Clinical evaluation of HIFU combined with GnRH-a and LNG-IUS for adenomyosis patients who failed to respond to drug therapies: two-year follow-up results

Effect of High-Intensity Focused Ultrasound on Different Types of Adenomyosis Based on Magnetic Resonance Imaging Classification

OBJECTIVE

We aimed to analyze the effect of high-intensity focused ultrasound (HIFU) on different types of adenomyosis (AM) based on magnetic resonance imaging (MRI) classification.

METHODS

A total of 206 AM patients who underwent HIFU between January 2017 and December 2021 were included in this retrospective study. The size and location of AM were evaluated based on T2-weighted imaging (T2WI) of MRI. Patients were divided into internal (subtype I), external (subtype II), intramural (subtype III), and full-thickness (subtype IV) AM groups. All patients underwent an MRI examination before and one day after HIFU. After ultrasound-guided HIFU ablation, the parameters of ultrasonic energy input during HIFU treatment among different groups were recorded and compared. The adverse reactions and complications among different groups were compared.

RESULTS

The lesion volume in the subtype IV group was significantly larger than the subtype II and III groups (P < .05). The HIFU irradiation time, treatment time, and total energy input in the subtype IV group were significantly higher than the subtype I and III groups (P < .05). The number of cases of abdominal pain and vaginal fluid in the treatment area in the subtype IV group was significantly higher than in the subtype II group.

CONCLUSION

Although HIFU has different treatment strategies and parameters for different subtypes of AM, it can achieve a satisfactory ablation rate, which is safe and effective.

Changes of serum CA125 and PGE2 before and after high-intensity focused ultrasound combined with GnRH-a in treatment of patients with adenomyosis

This study aimed to investigate the changes of serum carbohydrate antigen 125 (CA125) and prostaglandin E2 (PGE2) in patients with adenomyosis before and after treatment with high-intensity focused ultrasound (HIFU) combined with gonadotropin-releasing hormone agonist (GnRH-a). One hundred and sixty-five patients with adenomyosis who received HIFU combined with GnRH-a were selected as case group. Sixty-five healthy women who underwent physical examination at the same time were taken as normal control group. At the end of follow-up 6 months after treatment, the case group were divided into effective subgroup and ineffective subgroup according to clinical efficacy. Changes of serum CA125 and PGE2 were analyzed. Serum CA125 and PGE2 levels in the case group were higher than those in the normal control group before treatment (both P < 0.001). Serum CA125 and PGE2 levels in the case group 6 months after treatment were lower than those before treatment (both P < 0.001). There was no difference in serum CA125 and PGE2 levels between effective subgroup and ineffective subgroup before treatment (P = 0.351, 0.284, respectively). Serum CA125 and PGE2 levels in the effective subgroup were lower than those in the ineffective subgroup 6 months after treatment (both P < 0.001). Serum CA125 and PGE2 may be involved in the development of adenomyosis, and their expression levels may be related to the prognosis of patients. Levels of serum CA125 and PGE2 in patients with adenomyosis decrease after treatment with HIFU combined with GnRH-a. The detection of serum CA125 and PGE2 may be used as an index to diagnose adenomyosis and evaluate the therapeutic effect of HIFU combined with GnRH-a.

Individualized conservative therapeutic strategies for adenomyosis with the aim of preserving fertility

Adenomyosis is a diffuse or localized organic disease caused by benign invasion of endometrial glands and stroma into the myometrium. It is a common disease that seriously affects reproductive health of women in childbearing age. Due to the unknown etiology and pathophysiological mechanism, and the lack of unified diagnostic criteria and effective treatment methods, total or subtotal hysterectomy has become a radical treatment for adenomyosis, which will lead to the complete loss of fertility. With the continuous exploration of the treatment to adenomyotic patients who have infertility or fertility intentions, new drugs, surgical methods and treating concepts appears. Adopt individualized conservative therapeutic strategies for patients with different conditions, preserve the uterus as much as possible and protect the patient’s fertility, which will play an important role on the follow-up assisted reproductive treatment and long-term management of adenomyosis.

Risk of Recurrence and Reintervention After Uterine-Sparing Interventions for Symptomatic Adenomyosis: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the risk of recurrence and reintervention after uterine-sparing treatment options for symptomatic adenomyosis, including adenomyomectomy, uterine artery embolization (UAE), and image-guided thermal ablation.

DATA SOURCES

We searched electronic databases such as Web of Science, MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, and Google Scholar from January 2000 to January 2022. The search was conducted using the following search terms: "adenomyosis," "recurrence," "reintervention," "relapse," and "recur."

METHODS OF STUDY SELECTION

All studies that described the risk of recurrence or reintervention after uterine-sparing interventions for symptomatic adenomyosis were reviewed and screened according to the eligibility criteria. Recurrence was defined as the reappearance of symptoms (painful menses or heavy menstrual bleeding) after significant or complete remission, or the reappearance of adenomyotic lesions confirmed by ultrasonography or magnetic resonance imaging.

TABULATION, INTEGRATION, AND RESULTS

The outcome measures were presented as the frequency with percentage and pooled with 95% CI. A total of 42 studies (single-arm retrospective and prospective studies) that represented 5,877 patients were included. The recurrence rates after adenomyomectomy, UAE, and image-guided thermal ablation were 12.6% (95% CI 8.9-16.4%), 29.5% (95% CI 17.4-41.5%), and 10.0% (95% CI 5.6-14.4%), respectively. The reintervention rates were 2.6% (95% CI 0.9-4.3%), 12.8% (95% CI 7.2-18.4%), and 8.2% (95% CI 4.6-11.9%) after adenomyomectomy, UAE, and image-guided thermal ablation, respectively. Subgroup analysis and sensitivity analysis were performed, and the heterogeneity was reduced in several analyses.

CONCLUSION

Uterine-sparing techniques were successful in treating adenomyosis with low reintervention rates. Uterine artery embolization had higher recurrence and reintervention rates than other techniques; however, patients treated with UAE had larger uteri and larger adenomyosis, indicating that selection bias may influence these results. More randomized controlled trials with a larger population are needed in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021261289.

Comparison of the treatment efficacies of HIFU, HIFU combined with GnRH-a, and HIFU combined with GnRH-a and LNG-IUS for adenomyosis: A systematic review and meta-analysis

To compare the treatment efficacies of high-intensity focused ultrasound (HIFU), HIFU combined with gonadotrophin-releasing hormone agonist (GnRH-a), and HIFU combined with GnRH-a and levonorgestrel-releasing intrauterine system (LNG-IUS) for adenomyosis. We conducted a literature search in SCIENCE DIRECT, COCHRANE LIBRARY, WILLEY ONLINE LIBRARY, PUBMED, and TAYLOR FRANCIS. A total of 471 articles identified, 12 were included in a systematic review, and 11 of them deemed quantitively eligible included in the meta-analysis. The efficacies of the three treatment regimens were assessed using the dysmenorrhea and menstrual scores at 3, 6, 12, 24 months. Of the three regimens, HIFU combined with GnRH-a and LNG-IUS provides the best outcome. On dysmenorrhea score at 6 months there was significantly different higher heterogeneity with P < 0.00001 (I² = 100% WMD 21.44 [6.34, 36.53]) with statistical significance P = 0.005. At 12 months there was significantly different higher heterogeneity P < 0.00001 (I² = 100% WMD 23.47 [6.00, 40.94]) with statistically significant P < 0.008. At 24 months there was significantly different higher heterogeneity P < 0.0005 (I² = 92% WMD 6.05 [4.81, 7.30]) with statistical significance P < 0.00001. HIFU combined with GnRH-a and LNG-IUS on menstrual score at 3 months was significantly different higher heterogeneity with P < 0.00001 (I² = 100% WMD 56.23 [16.01, 96.45]) with statistical significance P = 0.006. At 6 months there was significantly different higher heterogeneity P < 0.00001 (I² = 99% WMD 93.86 [64.15, 123.57]) with statistical significance P < 0.00001. At 12 months there was significantly different higher heterogeneity P < 0.00001 (I² = 99% WMD 97.13 [67.81, 126.46]) with statistical significance P < 0.00001 compared to treatments with only HIFU and HIFU combined with GnRH-a. HIFU combined with GnRH-a and LNG-IUS treatment is more effective than only HIFU monotherapy and HIFU combined with GnRH-a.

Conservative surgical and drug therapies for adenomyosis Medicine

Adenomyosis is a benign invasion/infiltration of endometrial glands and stroma in the uterine myometrium. The optimal choice of adenomyosis treatment remains a subject of discussion. For patients with adenomyosis without fertility requirements, hysterectomy can be performed by laparotomy or laparoscopic surgery to eliminate symptoms. However, this is an inadequate option for women who want to preserve fertility or avoid more extensive surgery. To summarize the medicine and conservative surgery treatment for adenomyosis. An extensive literature search was performed using PubMed, Web of Science, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure (CNKI) without language restriction. The search terms were as follows: adenomyomas, adenomyosis, conservative therapy; combined therapy; medicine; surgery. The search included all titles and abstracts assessing conservative treatment for adenomyosis including medical and surgical therapy. All published papers were analyzed if considered relevant. Increasing current conservative treatments will not only improve the quality of life of the patients but also preserve fertility. Therefore, conservative treatment is extremely important for patients with fertility requirements or a strong desire to retain the uterus. Conservative treatment for adenomyosis may become a future trend in the field of gynecology.

Anti-Mullerian Hormone (AMH) and adenomyosis: Mini-review of literature of the last 5 years

INTRODUCTION

Adenomyosis is a form of endometriosis characterized by the presence of endometrial tissue in the myometrium. The correlation between anti-Mullerian hormone (AMH) expression and adenomyosis is unclear. Few studies investigated this possible correlation with promising results. The aim of this mini-review is to illustrate the potential prognostic and therapeutic role of AMH in adenomyosis.

MATERIALS AND METHODS

A study protocol was completed conforming to the Preferred Reporting Items for Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. We performed an electronic databases search from each database's inception from August 2017 to August 2022 for full-text articles and published abstracts. For database searches, the following main keywords were the following text words: "adenomyosis" or "uterine endometriosis" [Mesh] AND "AMH" or "anti-mullerian hormone".

RESULTS

From the literature search, 8 abstracts of studies were retrieved and independently screened for inclusion by three authors. It was found that the most common therapeutic strategies (such as adenomyomectomy and high-intensity focused ultrasound (HIFU) do not alter AMH levels. Moreover, a higher expression of the AMH receptor II was observed in adenomyotic tissue, hence a possible therapeutic use of AMH was hypothesized.

CONCLUSION

The available evidence shows an unclear relationship between adenomyosis and AMH. Probably, women with adenomyosis have lower levels of AMH and the surgical treatment (adenomyomectomy, HIFU) does not alter this characteristic, therefore in all of them, ovarian function is not influenced.