Three-dimensional color Doppler sonography and uterine artery arteriography of fibroids: assessment of changes in vascularity before and after embolization

The Diagnostic Value of Superb Microvascular Imaging in Prediction of Uterine Artery Embolization Treatment Response in Uterine Leiomyomas

OBJECTIVES

We aimed to determine if superb microvascular imaging (SMI) can predict response to uterine artery embolization (UAE) as compared with power Doppler ultrasound.

METHODS

The blood flow and the volume of the dominant leiomyoma was evaluated by power Doppler ultrasonography (PDUS) and SMI 1 day before and 3 months after the UAE procedure. SMI and PDUS blood flow were classified to 4 grades of vascularity. The change in fibroid volume in Grades 0-2 (hypovascular group) was compared to the hypervascular Grade 3 group.

RESULTS

Twenty-eight women (mean age, 40.9 years; range, 33-53 years) were examined with PDUS and SMI before and 3 months after UAE. The volume reduction was statistically significantly higher hypervascular group (P < .05). When we accept 30% or more volume reduction as a good response to UAE, the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of SMI were 100, 64, 73.6, 100, and 82.1%, respectively. There was excellent agreement between the two blinded observers in SMI measurements.

CONCLUSIONS

SMI, with its high reproducibility, provides further microvessel information than PDUS in uterine fibroids. It may be a useful tool in prediction of response to UAE treatment and improve counseling and patient selection for UAE versus medical or surgical treatment options.

Uterine fibroid vascularization: from morphological evidence to clinical implications

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.

Effect of intramural fibroid on uterine and endometrial vascularity in infertile women scheduled for in-vitro fertilization

PURPOSE

To study the effect of intramural fibroids on uterine and endometrial vascularity in infertile women scheduled for in-vitro fertilization (IVF).

METHODS

3D power Doppler was used to measure the endometrial volume and blood flow indices in 182 women with intramural fibroids not affecting the uterine cavity and compared them to a matched control group without fibroids.

RESULTS

There was significantly increased vascularity in the endometrium of the fibroid group as denoted by higher endometrial VI (p = 0.018), FI (p = 0.027) and Endometrial VFI. No significant difference in mean uterine artery RI (p = 0.277) or PI (p = 0.187). Among the fibroid group 62.6% had a fibroid > 4 cm. Women with fibroids > 4 cm had a significantly higher Endometrial FI (p = 0.037), and VFI (p = 0.02). Uterine artery blood flow was not affected, as uterine RI (p = 0.369) and PI (p = 0.321) were not statistically different. Compared with the control group (non fibroid), women with fibroids > 4 cm had significantly higher endometrial VI (p = 0.013), FI (p = 0.004), and VFI (p < 0.001), whereas women with fibroid ≤ 4 cm had no statistically significant differences in VI (p = 0.292), FI (p = 0.198), and VFI (p = 0.304).

CONCLUSION

Intramural fibroids > 4 cm significantly increase endometrial vascularity. This increase in blood flow may be a factor that affects the outcome of IVF.

Influence of ulipristal acetate therapy compared with uterine artery embolization on fibroid volume and vascularity indices assessed by three-dimensional ultrasound: prospective observational study

OBJECTIVE

To compare the effects of two alternative treatment options for uterine fibroids, ulipristal acetate (UPA) and uterine artery embolization (UAE), on fibroid volume and vascularity at 3-month follow-up.

METHODS

Premenopausal patients with symptomatic, intramural uterine fibroids were included in this prospective case-control study. Seventeen patients who qualified for preoperative UPA treatment were pair-matched with patients of similar age (± 5 years) and fibroid volume (± 10% of volume) who qualified for UAE. Patients undergoing UPA treatment received 5 mg/24 h of oral UPA for 3 months. UAE was performed in patients bilaterally by an interventional radiologist. To estimate dominant fibroid volume, Virtual Organ Computer-aided AnaLysis (VOCAL™) was used. The VOCAL program was also used to calculate three-dimensional power Doppler vascular indices: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Dominant fibroid volumes and VI, FI and VFI values were assessed before commencement of UPA treatment or UAE procedure and again at 3 months afterwards.

RESULTS

In both the UPA and UAE groups, fibroid volumes decreased significantly after treatment in comparison with baseline volumes obtained prior to treatment. The percentage of fibroid volume reduction after 3 months of UPA therapy (48.1%) was not significantly different from the reduction seen 3 months after the UAE procedure (47.3%). All vascular indices decreased significantly after treatment by UPA or UAE. The percentage reduction in VI and VFI 3 months after UAE (95.4% for both) was significantly greater than the percentage reduction in patients after 3 months of UPA therapy (51.5% and 62.5%, respectively); however the difference in FI reduction between treatment groups did not reach significance (54.3% for UAE and 30.9% for UPA). No significant side-effects were observed in either treatment group.

CONCLUSIONS

Fibroid treatment by UPA therapy results in a decrease in fibroid volume, comparable with that after UAE, and decreases fibroid vascularization, although to a lesser extent than does UAE.

Contribution of contrast-enhanced ultrasound with Sonovue to describe the microvascularization of uterine fibroid tumors before and after uterine artery embolization

OBJECTIVE

The principal objective of this study was to use contrast-enhanced ultrasonography to describe the characteristics of fibroid microvascularization before and after embolization.

STUDY DESIGN

Forty women had contrast-enhanced ultrasonography with Sonovue(®) injections before uterine artery embolization, the day afterwards, and at 6-12 months afterwards. An MRI was also performed before and after the procedure.

RESULTS

Two thirds of the fibroids took up the contrast product before the myometrium did, and 45.8% were vascularized along the peripheral rim of the fibroid, compared with 41.6% with a principal pedicle and from the center in three (12.6%). After embolization at day one (D1), the myometrium was fully enhanced, that is, perfusion of the myometrium was plainly visible, in 25 cases (69.4%; n=36), partially enhanced in eight (22.2%), and totally avascular in three (8.4%). Analysis of the failures according to imaging criteria the day after embolization (D1) showed failure in seven women, with partial enhancement for six, and total for one. In the imaging at 6 months (M6), contrast ultrasonography showed failure for three women, with enhancement of the largest fibroid. This enhancement was total in two cases and partial (40%) in one. There were five failures according to MRI at M6, with partial enhancement. Only two of these failures were simultaneously failures according to the contrast-enhanced ultrasonography. There were five clinical failures, two consistent with the imaging at 6 months and four predictable on D1.

CONCLUSION

Contrast-enhanced ultrasonography is feasible and useful to understand fibroid vascularization and for monitoring embolization; its correlation with MRI is good, its concordance less so.

Uterine artery Doppler flow velocity waveform analysis following uterine fibroid embolisation

The objective was to evaluate the relation of uterine artery Doppler flow pulsatility index (PI) with total uterine volume reduction following bilateral embolisation of uterine fibroids by injection of polyvinyl alcohol particles. Doppler flow velocity was examined before and within 8 days after embolisation (n = 13). Uterine size was assessed by magnetic resonance imaging (MRI) before, and at 3 and 6 months after, the procedure. Mean PI values (mean of right and left side) obtained before embolisation were negatively related to uterine size (r = -0.68, p = 0.010) but not to uterine volume reduction after the procedure. Mean PI values after the procedure were related to the percentage decrease in uterine volume both at 3 (r = 0.74, p = 0.004) and 6 months (p = 0.73, p = 0.005). Doppler ultrasound measures of the uterine arteries may be used to evaluate reduction of uterine size following fibroid embolisation.

Color Doppler sonography in obstetrics and gynecology

This review aims to provide the reader with an overview of the present and future clinical applications in color Doppler sonography for the evaluation of vascularity and blood flow within the uterus (both gravid and nongravid), ovaries, fetus and placenta. The clinical use of color Doppler sonography has been demonstrated within many organ systems. Color Doppler sonography has become an integral part of cardiovascular imaging. Significant improvements have recently occurred, improving the visualization and evaluation of intra-organ vascularity, resulting from enhancements in delineation of tissue detail through electronic compounding and harmonics, as well as enhancements in signal processing of frequency- and/or amplitude-based color Doppler sonography. Spatial representation of vascularity can be improved by utilizing 3D and 4D (live 3D) processing. Greater sensitivity of color Doppler sonography to macro- and microvascular flow has provided improved anatomic and physiologic assessment throughout pregnancy and for pelvic organs. The potential use of contrast enhancement is also mentioned as a means to further differentiate benign from malignant ovarian lesions. The rapid development of these new sonographic techniques will continue to enlarge the scope of clinical applications in a variety of obstetric and gynecologic disorders.

Three-dimensional volumetric sonography in gynecology: an overview of clinical applications

Three-dimensional (3D) sonography can significantly improve on the diagnostic ability of two-dimensional sonography of the pelvic organs. 3D sonography has become a problem-solving technique in the evaluation of a variety of gynecologic disorders involving the uterus, adnexa, and pelvic floor. It allows an accurate depiction of the uterine cavity and outline of the uterus in the coronal plane. 3D sonography is less expensive than other modalities, is convenient, and does not have the risk of radiation or potential nephrotoxicity from contrast that other imaging modalities have. It is a cost-effective tool to assess the pelvic organs.

Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma?

PURPOSE

To evaluate the role of gray-scale and color Doppler sonography to distinguish uterine leiomyosarcoma (LMS) from leiomyoma (LM).

METHODS

We analyzed the preoperative gray-scale and color Doppler sonographic findings of 8 patients with LMS, 21 patients with cellular leiomyomas, and 3 patients with smooth muscle tumors of uncertain malignant potential and compared these findings to 225 patients with benign LM. All patients underwent myomectomy or hysterectomy. Number, size, echotexture, degenerative changes, and vascularity (central or peripheral; absent, mild, moderate, or marked) were recorded and correlated to the histologic findings

RESULTS

LMSs were significantly larger than other uterine smooth muscle tumors. They were all solitary, and 7/8 lesions had a diameter >or=8 cm. Degenerative cystic changes were observed in 4 lesions, and increased peripheral and central vascularity was demonstrated in 7 lesions. Sensitivity, specificity, and positive predictive value of increased central and peripheral vascularity in the diagnosis of LMS were 100%, 86%, and 19%, respectively. Combining other sonographic findings with marked central vascularity, positive predictive value increased to 60%, but sensitivity decreased to 75%.

CONCLUSION

The findings of the present study suggest that the detection of hypervascularity in combination with other sonographic findings can identify suspicious uterine smooth muscle tumors that will require additional diagnostic evaluation before treatment.

Phase I/pilot study of SU5416 (semaxinib) in combination with irinotecan/bolus 5-FU/LV (IFL) in patients with metastatic colorectal cancer

OBJECTIVES

Determine the toxicity, tolerability, and pharmacokinetics of SU5416, a vascular endothelial growth factor receptor-2 (VEGFR-2) tyrosine kinase inhibitor, coadministered with bolus 5-fluorouracil (5-FU), leucovorin, and irinotecan (IFL) in untreated patients with metastatic colorectal cancer.

METHODS

SU5416 (85 or 145 mg/m2) was administered twice weekly throughout a 6-week period along with standard IFL (4 weeks on/2 weeks off). Plasma samples were assayed for SU5416, irinotecan, and SN-38 by reverse-phase HPLC. Contrast enhanced, color Doppler sonography was performed on patients at the MTD to identify changes in tumor perfusion.

RESULTS

Eleven patients received treatment with SU5416 85 mg/m2 (n = 5) or 145 mg/m2 (n = 6). At 85 mg/m2, no DLTs were observed. At 145 mg/m2, grade 3 diarrhea and vomiting were observed during cycle 1; other grade 3 toxicities included fatigue, nausea, anorexia, anemia, pain, urinary retention, and hypertension. The pharmacokinetics of irinotecan and SN-38 were not altered by coadministration of SU5416. SU5416 pharmacokinetics were not altered by IFL. Contrast-enhanced, color Doppler sonography was performed on 2 patients and demonstrated reduced tumor perfusion after treatment in a patient who responded to treatment and increased perfusion in a patient who developed progressive disease. Three patients (27%) had confirmed partial responses, 2 patients (18%) had unconfirmed partial responses, and 4 patients (36%) had stable disease.

CONCLUSIONS

Twice weekly SU5416 can be administered with bolus IFL without unexpected toxicities or altering the pharmacokinetic behavior of the administered drugs. Changes in tumor blood perfusion can be detected by contrast-enhanced, color Doppler sonography. The further development of SU5416 was halted before this study was completed.

Improving the efficiency of gynecologic sonography with 3-dimensional volumes: a pilot study

OBJECTIVE

The purpose of this study was to determine whether 3-dimensional (3D) sonography can provide a rapid, efficient, and accurate way to do a transvaginal gynecologic scan compared with traditional 2-dimensional (2D) sonography.

METHODS

Thirty-five consecutive patients who underwent gynecologic sonography formed the study cohort. After a standard 2D transvaginal scan was done, including measurements of the endometrium and abnormalities, 4 volume acquisitions were obtained, encompassing the uterus (2 volumes) and the ovaries. These volumes were reviewed offline without any patient information. Endometrium and other measurements were performed on the volumes. The 2D and 3D results were compared by paired t tests.

RESULTS

The mean time needed for the standard 2D scan was 2.6 minutes compared with 1.07 minutes for the 3D volume acquisitions. The mean time for the reconstruction, measurement, and interpretation of the volumes offline was 1.19 minutes. The mean time for the entire 3D examination (both parts) was 2.26 minutes (P = .047, comparing 2D with total 3D). There was no significant difference between the measurements of the endometrium, fibroids, and ovarian cysts when comparing 2D and reconstructed 3D images. Two-dimensional and 3D sonography differed little in their ability to identify the organs and the abnormalities on the scans.

CONCLUSIONS

This study shows that a complete transvaginal gynecologic examination can be done in 1.07 minutes of scan time and interpreted offline in an additional 1.19 minutes. The 35 cases were scanned and interpreted with the use of 3D sonography in 79.17 minutes total compared with 91.46 minutes of 2D scan time (P = .047). The accuracy of the scan was similar for both techniques.

Recent advances in the sonographic assessment of vascularity and blood flow in gynecologic conditions

OBJECTIVE

This overview presents recent advances in sonographic depiction of vascularity and blood flow in the uterus, ovaries, and breasts. Enhanced sonographic visualization and evaluation of intraorgan vascularity has resulted from improved image processing and display. Future advances, such as the use of contrast enhancement, are also mentioned in this overview as one of many topics for future investigation.

STUDY DESIGN

This is an overview of the topic based on review of the literature and the authors' experience.

RESULTS

Specifically, the sensitivity of color Doppler sonography has been enhanced with the use of amplitude or power Doppler techniques. Spatial depiction of vascularity has improved because of 3-dimensional and "live 3-dimensional" processing.

CONCLUSION

The combination of more sensitive color Doppler sonography and 3-dimensional imaging provides both anatomic and physiologic assessment of the vascularity and blood flow of the ovary, uterus, and breast.

Ultrasound-assisted laparoscopic cryomyolysis: two- and three-dimensional findings before, during and after treatment

OBJECTIVE

To investigate the role of two- and three-dimensional (2D and 3D) ultrasound and power Doppler before, during and after surgery in monitoring the effects of uterine fibroid laparoscopic cryomyolysis.

METHODS

This prospective study involved 10 premenopausal patients with a sonographic diagnosis of a single subserosal and/or intramural uterine myoma, who underwent laparoscopic cryomyolysis. All patients suffered from symptoms due to fibroids (menometrorrhagia, bulk-related symptoms, pelvic pain). During laparoscopy transvaginal sonography was performed to guide the insertion of the cryoprobe, monitor extension of the ice-ball and evaluate the reduction of the blood supply of the myoma. All patients underwent 2D and 3D sonographic and power Doppler imaging evaluation of the myoma 1 week before treatment, during cryomyolysis, and 1, 3 and 6 months after treatment; size, echostructure and vascularization were recorded.

RESULTS

With cryomyolysis, we achieved selective vessel and tissue damage within the fibroid alone. Eight patients were free of symptoms and two had improved after 3 months. Progressive shrinkage of the treated myoma was observed during follow-up with a reduction percentage after 1 month of 22.2%, after 3 months of 37.5% and after 6 months of 52.6%. After cryomyolysis a significant reduction in central blood flow of the myoma was observed. 2D and 3D power Doppler evaluation of vascularization did not differ although subjectively findings were best evaluated by 3D images.

CONCLUSION

Sonography can aid the safe accomplishment of cryomyolysis by assessing myomata preoperatively, guiding the freezing procedure during laparoscopy, and helping to monitor postoperative progress. The use of ultrasound in this new treatment of fibroids will permit the physician to modulate and individualize treatment.

Cyclosporine A Does Not Alter Ultrasonic Indices of Renal Blood Flow: A Potential Tool for Differentiating Toxicity from Acute Rejection?

The narrow therapeutic window of cyclosporine A (CsA) means its use is controlled by pharmacokinetic monitoring. However, pharmacokinetics do not always reflect the functional effects of a drug--its pharmacodynamics, such as vasoconstriction. We developed a technique for measuring renal blood flow and used a pig model to determine whether CsA-induced renal vasoconstriction could be detected, thus offering a tool for pharmacodynamic therapeutic drug monitoring. This has been shown to differentiate acute rejection from acute tubular necrosis. Power Doppler intensitometry was used to assess relative vascular volume, and the renal arteriovenous transit time was determined with an intravenous microbubble bolus. Measurements were taken before and at intervals after an intravenous bolus of CsA (10 mg/kg). There was no correlation between index and CsA concentration. Lack of detectable effect after CsA administration to high concentrations suggests that this technique may be able to differentiate CsA toxicity from acute rejection.

Quantified short-term outcome of uterine artery embolization with gelatin sponge particles and lipiodol for symptomatic myoma

OBJECTIVE

To investigate and quantify clinical outcomes and spectral Doppler analyses of uterine arteries in patients with myoma undergoing uterine artery embolization (UAE) with gelatin sponge particles and lipiodol.

DESIGN

Prospective observational study.

SETTING

Tertiary medical center.

PATIENT(S)

Forty premenopausal women with symptomatic myoma.

INTERVENTION(S)

Uterine artery embolization with gelatin sponge particles and lipiodol.

MAIN OUTCOMES MEASURE(S)

Hemoglobin, hematocrit, CA-125, pictorial blood loss assessment, visual analogue pain scale, questionnaire for symptoms, tumor volume, and spectral Doppler analyses of uterine arteries.

RESULT(S)

The mean follow-up period was 8.1 months (range, 6-12). Menstrual flow improved in 29 of 35 patients (83%) and decreased significantly by 78.4%. Menstrual pain improved in 27 of 35 patients (77%) and decreased significantly by 70%. Hematocrit and CA-125 improved significantly. The mean percentage reductions of uterine and myomal volumes were 40.2% and 54.9%, respectively. The mean peak systolic velocity of the uterine arteries decreased by 52%. The major complication rate was 2.56%. There was no correlation between tumor volume reduction and clinical outcome.

CONCLUSION(S)

Uterine artery embolization with gelatin sponge particles and lipiodol had satisfactory short-term outcomes, comparable to those associated with polyvinyl alcohol particles. Quantified and semiquantified measurements provided objective assessment of clinical outcomes. Serum CA-125 might play a role in clinical follow-up. Reduction of tumor volume is not predictive of UAE efficacy.

Contrast-enhanced sonography during uterine artery embolization for the treatment of leiomyomas

Uterine artery embolization (UAE) is a successful and safe treatment for symptomatic leiomyomas. However, rare complications such as premature menopause and uterine necrosis can arise because of embolization of non-target tissues. We studied the feasibility of using contrast-enhanced sonography with intravenous SonoVue just before, during and after complete occlusion of both uterine arteries. In a patient with multiple, large, symptomatic leiomyomas, contrast-enhanced imaging established that the UAE was technically successful and that myometrial vascularity was not reduced. Our case suggests that ultrasound contrast agents may have a role in monitoring UAE and thus may help prevent ischemic complications. Further studies are required to confirm this.

Minimally invasive management of uterine fibroids

PURPOSE OF REVIEW

Many minimally invasive techniques have recently been introduced for the management of uterine fibroids. The purpose of this review is to analyse recent data for techniques that are used to manage uterine fibroids.

RECENT FINDINGS

Laparoscopic myomectomy has provided a minimally invasive alternative to laparotomy for intramural and subserous myomata. However, this technique is still the subject of debate. With good surgical experience, the risk of perioperative complications is comparable with conventional surgery. Laparoscopic myomectomy is associated with faster postoperative recovery, and could potentially reduce the risk of postoperative adhesions compared with laparotomy. Spontaneous uterine rupture, although uncommon after laparoscopic myomectomy, is still a concern. The risk of recurrence seems to be higher after laparoscopic myomectomy than after myomectomy performed by laparotomy. Uterine artery embolization is another new and attractive treatment for patients with symptomatic fibroids. Uterine artery embolization provides excellent relief for abnormal bleeding, pelvic pain, and bulk-related symptoms. Early reports show that uterine artery embolization is associated with normal reproductive and obstetric functions. This technique is associated with a shorter hospital stay and a rapid recovery time.

SUMMARY

Laparoscopic myomectomy and uterine artery embolization are being performed more than ever. Current evidence proves the safety, reliability and reproducibility of both procedures. However, prospective randomized controlled trials comparing both procedures with conventional myomectomy are needed.