CLINICAL VISION by salutaria

Issue No 21 April 2013

ClinicalVision In this edition of Clinical Vision Dr. Di Stasi from A. Gemelli Hospital in Rome, Italy focuses on: Uterine Artery Embolization the radiologicalgynecological approach to fibroid management. Uterine fibroids are benign tumours that occur in 20-40% of women of reproductive age and in about half of these cause clinical significant symptoms including heavy bleeding, pelvic pain, pressure and bloating and subfertility. Traditional treatment has relied on surgery (hysterectomy or myomectomy) but in recent years a variety of alternative approaches have been developed to try to reduce cost, morbidity, and the lifestyle impact of surgical treatment(1). Undoubtedly the most significant therapeutic innovation has been the advent of uterine artery embolization (UAE) as a nonsurgical treatment for symptomatic fibroids(2). UAE is a minimally invasive radiological procedure in which embolic agents, typically polyvinyl alcohol (PVA) particles, are injected into both uterine arteries to achieve fibroid devascularization and progressive shrinkage. The result is improvement in symptoms, preservation of the uterus, avoidance of general anesthesia, and obviation of the potential complications and lengthy recovery associated with surgery. The procedure, which is typically performed under intravenous conscious sedation, takes about an hour to complete. Women are observed for up to 24 hours post-procedure and treated with narcotics and nonsteroidal analgesics for pain relief. Recovery is typically brief and relatively mild, and women can usually return to their regular activities within 7 to 10 days. UAE has been shown to lead to a 60-70% reduction in fibroid volume

Part of the team at A.Gemelli Hospital

and relief of symptoms in 85-90% of patients (1,3). The experience of our multidisciplinary team management on 260 patients has confirmed the effectiveness of UAE, with an observed reduction of 76% in fibroid volume and a 90% rate of symptom relief and patient satisfaction at two years. Long-term follow-up of our patients has demonstrated that the cumulative rates of failure of symptom control and subsequent interventions, as estimated by survival analysis, are 18% and 15% respectively after seven years (4). As with other studies (5,6) our results also demonstrate that morbidity of UAE is remarkably low. We have had a 7% rate of overall morbidity, with a 2.3% (6/260) rate of major morbidity – one endometrial atrophy, one Asherman syndrome and three incomplete fibroid expulsions requiring operative hysteroscopy, and one case of acute pelvic pain from partial detachment

Thanks to the following authors all based in either the Department of Radiological Sciences or the Department of Obstetrics and Gynecology at Università Cattolica del Sacro Cuore, “A.Gemelli” Hospital, Rome, Italy, for their cooperation: Carmine Di Stasi, Giovanna Tropeano, Alessandro Cina, Sonia Amoroso, Benedetta Gui, Riccardo Inchingolo, Floriana Mascilini, Valeria Masciullo, Adelaide Monterisi, Alessandro Pedicelli, Roberto Iezzi, Domenico Romano, Marilisa Scarciglia, Giovanni Scambia and Lorenzo Bonomo.

of a pedunculated subserosal fibroid requiring emergency laparoscopy. We had no cases of premature ovarian failure following UAE, although such complication has been reported elsewhere in 2-3% of patients under the age of 45 years and in approximately 8% of women aged 45 years or older (7,8). In terms of reproductive function, serial ultrasound and magnetic-resonance imaging (MRI) examinations at 3-6 months after UAE have documented rapid revascularization of the normal myometrium and an essentially normal appearance of the endometrium(9-10). We have had three spontaneous pregnancies with uncomplicated deliveries after UAE, in line with several reports demonstrating that women are able to conceive and carry successfully a pregnancy to term after UAE (11).

Embolization of a large subserosal-intramural-submucosal fibroid PROCEDURAL IMAGES

Patient background

OUTCOME IMAGES

Fig. 1a

Fig. 1b

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Fig. 11a

Fig. 11b

This was a 30-year-old woman, gravida 1 para 0, with a large subserosal-intramural-submucosal fibroid who complained of menorrhagia, pelvic pain, bulkrelated symptoms and infertility. Procedure Pre-procedure sagittal (Fig. 1A and 1B), axial (Fig. 2) and coronal (Fig. 3) T2-weighted RM images show the uterus markedly enlarged and the uterine cavity distorted by a 92 x 64 mm mass of low heterogeneous T2 - signal intensity.

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Fig. 2

Fig. 12

Fig. 3

Fig. 13

Enhanced MR shows the heterogeneous vascularization of the fibroid compared with the normal myometrium on axial T1-weighted fatsaturated images (Fig. 4) Digital subtraction angiogram with selective injection via the left internal iliac artery (Fig. 5) shows a hypertrophic uterine artery. Selective injection via the left uterine artery before (Fig. 6) and after (Fig. 7) embolization with 250-355 μm Contour™ Embolization particles (Boston Scientific).

Fig. 4 Fig. 9 Fig. 14

Digital subtraction angiogram with selective injection via the right internal iliac artery (Fig. 8). Selective injection via the right uterine artery before (Fig. 9) and after (Fig. 10) embolization with 250-355 μm Contour™ Embolization particles (Boston Scientific).

Outcome Post-embolization (6 months) sagittal (Fig. 11A and 11B), axial (Fig. 12) and coronal (Fig. 13) T2-weighted RM images show the fibroids to be decreased in volume (69 x 50 mm) and with low-signal intensity. Axial (Fig. 14) and sagittal (Fig. 15) T1-weighted fat-saturated enhanced MR images show fibroid infarction with complete devascularization.

Clinical Vision Issue No 21

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Embolization of intramural/subserosal fibroids PROCEDURAL IMAGES

Patient background

Fig. 1

OUTCOME IMAGES Fig. 6

Fig. 12

A 40-year-old woman, gravida 0, with a history of bicornuate bicollis uterus associated with multiple congenital anomalies presented with multiple symptomatic fibroids involving both uterine horns and secondary hydronephrosis. Procedure Pre-embolization coronal (Fig. 1) and axial (Fig. 2 and Fig 3) T2-weighted MR images show four intramural/subserosal fibroids, of which two originated from the right (Fig. 2) and two from the left horn of the uterus (Fig. 3), and dilatation of the pelvicaliceal system of the right kidney, which was presumably caused by ureteric obstruction secondary to pressure from the right-horn fibroids at the pelvic brim. On axial (Fig. 4 and Fig. 5) T1-weighted fatsaturated enhanced MR images all fibroids demonstrate homogeneous vascularization compared with the normal myometrium .

Fig. 7 Fig. 2

Fig. 13

Fig. 3

Fig. 14

Digital subtraction angiogram with selective injection via the left internal iliac artery (Fig. 6) shows a thin uterine artery. Selective injection via the left uterine artery before (Fig. 7) and after (Fig. 8) embolization with 250355 μm Contour™ Embolization particles (Boston Scientific). Digital subtraction angiogram with selective injection via the right internal iliac artery (Fig. 9).

Fig. 8

Fig. 9

Fig. 4

Fig. 10

Fig. 15

Selective injection via the right uterine artery before (Fig. 10) and after (Fig. 11) embolization with 250-355 μm Contour™ Embolization particles (Boston Scientific). Fig. 11

Outcome Post-procedure (6 months) coronal (Fig. 12) and axial (Fig. 13 and Fig. 14) T2-weighted MR images show the fibroids to be decreased in size and the hydronephrosis improved. T1-weighted fat-saturated enhanced MR images (Fig. 15 and Fig. 16) show fibroid infarction with complete devascularization.

Clinical Vision Issue No 21

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Embolization of a single anterior fibroid PROCEDURAL IMAGES

Patient background

Fig. 1

OUTCOME IMAGES Fig. 5

Fig. 9

A 32-year-old woman, gravida 2, para 2, presented with a 6-month history of pelvic pain and pressure and US diagnosis of a single anterior fibroid. Procedure Pre-procedure trans-vaginal color-Doppler US scans show an intramural/subserosal hypoechoic fibroid (Fig. 1), with peripheral arterial flow (perifibroid plexus) (Fig. 2).

Fig. 2 Fig. 10 Fig. 6

Digital subtraction angiogram with selective injection via the left internal iliac artery (Fig. 3). Selective injection via the left uterine artery before (Fig. 4) and after (Fig. 5) embolization with 250355 μm Contour™ Embolization particles (Boston Scientific). Digital subtraction angiogram with selective injection via the right internal iliac artery (Fig. 6).

Fig. 3

Selective injection via the right uterine artery before (Fig. 7) and after (Fig. 8) embolization with 250-355 μm Contour™ Embolization particles (Boston Scientific).

Fig. 7

Outcome Six months post-procedure trans-vaginal colordoppler US images (Fig. 9 and Fig.10 ) show a volume reduction of the fibroid (maximum diameter less than 1.5 cm) and the lack of vascularization.

Fig. 4 Fig. 8

Clinical Vision Issue No 21

Clinical Vision is a periodic publication produced by Boston Scientific for the purpose of sharing educationally interesting cases among the physician community. Physicians are invited to present cases involving minimally invasive procedures for publication. Note that any products described in the cases should be within their stated and approved indications. No fee is paid to contributing authors. Boston Scientific reserves the right to publish only those cases that are sufficiently novel or interesting, consistent with the goal of advancing clinical experience. Boston Scientific cannot guarantee to publish all cases presented. Submissions should include a title, patient history, description of diagnostic findings, details of the procedure and findings or results of the case. Written submissions should be accompanied by radiographs, photographs or other images which may help illustrate the key steps in the case.

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References for front cover article 1. Tropeano G, Amoroso S. et al. Non surgical management of uterine fibroids. Hum Reprod Update 2008; 14 (3): 259-274 2. Ravina JH, Herbreteau D, et al. Arterial embolization to treat uterine myomata. Lancet 1995; 346: 671-672 3. Van Der Kooij SM et al. Uterine artery embolization vs surgery in the treatment of symptomatic uterine fibroids: a systematic review and metaanalysis. Am J Obstet Gynecol 2011; 205: 317.e1-18 4. Tropeano G, Di Stasi C, et al. Incidence and risk factors for clinical failure of uterine leiomyoma embolization. Obstet Gynecol 2012; 120 (2): 269-276 5. Spies JB, Spector A, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100 (5) 873-870 6. Goodwin SC, Spies JB, el al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. Obstet Gynecol 2008; 111 (1): 22-33 7. Hascalik S, Celik O, et al. Transient ovarian failure: a rare complication of uterine fibroid embolization. Acta Obstet Gynecol Scand 2004; 83:682-685 8. Tropeano G, Di Stasi C, et al. Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study. Fertil Steril. 2010 Nov;94(6):2296-300. Epub 2010 Jan 13 9. DeSouza NM, William AD. Uterine arterial embolization for leiomyomas: perfusion and volume changes at MR imaging and relation to clinical outcome. Radiology 2002; 222: 367-374 10. Pelage JP, Guaou-Guaou N, et al. Uterine fibroid tumors: long-term MR imaging outcome after embolization. Radiology 2004; 230: 803-809 11. Homer H, Saridogan E. Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril 2010; 94 (1): 324-330

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