Incidence and risk factors for clinical failure of uterine leiomyoma embolization

Medical historical notes on myoma treatment by uterine artery embolization on the occasion of its introduction 30 years ago

BACKGROUND

 Since its development, uterine artery embolization (UAE) for the treatment of symptomatic fibroids has become an established minimally invasive alternative to surgical myoma treatment. Currently, more than 25,000 myoma patients worldwide are likely to be treated with UAE annually.

METHOD

 Thirty years ago, Jacques-Henri Ravina (b. 1930) and his Paris team first performed this therapy as a "substitute" for gynecologic surgery. We contacted him as part of the preparation of the present review. In addition, we performed a literature search with the aim of summarizing the current literature and data in addition to a historical account of the development of UAE.

RESULTS AND CONCLUSION

 On the occasion of this anniversary, we would like to recall the interdisciplinary roots and some facets of the history of the development of this relatively young myoma treatment method.

KEY POINTS

  · UAE is an established minimally invasive alternative to surgical myoma treatment.. · UAE was first developed 30 years ago.. · UAE has continuously increased in importance in recent years..

CITATION FORMAT

· Psilopatis I, Fleckenstein FN, Gebauer B et al. Medical historical notes on myoma treatment by uterine artery embolization on the occasion of its introduction 30 years ago. Fortschr Röntgenstr 2023; 195: 890 - 895.

The comparison of myomectomy, UAE and MRgFUS in the treatment of uterine fibroids: a meta analysis

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.

Transradial Embolization, an Underused Type of Uterine Artery Embolization Approach: A Systematic Review

Background and Objectives: The most utilized approach for the embolization of uterine arteries is the transfemoral path. However, the transradial approach (TRA) has been gaining popularity among cardiologic interventions in the last years but only few studies have shown its applicability in uterine myoma treatment. The objective of this paper is to assess the feasibility, safety and efficacy of TRA when compared with the transbrachial, transulnar or transfemoral approach (TFA) for uterine arteries embolization (UAE). Materials and methods: A systematic review of the literature that analyzes the TRA for UAE it was carried out, in order to assess its safety and effectiveness. It was systematically searched the literature (Google Scholar, PubMed/MEDLINE, Cochrane Library and Embase) using the words ''uterine artery embolization''/''uterine embolization'' and ''transradial''/''radial''. All the relevant papers published until March 2020 were retrieved and analyzed. Results: Ten studies were considered eligible for this topic. TRA is a comparable method with TFA for uterine artery embolization. Conclusions: These studies allowed us to conclude that TRA is as safe and efficient as TFA. Its advantages include few complications, shorter hospitalization period, and rapid mobilization but a steeper learning curve has the disadvantage of a longer learning curve compared to TFA. Yet, these findings are built on few reports and more research is needed.

Long-term outcome and pre-interventional predictors for late intervention after uterine fibroid embolization

OBJECTIVES

To assess the long-term freedom of surgical conversion after uterine fibroid embolization (UFE) and to define predictors for better clinical outcome. Additionally, the potential of pregnancy after UFE is assessed.

STUDY DESIGN

Single-center retrospective cohort study including 190 patients who underwent UFE between 2001 and 2016. Data were obtained by postal questionnaire including symptom severity, late reintervention rate and post procedural fertility. Patient characteristics were extracted from the patients' electronic medical records. The cumulative rate of freedom from treatment failure was determined by Kaplan-Meier analysis. Cox regression models were used for univariate analyses of the association between patient preinterventional characteristics and late surgical conversion. Secondary outcome measures were patient specific predictors of treatment failure and evaluation of post-procedural fertility.

RESULTS

Long-term follow-up was available for a median of 6.1 years (range 1.2-15.2 y) in 95 out of 190 patients (50 %). Freedom from treatment failure showed a cumulative rate of 72.9 % after 10 years and stable until end of follow-up. A 63.8 % reduction in symptoms and a 23.3% increase in quality of life was found. Significant increase of treatment failure was found in patients with increasing pre-interventional uterine volume (p = 0.0003) or dominant fibroid volume (p = 0.0042); 9 out of 23 patients (39.13 %) with child-bearing wish became pregnant and conceived one or more children after UFE.

CONCLUSION

UFE is associated with sustained long-term symptom control. Larger size uterus or dominant fibroma are correlated with higher late surgical conversion rate. Last, women can become pregnant and deliver after UFE.

Uterine artery embolisation for IVC syndrome and severe lower extremity oedema secondary to IVC compression from massive fibroids

A 66-year-old woman was admitted to an outside facility with leg swelling and dyspnea on exertion. Initial workup revealed severe aortic stenosis and congestive heart failure (CHF) thought to be the culprit; however, a CT performed in the emergency department revealed massive uterine mass resulting in significant inferior vena cava (IVC) compression. Her cardiac status precluded hysterectomy, due to concerns regarding intraoperative fluid shifts decreasing preload in the setting of preload dependence in severe aortic stenosis. Similarly, her degree of IVC compression was thought to make valve replacement unacceptably dangerous, so she was referred to interventional radiology for consideration of uterine artery embolisation (UAE) to relieve IVC compression. She underwent UAE without complication, and her leg swelling nearly completely resolved at follow-up.

Expanded Somatic Mutation Spectrum of MED12 Gene in Uterine Leiomyomas of Saudi Arabian Women

MED12, a subunit of mediator complex genes is known to harbor genetic mutations, (mostly in exon 2), causal to the genesis of uterine leiomyomas among Caucasian, African American, and Asian women. However, the precise relationship between genetic mutations vs. protein or disease phenotype is not well-explained. Therefore, we sought to replicate the MED12 mutation frequency in leiomyomas of Saudi Arabian women, who represents ethnically and culturally distinct population. We performed molecular screening of MED12 gene (in 308 chromosomes belonging to 154 uterine biopsies), analyzed the genotype-disease phenotype correlations and determined the biophysical characteristics of mutated protein through diverse computational approaches. We discovered that >44% (34/77) leiomyomas of Arab women carry a spectrum of MED12 mutations (30 missense, 1 splice site, and 3 indels). In addition to known codon 44, we observed novel somatic mutations in codons 36, 38, and 55. Most genetically mutated tumors (27/30; 90%) demonstrated only one type of genetic change, highlighting that even single allele change in MED12 can have profound impact in transforming the normal uterine myometrium to leiomyomas. An interesting inverse correlation between tumor size and LH is observed when tumor is positive to MED12 mutation (p < 0.05). Our computational investigations suggest that amino acid substitution mutations in exon-2 region of MED12 might contribute to potential alterations in phenotype as well as the stability of MED12 protein. Our study, being the first one from Arab world, confirms the previous findings that somatic MED12 mutations are critical to development and progression of uterine leiomyomas irrespective of the ethnic background. We recommend that mutation screening, particularly codon 44 of MED12 can assist in molecular diagnostics of uterine leiomyomas in majority of the patients.

Clinical Long-Term Outcome and Reinterventional Rate After Uterine Fibroid Embolization with Nonspherical Versus Spherical Polyvinyl Alcohol Particles

PURPOSE

This study was designed to evaluate the long-term clinical outcome and frequency of reinterventions in patients with uterine fibroids treated with embolization at a single center using polyvinyl alcohol microparticles.

METHODS

The study included all patients with symptomatic uterine fibroids treated with uterine fibroid embolization (UFE) with spherical (s-PVA) and nonspherical (ns-PVA) polyvinyl alcohol microparticles during the period January 2001 to January 2011. Clinical success and secondary interventions were examined. Hospital records were reviewed during follow-up, and symptom-specific questionnaires were sent to all patients.

RESULTS

In total, 515 patients were treated with UFE and 350 patients (67 %) were available for long-term clinical follow-up. Median time of follow-up was 93 (range 76-120.2) months. Eighty-five patients (72 %) had no reinterventions during follow-up in the group embolized with ns-PVA compared with 134 patients (58 %) treated with s-PVA. Thirty-three patients (28 %) underwent secondary interventions in the ns-PVA group compared with 98 patients (42 %) in s-PVA group (χ(2) test, p < 0.01).

CONCLUSIONS

Spherical PVA particles 500-700 µm showed high reintervention rate at long-term follow-up, and almost one quarter of the patients underwent secondary interventions, suggesting that this type of particle is inappropriate for UFE.

Incidence and predictive factors for complications after uterine leiomyoma embolization

STUDY QUESTION

What is the risk of complications after uterine leiomyoma embolization and what are the factors associated with complications?

SUMMARY ANSWER

The cumulative risk of complications after embolization is relatively low even in the long term, but submucosal leiomyoma location may increase the risk.

WHAT IS KNOWN ALREADY

A broad spectrum of complications after leiomyoma embolization have been described with widely varying rates. There is uncertainty over the actual risk of complications and the factors associated with this risk.

STUDY DESIGN, SIZE, DURATION

This was a prospective cohort study of 288 consecutive women undergoing leiomyoma embolization in the general gynaecology clinic of a university teaching hospital between January 2001 and December 2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Complications occurring after embolization were categorized as major or minor according to the severity of their impact on health, the level of care required and the outcome. Cumulative complication rates were estimated by survival analysis and log-rank tests according to baseline variables. Multivariable Cox proportional hazards analysis was performed to adjust for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 48 patients who experienced a complication at a median of 5 months (95% confidence interval, 4.1-11.4) after embolization. Complications were minor in 38 patients and major in 10 patients. The cumulative overall complication rate was 13% (95% CI, 9.0-17.0) at 6 months, 16% (95% CI, 11.0-20.0) at 1 year, 17% (95% CI, 12.0-22.0) at 3 years and 18% (95% CI, 12.9-22.8) at 5 years. The most frequent complication (19/48, 39.6%) was leiomyoma expulsion, which occurred spontaneously in 13 (68.4%) of these cases and required assistance in 6 (31.6%) cases. Eight (2.8%) patients underwent re-intervention, including six hysteroscopic myomectomies, one laparoscopic myomectomy and one hysteroscopic adhesiolysis, as a result of a complication. Submucosal leiomyoma location was the only baseline variable associated with an increased risk for complications [Hazard ratio (HR), 2.28, 95% CI, 1.24-4.18, P = 0.008].

LIMITATIONS, REASONS FOR CAUTION

Our population did not include women of African descent, who have been reported to be at higher risk of post-procedural complications compared with Causcasian women. If such women were involved in the study, higher morbidity rates might have been observed.

WIDER IMPLICATIONS OF THE FINDINGS

Women with submucosal leiomyomas at the time of embolization are more likely to have post-procedural complications. This is important new information for counselling patients contemplating this therapeutic approach.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare. The study was not supported by any external grant.

Uterine artery embolization in single symptomatic leiomyoma: do anatomical imaging criteria predict clinical presentation and long-term outcome?

BACKGROUND

Uterine artery embolization (UAE) has proven to be an effective treatment alternative for women suffering from symptomatic uterine leiomyomas. However, long-term clinical evaluation reveals treatment failure in approximately 25% of patients. To cope with the great variability in the extent of leiomyoma disease former studies are based on the simplifying assumption that the largest leiomyoma mainly causes the symptoms.

PURPOSE

To evaluate whether anatomical characteristics in women with a single symptomatic leiomyoma influence clinical presentation and outcome after UAE.

MATERIAL AND METHODS

Ninety-one patients with a single leiomyoma underwent UAE. Age, uterine and fibroid volume, fibroid location, and clinical symptoms (bleeding- and/or bulk-related symptoms) were documented. The need for reinterventions (i.e. repeat UAE, hysterectomy, myomectomy) and unchanged or worsened symptoms after UAE were classified as treatment failure (TF). Contrast-enhanced magnetic resonance imaging (MRI) 48-72 h after UAE was available in 38 women. The rate of fibroid infarction was determined and patients were assigned to one of three groups: complete (100%), almost complete (90-99%), or partial infarction (<90%). Cox regression analysis (CRA) was used to determine the influence of morphological and clinical parameters on outcome.

RESULTS

Follow-up was available in 79/91 (87%) women (median age, 42 years; range, 33-56 years) at a median of 5 years (range, 3.1-9.2 years) after UAE. Anatomical leiomyoma criteria neither connected to specific clinical presentation nor influenced clinical outcome. Younger women showed a higher risk for TF with every year older lowering the risk by the factor of 0.86 (P = 0.024). Subgroup analysis showed predictive value of fibroid infarction with a cumulative survival free from TF of 91% for complete vs. 0% for partial infarction (P < 0.001).

CONCLUSION

Even in women with single leiomyomas, anatomical criteria do not specify clinical presentation or predict clinical outcome. Younger patient age and incomplete fibroid infarction relate to higher rates of TF.

Clinical long-term outcome after uterine artery embolization: sustained symptom control and improvement of quality of life

PURPOSE

To evaluate long-term clinical efficacy of uterine artery embolization (UAE) for uterine fibroids with respect to symptom control and improvement in quality of life.

MATERIALS AND METHODS

Between October 2000 and October 2007, 380 consecutive women underwent UAE. To determine long-term efficacy, the rate of reinterventions (ie, repeat UAE, hysterectomy, myomectomy) and the clinical response regarding symptoms related to bleeding and bulk were documented. Persistence, worsening, or recurrence of symptoms and reinterventions were classified as treatment failure (TF). The cumulative rate of freedom from TF was determined by Kaplan-Meier analysis. Cox regression was used to identify possible clinical or morphologic predictors of outcome. Secondary outcome measures were changes in disease-specific quality of life and onset of menopause.

RESULTS

Follow-up was available for a median of 5.7 years (range, 3.1-10.1 y) after treatment in 304 of 380 (80%) patients. There were 54 TFs with subsequent reintervention in 46 women. Kaplan-Meier analysis revealed a cumulative TF rate of 23.3% after 10 years. Cox regression demonstrated a significantly higher likelihood of TF in patients<40 years old compared with patients>45 years old (hazard ratio, 2.28; P = .049). Women without TF showed sustained normalization of disease-specific quality of life (P <.001). Cessation of menstruation at a median age of 51 years was reported by 57 (22.8%) of 250 women.

CONCLUSIONS

UAE leads to long-term control of fibroid-related symptoms and normalization of quality of life in approximately 75% of patients. Younger women seem to have a higher risk of TF than older women closer to menopause.