CLINICAL VISION

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CLINICAL VISION

  1. 1. Uterine fibroids are benign tumoursthat occur in 20-40% of women ofreproductive age and in about halfof these cause clinical significantsymptoms including heavy bleeding,pelvic pain, pressure and bloating andsubfertility. Traditional treatment hasrelied on surgery (hysterectomy ormyomectomy) but in recent years avariety of alternative approaches havebeen developed to try to reduce cost,morbidity, and the lifestyle impact ofsurgical treatment(1). Undoubtedly themost significant therapeutic innovationhas been the advent of uterine arteryembolization (UAE) as a nonsurgicaltreatment for symptomatic fibroids(2).UAE is a minimally invasive radiologicalprocedure in which embolic agents,typically polyvinyl alcohol (PVA)particles, are injected into bothuterine arteries to achieve fibroiddevascularization and progressiveshrinkage. The result is improvement insymptoms, preservation of the uterus,avoidance of general anesthesia, andobviation of the potential complicationsand lengthy recovery associated withsurgery. The procedure, which istypically performed under intravenousconscious sedation, takes about an hourto complete.Women are observed for up to 24hours post-procedure and treated withnarcotics and nonsteroidal analgesicsfor pain relief. Recovery is typically briefand relatively mild, and women canusually return to their regular activitieswithin 7 to 10 days.UAE has been shown to lead to a60-70% reduction in fibroid volumeand relief of symptoms in 85-90%of patients(1,3). The experience of ourmultidisciplinary team managementon 260 patients has confirmed theeffectiveness of UAE, with an observedreduction of 76% in fibroid volumeand a 90% rate of symptom reliefand patient satisfaction at two years.Long-term follow-up of our patientshas demonstrated that the cumulativerates of failure of symptom control andsubsequent interventions, as estimatedby survival analysis, are 18% and 15%respectively after seven years(4).As with other studies(5,6)our resultsalso demonstrate that morbidity of UAEis remarkably low. We have had a 7%rate of overall morbidity, with a 2.3%(6/260) rate of major morbidity – oneendometrial atrophy, one Ashermansyndrome and three incompletefibroid expulsions requiring operativehysteroscopy, and one case of acutepelvic pain from partial detachmentof a pedunculated subserosal fibroidrequiring emergency laparoscopy. Wehad no cases of premature ovarianfailure following UAE, although suchcomplication has been reportedelsewhere in 2-3% of patients under theage of 45 years and in approximately8% of women aged 45 years or older (7,8).In terms of reproductive function, serialultrasound and magnetic-resonanceimaging (MRI) examinations at 3-6months after UAE have documentedrapid revascularization of the normalmyometrium and an essentially normalappearance of the endometrium(9-10).We have had three spontaneouspregnancies with uncomplicateddeliveries after UAE, in line with severalreports demonstrating that women areable to conceive and carry successfullya pregnancy to term after UAE(11).ClinicalVisionThanks to the following authors all based in either the Department of Radiological Sciences or the Department of Obstetricsand Gynecology at Università Cattolica del Sacro Cuore, “A.Gemelli” Hospital, Rome, Italy, for their cooperation: CarmineDi 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, GiovanniScambia and Lorenzo Bonomo.Issue No 21 April 2013In this edition of Clinical Vision Dr. Di Stasi from A. Gemelli Hospital inRome, Italy focuses on: Uterine Artery Embolization the radiological-gynecological approach to fibroid management.Part of the team at A.Gemelli Hospital
  2. 2. Patient backgroundThis was a 30-year-old woman,gravida 1 para 0, with a largesubserosal-intramural-submucosalfibroid who complained ofmenorrhagia, pelvic pain, bulk-related symptoms and infertility.ProcedurePre-procedure sagittal (Fig. 1A and 1B), axial (Fig.2) and coronal (Fig. 3) T2-weighted RM imagesshow the uterus markedly enlarged and theuterine cavity distorted by a 92 x 64 mm mass oflow heterogeneous T2 - signal intensity.Enhanced MR shows the heterogeneousvascularization of the fibroid compared with thenormal myometrium on axial T1-weighted fat-saturated images (Fig. 4)Digital subtraction angiogram with selectiveinjection via the left internal iliac artery (Fig. 5)shows a hypertrophic uterine artery. Selectiveinjection via the left uterine artery before (Fig.6) and after (Fig. 7) embolization with 250-355μm Contour™ Embolization particles (BostonScientific).Digital subtraction angiogram with selectiveinjection via the right internal iliac artery (Fig. 8).Selective injection via the right uterine arterybefore (Fig. 9) and after (Fig. 10) embolization with250-355 μm Contour™ Embolization particles(Boston Scientific).OutcomePost-embolization (6 months) sagittal (Fig. 11Aand 11B), axial (Fig. 12) and coronal (Fig. 13)T2-weighted RM images show the fibroids tobe decreased in volume (69 x 50 mm) and withlow-signal intensity. Axial (Fig. 14) and sagittal(Fig. 15) T1-weighted fat-saturated enhanced MRimages show fibroid infarction with completedevascularization.Clinical Vision Issue No 21Embolization of a large subserosal-intramural-submucosal fibroidOUTCOME IMAGESPROCEDURAL IMAGESFig. 1a Fig. 1bFig. 6Fig. 5Fig. 11a Fig. 11bFig. 14Fig. 15Fig. 7Fig. 9Fig. 8Fig. 10Fig. 2 Fig. 3Fig. 42 3Fig. 13Fig. 12
  3. 3. Patient backgroundA 40-year-old woman, gravida 0,with a history of bicornuate bicollisuterus associated with multiplecongenital anomalies presentedwith multiple symptomatic fibroidsinvolving both uterine horns andsecondary hydronephrosis.ProcedurePre-embolization coronal (Fig. 1) and axial (Fig. 2and Fig 3) T2-weighted MR images show fourintramural/subserosal fibroids, of which twooriginated from the right (Fig. 2) and two from theleft horn of the uterus (Fig. 3), and dilatation ofthe pelvicaliceal system of the right kidney, whichwas presumably caused by ureteric obstructionsecondary to pressure from the right-horn fibroidsat the pelvic brim.On axial (Fig. 4 and Fig. 5) T1-weighted fat-saturated enhanced MR images all fibroidsdemonstrate homogeneous vascularizationcompared with the normal myometrium .Digital subtraction angiogram with selectiveinjection 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 250-355 μm Contour™ Embolization particles (BostonScientific). Digital subtraction angiogram withselective injection via the right internal iliac artery(Fig. 9).Selective injection via the right uterine arterybefore (Fig. 10) and after (Fig. 11) embolizationwith 250-355 μm Contour™ Embolization particles(Boston Scientific).OutcomePost-procedure (6 months) coronal (Fig. 12)and axial (Fig. 13 and Fig. 14) T2-weighted MRimages show the fibroids to be decreased in sizeand the hydronephrosis improved. T1-weightedfat-saturated enhanced MR images (Fig. 15 andFig. 16) show fibroid infarction with completedevascularization.Clinical Vision Issue No 21Embolization of intramural/subserosal fibroidsFig. 1 Fig. 6 Fig. 12Fig. 13Fig. 14Fig. 15Fig. 16Fig. 8Fig. 10Fig. 7Fig. 9Fig. 11Fig. 2Fig. 3Fig. 4Fig. 54 5OUTCOME IMAGESPROCEDURAL IMAGES
  4. 4. Patient backgroundA 32-year-old woman, gravida 2,para 2, presented with a 6-monthhistory of pelvic pain and pressureand US diagnosis of a single anteriorfibroid.ProcedurePre-procedure trans-vaginal color-Doppler USscans show an intramural/subserosal hypoechoicfibroid (Fig. 1), with peripheral arterial flow(perifibroid plexus) (Fig. 2).Digital subtraction angiogram with selectiveinjection via the left internal iliac artery (Fig. 3).Selective injection via the left uterine artery before(Fig. 4) and after (Fig. 5) embolization with 250-355 μm Contour™ Embolization particles (BostonScientific).Digital subtraction angiogram with selectiveinjection via the right internal iliac artery (Fig. 6).Selective injection via the right uterine arterybefore (Fig. 7) and after (Fig. 8) embolization with250-355 μm Contour™ Embolization particles(Boston Scientific).OutcomeSix months post-procedure trans-vaginal color-doppler US images (Fig. 9 and Fig.10 ) showa volume reduction of the fibroid (maximumdiameter less than 1.5 cm) and the lack ofvascularization.Clinical Vision Issue No 21Fig. 1 Fig. 5 Fig. 9Fig. 10Fig. 6Fig. 8Fig. 7Fig. 2Fig. 3Fig. 46 7Embolization of a single anterior fibroidOUTCOME IMAGESPROCEDURAL IMAGES
  5. 5. Copyright © 2013 byBoston Scientific Corporationor its affiliates. All rights reserved.DINONC3500EAResults from case studies are not necessarily predictive of results in other cases. Results in other cases may vary.All cited trademarks are the property of their respective owners. CAUTION: The law restricts these devices to sale by or onthe order of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labellingsupplied with each device. Information for the use only in countries with applicable health authority product registrations.PI-142303-AA_March13 Printed in the UK by Gosling.Clinical Vision is a periodic publication producedby Boston Scientific for the purpose of sharingeducationally interesting cases among the physiciancommunity. Physicians are invited to presentcases involving minimally invasive procedures forpublication.Note that any products described in the cases should be within theirstated and approved indications. No fee is paid to contributing authors.Boston Scientific reserves the right to publish only those cases that aresufficiently novel or interesting, consistent with the goal of advancingclinical experience. Boston Scientific cannot guarantee to publish allcases presented. Submissions should include a title, patient history,description of diagnostic findings, details of the procedure and findingsor results of the case.Written submissions should be accompanied by radiographs, photographsor other images which may help illustrate the key steps in the case.Submissions will be edited to fit into the publication format. The editedversion of the case will be sent back to the contributor for approval priorto final publication. No case will be published without a signed approvalby the contributing physician(s).Upon approval Boston Scientific reserves the right to publish the casein its final edited and approved version in whatever media it deemsappropriate; e.g. printed material and electronic media such as theInternet, provided that any publication is clearly for the purpose ofeducation.All reports contained in this document reflect the opinions of theirrespective authors.References for front cover article1. Tropeano G, Amoroso S. et al. Non surgical management of uterine fibroids. Hum Reprod Update 2008; 14 (3): 259-2742. Ravina JH, Herbreteau D, et al. Arterial embolization to treat uterine myomata. Lancet 1995; 346: 671-6723. Van Der Kooij SM et al. Uterine artery embolization vs surgery in the treatment of symptomatic uterine fibroids: a systematic review andmetaanalysis. Am J Obstet Gynecol 2011; 205: 317.e1-184. Tropeano G, Di Stasi C, et al. Incidence and risk factors for clinical failure of uterine leiomyoma embolization. Obstet Gynecol 2012; 120 (2): 269-2765. Spies JB, Spector A, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100 (5) 873-8706. Goodwin SC, Spies JB, el al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. ObstetGynecol 2008; 111 (1): 22-337. Hascalik S, Celik O, et al. Transient ovarian failure: a rare complication of uterine fibroid embolization. Acta Obstet Gynecol Scand 2004; 83:682-6858. Tropeano G, Di Stasi C, et al. Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study. Fertil Steril. 2010Nov;94(6):2296-300. Epub 2010 Jan 139. DeSouza NM, William AD. Uterine arterial embolization for leiomyomas: perfusion and volume changes at MR imaging and relation to clinicaloutcome. Radiology 2002; 222: 367-37410. Pelage JP, Guaou-Guaou N, et al. Uterine fibroid tumors: long-term MR imaging outcome after embolization. Radiology 2004; 230: 803-80911. Homer H, Saridogan E. Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril 2010; 94 (1): 324-330Contact UsFor any questionson this issueplease email to:Marco Montanaro,Marketing Manager,Boston ScientificItaly, email:marco.montanaro@bsci.comPlease email yourcomments orcontributions to:Sharron Tansey, Marketing ManagerInterventional Oncology, BostonScientific EMEA, email:tanseys@bsci.com

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