The evaluation of uterine artery embolization as a nonsurgical treatment option for adenomyosis

An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus

Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.

Periprocedural imaging compared to endometrial biopsy: is biopsy required prior to uterine artery embolisation?

AIM

To compare the detection rate of magnetic resonance imaging (MRI) and ultrasound relative to endometrial biopsy for endometrial abnormalities in both pre- and post-menopausal women.

MATERIALS AND METHODS

The present study was an institutional review board-approved, single-institution retrospective analysis of patients who underwent pelvic MRI within 1 year of diagnostic-quality biopsies from 2008-2018 (n=668). There were 303 patients who received uterine artery embolisation (UAE) and 478 patients who received pelvic ultrasound within the study period. Medical records were evaluated for radiological-histopathological correlation, demographics, laboratory studies, and clinical follow-up.

RESULTS

In this cohort of 668 patients, there were 37 biopsies positive for malignancy; women with malignancy were older (58 versus 47 years, p<0.0001) and more likely to be post-menopausal (66% versus 12%, p<0.0001). There were 303 patients who underwent UAE and underwent a diagnostic-quality endometrial biopsy during the pre-procedural evaluation, none of whom were post-menopausal and had a mean age of 45 years. In women with abnormal uterine bleeding (AUB) or post-menopausal bleeding (PMB), the sensitivity of MRI for detecting endometrial cancer was 96.2%, with a negative predictive value (NPV) of 99.8%, compared to 68% and 97% for ultrasound, respectively. The receiver operating characteristic (ROC) curve of pre-biopsy MRI in identifying pre-malignant and malignant endometrial pathology demonstrated an AUC of 0.8920 (p<0.0001).

CONCLUSION

In women with AUB or PMB, MRI has a 99.8% NPV in ruling out endometrial cancer. Further consideration should be made towards optimising pre-procedural evaluation for UAE.

Current and Prospective Treatment of Adenomyosis

(1) Background: Adenomyosis is a poorly understood entity which makes it difficult to standardize treatment. In this paper we review and compare the currently approved medical and surgical treatments of adenomyosis and present the evidence behind them. (2) Methods: A PubMed search was conducted to identify papers related to the different treatments of adenomyosis. The search was limited to the English language. Articles were divided into medical and surgical treatments. (3) Results: Several treatment options have been studied and were found to be effective in the treatment of adenomyosis. (4) Conclusions: Further randomized controlled trials are needed to compare treatment modalities and establish a uniform treatment algorithm for adenomyosis.

Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis

BACKGROUND

Failing conservative therapies, uterine artery embolisation (UAE) has been proposed as a uterine-sparing option for treatment of symptomatic adenomyosis. UAE appears effective at short-term; however long-term durability is less well established.

AIMS

To evaluate the long-term clinical efficacy of UAE for treatment of adenomyosis.

MATERIALS AND METHODS

One hundred and four women with initial clinical success following UAE for adenomyosis (results previously published) were further followed with a two-part online survey. Part one inquired about menopause, symptom recurrence, need for further intervention and overall satisfaction. Part two comprised the Uterine Fibroid Symptom and health-related Quality of Life (UFS-QOL) questionnaire. Maintenance of clinical success was defined as remaining 'happy' or 'very happy' with overall outcome, no recurrence of symptoms, or need for further intervention.

RESULTS

Of those women with initial success, 91/104 (88%) participated in this long-term study at mean 52 months following UAE. Maintenance of clinical success was demonstrated in 82/91 (90%) women. For the remaining 9/91 (10%) women, mean time to failure was 31 months. There were 53/91 (58%) women who reached menopause at mean age of 51.5 years, occurring at mean 30 months post-UAE. UFS-QOL demonstrated significant decrease in symptom severity from 58.9 to 20.0 (P < 0.001); and significant increase in QOL from 40.3 to 86.3 (P < 0.001).

CONCLUSIONS

Long-term durability of UAE for treatment of adenomyosis was demonstrated, with cumulative success rate of 80% at mean 52 months. UAE did not appear to bring forward menopause. UAE should be considered as an alternative to hysterectomy to treat adenomyosis.

Progress of gelatin-based microspheres (GMSs) as delivery vehicles of drug and cell

Gelatin has various attractive features as biomedical materials, for instance, biocompatibility, low immunogenicity, biodegradability, and ease of manipulation. In recent years, various gelatin-based microspheres (GMSs) have been fabricated with innovative technologies to serve as sustained delivery vehicles of drugs and genetic materials as well as beneficial bacteria. Moreover, GMSs have exhibited promising potentials to act as both cell carriers and 3D scaffold components in tissue engineering and regenerative medicine, which not only exhibit excellent injectability but also could be integrated into a macroscale construct with the laden cells. Herein, we aim to thoroughly summarize the recent progress in the preparations and biomedical applications of GMSs and then to point out the research direction in future. First, various methods for the fabrication of GMSs will be described. Second, the recent use of GMSs in tumor embolization and in the delivery of cells, drugs, and genetic material as well as bacteria will be presented. Finally, several key factors that may enhance the improvement of GMSs were suggested as delivery vehicles.

Significance of changes in inflammatory parameters following uterine artery embolization in pre-menopausal females

The purpose of the present study was to describe the course of changes in laboratory inflammatory markers following bilateral uterine artery embolization (UAE) as a treatment for leiomyomas and adenomyosis. The body temperature was measured and blood samples were collected to determine white blood cell (WBC) count and C-reactive protein (CRP) levels in 270 patients on the day prior to UAE and for up to 4 days post-embolization. Aside from a single case with a non-inflammatory complication, none of the other cases had any complications. Post-UAE leukocytosis with a mean maximum value of 10.8±3.5x10⁹/l (range, 5.9-18.6x10⁹/l) was observed one-year post-intervention. The mean leukocyte numbers were indicated to be higher on day 3 post-UAE. The CRP level was also increased post-UAE, with a mean maximum value of 7.75±3.5 mg/dl. Maximum levels were reached in 8 patients on the 2nd and in 11 patients on the 3rd post-operative day. The maximum pain score was ~5.5 and reached its lowest level at the end of the 12th week post-intervention. The present study did not consider an association between the embolic material used or uterus size with the level of treatment success. No complications were observed post-UAE; however, a significant increase in the WBC count was observed within the first 3 days, indicating mild leukocytosis.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

Predisposing factors for predicting the therapeutic response of adenomyosis after uterine artery embolization: serum CA125 levels and accompanying endometriosis

PURPOSE

We aimed to identify predisposing factors that could help predict the therapeutic response of adenomyosis after uterine artery embolization (UAE).

METHODS

This was a retrospective, single-center study of patients admitted to the hospital for adenomyosis between 2013 and 2015. Sixty-eight patients with adenomyosis who underwent UAE with tris-acryl gelatin microspheres were divided into two groups based on their therapeutic response (complete or incomplete necrosis of lesions), and pre- and postprocedural pelvic magnetic resonance imaging (MRI) data. Patients were followed up for 12 months after UAE. Improvements in dysmenorrhea and menorrhagia were evaluated based on the symptom relief criteria. Improvement rates in both groups were analyzed and compared. Multivariate logistic regression analysis was used to identify the predisposing factors from retrospectively gathered baseline data that might affect the therapeutic response, including MRI features, clinical symptoms, biochemical index, and accompanying diseases of adenomyosis. Then, a prognostic model was established, and the receiver operating characteristic (ROC) curve of identified factors was drawn to determine their predictive value.

RESULTS

Following UAE, 46 patients (67.6%) showed complete necrosis, while 22 patients (32.4%) showed incomplete necrosis. At 12-month follow-up, dysmenorrhea symptom improvement was seen in 94.7% of complete necrosis and 50% of incomplete necrosis group (P < 0.001); menorrhagia symptom improvement was seen in 96.2% of complete necrosis and 57.1% of incomplete necrosis groups (P = 0.004). Multivariate logistic regression analysis determined serum cancer antigen 125 (CA125) levels (odds ratio [OR], 1.006; 95% confidence interval [CI], 1.002-1.010; P = 0.005) and accompanying endometriosis (OR, 6.869; 95% CI, 1.881-25.016; P = 0.004) as predisposing factors. The areas under the ROC curve of CA125, endometriosis, and these two indicators combined were 0.785, 0.708, and 0.845, which corresponded to sensitivities of 95.5%, 66.7%, and 68.2% and specificities of 52.2%, 80.0%, and 87.0% at optimal cutoff values, respectively.

CONCLUSION

Symptom relief of dysmenorrhea and menorrhagia for patients with complete necrosis was significantly better than that for patients with incomplete necrosis. Serum CA125 levels and accompanying endometriosis can effectively distinguish complete necrosis from incomplete necrosis.

Gene expression changes in cervical squamous cancers following neoadjuvant interventional chemoembolization

BACKGROUND

The efficacy of therapy for cervical cancer is related to the alteration of multiple molecular events and signaling networks during treatment. The aim of this study was to evaluate gene expression alterations in advanced cervical cancers before- and after-trans-uterine arterial chemoembolization- (TUACE).

METHODS

Gene expression patterns in three squamous cell cervical cancers before- and after-TUACE were determined using microarray technique. Changes in AKAP12 and CA9 genes following TUACE were validated by quantitative real-time PCR.

RESULTS

Unsupervised cluster analysis revealed that the after-TUACE samples clustered together, which were separated from the before-TUACE samples. Using a 2-fold threshold, we identified 1131 differentially expressed genes that clearly discriminate after-TUACE tumors from before-TUACE tumors, including 209 up-regulated genes and 922 down-regulated genes. Pathway analysis suggests these genes represent diverse functional categories. Results from real-time PCR confirmed the expression changes detected by microarray.

CONCLUSIONS

Gene expression signature significantly changes during TUACE therapy of cervical cancer. Theses alterations provide useful information for the development of novel treatment strategies for cervical cancers on the molecular level.

Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial

Background

Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking.

Objective

With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis.

Methods

This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)–confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE.

Results

Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started.

Conclusions

This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients’ wellbeing and quality of life.

Trial Registration

Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis

The effect of uterine artery embolization (UAE) on symptomatic adenomyosis was evaluated in a systematic review and meta-analysis. Four groups were evaluated: short-term (< 12 months) pure adenomyosis, short-term adenomyosis with fibroids (combined adenomyosis), long-term (> 12 months) pure adenomyosis, and long-term combined adenomyosis. Improvement of symptoms occurred in 83.1% (872/1,049) of patients. Reported symptom reduction was 4.8% greater in the short-term combined group (P = .169) and 11.4% greater in the long-term combined group (P = .003). Uterine volume was reduced in all patients at 3 months. The effects of UAE on symptom improvement and uterine volume reduction in patients with adenomyosis are encouraging.

Unique Learning System for Uterine Artery Embolization for Symptomatic Myoma and Adenomyosis for Obstetrician-Gynecologists in Cooperation with Interventional Radiologists: Evaluation of UAE From the Point of View of Gynecologists Who Perform UAE

STUDY OBJECTIVE

To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis.

INTERVENTIONS

We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted.

MEASUREMENTS AND MAIN RESULTS

A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely.

CONCLUSION

UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire

PURPOSE

The purpose of this study was to assess clinical outcomes 7 years after uterine artery embolization (UAE) in the treatment of symptomatic adenomyosis.

MATERIALS AND METHODS

In this prospective cohort study, one specialized hospital in the Netherlands recruited patients with symptomatic adenomyosis or adenomyosis in combination with fibroids for UAE. The 7-year post-intervention outcomes were health-related quality of life (HRQOL), symptom severity scores (SSS), satisfaction, menopause and re-interventions.

RESULTS

Twenty-nine patients with adenomyosis (15 with fibroids) were treated with UAE between September 2006 and January 2010. The 7-year questionnaire was mailed in November 2016. The mean follow-up was 95 months (SD 9.0) at a mean age of 50 (SD 5.4). Questionnaires were returned by 24/29 patients (83%). The remaining five patients were contacted through telephone. One of these patients was untraceable. Seven years after treatment 5 of 28 patients (18%) underwent a secondary hysterectomy. The HRQOL and SSS scores as measured by UFS-QOL at 3 months after UAE showed significant improvement of -57 points (score: 15) and +40 points (score: 91), respectively. These scores remained comparable stable up unto 7 years. The SSS showed a significant difference of 17 points (0-100) in favor of the adenomyosis in combination with fibroids group (p = 0.020). Menopause was reported by 10/28 patients (36%). Twenty-one of 29 (72%) patients declared to be at least fairly satisfied about UAE.

CONCLUSIONS

After 7 years of follow-up, in 82% of UAE-treated patients with symptomatic adenomyosis a hysterectomy was avoided.