An Altered Perception of Normal: Understanding Causes for Treatment Delay in Women with Symptomatic Uterine Fibroids

BACKGROUND

Uterine fibroids are benign tumors that are the leading cause of hysterectomy in the United States. Despite their high prevalence and associated morbidity, there are little qualitative data characterizing what drives women's treatment-seeking behavior for their fibroids.

METHODS

Women with symptomatic or recently treated uterine fibroids completed in-depth interviews and demographic surveys. Interviews were transcribed verbatim and uploaded to NVivo version 10 for data management and thematic coding. Coders identified major themes and subthemes that emerged from the interviews.

RESULTS

Sixty women (n = 60) completed the interviews. The kappa among coders was 0.94. The mean age of participants was 43.0 ± 6.8. 61.7% of participants self-identified as African American, 25.0% as Caucasian, 8.3% as Hispanic, and 5.0% as Asian. Many women reported obtaining a delayed diagnosis for their uterine fibroids despite experiencing severe symptoms. There were five subthemes that identified why women delayed seeking treatment, which included the perception that their symptoms were "normal," they had a low knowledge of fibroids, they did not perceive themselves to be at risk for fibroids, they engaged in avoidance-based coping strategies, and/or they dissociated themselves from their fibroids.

CONCLUSIONS

Many women with symptomatic fibroids live with this condition chronically without seeking care. It appears that for some, limited knowledge regarding fibroids and normal menstruation may lead to a distorted view of what is normal with regard to uterine bleeding, resulting in limited treatment seeking behavior. Others know their symptoms are abnormal but simply avoid the problem. There is a need for patient-centered and community-based education to improve women's knowledge of fibroids and symptoms and to promote treatment options.

Cancer concepts and principles: primer for the interventional oncologist-part II

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

Forward and reverse genetics of rapid-cycling Brassica oleracea

Seeds of rapid-cycling Brassica oleracea were mutagenized with the chemical mutagen, ethylmethane sulfonate. The reverse genetics technique, TILLING, was used on a sample population of 1,000 plants, to determine the mutation profile. The spectrum and frequency of mutations induced by ethylmethane sulfonate was similar to that seen in other diploid species such as Arabidopsis thaliana. These data indicate that the mutagenesis was effective and demonstrate that TILLING represents an efficient reverse genetic technique in B. oleracea that will become more valuable as increasing genomic sequence data become available for this species. The extensive duplication in the B. oleracea genome is believed to result in the genetic redundancy that has been important for the evolution of morphological diversity seen in today's B. oleracea crops (broccoli, Brussels sprouts, cauliflower, cabbage, kale and kohlrabi). However, our forward genetic screens identified 120 mutants in which some aspect of development was affected. Some of these lines have been characterized genetically and in the majority of these, the mutant trait segregates as a recessive allele affecting a single locus. One dominant mutation (curly leaves) and one semi-dominant mutation (dwarf-like) were also identified. Allelism tests of two groups of mutants (glossy and dwarf) revealed that for some loci, multiple independent alleles have been identified. These data indicate that, despite genetic redundancy, mutation of many individual loci in B. oleracea results in distinct phenotypes.

Treatment of unresectable primary and metastatic liver cancer with yttrium-90 microspheres (TheraSphere): assessment of hepatic arterial embolization

In Canada and Europe, yttrium-90 microspheres (TheraSphere); MDS Nordion, Ottawa, Canada) are a primary treatment option for primary and secondary hepatic malignancies. We present data from 30 patients with hepatocellular carcinoma (HCC) and metastatic liver disease treated with TheraSphere from a single academic institution to evaluate the angiographically evident embolization that follows treatment. Seven interventional radiologists from one treatment center compared pretreatment and posttreatment angiograms. The reviewers were blinded to the timing of the studies. The incidence of postembolization syndrome (PES) was determined as well as objective tumor response rates by the World Health Organization (WHO), Response Evaluation Criteria in Solid Tumors (RECIST), and European Association for the Study of the Liver (EASL) criteria. There were 420 independent angiographic observations that were assessed using the chi-squared statistic. The pretreatment and posttreatment angiograms could not be correctly identified on average more than 43% of the time (p = 0.0004). The postprocedure arterial patency rate was 100%. The objective tumor response rates for all patients were 24%, 31%, and 72% for WHO, RECIST, and EASL criteria, respectively. All of the patients tolerated the procedure without complications and were treated on an outpatient basis, and four patients had evidence of PES. This treatment method does not result in macroscopic embolization of the hepatic arteries, thereby maintaining hepatic tissue perfusion. These data support the principle that the favorable response rates reported with TheraSphere are likely due to radiation and microscopic embolization rather than flow-related macroscopic embolization and ischemia.

Use of a Partially Deployed Wallstent to Act as an Inferior Vena Cava Filtration Device during Coil Embolization of a High-flow Arteriovenous Fistula

Closure of high-flow arteriovenous (AV) fistulas with endovascular coil embolization can be technically challenging and fraught with complication as a result of the possibility of coil migration into venous circulation and subsequent embolization to distant sites such as the heart and lungs. Filtration of the AV fistula's central venous outflow may allow trapping of coils that inadvertently pass into the venous system during the procedure. This useful measure can reduce the morbidity associated with such interventions. The present report describes an unusual case of a large high-flow renal AV fistula embolized with the use of a partially deployed Wallstent as a temporary filtration device within an enlarged suprarenal inferior vena cava. This method further allows removal of any trapped coils without the need for a snare device.

Patterns of sequence loss and cytosine methylation within a population of newly resynthesized Brassica napus allopolyploids

Allopolyploid formation requires the adaptation of two nuclear genomes within a single cytoplasm, which may involve programmed genetic and epigenetic changes during the initial generations following genome fusion. To study the dynamics of genome change, we synthesized 49 isogenic Brassica napus allopolyploids and surveyed them with 76 restriction fragment length polymorphism (RFLP) probes and 30 simple sequence repeat (SSR) primer pairs. Here, we report on the types and distribution of genetic and epigenetic changes within the S(1) genotypes. We found that insertion/deletion (indel) events were rare, but not random. Of the 57,710 (54,383 RFLP and 3,327 SSR) parental fragments expected among the amphidiploids, we observed 56,676 or 99.9%. Three loci derived from Brassica rapa had indels, and one indel occurred repeatedly across 29% (14/49) of the lines. Loss of one parental fragment was due to the 400-bp reduction of a guanine-adenine dinucleotide repeat-rich sequence. In contrast to the 4% (3/76) RFLP probes that detected indels, 48% (35/73) detected changes in the CpG methylation status between parental genomes and the S1 lines. Some loci were far more likely than others to undergo epigenetic change, but the number of methylation changes within each synthetic polyploid was remarkably similar to others. Clear de novo methylation occurred at a much higher frequency than de novo demethylation within allopolyploid sequences derived from B. rapa. Our results suggest that there is little genetic change in the S(0) generation of resynthesized B. napus polyploids. In contrast, DNA methylation was altered extensively in a pattern that indicates tight regulation of epigenetic changes.

Primary Failure of Uterine Artery Embolization: Use of Magnetic Resonance Imaging to Select Patients for Repeated Embolization

The purpose of this study was to determine if contrast material-enhanced magnetic resonance (MR) imaging could be used to stratify patients who have undergone failed primary uterine artery embolization (UAE) for repeated embolization. One hundred one consecutive patients who underwent UAE at a single center were followed prospectively and assessed for the presence of persistent contrast enhancement of leiomyomas on follow-up MR imaging. Among 11 of the 111 patients with primary clinical failure (10%), MR imaging showed persistent enhancement in eight. Of the eight cases of failure with continued tumor enhancement on MR imaging, six were treated with repeated embolization. All six patients showed complete symptomatic relief at 12-month follow-up. In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE.

Filter-related, thrombotic occlusion of the inferior vena cava treated with a Gianturco stent

The authors report a case of complete thrombotic occlusion of the inferior vena cava (IVC), which occurred 4 weeks after placement of an IVC filter (TrapEase; Cordis, Miami FL). Initial treatment with suction thrombectomy and thrombolysis was ineffective. Percutaneous removal of the filter was unsuccessful because of the long period of implantation. TrapEase filters (Cordis) are easily collapsible because of their symmetric design and composition (nitinol). An expandable metallic Gianturco Z stent (Cook, Bloomington, IN) was used to exclude the filter from the vessel lumen. In cases of persistent filter-related, thrombotic occlusion of the IVC, in which initial treatment has failed, the use of a Gianturco stent (Cook) to exclude the filter from the vessel lumen is a viable treatment option if the filter has a collapsible design.

VI. Uterine fibroid embolization: developing a clinical service

Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.

Peliosis hepatis with intrahepatic hemorrhage: successful embolization of the hepatic artery

Peliosis hepatis is defined as the appearance of blood filled lakes in the hepatic parenchyma. It has been associated with various pharmacological agents and infections. Treatment has been primarily symptomatic and includes discontinuation of offending medications, partial hepatectomy or occasionally liver transplantation. We report a 58 year old white female on hormone replacement therapy who developed symptomatic peliosis hepatis and underwent successful superselective hepatic artery embolization with control of bleeding.

Treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis

We reviewed an experience with treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis to identify clinical and computed tomography (CT) parameters that are helpful in the selection of patients for treatment and to assess treatment outcome. The extent of CT abnormalities determined a CT severity score (mild = 1, severe = 4). From 1985 to 1990, 650 patients were hospitalized with acute pancreatitis; a peripancreatic fluid collection was found in 36 patients (5.5 percent). Ten of 11 patients with successful outcome after no invasive treatment (group 1) had a low CT severity score of 1 or 2; mean serum albumin was 4.0 gram percent. Of 25 patients who had some form of drainage, 12 had a high CT severity score of 3 or 4 (p < 0.05) and a mean serum albumin of 3.4 grams percent (p < 0.05). Nine patients had only operative drainage (group 2) and 16 had CT-directed percutaneous catheter drainage (group 3). In group 3, percutaneous catheter drainage successfully drained the fluid collection in six patients, while ten patients needed an operation, in addition to percutaneous drainage, to effectively débride and drain the necrotizing pancreatic problem. As a result of the current review, we propose an algorithm for treatment of these patients.

Preoperative CT and MR imaging of ischiopagus twins

Each case of conjoint twins is unique. Preoperative imaging is helpful to determine the feasibility of separation. Shared and separate organs can be delineated; and operative technique and problems anticipated. We performed ultrasonography, CT, magnetic resonance imaging, and arteriography preoperatively on ischiopagus conjoint twins. The single most helpful study was CT performed during a bolus intravenous contrast medium injection into one twin. Arteriography was also very helpful. The other studies were complementary but added little additional structural details. Sedation of conjoint twins is complicated yet crucial for optimal imaging studies. A combination of oral and intramuscular sedation was used and worked well for all of the studies.

Selective preoperative evaluation for possible N2 disease in carcinoma of the lung

The efficacy of computed tomography and surgical mediastinal exploration in determining tumor resectability were retrospectively evaluated in 92 consecutive patients with non-small cell lung carcinoma. Status of mediastinal nodes was ultimately determined by surgical mediastinal exploration or thoracotomy. Patients were divided into three groups on the basis of chest roentgenography: Group I comprised 30 patients with peripheral T1 or T2 lesions with normal hilar and mediastinal shadows. Only one patient was found to have an involved node. Chest roentgenography had an accuracy rate of 96% and computed tomography, 93%. Thoracotomy is recommended without either computed tomography or surgical mediastinal exploration in this group. Group II comprised 47 patients with T1 or T2 lesions with an abnormal hilus, an abnormal mediastinal shadow, or either the hilus or mediastinum obscured by overlying parenchymal disease. Computed tomography revealed mediastinal nodes 1 cm or greater in size (abnormal node group) in 21 patients (45%) and smaller than 1 cm (normal node group) in 26 patients (55%). Surgical mediastinal exploration was performed in the abnormal node group and involved nodes were found in 17 of 21 patients (81%). In the normal node group, thoracotomy only was performed and no involved nodes were found. Computed tomography is recommended in all patients in Group II. Patients in the normal node group may be subjected to thoracotomy only and those in the abnormal node group should undergo surgical mediastinal exploration as the next diagnostic step before thoracotomy. Group III comprised 15 patients with grossly abnormal mediastinal shadows. Findings from computed tomography were abnormal in all 10 patients in whom it was done. Surgical mediastinal exploration was done in all 15 and yielded abnormal results in 14. It is recommended in this group that computed tomography is unnecessary and surgical mediastinal exploration should be the only diagnostic procedure. Thus, in potentially resectable non-small cell lung carcinoma, the use of computed tomography and surgical mediastinal exploration should be selective and should be determined by appropriate initial interpretation of the chest roentgenogram.

Ultrasonographic features of prostatic carcinoma

Over an 18-mo period, 93 prostate examinations were performed by a suprapubic transabdominal approach. By applying ultrasonographic tissue textural analysis, we were able to identify 16 out of 19 carcinomas. Most of these analyses showed ill-defined focal abnormalities located either in the posterior or the posterior-lateral portion of the gland. Ten of the analyses demonstrated increase echogenicity, while six demonstrated decreased echogenicity. Irregularity of the capsule was an unreliable sign in determining capsular invasion. The degree of extension appears to be better evaluated by computed tomography (CT). In conclusion, transabdominal ultrasound holds promise in the detection of prostatic carcinoma, while staging should be done by CT.