Alternatives to hysterectomy: focus on global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound

Discovery and Characterization of BAY 1214784, an Orally Available Spiroindoline Derivative Acting as a Potent and Selective Antagonist of the Human Gonadotropin-Releasing Hormone Receptor as Proven in a First-In-Human Study in Postmenopausal Women

The growth of uterine fibroids is sex hormone-dependent and commonly associated with highly incapacitating symptoms. Most treatment options consist of the control of these hormonal effects, ultimately blocking proliferative estrogen signaling (i.e., oral contraceptives/antagonization of human gonadotropin-releasing hormone receptor [hGnRH-R] activity). Full hGnRH-R blockade, however, results in menopausal symptoms and affects bone mineralization, thus limiting treatment duration or demanding estrogen add-back approaches. To overcome such issues, we aimed to identify novel, small-molecule hGnRH-R antagonists. This led to the discovery of compound BAY 1214784, an orally available, potent, and selective hGnRH-R antagonist. Altering the geminal dimethylindoline core of the initial hit compound to a spiroindoline system significantly improved GnRH-R antagonist potencies across several species, mandatory for a successful compound optimization in vivo. In a first-in-human study in postmenopausal women, once daily treatment with BAY 1214784 effectively lowered plasma luteinizing hormone levels by up to 49%, at the same time being associated with low pharmacokinetic variability and good tolerability.

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.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Radiofrequency-induced endometrial ablation for the treatment of postpartum hemorrhage after vaginal delivery: Case report

RATIONALE

Postpartum hemorrhage is a common complication and difficult problem in obstetrics. Radiofrequency-induced endometrial ablation (RFIEA) widely used in abnormal uterine bleeding and achieved good effects. This article will investigate the effect of RFIEA for treatment of postpartum hemorrhage.

PATIENTS CONCERNS

A 26-year-old healthy full-term parturient woman presented with postpartum hemorrhage after vaginal delivery for 11 hours, who was ready to emergency surgery (hysterectomy) 7 hours after inserting an intrauterine balloon into uterine cavity.

DIAGNOSES

Blood loss after vaginal delivery was more than 500 mL during 11 hours in the full-term parturient woman.

INTERVENTION

We applied RFIEA to treatment of postpartum hemorrhage. With the patient in dorsal lithotomy position, we advanced the disposable device according to the instruction and operated the Novasure system in semi-automatic mode.

OUTCOMES

There was no obvious endometrial bleeding found with hysteroscopy at the end of surgery. No complications (such as thermal injury to adjacent tissue, uterine perforation, bowel perforation) were observed.

LESSONS

It is safe and effective to treat postpartum hemorrhage after vaginal delivery using RFIEA.

Halofuginone suppresses growth of human uterine leiomyoma cells in a mouse xenograft model

STUDY QUESTION

Does halofuginone (HF) inhibit the growth of human uterine leiomyoma cells in a mouse xenograft model?

SUMMARY ANSWER

HF suppresses the growth of human uterine leiomyoma cells in a mouse xenograft model through inhibiting cell proliferation and inducing apoptosis.

WHAT IS KNOWN ALREADY

Uterine leiomyomas are the most common benign tumors of the female reproductive tract. HF can suppress the growth of human uterine leiomyoma cells in vitro. The mouse xenograft model reflects the characteristics of human leiomyomas.

STUDY DESIGN, SIZE, DURATION

Primary leiomyoma smooth muscle cells from eight patients were xenografted under the renal capsule of adult, ovariectomized NOD-scid IL2Rγ(null) mice (NSG). Mice were treated with two different doses of HF or vehicle for 4 weeks with six to eight mice per group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mouse body weight measurements and immunohistochemical analysis of body organs were carried out to assess the safety of HF treatment. Xenografted tumors were measured and analyzed for cellular and molecular changes induced by HF. Ovarian steroid hormone receptors were evaluated for possible modulation by HF.

MAIN RESULTS AND THE ROLE OF CHANCE

Treatment of mice carrying human UL xenografts with HF at 0.25 or 0.50 mg/kg body weight for 4 weeks resulted in a 35-40% (P < 0.05) reduction in tumor volume. The HF-induced volume reduction was accompanied by increased apoptosis and decreased cell proliferation. In contrast, there was no significant change in the collagen content either at the transcript or protein level between UL xenografts in control and HF groups. HF treatment did not change the expression level of ovarian steroid hormone receptors. No adverse pathological effects were observed in other tissues from mice undergoing treatment at these doses.

LIMITATIONS, REASONS FOR CAUTION

While this study did test the effects of HF on human leiomyoma cells in an in vivo model, HF was administered to mice whose tolerance and metabolism of the drug may differ from that in humans. Also, the longer term effects of HF treatment are yet unclear.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study showing the effectiveness of HF in reducing UL tumor growth by interfering with the main cellular processes regulating cell proliferation and apoptosis are in agreement with previous studies on the effects of HF on other fibrotic diseases. HF can be considered as a candidate for reducing the size of leiomyomas, particularly prior to surgery.

STUDY FUNDING/COMPETING INTERESTS

This project was funded by NIH PO1HD057877 and R01 HD064402. Authors report no competing interests.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Levonorgestrel intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: A meta-analysis of randomized controlled trials

At present, there have been no standard research outcomes as to whether the levonorgestrel intrauterine system (LNG-IUS) or thermal balloon ablation (TBA) is superior for the treatment of patients suffering from heavy menstrual bleeding (HMB). Therefore, in the present study, a meta-analysis of randomized controlled trials (RCTs) was conducted in order to compare the effectiveness and affordability of the LNG-IUS with TBA in the treatment of HMB. A literature search of the following electronic databases was conducted: PubMed, EMBASE, the Cochrane Library, Google Scholar, the Chinese Scientific Journals Database, and the China National Knowledge Infrastructure; and a statistical analysis was performed using RevMan 5.2 software. Seven RCTs involving 467 patients (235 LNG-IUS, 232 TBA) met the inclusion criteria for the present study. As assessed by pictorial blood loss assessment chart (PBAC) scores, the LNG-IUS significantly reduced menstrual bleeding after 24 months [standardized mean difference (SMD), −0.86; 95% confidence interval (CI), −1.22 to −0.50; P<0.00001]. Furthermore, the total treatment cost of the LNG-IUS was lower than that of TBA (SMD, −2.35; 95% CI, −2.98 to −1.72; P<0.00001). However, at the 24 month follow-up, side effects such as amenorrhea occurred more frequently in patients treated with the LNG-IUS, as compared with TBA (relative risk, 2.49; 95% CI, 1.46–4.25; P=0.0008). No significant differences in hemoglobin levels and quality of life were demonstrated between the two treatment groups. The results of the present meta-analysis suggest that the LNG-IUS may be more effective and affordable than TBA as a long-term treatment (24 months) for HMB. However, following 12–24 months of treatment, side effects such as amenorrhea may be more frequent in patients treated with the LNG-IUS. When considering short-term treatment for HMB, controversy remains regarding the two methods and further studies are required to precisely evaluate the outcomes.

Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

OBJECTIVES

Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives.

METHODS

A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy.

RESULTS

Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy.

CONCLUSION

Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

High-Intensity Focused Ultrasound Ablation of Uterine Fibroids - Potential Impact on Fertility and Pregnancy Outcome

Laparoscopic myomectomy is regarded as the gold standard for women with symptomatic fibroids who wish to become pregnant. High-intensity focused ultrasound (HIFU or MRgFUS) ablation of uterine fibroids is also being discussed as a non-surgical, minimally invasive, therapeutic option. This review examines the available data on the impact of HIFU/MRgFUS on fertility and pregnancy, focusing particularly on potential direct side-effects of this type of intervention on ovaries, fallopian tubes and uterus and potential late effects on pregnancy and birth, based on the current literature. All pregnancies after HIFU/MRgFUS published to date (around 100 cases) were evaluated. The published case series suggest that HIFU/MRgFUS ablation has no impact on the rate of miscarriages or other obstetrical outcome parameters. Because no prospective studies exist which permit firm conclusions to be drawn on the impact of HIFU/MRgFUS on fertility and pregnancy outcome in women with symptomatic fibroids, this approach is currently only recommended for women with suspected fertility problems due to uterine fibroids who either decline surgery or who have an unacceptably high surgical risk.

Emerging technologies for image guidance and device navigation in interventional radiology

Recent developments in image-guidance and device navigation, along with emerging robotic technologies, are rapidly transforming the landscape of interventional radiology (IR). Future state-of-the-art IR procedures may include real-time three-dimensional imaging that is capable of visualizing the target organ, interventional tools, and surrounding anatomy with high spatial and temporal resolution. Remote device actuation is becoming a reality with the introduction of novel magnetic-field enabled instruments and remote robotic steering systems. Robots offer several degrees of freedom and unprecedented accuracy, stability, and dexterity during device navigation, propulsion, and actuation. Optimization of tracking and navigation of interventional tools inside the human body will be critical in converting IR suites into the minimally invasive operating theaters of the future with increased safety and unsurpassed therapeutic efficacy. In the not too distant future, individual image guidance modalities and device tracking methods could merge into autonomous, multimodality, multiparametric platforms that offer real-time data of anatomy, morphology, function, and metabolism along with on-the-fly computational modeling and remote robotic actuation. The authors provide a concise overview of the latest developments in image guidance and device navigation, while critically envisioning what the future might hold for 2020 IR procedures.

Validation of the UFS-QOL-hysterectomy questionnaire: modifying an existing measure for comparative effectiveness research

OBJECTIVE

The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, a validated patient-reported outcome measure of fibroid symptoms and health-related quality of life, was modified for use posthysterectomy. This study was conducted to psychometrically validate the UFS-QOL-Hysterectomy questionnaire for potential use in comparative effectiveness research to evaluate uterine fibroid treatments.

METHODS

This multicenter prospective study enrolled premenopausal women aged 30 to 50 years with uterine fibroids who were scheduled for hysterectomy, myomectomy, or uterine fibroid embolization. All participants completed the UFS-QOL questionnaire and short form 36 health survey at baseline prior to treatment and 6 and 12 months postprocedure. Women with hysterectomy completed the UFS-QOL-Hysterectomy questionnaire during follow-up visits. Internal consistency reliability, discriminant and concurrent validity, and responsiveness were assessed.

RESULTS

A total of 274 women were enrolled (107 uterine fibroid embolization, 61 myomectomy, and 106 hysterectomy) and 89 (83%), 55 (90%), and 91 (86%), respectively, completed the 12-month follow-up. The mean age was 43.2 (uterine fibroid embolization), 40.6 (myomectomy), and 44.5 (hysterectomy) years; 53%, 43%, and 37%, respectively, were black. Cronbach's alphas for the UFS-QOL-Hysterectomy questionnaire at 6 months ranged from 0.70 to 0.96 and from 0.66 to 0.95 at 12 months. Effect sizes ranged from 1.23 to 2.55, indicating that the UFS-QOL-Hysterectomy questionnaire was highly responsive.

CONCLUSIONS

The UFS-QOL-Hysterectomy questionnaire is a valid and reliable patient-reported outcome measure of uterine fibroid treatment with hysterectomy and can be used in conjunction with the UFS-QOL questionnaire to compare patient-reported outcomes across treatments.

18F-FLT PET performs better than 18F-FDG PET in differentiating malignant uterine corpus tumors from benign leiomyoma

PURPOSE

The aim of this study is to test the hypothesis that positron emission tomography (PET) with 3'-deoxy-3'-[(18)F]-fluorothymidine ((18)F-FLT) can differentiate malignancy from benign leiomyoma better than PET with 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F-FDG), and to evaluate whether (18)F-FLT and (18)F-FDG uptake correlate with immunohistochemical index of cell proliferation.

METHODS

The protocol of this prospective study was approved by the institutional ethics committee, and all patients gave written informed consent. Fifteen patients (aged 26-65 years, median 44 years) with uterine corpus tumor which has the possibility of being leiomyosarcoma underwent (18)F-FLT and (18)F-FDG PET scans. Maximum standard uptake value (SUV(max)) of PET scans and Ki-67 labeling index of surgical specimens were evaluated. Mann-Whitney's U test was used for comparing uptakes between benign and malignant, and linear regression analysis was used for evaluating the correlation between Ki-67 labeling index and SUV(max).

RESULTS

Five cases were diagnosed as malignant (leiomyosarcoma for 3 cases, and carcinoma for 2 cases), and the others were benign leiomyoma. Sensitivity and negative predictive value of both tracers for detecting malignancy was 100%. Specificity, positive predictive value and accuracy of (18)F-FLT PET were higher than those of (18)F-FDG PET. Difference in SUV(max) between malignant and benign was significant for (18)F-FLT PET (P < 0.01), but not for (18)F-FDG PET. While all the malignant cases showed positive uptake in both tracers, a case of leiomyosarcoma with huge necrosis showed relatively low uptake. Uptake of (18)F-FLT showed better correlation with Ki-67 labeling index compared with (18)F-FDG (R(2) = 0.91 vs. R(2) = 0.26).

CONCLUSION

Negative findings on additional (18)F-FDG or (18)F-FLT PET may rule out the possibility of malignancy for the patients with suspected leiomyosarcoma diagnosed by conventional methods. (18)F-FLT PET is superior to (18)F-FDG PET in differentiating malignant from benign leiomyoma. Moreover, (18)F-FLT uptake correlated well with the immunohistochemical index of cell proliferation.

Surgical management of neurovascular bundle in uterine fibroid pseudocapsule

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.