Uterine Artery Embolization as a Treatment Option for Uterine Myomas

Our Experience with Hydrogel-Coated Trisacryl Microspheres in Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids and Adenomyosis: A Follow-Up of 11 Years

Uterine artery embolization (UAE) for the treatment of symptomatic uterine fibroids and non-controllable adenomyosis symptoms is a relatively new procedure for organ-preserving therapy. These benign conditions can become symptomatic in about 30% of women between the ages of 35 and 50. The purpose of the UAE either for fibroids or adenomyosis is the elimination of blood loss, the reduction in pain, and bulky or rectal pressure symptoms. The purpose of this study is to present our experience in UAE with the use of hydrogel-coated tris acryl microspheres for the treatment of symptomatic uterine fibroids and adenomyosis.

Life Quality in Premenopausal Women after Embolization of Uterine Myomas

Objectives: Fibroids cause significant morbidity and are the most common indication for hysterectomies worldwide, delimiting a major public health problem. Uterine artery embolization (UAE) is an alternative therapy to surgical treatment of symptomatic fibroids; it has satisfactory long-time results and is no longer considered investigational for the treatment of symptomatic fibroids. This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after UAE and to optimize the assessment of safety and outcomes measures for participants who receive UAE to objective compare UAE and surgical alternatives for therapy of symptomatic fibroids. Study design: The analysis was based on questionnaires completed by 270 pre-menopausal females with a mean age of 42 years (range, 38-50 years) who underwent UAE for uterine leiomyomas and/or adenomyosis from November 2013 through December 2019. Only symptomatic women were selected whose symptoms were not improving with medication and who did not wish to have children. The primary outcome measure was a change in fibroid symptoms and HRQOL (health related quality of life) after UAE. Secondary outcomes included the decrease in uterine volume after UAE. Results: Questionnaires were completed by 270 women (100%) at a mean of 12.1 months from UAE. The median follow-up period was two years. Uterine fibroid embolization led to a shrinkage at three months for the 90% of the participants. A reduction of bleeding symptoms, pain and bulk-related symptoms was observed in 89.7%, 88.9%, and 89.5% of the patients, respectively. In the long term, there was no significant difference in parameters assessed compared with the midterm follow-up findings. A total of 6 patients (2.3%) underwent fractional curettage an average of 32.1 months after intervention due to necrotic changes in submucosal fibroids. All participants continued to be satisfied with the intervention, and 240 patients (88.9%) answered that they would recommend uterine fibroid embolization to other patients. Conclusions: Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL which is associated with high levels of satisfaction with the procedure (even when subsequent therapies are pursued).

Clinical outcomes of uterine artery embolization and experience of postoperative transvaginal fibroid expulsion: a retrospective analysis

PURPOSE

To explore the efficacy of uterine artery embolization (UAE) in the treatment of uterine fibroid and share the experience of transvaginal fibroid expulsion (FE) after UAE.

METHODS

We retrospectively analyzed the changes in uterine and fibroid volume in 152 patients with symptomatic uterine fibroid after UAE at Fujian Provincial Hospital and Fujian Longyan People Hospital from March 2014 to March 2020. After a 12-month follow-up, the improvement in postoperative clinical symptoms and the incidence of complications were evaluated. We also shared the clinical features and imaging findings of four patients with FE after UAE.

RESULTS

All 152 patients successfully underwent UAE. After a 12-month follow-up, the postoperative volumes of the uterus and fibroid at 3, 6, and 12 months were significantly reduced or disappeared compared to those before surgery (P < 0.05). Clinical symptoms, such as menorrhagia, dysmenorrhea, prolonged menstrual period, anemia, increased leucorrhea, pelvic discomfort, and urinary tract compression, were significantly improved after UAE. Among the 152 patients, the incidences of postoperative fever, nausea, vomiting, lower abdominal pain, and increased vaginal secretion were 7.89%, 7.24%, 3.95%, 19.08%, and 4.61%, respectively. Additionally, there were six cases of FE, with an incidence of 3.95%. Three cases of fibroid specimens and pathological images of fibroid biopsy, which were expelled through the vagina, were also provided.

CONCLUSION

UAE is a satisfactory alternative surgical method for symptomatic uterine fibroid with definitive efficacy and high safety. However, it is necessary to guard against the occurrence of postoperative complications such as FE.

Reducing the risk of bleeding after myomectomy: is preemptive embolization a valuable tool?

PURPOSE

Abdominal myomectomy can be a challenging procedure, with elevated intraoperative blood loss and post-operative complications such as the need for blood transfusion and hemostasis with sometimes hysterectomy. Previous studies suggested that preemptive uterine artery embolization (PUAE) might reduce intraoperative blood loss.

MATERIALS AND METHODS

We reviewed all cases of abdominal myomectomy in our institution between January 2016 and June 2018. Out of 119 cases, 16 patients had PUAE and 103 did not. The objective of our study was to determine whereas PUAE reduced blood loss and post-operative complication rate.

RESULTS

In our study, there was no difference between the two groups in regard to average blood loss (128 vs 192 mL, OR 1,00 [0.99;1,01], p = 0,73), difference between pre- and post-operative hemoglobin level (- 1,15 g/dL vs - 1,32 g/dL, OR 0,91 [0.47;1,73], p = 0,79), and post-operative complications (need for transfusion, surgical revision, post-operative embolization, hysterectomy).

CONCLUSION

Our findings could not conclude that PUAE is effective in reducing intraoperative blood loss during abdominal myomectomy, but it should still be considered an option for patients with large or multiple myomas, with a specific situation or previously operated, who wish to preserve their uterus.

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

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

Impact of grayscale and Doppler ultrasound characteristics on reducing the size of tumors in the treatment of uterine fibroids by uterine artery embolization

Aim of the study

Uterine fibroids are one of the most prevalent benign tumors. This study aimed to evaluate the effect of uterine artery embolization on treating and reducing the size of symptomatic uterine fibroids.

Material and methods

Eighty patients with uterine fibroids were selected for this study. Then ultrasound and Doppler were performed by a radiologist to evaluate the size, number, echogenicity, vascularity, and location of fibroids in the uterine wall. Before performing uterine artery embolization, prothrombin time, partial thromboplastin time, international normalized ratio, blood urea nitrogen, and creatinine tests were performed for all the patients to identify background problems. Finally, SPSS 22 was used for data analysis.

Results

The dominant fibroid volume before the embolization was 244.57 cm³, which decreased to 219.96 cm³, 190.58 cm³, 114.18 cm³, 140.51 cm³, and 78.86 cm³ in the first week, first month, third month, sixth month and first year after embolization, which was statistically significant (p < 0.001 in all cases). Uterine volume in multiple tumor before the embolization was 486.27 cm³, which decreased to 408.36 cm³, 387.60 cm³, 299.67 cm³, 190.00 cm³ and 172.33 cm³ after the first week, first month, third month, sixth month and first year after embolization, which in the first week and third month was statistically significant and not significant in other cases (p = 0.003, p = 0.500, p = 0.028, p = 0.068, p = 0.109). The relationships of the number of fibroid tumors, echogenicity and vascularity with volume reduction were not statistically significant (p = 0.924, p = 0.208, p = 0.455).

Conclusions

Uterine artery embolization is an effective treatment for fibroid tumors. In this study, the number of tumors, echogenicity, and vascularity of tumors had no effect on tumor volume reduction.

Postoperative Quality of Life and Sexual Function in Premenopausal Women Undergoing Laparoscopic Myomectomy for Symptomatic Fibroids: A Prospective Observational Cohort Study

Introduction

Uterine leiomyomas are the most common benign gynecologic tumors. To date laparoscopy myomectomy is the gold standard for treatment of symptomatic fibroids in reproductive-aged women. Detailed counseling about the effects of this procedure on postoperative sexuality and quality of life is important in these patients. However, available data on these subjects are limited and contradictory. The aim of this study was to assess sexual function and quality of life in premenopausal women undergoing laparoscopic myomectomy for symptomatic uterine fibroids.

Material and Methods

All premenopausal women who underwent laparoscopic myomectomy for symptomatic fibroids between April 2012 and August 2014 at a tertiary university center were enrolled in this prospective observational cohort study. Sexual function and quality of life were assessed for the pre- and postoperative (six months post-operatively) state using two validated questionnaires, the Female Sexual Function Index (FSFI) and the European Quality of Life Five-Dimension Scale (EQ-5D).

Results

Ninety-five of the 115 (83%) eligible patients completed the study. Overall a significant improvement in quality of life and sexual function was observed in the study cohort: Median FSFI (28 (18.7–35.2)) and EQ-5D scores (1 (0.61–1) after laparoscopic myomectomy were significantly higher than preoperative scores (21.2 (5.2–33.5); 0.9 (0.2–1); p ≤ 0.01). The number, position and localization of the largest fibroids were not correlated with pre- or postoperative sexual function or quality of life.

Conclusion

Laparoscopic myomectomy might have positive short-term effects on postoperative quality of life and sexual function in premenopausal women suffering from symptomatic fibroids.

Management of fibroids in perimenopausal women

PURPOSE OF REVIEW

This article reviews fibroids management in the perimenopausal period, and addresses future directions in care.

RECENT FINDINGS

Aromatase inhibitors, selective estrogen receptor modulators and antiprogestogens for medical management and minimally surgical techniques are promising treatments.

SUMMARY

The disease and the symptoms may persist in the peri and postmenopausal periods. The assumption that they will resolve with the onset of the menopause is too simplistic and not always valid. The number of perimenopausal women who wish to retain their uterus for reasons other than childbearing is increasing. The accurate diagnosis of these conditions may result in minor surgical or medical treatments being directed at the specific pathology and may avoid the need for major surgery.

Synthesis and characterization of image-able polyvinyl alcohol microspheres for image-guided chemoembolization

Therapeutic embolization of blood vessels is a minimally invasive, catheter-based procedure performed with solid or liquid emboli to treat bleeding, vascular malformations, and vascular tumors. Hepatocellular carcinoma (HCC) affects about half a million people per year. When unresectable, HCC is treated with embolization and local drug therapy by transarterial chemoembolization (TACE). For TACE, drug eluting beads (DC Bead(®)) may be used to occlude or reduce arterial blood supply and deliver chemotherapeutics locally to the tumor. Although this treatment has been shown to be safe and to improve patient survival, the procedure lacks imaging feedback regarding the location of embolic agent and drug coverage. To address this shortcoming, herein we report the synthesis and characterization of image-able drug eluting beads (iBeads) from the commercial DC Bead(®) product. Two different radiopaque beads were synthesized. In one approach, embolic beads were conjugated with 2,3,5-triiodobenzyl alcohol in the presence of 1,1'-carbonyldiimidazol to give iBead I. iBead II was synthesized with a similar approach but instead using a trimethylenediamine spacer and 2,3,5-triiodobenzoic acid. Doxorubicin was loaded into the iBeads II using a previously reported method. Size and shape of iBeads were evaluated using an upright microscope and their conspicuity assessed using a clinical CT and micro-CT. Bland and Dox-loaded iBeads II visualized with both clinical CT and microCT. Under microCT, individual bland and Dox loaded beads had a mean attenuation of 7904 ± 804 and 11,873.96 ± 706.12 HU, respectively. These iBeads have the potential to enhance image-guided TACE procedures by providing localization of embolic-particle and drug.

Embolization of uterine fibroids from the point of view of the gynecologist: pros and cons

Uterine artery embolization (UAE) is a minimally invasive procedure with large symptomatic potential in treatment of women with uterine leiomyomas. Due to specificities of this method and possible complications the appropriate indication is crucial. Patient’ symptoms, age, plans for pregnancy, and surgical and reproductive history play a major role in decision-making regarding appropriate subjects for UAE. Close cooperation between the gynecologist and the interventional radiologist is necessary. UAE is usually offered as an alternative to surgical treatment. In patients with no fertility plans, it is a less invasive option than abdominal hysterectomy, with a comparable effect on fibroid-related symptoms and quality of life. The need for reintervention is markedly greater in patients after UAE (up to 35% within 5 years) than after hysterectomy. Women with large symptomatic fibroids wishing to retain the uterus and ineligible for minimally invasive (laparoscopic or vaginal) hysterectomy are good candidates for UAE. However, studies comparing UAE with minimally invasive hysterectomy are lacking. Use of UAE in younger women desiring pregnancy is more controversial, mainly because of the significant risk of miscarriage (as high as 64% in some studies) as well as the increased risk of other complications of pregnancy, such as preterm delivery, abnormal placentation, and post-partum hemorrhage. The risk of infertility or subfertility following UAE is unknown. Even poor candidates for myomectomy should be carefully selected for UAE after counseling about all possible adverse effects on fertility. Good prospective studies focused on fertility comparing UAE with no treatment or with myomectomy are needed but would be ethically questionable. This review summarizes the current knowledge regarding the benefits and potential risks of UAE from the point of view of the gynecologist, who should be responsible for proper indication of this treatment.

Placenta accreta in a patient with a history of uterine artery embolization for postpartum hemorrhage

Uterine artery embolization (UAE) is used to treat various conditions from uterine leiomyoma to uncontrollable bleeding. We describe a case of placenta accreta after a prior delivery, which required UAE to control a postpartum hemorrhage. This case highlights the importance of both antenatal evaluation of placentation and heightened precaution for delivery in subsequent pregnancies for women who have undergone this procedure.

Uterine Fibroid Embolisation - Potential Impact on Fertility and Pregnancy Outcome

The current standard therapy to treat myomas in women wishing to have children consists of minimally invasive surgical myomectomy. Uterine artery embolisation (UAE) has also been discussed as another minimally invasive treatment option to treat myomas. This review evaluates the literature of the past 10 years on fibroid embolisation and its impact on fertility and pregnancy. Potential problems associated with UAE such as radiation exposure of the ovaries, impairment of ovarian function and the impact on pregnancy and child birth are discussed in detail. Previously published reports of at least 337 pregnancies after UAE were evaluated. The review concludes that UAE to treat myomas can only be recommended in women with fertility problems due to myomas who refuse surgery or women with an unacceptably high surgical risk, because the evaluated case reports and studies show that UAE significantly increases the risk of spontaneous abortion; there is also evidence of pathologically increased levels for other obstetric outcome parameters. There are still very few prospective studies which provide sufficient evidence for a definitive statement on the impact of UAE therapy on fertility rates and pregnancy outcomes.

Uterine artery embolization: a safe and effective, minimally invasive, uterine-sparing treatment option for symptomatic fibroids

Leiomyomas (or fibroids) are exceedingly common lesions. The indications to initiate treatment are based on the symptoms that can arise from their presence. In general, medical therapy should be considered the first line of treatment. Currently, the treatment of fibroids is in evolution. Since uterine artery embolization (UAE) was first described by Ravina et al in 1995, it has been shown to be a safe, efficacious, and cost-effective alternative to traditional surgical options, with data from long-term studies now available. Appropriate patient evaluation and selection are vital; the ideal candidate is one who is premenopausal, has symptomatic fibroids resistant to medical therapy, no longer desires fertility, and wishes to maintain her uterus. Uterine artery embolization is primarily an angiographic procedure, but periprocedural clinical management is critical for patient satisfaction. This article discusses the various embolic materials that are commonly used and available for UAE; understanding the technical nuances is critical for long-term success.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Pregnancy after uterine arterial embolization

OBJECTIVE

To evaluate pregnancy outcomes, complications and neonatal outcomes in women who had previously undergone uterine arterial embolization.

METHODS

A retrospective study of 187 patients treated with uterine arterial embolization for symptomatic uterine fibroids between 2005-2008 was performed. Uterine arterial embolization was performed using polyvinyl alcohol particles (500-900 mm in diameter). Pregnancies were identified using screening questionnaires and the study database.

RESULTS

There were 15 spontaneous pregnancies. Of these, 12.5% were miscarriages (n = 2), and 87.5% were successful live births (n = 14). The gestation time for the pregnancies with successful live births ranged from 36 to 39.2 weeks. The mean time between embolization and conception was 23.8 months (range, 5-54). One of the pregnancies resulted in twins. The newborn weights (n = 14) ranged from 2.260 to 3.605 kg (mean, 3.072 kg). One (7.1%) was considered to have a low birth weight (2.260 kg). There were two cases of placenta accreta (12.5%, treated with hysterectomy in one case [6.3%]), one case of premature rupture of the membranes (PRM) (6.3%), and one case of preeclampsia (6.3%). All of the patients were delivered via Cesarean section.

CONCLUSION

In this study, there was an increased risk of Cesarean delivery. There were no other major obstetric risks, suggesting that pregnancy after uterine arterial embolization is possible without significant morbidity or mortality.

Novel, orally active selective progesterone receptor modulator CP8947 inhibits leiomyoma cell proliferation without adversely affecting endometrium or myometrium

Uterine leiomyomas are highly prevalent and often symptomatic, but current medical therapies are limited. A novel, potent, selective, orally active therapy is needed. The goal of these studies was to determine the progesterone receptor (PR) specificity and activation, endometrial response, and impact on leiomyoma cell proliferation and extracellular matrix (ECM) production of the novel non-steroidal selective progesterone receptor modulators (SPRMs) CP8863 and CP8947. In vitro progestational activity was assessed by alkaline phosphatase assay and ER-α expression. In vivo progestational activity was assayed by the McPhail assay. Proliferation and gene expression studies were performed in immortalized human leiomyoma and myometrial cells. Both CP8863 and CP8947 were highly selective for progesterone receptor (PR) but not for ER-α, AR, and GR. Both compounds induced alkaline phosphatase comparably to progesterone, while CP8947 induced ER-α in leiomyoma cells but not myometrial cells. CP8947 was progestational in rabbit endometrium. Nanomolar CP8947 treatment inhibited human leiomyoma but not myometrial cell proliferation. Extracellular matrix components were decreased in leiomyoma cells, including COL1A1 and COL7A1 at nanomolar concentrations. CP8947 was a potent novel non-steroidal SPRM that was selective for PR, demonstrated progestational activity in endometrium, inhibited leiomyoma cell proliferation and decreased ECM component production, without disrupting myometrial cell proliferation.

Uterine fibroid embolisation for symptomatic uterine fibroids: a survey of clinical practice in Europe

Purpose

To assess current uterine fibroid embolisation (UFE) practice in European countries and determine the clinical environment for UFE in different hospitals.

Material and Methods

In May 2009, an invitation for an online survey was sent by e-mail to all members of the Cardiovascular and Interventional Radiologic Society of Europe, representing a total number of 1,250 different candidate European treatment centres. The survey covered 21 questions concerning local UFE practice.

Results

A total of 282 respondents completed the questionnaire. Fifteen questionnaires were excluded because they were doubles from centres that had already returned a questionnaire. The response rate was 267 of 1,250 centres (21.4%). Ninety-four respondents (33%) did not perform UFE and were excluded, and six centres were excluded because demographic data were missing. The remaining 167 respondents from different UFE centres were included in the study. Twenty-six percent of the respondents were from the United Kingdom (n = 43); 16% were from Germany (n = 27); 11% were from France (n = 18); and the remaining 47% (n = 79) were from other European countries. Most centres (48%, n = 80) had 5 to 10 years experience with UFE and performed 10 to 50 procedures annually (53% [n = 88]) of respondents). Additional demographic data, as well as specific data on referral of patients, UFE techniques used, and periprocedural and postprocedural, care will be provided.

Conclusion

Although UFE as an alternative treatment for hysterectomy or myomectomy is widespread in Europe, its impact on the management of the patient with symptomatic fibroids seems, according to the overall numbers of UFE procedures, somewhat disappointing. Multiple factors might be responsible for this observation.

Complications of percutaneous procedures

Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures.

The uterus and fertility

OBJECTIVE

To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function.

DESIGN

The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed.

CONCLUSION(S)

Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

The management of patients with uterine sarcoma: a debated clinical challenge

Uterine sarcomas include a heterogeneous group of rare tumours that usually have an aggressive clinical behaviour and a poor prognosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard surgical treatment. Pelvic and/or para-aortic lymphadenectomy is indicated for carcinosarcoma, but not for leiomyosarcoma and undifferentiated endometrial sarcoma. Some recent data on low numbers of patients with low-grade endometrial stromal sarcoma appear to show an incidence of nodal involvement higher than previously expected, thus suggesting a role for lymphadenectomy in this malignancy. Carcinosarcoma also requires a comprehensive surgical peritoneal staging. Postoperative treatment of uterine sarcomas has been long debated. Adjuvant pelvic radiotherapy appears to improve local control without any significant impact on overall survival. There is little evidence in the literature supporting the use of adjuvant chemotherapy in any gynaecological sarcomas except for carcinosarcomas. However, uterine sarcomas have a high tendency to develop distant recurrences, and recent data on adjuvant chemotherapy in soft tissue sarcomas are promising. As for the drugs to be used, it is worth noting that in a Swiss study, the combination of ifosfamide (IFO) and doxorubicin (DOX) obtained similar response rates in advanced gynaecological sarcomas and in advanced soft tissue sarcomas of other sites. In our decision-making scheme for early-stage disease, patients with leiomyosarcoma or undifferentiated endometrial sarcoma should receive adjuvant doxorubicin/epidoxorubicin (EPIDX)+ifosfamide, and those with carcinosarcoma should be treated with adjuvant cisplatin (CDDP)-based chemotherapy. The same drug regimens are used for the treatment of advanced disease. Sequential pelvic radiotherapy following chemotherapy could be delivered to selected cases. Recurrent disease often requires the integration of different therapeutic modalities, but no curative option is currently available with the possible exception of surgery for lung metastases and hormone therapy with or without debulking surgery for recurrent low-grade endometrial stromal sarcoma. Patients should be encouraged to enter clinical trials designed to identify new active drugs for these malignancies.

Retinoic acid pathway genes show significantly altered expression in uterine fibroids when compared with normal myometrium

Fibroids are benign neoplasms of myometrial smooth muscle cells (SMC). Despite being the most common tumor in humans, their etiology is poorly understood. Recent microarray studies have demonstrated that multiple members of the retinoid pathway are differentially expressed between myometrium and fibroids. The aim of this present study was to investigate gene expression of members of the retinoid pathway in matched myometrium and fibroids. We have demonstrated differential gene expression of two binding proteins [cellular retinol-binding proteins (CRBP) 1 and 2], three enzymes [alcohol dehydrogenase 1 (ADH1), aldehyde dehydrogenase (ALDH1) and retinol dehydrogenase (RODH)] and two receptors [retinoid X receptors (RXR) alpha and gamma] involved in the retinoid pathway by real-time PCR. There were no differences in gene expression for retinoid receptors RARalpha, beta, gamma and RXRbeta, and for the metabolizing enzyme cytochrome P450, family 26 subfamily A. We confirmed results for ADH1, ALDH1, CRBP1 and CRABP2 at the protein level by western blot. Using immunohistochemistry these proteins were mostly localized to myometrial and fibroid SMC. An exception to this was ALDH1 protein, which displayed strong staining localized to cells of the connective tissue, presumably fibroblasts, with a striking differential expression pattern between myometrium and fibroids. These results demonstrate that the retinoid pathway is altered in fibroids when compared with normal myometrium and specifically identify ALDH1 in fibroid fibroblasts. These alterations can lead to aberrant retinoic acid (RA) production and signaling, and alter the expression of RA target genes, which may be an important step in fibroid development.

Clinical care of patients undergoing uterine artery embolization

Uterine artery embolization (UAE) is a relatively recent, safe, and minimally invasive procedure for women experiencing symptomatic fibroids. This process of percutaneous occlusion of blood vessels to disrupt blood flow will consequently impede nourishment to the uterine fibroids and cause infarction. To have proper patient treatment to optimize overall clinical success, guidelines should be rigorously followed. This article will delineate a suitable patient care process for UAE in which subsequent interventional radiologists can employ.