Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis

Percutaneous cryoablation therapy for abdominal wall endometriosis: a systematic review and meta-analysis

OBJECTIVES

Abdominal wall endometriosis (AWE) consists of endometrial tissue between the peritoneum and the abdominal wall. The established treatment involves amenorrheic drugs-not always successful and tolerated-or invasive surgery. In this scenario, minimally invasive techniques such as cryoablation are a potential option. In this study, we primarily aimed to evaluate the efficacy of percutaneous cryoablation in reducing pain scores of AWE patients and analyze their satisfaction with the procedure and its related adverse events.

MATERIALS AND METHODS

MEDLINE, EMBASE, and Cochrane's databases were systematically searched for studies that employed percutaneous cryoablation therapy for AWE and reported any of the outcomes of interest. The primary outcome was the reduction in the visual analog scale (VAS) score after treatment. R Software was used for the statistical analysis. Heterogeneity was assessed using I2 statistics. The Risk Of Bias In Non-Randomized Studies-of Interventions framework assessed potential bias in each selected study.

RESULTS

We included 4 studies, containing 126 patients. All articles were retrospective studies. The difference between the VAS scores before and after treatment was on average 5.97 points (95% CI 5.42-6.52; P <.01; I2 = 0%). The pooled satisfaction rate among patients in the selected studies was 93.1% (95% CI 88.66-97.34; P = .51; I2 = 0%). The pooled prevalence of adverse events was only 5.48% (95% CI 1.71-11.20; P = .58; I2 = 0%). Bias analysis showed an overall moderate risk in all included articles.

CONCLUSION

Our study demonstrated that cryoablation could reduce pain complaints in patients, while presenting a low incidence rate of adverse effects. Randomized clinical trials with a larger number of patients are necessary for greater conclusions.

ADVANCES IN KNOWLEDGE

(1) AWE affects about 3.5% of women. The standard treatment is invasive surgery. (2) This meta-analysis demonstrated that cryoablation can effectively reduce pain scores while presenting a low rate of adverse effects. (3) Cryoablation is a feasible treatment for AWE, furthermore allowing shorter hospital stays and few complications for the patients.

Percutaneous cryoablation of abdominal wall endometriosis: a systematic literature review of safety and efficacy

PURPOSE

To investigate over 10 years the safety and efficacy of percutaneous cryoablation for the treatment of abdominal wall endometriosis (AWE).

METHODS

A systematic review was conducted of literature published between March 2014 and March 2024. Inclusion criteria focused on treatment efficacy studies, while exclusion criteria targeted case reports and studies lacking pertinent outcome data. Methodological quality was assessed using the Newcastle-Ottawa Scale for cohort studies.

RESULTS

A total of eight studies were included. Local pain scores decreased from a median of 8/10 (interquartile range (IQR) 7-9) on the visual analog scale to 1/10 (IQR 0-2) at the last follow-up (p < 0.0001). Median complete local pain response rates ranged from 80% to 100%, with median local pain-free survival rates reaching 76.8% (IQR 55.3-83.8) at the longest follow-up. Notably, no patient reported a post-procedure pain score higher than that they reported pre-cryoablation. The studies indicated minor complications in 3.5 to 11% of cases, with major complications occurring in less than 2% of cases, graded following the guidelines of the Society of Interventional Radiology.

CONCLUSION

In the last decade, percutaneous image-guided cryoablation has offered consistent results and appears to be a promising, minimally invasive option for AWE treatment. Prospective trials are now essential to establish cryoablation as a new standard in patient care for AWE.

CRITICAL RELEVANCE STATEMENT

Over a decade-long study, percutaneous cryoablation has proven to be a safe and effective minimally invasive treatment for abdominal wall endometriosis, significantly reducing pain with minimal complications.

KEY POINTS

Percutaneous cryoablation significantly reduced local pain scores for abdominal wall endometriosis. The procedure demonstrated a favorable safety profile with minor complications. Cryoablation has emerged as a minimally invasive alternative to traditional treatments.

Long-term outcomes after percutaneous cryoablation of abdominal wall endometriosis

OBJECTIVE

To retrospectively evaluate the long-term outcomes after percutaneous cryoablation of abdominal wall endometriosis (AWE).

METHOD

The Institutional Review Board approved this retrospective observational review of 40 consecutive patients, of a median age of 37 years (interquartile range [IQR] 32-40 years), presenting with a total of 52 symptomatic AWE nodules. All patients underwent cryoablation between January 2013 and May 2022 with a minimum follow-up period of 12 months. Outcomes were assessed using a visual analog scale (VAS) that measured pain, as well as by magnetic resonance imaging (MRI). The pain-free survival rates were derived using the Kaplan-Meier estimator. Adverse events were analyzed and graded using the classification system of the Cardiovascular and Interventional Radiological Society of Europe.

RESULTS

The median follow-up time was 40.5 months (IQR 26.5-47.2 months). The median VAS score before cryoablation was 8 (IQR 7-9). Complete relief of symptoms was documented in 80% (32/40) of patients at 3 months after initial cryoablation and correlated with the absence of residual endometriosis nodules on MRI. The median pain-free survival rates were 89.2% [95% CI, 70.1-96.4%] at 36 months and 76.8% [95% CI, 55.3-83.8%] after 60 months. No patient or lesion characteristics were found to be prognostic of failure. No major adverse events or side effects were reported in long term.

CONCLUSION

Cryoablation safely and effectively afforded long-term pain relief for patients with AWE nodules.

CLINICAL RELEVANCE STATEMENT

AWE cryoablation was found to be safe and effective in the long-term.

KEY POINTS

• Cryoablation is highly effective with 80% of patients experiencing complete relief of AWE symptoms after a single procedure. • Cryoablation is safe without long-term adverse events or side effects. • The median pain-free survival rates are 89.2% at 36 months and 76.8% at 60 months.

Surgical and Percutaneous Image-Guided Therapies of Abdominal Wall Endometriosis: A Systematic Review of Current Evidence

OBJECTIVE

Despite various surgical and nonsurgical strategies for abdominal wall endometriosis, the lack of definitive guidance on optimal treatment choice leads to clinical uncertainty. This review scrutinizes the safety and efficacy of abdominal wall endometriosis treatments to aid in decision-making.

DATA SOURCES

We performed a systematic literature review of PubMed, Embase, and Cochrane Library databases from 1947 until December 2023.

METHODS OF STUDY SELECTION

A comprehensive literature search identified studies that assessed both surgical and nonsurgical interventions, including high-intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation, and microwave ablation. This review is registered in NIHR-PROSPERO (CRD 42023494969). Local tumor control (LTC), local pain relief (LPR), and adverse events (AE) were recorded.

TABULATION, INTEGRATION, AND RESULTS

This review included 51 articles among 831 identified. All study designs were considered eligible for inclusion. A total of 2674 patients are included: 2219 patients (83%) undergoing surgery, and 455 (17%) undergoing percutaneous interventions (342 HIFU, 103 cryoablation, 1 radiofrequency ablation, 9 microwave ablation). Follow-up length was 18 months in median, ranging from 1 to 235 months. Overall LTC rates ranged from 86% to 100%. Surgical interventions consistently demonstrated the highest rate of LTC with a median rate of 100%, and LPR with a median rate of 98.2% (95% confidence interval [CI]: 93.9-97.7). HIFU showed median LTC and LPR rates, respectively of 95.65% (95% CI, 87.7-99.9) and 76.1% (95% CI, 61.8-90.4); and cryoablation of 85.7% (95% CI, 66.0-99.9) and 79.2% (95% CI, 67.4-91.03). Minor AE was reported after surgery in 17.5% of patients (225/1284) including 15.9% (199/1284) of mesh implantation; 76.4% (239/313) after HIFU; and 8.7% (9/103) after cryoablation. Severe AE was reported in 25 patients in the surgery group and 1 in the percutaneous group.

CONCLUSION

The safety profile and efficacy of nonsurgical interventions support their clinical utility for management of abdominal wall endometriosis.

Percutaneous cryoablation of abdominal wall endometriosis: An analysis of 38 patients

PURPOSE

The purpose of this study was to evaluate the efficacy of percutaneous cryoablation in the treatment of abdominal wall endometriosis (AWE) nodules.

MATERIALS AND METHODS

Thirty-eight women treated for symptomatic AWE nodules with percutaneous cryoablation under ultrasound and computed tomography (CT) guidance between May 2020 and July 2023 were retrospectively included. Pain was estimated using visual analog scale (VAS) and assessed at baseline, three months, six months, and 12 months after percutaneous cryoablation. Baseline VAS score, volume of AWE nodule and magnetic resonance imaging (MRI) features of AWE nodules were compared to those obtained after percutaneous cryoablation. Major complications, if any, were noted.

RESULTS

Thirty-eight women with a median age of 35.5 years (interquartile range [IQR]: 32, 39; range: 24-48 years) and a total of 60 AWE nodules were treated. Percutaneous cryoablation was performed under local or regional anesthesia in 30 women (30/38; 79%). Significant decreases between initial median VAS score (7; IQR: 6, 8; range: 3-10) and median VAS score after treatment at three months (0; IQR: 0, 5; range; 0-8) (P < 0.001), six months (0; IQR: 0, 1; range; 0-10) (P < 0.001) and 12 months (0; IQR: 0, 2; range: 0-7) (P < 0.001) were observed. Percutaneous cryoablation resulted in effective pain relief in 31 out of 38 women (82%) at six months and 15 out of 18 women (83%) at 12 months. Contrast-enhanced MRI at six-month follow-up showed a significant decrease in the volume of AWE nodules and the absence of AWE nodule enhancement after treatment by comparison with baseline MRI (P < 0.001). No major complications were reported.

CONCLUSION

Percutaneous cryoablation is an effective, minimally invasive intervention for the treatment of AWE nodules that conveys minimal or no morbidity.

Radiofrequency Ablation: A Promising Treatment Method for Abdominal Wall Endometriosis

PURPOSE

To evaluate the application of radiofrequency ablation (RFA) as a treatment method for abdominal wall endometriosis (AWE).

MATERIALS AND METHODS

The characteristics of the AWE lesions in the patients were obtained using ultrasound (US). The patients received general and local anesthesia, and then, AWE lesions were divided into 1 cm3 sections visually, and each of these sections underwent US-guided RFA using the moving shot technique. Follow-up included outpatient appointments, including a US examination 1, 3, and 6 months after the treatment to assess the volume of the lesions. In addition, the level of pain experienced by the patients was measured using a visual analogue scale (VAS) before and the day after the procedure, as well as at each follow-up appointment.

RESULTS

Ten patients were treated with RFA. The procedural success was achieved in all of the patients. The median volume of the lesions decreased from 7.3 cm3 (IQR = 4.39,23.75) to 2.95 cm3 (IQR = 1.65,9.09) (P = 0.005). All patients reported reduced pain levels, and the median of their VAS score decreased from 9 (IQR = 8,9) to 0 (IQR = 0,1.25) (P = 0.004) at the end of the follow-up period. None of the patients experienced complications related to RFA treatment.

CONCLUSION

Based on the study's findings, RFA appears to be a promising minimally invasive treatment for AWE. However, larger studies with longer follow-up periods are required for a more comprehensive understanding of its efficacy and safety.

LEVEL OF EVIDENCE

Level 4, Case Series.

Laparoscopic treatment of abdominal wall endometriosis: A case series

Objective

This report summarizes the characteristics of a series of 8 recent (2020-2022) patients with abdominal wall endometriosis (AWE) who underwent laparoscopic surgery. The feasibility and advantages of laparoscopy in the treatment of AWE are set out.

Methods

The clinical data of the 8 AWE patients were retrospectively analysed. Basic clinical characteristics, operation details and postoperative details were collected and analysed.

Results

Laparoscopic treatment was successful in all 8 cases. The mean operation time was 212.13 ± 48.16 min, the mean estimated blood loss was 25.00 ± 11.18 ml, and the mean postoperative hospital stay was 5.25 ± 1.39 days. 7 of the patients were found to have concomitant pelvic endometriosis, and 1 patient was found to have concealed inguinal hernias during surgery. Concomitant laparoscopic surgery for pelvic lesions was performed, including electrocautery or lesion resection of the pelvic endometriosis lesions in 7 patients, uterine fibroidectomy in 2 patients, high ligation of the hernia sac in 1 patient and endometrial biopsy under hysteroscopy in 1 patient. Endometrial-like tissue was confirmed by postoperative pathological examination of resected AWE lesions in all patients. There were no intraoperative or postoperative complications. The mean follow-up time was 18.75 ± 3.96 months, and no recurrence of AWE was found.

Conclusion

Laparoscopic surgery is a safe, effective and feasible treatment option for AWE patients and has the advantages of simultaneous diagnosis and treatment of other pelvic lesions.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Percutaneous Imaging-guided Cryoablation of Endometriosis Scars of the Anterior Abdominal Wall

STUDY OBJECTIVE

To evaluate the safety and clinical efficacy of percutaneous imaging-guided cryoablation for the management of anterior abdominal wall endometriosis.

DESIGN

Patients with abdominal wall endometriosis underwent percutaneous imaging-guided cryoablation and had a 6-month follow-up.

SETTING

Data dealing with patients' and anterior abdominal wall endometriosis (AAWE) characteristics, cryoablation, and clinical and radiologic outcomes were retrospectively collected and analyzed.

PATIENTS

Twenty-nine consecutive patients underwent cryoablation from June 2020 to September 2022.

INTERVENTIONS

Interventions were performed under US/computed tomography (CT) guidance or magnetic resonance imaging (MRI) guidance. Cryoprobes were directly inserted into the AAWE, and cryoablation was performed with a single 5 to 10 minute freezing cycle, which was stopped when the iceball expanded 3 to 5 mm beyond AAWE borders as assessed on intra-procedural cross-sectional imaging.

MEASUREMENTS AND MAIN RESULTS

Fifteen patients (15/29; 51.7%) had prior endometriosis, 28 (28/29; 95.5%) had previous cesarian section, and 22 (22/29; 75.9%) referred association between symptoms and menses. Cryoablation was performed under local (16/29; 55.2%) or general anesthesia (13/29; 44.8%) and mainly in an out-patient basis (18/20; 62%). There was only one (1/29; 3.5%) minor procedure-related complication. Complete symptom relief was recorded in 62.1% (18/29) and 72.4% (21/29) patients at 1 and 6 months, respectively. In the whole population, pain significantly dropped at 6 months compared to the baseline (1.1 ± 2.3; range 0-8 vs 7.1 ± 1.9; range 3-10; p <.05). Eight (8/29; 27.6%) patients presented residual symptoms at 6 months, and 4 (4/29; 13.8%) had an MRI-confirmed residual/recurring disease. Contrast-enhanced MRI obtained for the first 14 (14/29; 48.3%) patients of the series, all without signs of residual/recurring disease, demonstrated a significantly smaller ablation area compared to the baseline volume of the AAWE (1.0 cm3 ± 1.4; range 0-4.7; vs 11.1 ± 9.9 cm3; range 0.6-36.4; p <.05).

CONCLUSION

Percutaneous imaging-guided cryoablation of AAWE is safe and clinically effective in achieving pain relief.

Pictorial essay: MRI evaluation of endometriosis-associated neoplasms

Endometriosis is a frequent pathology mostly affecting women of young age. When typical aspects are present, the diagnosis can easily be made at imaging, especially at MRI. Transformation of benign endometriosis to endometriosis-associated neoplasms is rare. The physiopathology is complex and remains controversial. Endometrioid carcinoma and clear cell carcinoma are the main histological subtypes. Our goal was to review the main imaging characteristics that should point to an ovarian or extra-ovarian endometriosis-related tumor, especially at MRI, as it may be relevant prior to surgical management.Key points• Transformation of benign endometriosis to endometriosis-associated neoplasms is rare.• MRI is useful when displaying endometriosis lesions associated to an ovarian tumor.• Subtraction imaging should be used in the evaluation of complex endometriomas.

Resolution of Pain after Percutaneous Image-Guided Cryoablation of Extraperitoneal Endometriosis

PURPOSE

To retrospectively evaluate the relief of pain after percutaneous image-guided cryoablation of symptomatic extraperitoneal endometriosis (EE).

MATERIAL AND METHODS

From 2017 to 2022, cryoablation of EE was performed at a single institution on a total of 47 lesions in 42 consecutive patients (median age, 37 years; interquartile range [IQR], 33-39.5 years). Patient and procedural characteristics were reviewed retrospectively. Tolerance and outcomes in terms of pain and patient satisfaction were evaluated.

RESULTS

The median follow-up duration was 13.5 months (IQR, 1.1-37.7 months) after cryoablation. The median pain-free survival rate was 93.8% (95% confidence interval [CI], 77.3-98.4) at 6 months and 82.7% (95% CI, 58.8-93.5) after 12 months. Pain decreased from a median of 8/10 (IQR, 7-9) on the visual analog scale to 0/10 (IQR, 0-1) at the last follow-up (P < .0001). The median Patient Global Impression of Change score recorded at the last follow-up was 1/7 (IQR, 1-2). The efficacy rate of cryoablation to avoid secondary surgery was 92.8% (39/42) per patient and 93.6% (44/47) per nodule treated. Four patients (9.5%, 4/42) experienced an adverse event in the days following the procedure, and 1 patient (2%) experienced a severe adverse event.

CONCLUSIONS

Percutaneous cryoablation is safe and effective in significantly reducing pain and obtaining local control of EE.

Surgery of abdominal wall endometriosis associated with clear-cell carcinoma: Case report and review

Abdominal wall is a rare location for endometriosis, with a reported incidence of parietal endometriosis of approximately 0.03 to 0.4%. It most often occurs in the aftermath of a caesarean section and is associated with pelvic endometriosis in only 5 to 15% of cases. Rare cases of malignant transformation have been described, mainly in the form of clear-cell tumours. We report the case of a 52-year-old patient with a history of endometriosis who presented with a retractile parietal mass at the level of her caesarean scar. Histological analysis confirmed a clear-cell adenocarcinoma (CCC). Few cases of endometriosis - associated CCC are described in the literature. A review of the literature suggests radical surgical treatment combined with adjuvant radio-chemotherapy. However, the prognosis is poor. The aim of this case report is to suggest the diagnosis of malignant transformation in the presence of a rapidly evolving parietal mass in the context of endometriosis and a history of caesarean section.

Safety and efficacy of microwave ablation for abdominal wall endometriosis: A retrospective study

Objectives

This retrospective study aimed to evaluate the safety and feasibility of ultrasound-guided microwave ablation in the treatment of abdominal wall endometriosis (AWE).

Background

AWE is a rare form of endometriosis that often results in cyclic abdominal pain. The current treatment algorithm for AWE is not well established. Microwave ablation technology is a promising new thermal ablation technique for treating AWE.

Methods

This was a retrospective study of nine women with pathologically proven endometriosis of the abdominal wall. All patients were treated with ultrasound-guided microwave ablation. Grey-scale and color Doppler flow ultrasonography, contrast-enhanced ultrasonography, and MRI were used to observe the lesions before and after treatment. The complications, pain relief, AWE lesion volume, and volume reduction rate were recorded 12 months after treatment to evaluate the treatment efficacy. Complications were classified according to the Common Terminology Criteria for Adverse Events and the Society of Interventional Radiology classification system.

Results

Contrast-enhanced ultrasound showed that all lesions underwent successful treatment with microwave ablation. The average initial nodule volume was 7.11 ± 5.75 cm³, which decreased significantly to 1.85 ± 1.02 cm³ at the 12-month follow-up with a mean volume reduction rate of 68.77 ± 12.50%. Periodic abdominal incision pain disappeared at 1 month after treatment in all nine patients. The adverse events and complications were Common Terminology Criteria for Adverse Events grade 1 or Society of Interventional Radiology classification grade A.

Conclusions

Ultrasound-guided microwave ablation is a safe and effective technique for the treatment of AWE, and further study is warranted.