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Makary MS, Zane K, Hwang GL, Kim CY, Ahmed O, Knavel Koepsel EM, Monroe EJ, Scheidt MJ, Smolock AR, Stewart EA, Wasnik AP, Pinchot JW. ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update. J Am Coll Radiol 2024; 21:S203-S218. [PMID: 38823944 DOI: 10.1016/j.jacr.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Mina S Makary
- Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Kylie Zane
- Research Author, University of Chicago Hospitals, Chicago, Illinois
| | - Gloria L Hwang
- Stanford University School of Medicine, Stanford, California
| | - Charles Y Kim
- Panel Chair, Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth A Stewart
- Mayo Clinic and Mayo Clinic Alix School of Medicine; American College of Obstetricians and Gynecologists
| | | | - Jason W Pinchot
- Specialty Chair, University of Wisconsin, Madison, Wisconsin
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Barat M, Dohan A, Kohi M, Marcelin C, Pelage JP, Denys A, Mafeld S, Kaufman CS, Soyer P, Cornelis FH. Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences. Diagn Interv Imaging 2024; 105:87-96. [PMID: 38065817 DOI: 10.1016/j.diii.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 01/16/2024]
Abstract
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.
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Affiliation(s)
- Maxime Barat
- Department of Radiology, Hopital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Anthony Dohan
- Department of Radiology, Hopital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Maureen Kohi
- Department of Radiology, University of North Carolina at Chapel Hill, NC 27599, USA
| | - Clement Marcelin
- Department of Radiology, Centre Hospitalo-Universitaire de Bordeaux, 33076 Bordeaux, France
| | - Jean-Pierre Pelage
- Department of Radiology, Research Institute of McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital CHUV, Lausanne and University of Lausanne (UNIL), 1011 Lausanne, Switzerland
| | - Sebastian Mafeld
- Department of Medical Imaging, Division of Vascular and Interventional Radiology, Toronto General Hospital, University of Toronto, Toronto, ON, M5G 2C4, Canada
| | - Claire S Kaufman
- Dotter Interventional Institute, Oregon Health & Science University, Portland, OR 97239-3011, USA
| | - Philippe Soyer
- Department of Radiology, Hopital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Francois H Cornelis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA.
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Dou Y, Zhang L, Liu Y, He M, Wang Y, Wang Z. Long-term outcome and risk factors of reintervention after high intensity focused ultrasound ablation for uterine fibroids: a systematic review and meta-analysis. Int J Hyperthermia 2024; 41:2299479. [PMID: 38164630 DOI: 10.1080/02656736.2023.2299479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVES To quantify the reintervention rate and analyze the risk factors for reintervention after high-intensity focused ultrasound (HIFU) ablation of uterine fibroids. METHODS Eighteen studies were selected from the seven databases. A meta-analysis was applied to synthesize the reintervention rates for fibroids across various follow-up durations. Subgroup-analysis was conducted based on the year of surgery, sample size, guide methods, and non-perfusion volume ratio (NPVR). Signal intensity of T2-weighted imaging (T2WI) was independently evaluated for reintervention risk. RESULTS The study enrolled 5216 patients with fibroids treated with HIFU. There were 3247, 1239, 1762, and 2535 women reaching reintervention rates of 1% (95% confidence interval (CI): 1-1), 7% (95% CI: 4-11), 19% (95% CI: 11-27), and 29% (95% CI: 14-44) at 12, 24, 36, and 60-month after HIFU. The reintervention rates of patients treated with US-guided HIFU (USgHIFU) were significantly lower than those of patients treated with MR-guided focused ultrasound surgery (MRgFUS). When the NPVR of fibroids was over 50%, the reintervention rates at 12, 36 and 60-month after HIFU were 1% (95% CI: 0.3-2), 5% (95% CI: 3-8), and 15% (95% CI: 9-20). The reintervention risk for hyper-intensity fibroids on T2WI was 3.45 times higher (95% CI: 2.7-4.39) for hypo-/iso-intensity fibroids. CONCLUSION This meta-analysis showed that the overall reintervention rates after HIFU were acceptable and provided consultative suggestions regarding treatment alternatives for patients with fibroids. Subgroup-analysis revealed that USgHIFU, NPVR ≥ 50%, and hypo-/iso-intensity of fibroids on T2WI were significant factors in reducing reintervention. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42023456094.
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Affiliation(s)
- Yuya Dou
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, Southwest Hospital, Army Military Medical University, Chongqing, China
| | - Lian Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yu Liu
- Department of Obstetrics and Gynecology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Min He
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, Southwest Hospital, Army Military Medical University, Chongqing, China
| | - Zhibiao Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
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Lin LC, Chang HY, Kuo TT, Chen HY, Liu WS, Lo YJ, Hsia SM, Huang TC. Oxidative stress mediates the inhibitory effects of Manzamine A on uterine leiomyoma cell proliferation and extracellular matrix deposition via SOAT inhibition. Redox Biol 2023; 66:102861. [PMID: 37666118 PMCID: PMC10491796 DOI: 10.1016/j.redox.2023.102861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/21/2023] [Indexed: 09/06/2023] Open
Abstract
Uterine fibroids, the most common benign tumors of the myometrium in women, are characterized by abnormal extracellular matrix deposition and uterine smooth muscle cell neoplasia, with high recurrence rates. Here, we investigated the potential of the marine natural product manzamine A (Manz A), which has potent anti-cancer effects, as a treatment for uterine fibroids. Manz A inhibited leiomyoma cell proliferation in vitro and in vivo by arresting cell cycle progression and inducing caspase-mediated apoptosis. We performed target prediction analysis and identified sterol o-acyltransferases (SOATs) as potential targets of Manz A. Cholesterol esterification and lipid droplet formation were reduced by Manz A, in line with reduced SOAT expression. As a downstream target of SOAT, Manz A also prevented extracellular matrix deposition by inhibiting the β-catenin/fibronectin/metalloproteinases axis and enhanced autophagy turnover. Excessive free fatty acid accumulation by SOAT inhibition led to reactive oxygen species to impair mitochondrial oxidative phosphorylation and trigger endoplasmic reticulum stress via PERK/eIF2α/CHOP signaling. The inhibitory effect of ManzA on cell proliferation was partially restored by PERK knockdown and eliminated by tauroursodeoxycholic acid, suggesting oxidative stress plays a critical role in the mechanism of action of Manz A. These findings suggest that targeting SOATs by Manz A may be a promising therapeutic approach for uterine fibroids.
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Affiliation(s)
- Li-Chun Lin
- PhD Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan; School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Hsin-Yi Chang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, 11031, Taiwan; Department of Research and Development, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Ting Kuo
- PhD Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan
| | - Hsin-Yuan Chen
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Wen-Shan Liu
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan
| | - Yii-Jwu Lo
- Graduate Institute of Metabolism and Obesity Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Shih-Min Hsia
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan; Graduate Institute of Metabolism and Obesity Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan; School of Food Safety, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Tsui-Chin Huang
- PhD Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan; Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan; Master Program in Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, 11031, Taiwan; TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Cancer Center, Wan Fang Hospital, Taipei Medical University, Taipei, 11031, Taiwan.
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Lenis YY, George JW, Lind S, Balboula A, Teixeira JM, Patterson AL. The Effects of Periostin Expression on Fibroid-Like Transition of Myometrial Cells. Reprod Sci 2023; 30:1616-1624. [PMID: 36418534 DOI: 10.1007/s43032-022-01128-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/11/2022] [Indexed: 11/26/2022]
Abstract
Fibroids, benign tumors of the myometrium, are the most common tumors in women and are associated with spontaneous abortion, preterm birth, placenta abruption, and infertility, among others. The incidence of fibroids in reproductive aged women is 20-89%. Fibroids are characterized by high production of extracellular matrix (ECM), particularly collagens, which play a role in their growth. However, their pathogenesis is poorly understood. Recently, we and others have found periostin (POSTN), a regulatory ECM protein, to be overexpressed in the majority of fibroids analyzed. Periostin is an ECM protein that is a critical regulator and well-established biomarker for fibrosis in tissues such as the lung, skin, and kidney. Our hypothesis was that periostin plays a role in the fibrotic transition of myometrial cells to fibroid cells. To test this, we evaluated the effects of POSTN overexpression in myometrial cells. Telomerase-immortalized myometrial cells were transduced with control or POSTN-overexpression lentivirus particles, generating one control (dCas9-Mock) and two overexpression (dCas9-POSTN-01, dCas9-POSTN-02) cell lines. Overexpression of POSTN in immortalized myometrial cells resulted in a change in phenotype consistent with fibroid cells. They upregulated expression of key fibroid genes and had increased proliferation, adhesion, and migration in vitro. Here, we show a potential role for periostin in the transition of myometrial cells to fibroid cells, giving rationale for future investigation into the role of periostin in fibroid pathogenesis and its potential as a therapeutic target.
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Affiliation(s)
- Yasser Y Lenis
- Division of Animal Sciences, University of Missouri, Columbia, MO, USA
- Research Group OHVRI, School of Veterinary Medicine, Faculty of Agrarian Science, Universidad de Antioquia, Medellín, Colombia
| | - Jitu W George
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sarah Lind
- Division of Animal Sciences, University of Missouri, Columbia, MO, USA
| | - Ahmed Balboula
- Division of Animal Sciences, University of Missouri, Columbia, MO, USA
| | - Jose M Teixeira
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids, MI, USA
| | - Amanda L Patterson
- Division of Animal Sciences, University of Missouri, Columbia, MO, USA.
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA.
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Yuan Y, Xu W, Shen H, Lin Z, Xu F, Shi Q, Zhan P, Liu M, Shu J, Chen J, Xing HR. Long-term outcomes of ultrasound guided high intensity focused ultrasound ablation for patients with uterine fibroids classified by T2WI: a multicenter retrospective study. Int J Hyperthermia 2023; 40:2212887. [PMID: 37202174 DOI: 10.1080/02656736.2023.2212887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/04/2023] [Accepted: 05/07/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To evaluate the long-term outcomes of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation of uterine fibroids classified by T2-weighted magnetic resonance imaging (T2WI-MRI). MATERIALS AND METHODS The data of 1427 premenopausal women with symptomatic uterine fibroids who underwent USgHIFU at four teaching hospitals in China were analyzed retrospectively. The uterine fibroids were classified based on their T2WI-MRI signal intensities relative to that of skeletal muscle, myometrium and endometrium as: hypointense, isointense, heterogeneous hyperintense fibroids (HHF), slightly HHF (sHHF) and markedly HHF (mHHF), respectively. The rates of symptom relief and reintervention post-USgHIFU ablation were compared between the classified groups. RESULTS A total of 1303 patients were followed up for 44 (40, 49) months. The symptom relief rate of the hypointense and isointense fibroids was 83.3% and 79.5%, respectively, which were significantly higher (p < .05) compared to that of HHF, sHHF and mHHF (58.3%, 44.2% and 60.4%), respectively. sHHF had the lowest symptom relief rate (p < .05). The cumulative reintervention rate for hypointense, isointense, HHF, sHHF and mHHF types were 8.8%, 10.8%, 21.4%, 39.9% and 19.8%, respectively. The reintervention rate of hypointense/isointense fibroids was significantly lower than that of HHF/mHHF/sHHF (p < .01), while sHHF had the highest re-intervention rate (p < .01). Thus, reintervention rate is inversely correlated to the rate of symptom relief. CONCLUSIONS USgHIFU ablation is effective for hypointense, isointense, HHF and mHHF with acceptable long-term follow-up outcomes. However, sHHF is associated with a higher reintervention rate.
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Affiliation(s)
- Yuan Yuan
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Sichuan Provincial Center for Gynaecology and Breast Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wei Xu
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Huangpin Shen
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Zhenjiang Lin
- Department of Obstetrics and Gynecology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fan Xu
- Department of Obstetrics and Gynecology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical University, Nanchong, China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Ping Zhan
- Sichuan Provincial Center for Gynaecology and Breast Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Mali Liu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian Shu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinyun Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - H Rosie Xing
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
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Zhou Y, Zhang J, Chen J, Yang C, Gong C, Li C, Li F. Prediction using T2-weighted magnetic resonance imaging-based radiomics of residual uterine myoma regrowth after high-intensity focused ultrasound ablation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:681-692. [PMID: 36054291 PMCID: PMC9828488 DOI: 10.1002/uog.26053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To develop and evaluate magnetic resonance imaging (MRI)-based radiomics models for predicting residual myoma regrowth within 1 year after high-intensity focused ultrasound (HIFU) ablation of uterine myomas. METHODS A retrospective analysis of residual myoma regrowth within 1 year was performed on 428 myomas in 339 patients who were diagnosed with uterine myoma and treated with HIFU ablation in two hospital centers. In total, 851 radiomics features were extracted from T2-weighted images (T2WI) obtained 1 day after HIFU ablation, and the least absolute shrinkage and selection operator in the training cohort (n = 243) was employed to select radiomics features. Support vector machines were adopted to develop radiomics, clinicoradiological and combined radiomics-clinical models to predict residual myoma regrowth, defined as an increase in residual myoma volume of > 10% between that at day 1 post HIFU and that at follow-up MRI within 1 year. These models were validated in both internal (n = 81) and external (n = 104) test cohorts. The predictive performance and clinical application of these models were assessed using receiver-operating-characteristics-curve analysis, the area under the curve (AUC) and decision-curve analysis. RESULTS The AUCs of the T2WI-based radiomics prediction model in the internal and external test cohorts were 0.834 (95% CI, 0.747-0.920) and 0.801 (95% CI, 0.712-0.889), respectively, and those of the clinicoradiological model were 0.888 (95% CI, 0.816-0.960) and 0.912 (95% CI, 0.851-0.973), respectively. The combined model had better predictive performance than either the radiomics or the clinicoradiological model, with AUC values of 0.922 (95% CI, 0.857-0.987) and 0.930 (95% CI, 0.880-0.980) in the internal and external test cohorts, respectively. Decision-curve analysis also indicated that application of the combined model has clinical value, this model achieving more net benefits than the other two models. CONCLUSION T2WI-based radiomics features can predict effectively the occurrence of residual myoma regrowth within 1 year after HIFU ablation of uterine myomas, which serves as an accurate and convenient reference for clinical decision-making. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y. Zhou
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Key Laboratory of Biorheological Science and Technology of the Ministry of EducationChongqing UniversityChongqingChina
| | - J. Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
| | - J. Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
| | - C. Yang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
| | - C. Gong
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
| | - C. Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
| | - F. Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical EngineeringChongqing Medical UniversityChongqingChina
- Chongqing Key Laboratory of Biomedical EngineeringChongqing Medical UniversityChongqingChina
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Astragaloside IV Inhibits the Proliferation of Human Uterine Leiomyomas by Targeting IDO1. Cancers (Basel) 2022; 14:cancers14184424. [PMID: 36139584 PMCID: PMC9496999 DOI: 10.3390/cancers14184424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 11/27/2022] Open
Abstract
Simple Summary Immunotherapy is increasingly becoming a success strategy for oncology treatment. Indoleamine-2,3-dioxygenase1 (IDO1) is a tryptophan-degrading enzyme involved in immunological escape mechanisms, which is considered as a potential target for tumor therapy. However, the clinical efficacy of IDO1 inhibitors is not promising. Therefore, there is an urgent to investigate the mechanism between chemical drugs with antitumor effects and IDO1-mediated immunosuppression. The Chinese medicine AS-IV exerts antitumor effects with many advantages, including fewer toxic side effects and immunomodulatory effects. We noted the lack of studies of AS-IV on benign tumors. Therefore, our study demonstrates the Inhibitory effect of AS-IV on ULMs and elucidates the underlying mechanism. Abstract Astragaloside IV (AS-IV) is a chemical found in traditional Chinese medicine called Astragalus membranaceus (Fisch.) Bunge that has antitumor properties. However, the roles and mechanisms of AS-IV in uterine leiomyomas (ULMs) are unclear. The immunosuppressive enzyme indoleamine-2,3-dioxygenase-1 (IDO1) is involved in tumor formation. IDO1 is a new and reliable prognostic indicator for several cancers. In this work, AS-IV was applied to ULM cells in various concentrations. CCK-8, immunofluorescence, and flow cytometry were used to examine the proliferation and apoptosis of ULM cells caused by AS-IV. After lentiviral vector transduction with IDO1 short hairpin RNA (shRNA), the knockdown and overexpression of IDO1 were stable in ULM cells. To verify the antitumor effect of AS-IV in vivo, we established a rat model of uterine leiomyoma. HE staining, Masson staining, and transmission electron microscopy were used to observe pathological changes in the uterus, and the levels of serum sex hormones were measured by radio immune assay (RIA). The levels of CD3+T, CD4+T, and CD25+ Foxp3+Treg in rat peripheral blood were detected by flow cytometry. Western blotting and immunohistochemistry were used to examine protein expression. We found that AS-IV dramatically increased the apoptotic rate of ULM cells and reduced viability in a time- and dosage-dependent manner. After sh-IDO1 lentiviral transfection, we discovered that knocking down IDO1 reversed the effects of AS-IV on ULM cell proliferation and autophagy. We also found that AS-IV can effectively inhibit the growth of ULMs in vivo. AS-IV may promote apoptosis and autophagy in ULMs by activating PTEN/PI3K/AKT signaling through inhibition of IDO1. These findings imply that AS-IV exerts antifibroid effects, and the underlying mechanism may be IDO1, which is involved in proliferation, apoptosis, and autophagy.
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Zhang J, Yang C, Gong C, Zhou Y, Li C, Li F. Magnetic resonance imaging parameter-based machine learning for prognosis prediction of high-intensity focused ultrasound ablation of uterine fibroids. Int J Hyperthermia 2022; 39:835-846. [PMID: 35764325 DOI: 10.1080/02656736.2022.2090622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Objectives: To develop and apply magnetic resonance imaging (MRI) parameter-based machine learning (ML) models to predict non-perfused volume (NPV) reduction and residual regrowth of uterine fibroids after high-intensity focused ultrasound (HIFU) ablation.Methods: MRI data of 573 uterine fibroids in 410 women who underwent HIFU ablation from the Chongqing Haifu Hospital (training set, N = 405) and the First Affiliated Hospital of Chongqing Medical University (testing set, N = 168) were retrospectively analyzed. Fourteen MRI parameters were screened for important predictors using the Boruta algorithm. Multiple ML models were constructed to predict NPV reduction and residual fibroid regrowth in a median of 203.0 (interquartile range: 122.5-367.5) days. Furthermore, optimal models were used to plot prognostic prediction curves.Results: Fourteen features, including postoperative NPV, indicated predictive ability for NPV reduction. Based on the 10-fold cross-validation, the best average performance of multilayer perceptron achieved with R2 was 0.907. In the testing set, the best model was linear regression (R2 =0.851). Ten features, including the maximum thickness of residual fibroids, revealed predictive power for residual fibroid regrowth. Random forest model achieved the best performance with an average area under the curve (AUC) of 0.904 (95% confidence interval (CI), 0.869-0.939), which was maintained in the testing set with an AUC of 0.891 (95% CI, 0.850-0.929).Conclusions: ML models based on MRI parameters can be used for prognostic prediction of uterine fibroids after HIFU ablation. They can potentially serve as a new method for learning more about ablated fibroids.
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Affiliation(s)
- Jinwei Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Chao Yang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Chunmei Gong
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Ye Zhou
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Chenghai Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Faqi Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
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circFAT1(e2) Inhibits Cell Apoptosis and Facilitates Progression in Vascular Smooth Muscle Cells through miR-298/MYB Axis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:1922366. [PMID: 34938350 PMCID: PMC8687778 DOI: 10.1155/2021/1922366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/25/2021] [Indexed: 11/20/2022]
Abstract
Presently, as one of the three types of muscles in the human body, smooth muscle carries out many biological activities. Meanwhile, its abnormal development also leads to many diseases. Circular RNA, belonging to the noncoding RNA family, is demonstrated to function importantly in various diseases including smooth muscle. Here, we assumed circFAT1(e2) probably exhibited a primary role in vascular smooth muscle. Therefore, we conducted cell viability and cell apoptosis assay to validate the effects of circFAT1(e2) on vascular smooth muscle progression. Then, we supposed miR-298 was one target of circFAT1(e2) and executed corresponding experiments to test this hypothesis. Dual-luciferase reporter assay indicated miR-298 could bind to circFAT1(e2) and then modulated MYB level, thus regulating smooth muscle progression. Subsequently, based on the GSE41177 dataset, we identified 1982 differentially expressed genes (DEGs) in atrial fibrillation, and all DEGs were upregulated, including MYB. Finally, enrichment analysis of upregulated genes indicated that they were related to endodermal cell differentiation. The protein-protein interaction network revealed that EGFR, GNG2, and FPR2 were related to atrial fibrillation. In conclusion, our data find that circFAT1(e2) sponges miR-298 and then regulates MYB expression, thus affecting atrial fibrillation progression. Our findings provide a newly produced indicator and target for vascular smooth muscle diagnosis and treatment.
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11
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Anneveldt KJ, Nijholt IM, Schutte JM, Dijkstra JR, Frederix GWJ, Ista E, Verpalen IM, Veersema S, Huirne JAF, Hehenkamp WJK, Boomsma MF. Comparison of (Cost-)Effectiveness of Magnetic Resonance Image-Guided High-Intensity-Focused Ultrasound With Standard (Minimally) Invasive Fibroid Treatments: Protocol for a Multicenter Randomized Controlled Trial (MYCHOICE). JMIR Res Protoc 2021; 10:e29467. [PMID: 34821569 PMCID: PMC8663707 DOI: 10.2196/29467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/30/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Magnetic resonance image-guided high-intensity-focused ultrasound (MR-HIFU) is a rather new, noninvasive option for the treatment of uterine fibroids. It is safe, effective, and has a very short recovery time. However, a lack of prospectively collected data on long-term (cost-)effectiveness of the MR-HIFU treatment compared with standard uterine fibroid care prevents the MR-HIFU treatment from being reimbursed for this indication. Therefore, at this point, when conservative treatment for uterine fibroid symptoms has failed or is not accepted by patients, standard care includes the more invasive treatments hysterectomy, myomectomy, and uterine artery embolization (UAE). Primary outcomes of currently available data on MR-HIFU treatment often consist of technical outcomes, instead of patient-centered outcomes such as quality of life (QoL), and do not include the use of the latest equipment or most up-to-date treatment strategies. Moreover, data on cost-effectiveness are rare and seldom include data on a societal level such as productivity loss or use of painkillers. Because of the lack of reimbursement, broad clinical implementation has not taken place, nor is the proper role of MR-HIFU in uterine fibroid care sufficiently clear. OBJECTIVE The objective of our study is to determine the long-term (cost-)effectiveness of MR-HIFU compared with standard (minimally) invasive fibroid treatments. METHODS The MYCHOICE study is a national, multicenter, open randomized controlled trial with randomization in a 2:1 ratio to MR-HIFU or standard care including hysterectomy, myomectomy, and UAE. The sample size is 240 patients in total. Women are included when they are 18 years or older, in premenopausal stage, diagnosed with symptomatic uterine fibroids, conservative treatment has failed or is not accepted, and eligible for MR-HIFU. Primary outcomes of the study are QoL 24 months after treatment and costs of treatment including direct health care costs, loss of productivity, and patient costs. RESULTS Inclusion for the MYCHOICE study started in November 2020 and enrollment will continue until 2024. Data collection is expected to be completed in 2026. CONCLUSIONS By collecting data on the long-term (cost-)effectiveness of the MR-HIFU treatment in comparison to current standard fibroid care, we provide currently unavailable evidence about the proper place of MR-HIFU in the fibroid treatment spectrum. This will also facilitate reimbursement and inclusion of MR-HIFU in (inter)national uterine fibroid care guidelines. TRIAL REGISTRATION Netherlands Trial Register NL8863; https://www.trialregister.nl/trial/8863. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/29467.
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Affiliation(s)
- Kimberley J Anneveldt
- Department of Radiology, Isala Hospital, Zwolle, Netherlands.,Department of Gynecology, Isala Hospital, Zwolle, Netherlands
| | | | - Joke M Schutte
- Department of Gynecology, Isala Hospital, Zwolle, Netherlands
| | | | - Geert W J Frederix
- Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Inez M Verpalen
- Department of Radiology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, Netherlands
| | - Sebastiaan Veersema
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Judith A F Huirne
- Department of Gynecology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, Netherlands.,Department of Gynecology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, Netherlands
| | - Wouter J K Hehenkamp
- Department of Gynecology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, Netherlands
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12
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Xu F, Deng L, Zhang L, Hu H, Shi Q. The comparison of myomectomy, UAE and MRgFUS in the treatment of uterine fibroids: a meta analysis. Int J Hyperthermia 2021; 38:24-29. [PMID: 34420449 DOI: 10.1080/02656736.2021.1933216] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To compare the re-intervention rates of myomectomy, uterine artery embolization (UAE) and magnetic resonance-guided focused ultrasound surgery (MRgFUS) for uterine fibroids (UFs) in different follow-up time. METHODS Two investigators searched PubMed for clinical studies published in English from 1 Jan 2000 to 31 Dec 2020, and independently examined the paper to select qualified studies, extracted relevant information and assessed the risk of bias. Meanwhile, a meta-analysis of 31 studies containing totally 42103 patients was conducted to compare the re-intervention rate of myomectomy, UAE and MRgFUS. RESULTS In the meta-analysis of 42103 patients, the 12-month re-intervention rates of myomectomy, UAE and MRgFUS for UFs were 0.06 (95%CI, 0.01-0.11), 0.07 (95%CI, 0.06-0.09), and 0.12 (95%CI, 0.04-0.20) respectively. The 24-month re-intervention rates were 0.10 (95%CI, 0.04-0.16), 0.08 (95%CI, 0.01-0.17), and 0.14 (95%CI, 0.07-0.21) respectively. The 36-month re-intervention rates were 0.09 (95%CI, 0.05-0.13), 0.14 (95%CI, 0.05-0.23), and 0.22 (95%CI, 0.11-0.32) respectively. Additionally, the 60-month re-intervention rates were 0.19 (95%CI, 0.15-0.24), 0.21 (95%CI, 0.17-0.25), and 0.49 (95%CI, 0.21-0.77) respectively. CONCLUSIONS The myomectomy has the lowest re-intervention rate of the three regimens in short time and long time while the MRgFUS has the highest. The rate of MRgFUS increased rapidly in the 60th month after the treatment.
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Affiliation(s)
- Fan Xu
- Department of Obstetrics and Gynecology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical University, Nanchong, PR China.,State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China
| | - Lihong Deng
- Department of Obstetrics and Gynecology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical University, Nanchong, PR China
| | - Lijun Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China
| | - Huiquan Hu
- Department of Obstetrics and Gynecology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical University, Nanchong, PR China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China.,School of Public Health and Management, Chongqing Medical University, Chongqing, PR China
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13
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Yu L, Zhu S, Zhang H, Wang A, Sun G, Liang J, Wang X. The efficacy and safety of MR-HIFU and US-HIFU in treating uterine fibroids with the volume <300 cm 3: a meta-analysis. Int J Hyperthermia 2021; 38:1126-1132. [PMID: 34325610 DOI: 10.1080/02656736.2021.1954245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND High-intensity focused ultrasound (HIFU) is a promising and non-invasive therapy for symptomatic uterine fibroids. Currently, the main image-guided methods for HIFU include magnetic resonance-guided (MR-HIFU) and ultrasound-guided (US-HIFU). However, there are few comparative studies on the therapeutic efficacy and safety of MR-HIFU and US-HIFU in treating symptomatic uterine fibroids with a volume <300 cm3. OBJECTIVE We performed this meta-analysis to evaluate the efficacy and safety of MR-HIFU and US-HIFU in treating symptomatic uterine fibroids with a volume <300 cm3. METHODS We searched relevant literature in PubMed, EMBASE, Cochrane Library CNKI from inception until 2021. The mean value, the proportion, and their 95% confidence intervals (CIs) were measured by random-effects models. Publication bias was assessed using funnel plots. RESULTS 48 studies met our inclusion criteria-28 describing MR-HIFU and 20 describing US-HIFU. The mean non-perfused volume rate (NPVR) was 81.07% in the US-HIFU group and 58.92% in the MR-HIFU group, respectively. The mean volume reduction rates at month-3, month-6, and month-12 were 42.42, 58.72, and 65.55% in the US-HIFU group, while 34.79, 37.39, and 36.44% in the MR-HIFU group. The incidence of post-operative abdominal pain and abnormal vaginal discharge in the US-HIFU group was lower than that of MRI-HIFU. However, post-operative skin burn and sciatic nerve pain were more common in the US-HIFU group compared with MRI-HIFU. The one-year reintervention rate after MR-HIFU was 13.4%, which was higher than 5.2% in the US-HIFU group. CONCLUSION US-HIFU may show better efficiency and safety than MR-HIFU in treating symptomatic fibroids with a volume <300 cm3.
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Affiliation(s)
- Liang Yu
- Nanjing Medical University, Nanjing, China
| | - Shu Zhu
- Department of Gynecology, Jiangsu Province Hospital, Nanjing, China
| | | | - Anqi Wang
- Nanjing Medical University, Nanjing, China
| | - Guodong Sun
- Department of Gynecology, Jiangsu Province Hospital, Nanjing, China
| | - JiaLe Liang
- Department of Gynecology, Jiangsu Province Hospital, Nanjing, China
| | - Xiuli Wang
- Department of Gynecology, Jiangsu Province Hospital, Nanjing, China
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14
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Li W, Jiang Z, Deng X, Xu D. Long-term follow-up outcome and reintervention analysis of ultrasound-guided high intensity focused ultrasound treatment for uterine fibroids. Int J Hyperthermia 2021; 37:1046-1051. [PMID: 32878497 DOI: 10.1080/02656736.2020.1807617] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To investigate the long-term reintervention of ultrasound-guided high intensity focused ultrasound (USgHIFU) treatment for uterine fibroids and analyze the factors affecting reintervention rate after USgHIFU. MATERIALS AND METHODS Three hundred and eight-one patients with uterine fibroids treated by USgHIFU at the third Xiangya Hospital of Central South University from April 2012 to December 2014 were retrospectively reviewed. The factors that affect the reintervention rate were analyzed. RESULTS The mean follow-up time was 70.0 ± 9.0 months. During the follow-up period, 86.4% (329/381) of the patients reported symptomatic relief and the fibroids shrank after USgHIFU treatment. Seventy-nine patients received reintervention included myomectomy, a second session of HIFU, and hysterectomy. The overall reintervention rate was 20.7% (79/381). The reasons for reintervention included symptomatic recurrence in 50 (50/79, 63.3%) patients, psychological factors in 14 (14/79, 17.7%) patients, fertility requirement in three (3/79, 3.8%) patients, suspected uterine sarcoma in two (2/79, 2.5%) patients and others in 10 (10/79, 12.7%) patients. The reintervention rate has significant correlation with some factors including age, size, type and the signal intensity on T2 weighted image (T2WI) of the uterine fibroids. CONCLUSION USgHIFU for uterine fibroids is effective due to low reintervention rate in a long-term follow-up.
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Affiliation(s)
- Waixing Li
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhaoying Jiang
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xinliang Deng
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Dabao Xu
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
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15
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Ierardi AM, Carnevale A, Pellegrino F, Stefano GD, Bonelli C, Renzulli M, Giganti M, Carrafiello G. Uterine Myomas: Extravascular Treatment. Semin Ultrasound CT MR 2020; 42:56-74. [PMID: 33541590 DOI: 10.1053/j.sult.2020.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Uterine fibroids are common benign tumors that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality. The main advantages offered by mini invasive techniques are low grade of invasiveness and short times of hospitalization. The most diffuse technique is uterine artery embolization (UAE). Common concerns with UAE include postprocedural pain, postembolization syndrome, and risk of infection. Image-guided thermal ablation techniques like radiofrequency ablation, percutaneous microwave ablation, and imaging-guided high-intensity focused ultrasound were introduced to overcome the side effects related to UAE and surgery. The aim of this review is to briefly analyze the ablative procedures and their role in the management of symptomatic fibroids, and to describe the safety profile and outcomes of these modalities.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Unit, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Aldo Carnevale
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Fabio Pellegrino
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Giuseppina Di Stefano
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Cristian Bonelli
- Healthcare Professional Department, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melchiore Giganti
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Gianpaolo Carrafiello
- Radiology Unit, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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16
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Weston M, Soyer P, Barral M, Dohan A, Pierre S, Rabei R, Garcia-Reyes K, Kohi MP. Role of Interventional Procedures in Obstetrics and Gynecology. Radiol Clin North Am 2020; 58:445-462. [PMID: 32044017 DOI: 10.1016/j.rcl.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.
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Affiliation(s)
- Michael Weston
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK.
| | - Philippe Soyer
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Matthias Barral
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Anthony Dohan
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Sacha Pierre
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK
| | - Rana Rabei
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Kirema Garcia-Reyes
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
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17
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The Focused Ultrasound Myoma Outcome Study (FUMOS); a retrospective cohort study on long-term outcomes of MR-HIFU therapy. Eur Radiol 2020; 30:2473-2482. [DOI: 10.1007/s00330-019-06641-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/15/2019] [Accepted: 12/17/2019] [Indexed: 01/24/2023]
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18
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Izadifar Z, Izadifar Z, Chapman D, Babyn P. An Introduction to High Intensity Focused Ultrasound: Systematic Review on Principles, Devices, and Clinical Applications. J Clin Med 2020; 9:jcm9020460. [PMID: 32046072 PMCID: PMC7073974 DOI: 10.3390/jcm9020460] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Ultrasound can penetrate deep into tissues and interact with human tissue via thermal and mechanical mechanisms. The ability to focus an ultrasound beam and its energy onto millimeter-size targets was a significant milestone in the development of therapeutic applications of focused ultrasound. Focused ultrasound can be used as a non-invasive thermal ablation technique for tumor treatment and is being developed as an option to standard oncologic therapies. High-intensity focused ultrasound has now been used for clinical treatment of a variety of solid malignant tumors, including those in the pancreas, liver, kidney, bone, prostate, and breast, as well as uterine fibroids and soft-tissue sarcomas. Magnetic resonance imaging and Ultrasound imaging can be combined with high intensity focused ultrasound to provide real-time imaging during ablation. Magnetic resonance guided focused ultrasound represents a novel non-invasive method of treatment that may play an important role as an alternative to open neurosurgical procedures for treatment of a number of brain disorders. This paper briefly reviews the underlying principles of HIFU and presents current applications, outcomes, and complications after treatment. Recent applications of Focused ultrasound for tumor treatment, drug delivery, vessel occlusion, histotripsy, movement disorders, and vascular, oncologic, and psychiatric applications are reviewed, along with clinical challenges and potential future clinical applications of HIFU.
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Affiliation(s)
- Zahra Izadifar
- Division of Biomedical Engineering, College of Engineering, University of Saskatchewan, Saskatoon, SK S7N 5A9, Canada
- Correspondence: ; Tel.: +1-306-966-7827; Fax: +1-306-966-4651
| | - Zohreh Izadifar
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
| | - Dean Chapman
- Anatomy & Cell Biology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
| | - Paul Babyn
- Department of Medical Imaging, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada
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19
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Verpalen IM, Anneveldt KJ, Nijholt IM, Schutte JM, Dijkstra JR, Franx A, Bartels LW, Moonen CT, Edens MA, Boomsma MF. Magnetic resonance-high intensity focused ultrasound (MR-HIFU) therapy of symptomatic uterine fibroids with unrestrictive treatment protocols: A systematic review and meta-analysis. Eur J Radiol 2019; 120:108700. [DOI: 10.1016/j.ejrad.2019.108700] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/02/2019] [Indexed: 12/29/2022]
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20
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Anastasiadis P, Mohammadabadi A, Fishman MJ, Smith JA, Nguyen BA, Hersh DS, Frenkel V. Design, characterization and evaluation of a laser-guided focused ultrasound system for preclinical investigations. Biomed Eng Online 2019; 18:36. [PMID: 30922312 PMCID: PMC6440155 DOI: 10.1186/s12938-019-0656-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/19/2019] [Indexed: 01/29/2023] Open
Abstract
Background The clinical applications of transcranial focused ultrasound continue to expand and include ablation as well as drug delivery applications in the brain, where treatments are typically guided by MRI. Although MRI-guided focused ultrasound systems are also preferred for many preclinical investigations, they are expensive to purchase and operate, and require the presence of a nearby imaging center. For many basic mechanistic studies, however, MRI is not required. The purpose of this study was to design, construct, characterize and evaluate a portable, custom, laser-guided focused ultrasound system for noninvasive, transcranial treatments in small rodents. Methods The system comprised an off-the-shelf focused ultrasound transducer and amplifier, with a custom cone fabricated for direct coupling of the transducer to the head region. A laser-guidance apparatus was constructed with a 3D stage for accurate positioning to 1 mm. Pressure field simulations were performed to demonstrate the effects of the coupling cone and the sealing membrane, as well as for determining the location of the focus and acoustic transmission across rat skulls over a range of sizes. Hydrophone measurements and exposures in hydrogels were used to assess the accuracy of the simulations. In vivo treatments were performed in rodents for opening the blood–brain barrier and to assess the performance and accuracy of the system. The effects of varying the acoustic pressure, microbubble dose and animal size were evaluated in terms of efficacy and safety of the treatments. Results The simulation results were validated by the hydrophone measurements and exposures in the hydrogels. The in vivo treatments demonstrated the ability of the system to open the blood–brain barrier. A higher acoustic pressure was required in larger-sized animals, as predicted by the simulations and transmission measurements. In a particular sized animal, the degree of blood–brain barrier opening, and the safety of the treatments were directly associated with the microbubble dose. Conclusion The focused ultrasound system that was developed was found to be a cost-effective alternative to MRI-guided systems as an investigational device that is capable of accurately providing noninvasive, transcranial treatments in rodents.
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Affiliation(s)
- Pavlos Anastasiadis
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Mohammadabadi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
| | - Meyer J Fishman
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
| | - Jesse A Smith
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
| | - Ben A Nguyen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
| | - David S Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Victor Frenkel
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA. .,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Moncion A, Harmon JN, Li Y, Natla S, Farrell EC, Kripfgans OD, Stegemann JP, Martín-Saavedra FM, Vilaboa N, Franceschi RT, Fabiilli ML. Spatiotemporally-controlled transgene expression in hydroxyapatite-fibrin composite scaffolds using high intensity focused ultrasound. Biomaterials 2019; 194:14-24. [PMID: 30572283 PMCID: PMC6339574 DOI: 10.1016/j.biomaterials.2018.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/13/2018] [Accepted: 12/09/2018] [Indexed: 01/05/2023]
Abstract
Conventional tissue engineering approaches rely on scaffold-based delivery of exogenous proteins, genes, and/or cells to stimulate regeneration via growth factor signaling. However, scaffold-based approaches do not allow active control of dose, timing, or spatial localization of a delivered growth factor once the scaffold is implanted, yet these are all crucial parameters in promoting tissue regeneration. To address this limitation, we developed a stable cell line containing a heat-activated and rapamycin-dependent gene expression system. In this study, we investigate how high intensity focused ultrasound (HIFU) can spatiotemporally control firefly luciferase (fLuc) transgene activity both in vitro and in vivo by the tightly controlled generation of hyperthermia. Cells were incorporated into composite scaffolds containing fibrin and hydroxyapatite particles, which yielded significant increases in acoustic attenuation and heating in response to HIFU compared to fibrin alone. Using 2.5 MHz HIFU, transgene activation was observed at acoustic intensities of 201 W/cm2 and higher. Transgene activation was spatially patterned in the scaffolds by rastering HIFU at speeds up to 0.15 mm/s. In an in vivo study, a 67-fold increase in fLuc activity was observed in scaffolds exposed to HIFU and rapamycin versus rapamycin only at 2 days post implantation. Repeated activation of transgene expression was also demonstrated 8 days after implantation. No differences in in vivo scaffold degradation or compaction were observed between +HIFU and -HIFU groups. These results highlight the potential utility of using this heat-activated and rapamycin-dependent gene expression system in combination with HIFU for the controlled stimulation of tissue regeneration.
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Affiliation(s)
- Alexander Moncion
- Applied Physics Program, University of Michigan, Ann Arbor, MI, USA; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jennifer N Harmon
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Yan Li
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Sam Natla
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Easton C Farrell
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Oliver D Kripfgans
- Applied Physics Program, University of Michigan, Ann Arbor, MI, USA; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jan P Stegemann
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Francisco M Martín-Saavedra
- Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - Nuria Vilaboa
- Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - Renny T Franceschi
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mario L Fabiilli
- Applied Physics Program, University of Michigan, Ann Arbor, MI, USA; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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New and Emerging Applications of Magnetic Resonance Elastography of Other Abdominal Organs. Top Magn Reson Imaging 2019; 27:335-352. [PMID: 30289829 DOI: 10.1097/rmr.0000000000000182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Increasing clinical experience and ongoing research in the field of magnetic resonance elastography (MRE) is leading to exploration of its applications in other abdominal organs. In this review, the current research progress of MRE in prostate, uterus, pancreas, spleen, and kidney will be discussed. The article will describe patient preparation, modified technical approach including development of passive drivers, modification of sequences, and inversion. The potential clinical application of MRE in the evaluation of several disease processes affecting these organs will be discussed. In an era of increasing adoption of multiparametric magnetic resonance imaging approaches for solving complex abdominal problems, abdominal MRE as a biomarker may be seamlessly incorporated into a standard magnetic resonance imaging examination to provide a rapid, reliable, and comprehensive imaging evaluation at a single patient appointment in the future.
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Mohr-Sasson A, Machtinger R, Mashiach R, Nir O, Inbar Y, Maliyanker N, Goldenberg M, Rabinovici J. Long-term outcome of MR-guided focused ultrasound treatment and laparoscopic myomectomy for symptomatic uterine fibroid tumors. Am J Obstet Gynecol 2018; 219:375.e1-375.e7. [PMID: 30217580 DOI: 10.1016/j.ajog.2018.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/24/2018] [Accepted: 09/04/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fibroid tumors are the most common benign tumors in women of reproductive age. Treatment is usually indicated for those who are symptomatic, with different techniques being used. OBJECTIVE The purpose of this study was to compare the long-term outcome of laparoscopic myomectomy with magnetic resonance-guided focused ultrasound for symptomatic uterine fibroid tumors. STUDY DESIGN A cohort study was conducted on all patients with symptomatic uterine fibroid tumors who were admitted to a single tertiary care center and treated operatively with laparoscopic myomectomy or treated conservatively with magnetic resonance-guided focused ultrasound from January 2012 until January 2017. Assessment for further interventions and sustained fibroid-associated symptoms was performed, with the use of the Uterine Fibroid Symptom and Quality of Life symptom severity score. RESULTS One hundred fifty-four women met the inclusion criteria. Complete follow-up evaluation was achieved for 64 women who underwent laparoscopic myomectomy and for 68 women who were treated by magnetic resonance-guided focused ultrasound. Follow-up time was similar for the 2 groups (median, 31 months [interquartile range, 17-51 months] vs 36 months [interquartile range, 24-41]; P=.95). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (P=0.312). Similarly, the Uterine Fibroid Symptom and Quality of Life symptom severity score questionnaire score at follow-up interviews revealed comparable median scores of 17 (interquartile range, 12-21) vs 17 (interquartile range, 13-22) for laparoscopic myomectomy and magnetic resonance-guided focused ultrasound, respectively (P=.439). Analysis of each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue) did not change these findings, nor did a multivariate analysis. CONCLUSION Satisfaction with long-term outcome and rate of reinterventions after magnetic resonance-guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.
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Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ronit Machtinger
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer Nir
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Inbar
- Department of Radiology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nirit Maliyanker
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Motti Goldenberg
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jaron Rabinovici
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
Uterine leiomyomas are common and life-altering for many women. Despite a wide range of symptoms, varying characteristics of the uterus and the leiomyomas themselves, and many alternatives, hysterectomy accounts for almost three fourths of all surgical therapy, yet there is increasing evidence for a variety of procedural therapies for symptomatic leiomyomas and a new generation of medical therapies under development. With increasing evidence of long-term risk from hysterectomy and new data regarding leiomyoma biology, individualized medical approaches to leiomyomas are likely in the near future. Key biological attributes that influence this disease process are common driver mutations and the new appreciation of the interaction of smooth muscle cells and fibroblasts. Additionally, the interaction between cell types and steroid hormone responsiveness likely plays a role in pathogenesis that can be leveraged in individualized therapy. However, given the independent clonal nature of leiomyomas within the same uterus, moving in the direction of biopsies for individual leiomyomas to understand the biology is unlikely to be fruitful. Use of advanced imaging will likely continue to evolve not only to accurately predict malignant disease, including sarcomas, but to predict leiomyoma subtypes, response to therapy, or both. We predict the continued evolution of therapy from excisional or interventional therapies to medical therapies and ultimately prediction of at-risk individuals. Ideally, individualized therapies will offer primary prevention for women at high risk of leiomyomas and secondary prevention after initial treatment.
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Affiliation(s)
- Shannon K. Laughlin-Tommaso
- Division of Gynecology, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Elizabeth A. Stewart
- Department of Surgery, Mayo Clinic, Rochester, MN
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
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25
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Jondal DE, Wang J, Chen J, Gorny KR, Felmlee J, Hesly G, Laughlin-Tommaso S, Stewart EA, Ehman R, Woodrum DA. Uterine fibroids: correlations between MRI appearance and stiffness via magnetic resonance elastography. Abdom Radiol (NY) 2018; 43:1456-1463. [PMID: 28952003 DOI: 10.1007/s00261-017-1314-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
RATIONALE AND OBJECTIVES Magnetic resonance elastography has proven to be a valuable tool in the diagnosis of liver fibrosis, breast and cervical cancer, but its application in uterine fibroids requires further characterization. The aim of the present study was to examine the relationship between uterine fibroid stiffness by MRE and MR imaging characteristics. MATERIALS AND METHODS An IRB-approved, HIPAA compliant review was performed of prospectively collected pelvic MRI and 2D-MRE data in patients with symptomatic uterine fibroids (N = 102). T1 and T2 weighted pelvic MRI with gadolinium enhancement were performed. In a small patient subset, fibroid stiffness was assessed by both 2D and 3D MRE. Fibroid stiffness by modality or imaging characteristics was analyzed using one-way analysis of variance followed by Student t test. RESULTS Four fibroid groups were identified based on T2 appearance: Isointense (N = 7), bright (N = 6), dark with minimal heterogeneity (N = 69), and dark with substantial heterogeneity (N = 20). Mean fibroid stiffness was 4.81 ± 2.12 kPa. Comparison of fibroid stiffness by T2 signal intensity showed that T2 bright fibroids were significantly less stiff than fibroids appearing T2 dark with minimal heterogeneity (mean stiffness difference = 2.38 kPa; p < 0.05) and T2 dark fibroids with substantial heterogeneity were significantly less stiff than T2 dark fibroids with minimal heterogeneity (mean difference = 1.25 kPa; p < 0.05). There was no significant association between fibroid stiffness and T1 signal characteristics or gadolinium enhancement. There was no significant difference in stiffness values obtained by either 2D vs. 3D MRE. CONCLUSIONS These data suggest differences in fibroid stiffness are associated with different T2 imaging characteristics with less stiff fibroids being T2 bright and more stiff fibroids being T2 dark. Further studies are needed to determine if fibroid stiffness by MRE may serve as an imaging biomarker to help predict MR-guided treatment response.
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Affiliation(s)
- Danielle E Jondal
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jin Wang
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jun Chen
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Krzysztof R Gorny
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Joel Felmlee
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Gina Hesly
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Richard Ehman
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David A Woodrum
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Reintervention risk and quality of life outcomes after uterine-sparing interventions for fibroids: a systematic review and meta-analysis. Fertil Steril 2018; 109:698-707.e1. [DOI: 10.1016/j.fertnstert.2017.11.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 12/23/2022]
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Sridhar D, Kohi MP. Updates on MR-Guided Focused Ultrasound for Symptomatic Uterine Fibroids. Semin Intervent Radiol 2018; 35:17-22. [PMID: 29628611 PMCID: PMC5886770 DOI: 10.1055/s-0038-1636516] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Magnetic-resonance-guided focused ultrasound (MRgFUS), also called high-intensity focused ultrasound (HIFU) is an effective, noninvasive uterine-preserving treatment for symptomatic uterine fibroids. As the use of this therapeutic modality is not yet widespread, it may remain unfamiliar to many interventional radiologists. The purpose of this review is to discuss MRgFUS, including technology, patient selection, technique, outcomes, complications, and recent data on fertility and comparative effectiveness.
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Affiliation(s)
- Divya Sridhar
- Department of Radiology, NYU Langone Health, New York, New York
| | - Maureen P. Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Abstract
AbstractUterine fibroids affect a wide cross-section of the population, with prevalence, symptom severity, and overall disease burden generally higher among black women, likely due to both genetic and environmental factors. Potential symptoms of uterine fibroids include painful and excessive uterine bleeding, interference with everyday life and self-image, and impaired fertility. Because of the high estimated prevalence and costs associated with treatments, the direct and indirect costs of uterine fibroids are substantial for both the health care system and the individual patient. Special patient populations—such as black women, women seeking to retain fertility, and women with asymptomatic fibroids—have particular treatment needs that require a variety of diagnostic methods and treatment options. Despite the widespread occurrence of uterine fibroids and newer treatment options, little high-quality data are available to formulate evidence-based guidelines that address these unmet patient needs. Specific areas in need of attention include improving diagnostic techniques, increasing patient access to early treatment, and identifying best practices for this diverse patient population.
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Affiliation(s)
- Ayman Al-Hendy
- Division of Translational Research, Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Evan Robert Myers
- Division of Clinical and Epidemiological Research, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth Stewart
- Department of Obstetrics and Gynecology and Surgery, Mayo Clinic, Rochester, Minnesota
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Iversen H, Dueholm M. Radiofrequency Thermal Ablation for Uterine Myomas: Long-term Clinical Outcomes and Reinterventions. J Minim Invasive Gynecol 2017; 24:1020-1028. [DOI: 10.1016/j.jmig.2017.05.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 04/07/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
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Non-surgical Management of Myomas. J Minim Invasive Gynecol 2017; 25:229-236. [PMID: 28821471 DOI: 10.1016/j.jmig.2017.08.642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 12/24/2022]
Abstract
Uterine myomas are a common condition and the leading cause of hysterectomy. Clinically, myomas can be challenging because they range from asymptomatic to causing severe, debilitating symptoms and occur in many women before childbearing is complete. Thus, women often seek uterine-conserving and nonsurgical management of their myomas. In this review the available uterine-conserving treatment options from medical management through minimally invasive procedures are discussed. To the extent of research available, the sustainability of symptom improvement and the effects on future fertility are reviewed. Future research may lead to therapies that reduce the risks of major surgery, decrease side effects, and offer primary or secondary prevention options.
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31
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Silberzweig JE, Powell DK, Matsumoto AH, Spies JB. Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques. Radiology 2017; 280:675-92. [PMID: 27533290 DOI: 10.1148/radiol.2016141693] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.
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Affiliation(s)
- James E Silberzweig
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - Daniel K Powell
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - Alan H Matsumoto
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - James B Spies
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
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32
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Kim YS. Clinical application of high-intensity focused ultrasound ablation for uterine fibroids. Biomed Eng Lett 2017; 7:99-105. [PMID: 30603156 DOI: 10.1007/s13534-017-0012-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/26/2016] [Accepted: 11/06/2016] [Indexed: 12/17/2022] Open
Abstract
HIFU (high-intensity focused ultrasound) ablation is an emerging therapeutic modality that induces thermal coagulative necrosis of biological tissues by focusing high-energy ultrasound waves onto one small spot. This technique is at various stages of clinical applications in several organs. However, it has increasingly been used in the treatment of symptomatic uterine fibroids, a common condition affecting women. Since its first clinical use for symptomatic uterine fibroids, this technique has been recognized for safety, satisfactory therapeutic efficacy in symptom control, uterus-preserving ability, radiation-free nature, and because of the fact that it does not require hospitalization. Owing to its numerous benefits, HIFU ablation is currently one of the major therapeutic options for symptomatic uterine fibroids. In this review, several aspects ranging from the physical principle of HIFU to the long-term outcomes are summarized from the perspective of the clinical application for uterine fibroids.
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Affiliation(s)
- Young-Sun Kim
- 1Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710 Korea.,Present Address: Department of Radiology, Uterine Fibroid Integrated Management Center, MINT Intervention Hospital, 640-3, Munjeong-dong, Songpa-gu, Seoul, Korea
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34
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Jeong JH, Hong GP, Kim YR, Ha JE, Lee KS. Clinical Consideration of Treatment to Ablate Uterine Fibroids with Magnetic Resonance Imaging-guided High Intensity Focused Ultrasound (MRgFUS): Sonalleve. J Menopausal Med 2016; 22:94-107. [PMID: 27617244 PMCID: PMC5016510 DOI: 10.6118/jmm.2016.22.2.94] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/17/2016] [Accepted: 07/26/2016] [Indexed: 12/18/2022] Open
Abstract
Objectives Magnetic resonance imaging (MRI)-guided high intensity focused ultrasound surgery (MRgFUS) is a newly emerging non-invasive technique for the treatment of uterine fibroids. The purpose of this study is to review the clinical impact of MRgFUS. Methods This study examined 157 patients. The high intensity focused ultrasound (HIFU) utilized in this study was Philips Achieva 1.5 Tesla MR (Philips Healthcare, Best, the Netherlands) and Sonalleve HIFU system. The patients were followed in post-operative Month 1, Month 3, and Month 6 to investigate any change. Then, these were further classified according to the use of uterine stimulant (oxytocin) in parallel, Funaki Type of uterine fibroid, HIFU intensity, and non-perfused volume (NPV) ratio. Results When the uterine stimulant was utilized, the HIFU intensity was measured at significantly lower levels, compared with the group not using uterine stimulant, and treatment duration was significantly. The NPV ratio was found significantly higher in the group using uterine stimulant. Concerning the correlation between Funaki Type of uterine fibroid and average sonication power, it was found that the closer to Type I, the lower the sonication power, the shorter the treatment duration, and the higher the NPV ratio significantly. Conclusions In this study, it was found that the lower the Funaki Types of uterine fibroids, and the higher the NPV ratio immediately after the operation, the larger the uterine fibroid volume decrease and SSS change were. Also, if uterine stimulant was used in parallel in treatment, treatment duration and HIFU intensity could become shorter and lower.
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Affiliation(s)
- Jae-Hyeok Jeong
- Department of Obstetrics & Gynecology, Hwa Myung Il Sin Christian Hospital, Busan, Korea
| | - Gil Pyo Hong
- Department of Obstetrics & Gynecology, Hwa Myung Il Sin Christian Hospital, Busan, Korea
| | - Yu-Ri Kim
- Department of Obstetrics & Gynecology, Hwa Myung Il Sin Christian Hospital, Busan, Korea
| | - Jae-Eun Ha
- Department of Obstetrics & Gynecology, Hwa Myung Il Sin Christian Hospital, Busan, Korea
| | - Kyu-Sup Lee
- Department of Obstetrics & Gynecology, Pusan National University School of Medicine, Busan, Korea
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Stewart EA, Laughlin-Tommaso SK, Catherino WH, Lalitkumar S, Gupta D, Vollenhoven B. Uterine fibroids. Nat Rev Dis Primers 2016; 2:16043. [PMID: 27335259 DOI: 10.1038/nrdp.2016.43] [Citation(s) in RCA: 270] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Uterine fibroids (also known as leiomyomas or myomas) are common clonal neoplasms of the uterus. Fibroids have both smooth muscle and fibroblast components, in addition to a substantial amount of fibrous extracellular matrix, which all contribute to the pathogenetic process. Fibroids are extremely heterogeneous in their pathophysiology, size, location and clinical symptomatology. They are also a part of a range of disease in which some variants have facets of malignant behaviour but overall are benign. Risk for fibroids is associated with race; black women have a higher risk of developing fibroids earlier in life than their white counterparts and also develop more-severe forms of the disease. Clinically, fibroids account for one-third to half of all hysterectomies and are associated with substantial morbidity and health care costs for women of reproductive age. Indeed, current treatments are primarily surgical and interventional; approximately three-quarters of all fibroid treatments are hysterectomies. However, clinical innovations are emerging in the use of progesterone receptor modulators as a medical therapy. New information is rapidly accumulating about the genetic subgroups that lead to fibroid formation, which might aid further understanding of the clinical heterogeneity of this disease and lead to individualized treatments. This information is a crucial development given the current lack of high-quality evidence on which to base therapeutic decisions.
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Affiliation(s)
- Elizabeth A Stewart
- Departments of Obstetrics and Gynecology and Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Shannon K Laughlin-Tommaso
- Departments of Obstetrics and Gynecology and Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - William H Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sujata Lalitkumar
- Department of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Devashana Gupta
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia.,Women's Program, Monash Health, Melbourne, Victoria, Australia.,Monash IVF, Clayton, Victoria, Australia
| | - Beverley Vollenhoven
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia.,Women's Program, Monash Health, Melbourne, Victoria, Australia.,Monash IVF, Clayton, Victoria, Australia
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Carias M, Hynynen K. Combined Therapeutic and Monitoring Ultrasonic Catheter for Cardiac Ablation Therapies. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:196-207. [PMID: 26431798 DOI: 10.1016/j.ultrasmedbio.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 08/13/2015] [Accepted: 08/19/2015] [Indexed: 06/05/2023]
Abstract
This study evaluated the feasibility of a combined therapeutic and diagnostic ultrasonic catheter for cardiac ablation therapies. Ultrasound can be used to determine when diseased cardiac tissues have become fully coagulated through a method known as local harmonic motion imaging (LHMI). LHMI is an imaging modality for treatment monitoring that uses acoustic radiation force, displacement tracking and the different mechanical properties of viable and ablated tissues. In this study, we developed catheters that are capable of LHMI measurements. Experiments were conducted in phantoms, ex vivo cardiac samples and the in vivo beating hearts of healthy porcine subjects. In vivo experiments revealed that four of four epicardial sonications revealed a decrease in measured displacements from LHMI experiments and that when lower power was used, no lesions formed and there was no corresponding decrease in measured displacement amplitudes. In addition, two of three endocardial lesions were confirmed and corresponded to a decrease in the measured displacement amplitude.
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Affiliation(s)
- Mathew Carias
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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Thiburce AC, Frulio N, Hocquelet A, Maire F, Salut C, Balageas P, Bouzgarrou M, Hocké C, Trillaud H. Magnetic resonance-guided high-intensity focused ultrasound for uterine fibroids: Mid-term outcomes of 36 patients treated with the Sonalleve system. Int J Hyperthermia 2015; 31:764-70. [DOI: 10.3109/02656736.2015.1063169] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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McLucas B, Voorhees III WD, Elliott S. Fertility after uterine artery embolization: a review. MINIM INVASIV THER 2015; 25:1-7. [DOI: 10.3109/13645706.2015.1074082] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
In this review, several clinical applications of magnetic resonance (MR)-guided focused ultrasound (FUS) are updated. MR-guided FUS is used clinically for thermal ablation of uterine fibroids and bone metastases. Thousands of patients have successfully been treated. Transcranial MR-guided FUS has received CE certification for ablation of deep, central locations in the brain. Thermal ablation of specific parts of the thalamus can result in relief of the symptoms in a number of neurological disorders. Several approaches have been proposed for ablation of prostate and breast cancer and clinical trials should show the potential of MR-guided FUS for these and other applications.
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Commandeur AE, Styer AK, Teixeira JM. Epidemiological and genetic clues for molecular mechanisms involved in uterine leiomyoma development and growth. Hum Reprod Update 2015; 21:593-615. [PMID: 26141720 DOI: 10.1093/humupd/dmv030] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 06/09/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Uterine leiomyomas (fibroids) are highly prevalent benign smooth muscle tumors of the uterus. In the USA, the lifetime risk for women developing uterine leiomyomas is estimated as up to 75%. Except for hysterectomy, most therapies or treatments often provide only partial or temporary relief and are not successful in every patient. There is a clear racial disparity in the disease; African-American women are estimated to be three times more likely to develop uterine leiomyomas and generally develop more severe symptoms. There is also familial clustering between first-degree relatives and twins, and multiple inherited syndromes in which fibroid development occurs. Leiomyomas have been described as clonal and hormonally regulated, but despite the healthcare burden imposed by the disease, the etiology of uterine leiomyomas remains largely unknown. The mechanisms involved in their growth are also essentially unknown, which has contributed to the slow progress in development of effective treatment options. METHODS A comprehensive PubMed search for and critical assessment of articles related to the epidemiological, biological and genetic clues for uterine leiomyoma development was performed. The individual functions of some of the best candidate genes are explained to provide more insight into their biological function and to interconnect and organize genes and pathways in one overarching figure that represents the current state of knowledge about uterine leiomyoma development and growth. RESULTS In this review, the widely recognized roles of estrogen and progesterone in uterine leiomyoma pathobiology on the basis of clinical and experimental data are presented. This is followed by fundamental aspects and concepts including the possible cellular origin of uterine fibroids. The central themes in the subsequent parts are cytogenetic aberrations in leiomyomas and the racial/ethnic disparities in uterine fibroid biology. Then, the attributes of various in vitro and in vivo, human syndrome, rodent xenograft, naturally mutant, and genetically modified models used to study possible molecular mechanisms of leiomyoma development and growth are described. Particular emphasis is placed on known links to fibrosis, hypertrophy, and hyperplasia and genes that are potentially important in these processes. CONCLUSIONS Menstrual cycle-related injury and repair and coinciding hormonal cycling appears to affect myometrial stem cells that, at a certain stage of fibroid development, often obtain cytogenetic aberrations and mutations of Mediator complex subunit 12 (MED12). Mammalian target of rapamycin (mTOR), a master regulator of proliferation, is activated in many of these tumors, possibly by mechanisms that are similar to some human fibrosis syndromes and/or by mutation of upstream tumor suppressor genes. Animal models of the disease support some of these dysregulated pathways in fibroid etiology or pathogenesis, but none are definitive. All of this suggests that there are likely several key mechanisms involved in the disease that, in addition to increasing the complexity of uterine fibroid pathobiology, offer possible approaches for patient-specific therapies. A final model that incorporates many of these reported mechanisms is presented with a discussion of their implications for leiomyoma clinical practice.
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Affiliation(s)
- Arno E Commandeur
- Center for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Aaron K Styer
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jose M Teixeira
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, 333 Bostwick Ave NE, 4018A, Grand Rapids, MI, USA Department of Women's Health, Spectrum Health Systems, Grand Rapids, MI, USA
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Quinn S, Vedelago J, Gedroyc W, Regan L. Safety and five-year re-intervention following magnetic resonance-guided focused ultrasound (MRgFUS) for uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2014; 182:247-51. [DOI: 10.1016/j.ejogrb.2014.09.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 09/19/2014] [Accepted: 09/29/2014] [Indexed: 11/28/2022]
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Matsumoto AH. Moving forward with sound technology. J Vasc Interv Radiol 2014; 25:1513-4. [PMID: 25255946 DOI: 10.1016/j.jvir.2014.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee Street, Box 800170, Charlottesville, VA 22908.
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