were recruited in seven separate centers to provide contemporaneous assessment of safety. The adverse-event profile and disability parameters were prospectively assessed. Patients were also screened at baseline and at 1, 3 and 6 months using the SF-36 health survey questionnaire.

RESULTS

There were no life-threatening adverse events in either group. Overall, the number of significant clinical complications and adverse events was lower in women in the MRgFUS group compared to women undergoing hysterectomy. MRgFUS was associated with significantly faster recovery, including resumption of usual activities. At 6 months of follow-up, there were four (4%) treatment failures in the MRgFUS arm. Regarding SF-36 subscale scores, at 6 months there was improvement in all SF-36 subscales for both treatment groups. However, most of the SF-36 subscale scores were significantly better at this stage in the hysterectomy group than in the MRgFUS group. Women undergoing MRgFUS had steady improvement in all parameters throughout the 6-month follow-up period, despite the fact that they continued to have myomatous uteri and menstruation, which at baseline had given them significant symptomatology.

CONCLUSIONS

The results of this study show that MRgFUS treatment of uterine leiomyomas leads to clinical improvement with fewer significant clinical complications and adverse events compared to hysterectomy at 6 months' follow-up.

Infrared microspectroscopy analysis of ibuprofen release from drug eluting beads in uterine tissue

Ibuprofen loaded embolization beads (IBU-BB) have been developed to reduce inflammation and pain following uterine artery embolization for the treatment of uterine fibroids. The present work has investigated the elution properties of IBU-BB in situ after embolization with Fourier Transform Infrared Microspectroscopy (FTIRMS). Twelve sheep underwent uterine artery embolization with IBU-BB (485 mM) or control unloaded beads. IBU concentration was determined inside the beads and in the tissue surrounding the beads using FTIRMS of uterine tissue sections sampled 24 h or 1 week after embolization. After 24 h, IBU concentration inside the bead was only 18.6 mM out of the 485 mM initially loaded (p < 0.0001, univariate sign test). The concentration in the tissue around the beads was 8 mM, which is well above the in vitro therapeutic levels (6 microM). After one week the concentration of IBU had decreased to 4.9 mM in the beads (p = 0.0502, Mann Whitney) and no IBU was detected in the surrounding tissue. This work has demonstrated that IBU-BB can provide a sustained release of the anti-inflammatory drug over at least one week. The in vivo elution properties of IBU-BB may be suitable to alleviate pain and inflammation after embolization.

Safety and feasibility of outpatient transcatheter hepatic arterial embolization for hepatocellular carcinoma

PURPOSE

To evaluate the feasibility and safety of performing image-guided bland embolization and chemoembolization as an outpatient-based procedure in selected patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This is a retrospective review of the authors' experience with outpatient embolization and chemoembolization from January 2005 to June 2006. Patients with nonresectable HCC not eligible for liver transplantation were enrolled. Patients with Child-Pugh class A and early class B liver disease were treated by using the outpatient protocol, patients with Child-Pugh class C and late class B liver disease and those with elevated bilirubin or creatinine levels were excluded and treated as inpatients or denied embolization therapy. One hundred thirty-three bland embolizations or chemoembolizations were performed in 77 patients on an outpatient basis during the study period.

RESULTS

Patients were discharged home on the same day after 131 of the 133 procedures (99%; 95% confidence interval [CI]: +/-2%), in two cases (2%, 95% CI: +/-2%), patients were admitted the day of the procedure. In two of the 131 cases (2%, 95% CI: +/-2%), patients discharged home returned to the emergency department 1-6 days after the procedure. One hundred twenty-nine of the 133 cases (97%, 95% CI: +/-3%) were successfully treated by using the outpatient embolization or chemoembolization protocol, with subsequent hospitalization needed in only four of 133 cases (3%, 95% CI: +/-3%).

CONCLUSIONS

Image-guided hepatic bland embolization and chemoembolization performed with an outpatient protocol in carefully selected patients with HCC with aggressive follow-up is safe, with relatively few complications and few requirements for admission or revisitation to the emergency department.

[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.

Overview of contemporary interventional fluoroscopy procedures

Interventional fluoroscopy procedures are increasingly important in medical practice. As new procedures are introduced and validated, they tend to replace the equivalent surgical procedure. There is wide variation in patient dose, both among procedures and for a specific procedure. Stochastic risk is present, but interventional fluoroscopy procedures may also present deterministic risk. Radiation risk/benefit analyses are different for interventional fluoroscopy procedures than they are for diagnostic imaging procedures. The radiation risk component of an interventional fluoroscopy procedure is substantially less than the other procedural risks, and there is always clear and measurable benefit to the patient from a successful procedure. Optimizing patient dose will require both improvements in equipment technology and greater attention from regulators, accrediting bodies and medical organizations. Ensuring adequate operator training is essential.

Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids

OBJECTIVES

To determine whether women will experience permanent amenorrhea following uterine artery embolization for fibroids, and whether rates of onset differ in the long term according to age at the time of the procedure.

METHODS

Over 77 months, 211 consecutive eligible women were grouped by age (group A, <40 years [n=39]; group B, 40-44 years [n=98]; and group C, > or =45 years [n=74]) and the cumulative rates of onset of permanent amenorrhea were compared between the groups.

RESULTS

The likelihood of incurring permanent amenorrhea was significantly higher in group C. The cumulative rates in groups A, B, and C were 0%, 1.4%, and 19.7% at 3 years and 0%, 11.2%, and 40.4% at 6 years.

CONCLUSION

The rates of onset of permanent amenorrhea changed over time and differed according to age at the time of the procedure, with little likelihood of permanent amenorrhea at 6 years for women younger than 40 years at the time of the procedure.