Comparison of high‐intensity focused ultrasound ablation and secondary myomectomy for recurrent symptomatic uterine fibroids following myomectomy: a retrospective study

The Impact of HIFU Ablation on the Histopathological Features of Locally Recurrent Fibroids Tissue Post-HIFU Treatment

OBJECTIVE

To evaluate the impact of high-intensity focused ultrasound (HIFU) ablation on the histopathological features of locally recurrent fibroids tissue.

METHODS

Patients who underwent transabdominal hysterectomy or myomectomy for uterine fibroids from January 1, 2021 to July 1, 2023 at a teaching hospital in China were enrolled in this prospective study. The patients who underwent surgery for local recurrence of uterine fibroids after HIFU ablation were categorized as the HIFU group, and patients who had not undergone HIFU ablation for uterine fibroids were the control group. Hematoxylin-eosin (HE) staining, Masson staining, and immunohistochemical staining were performed to analyze the counts of smooth muscle cells (SMCs), collagen content, microvascular count, and the expression levels of estrogen receptor (ER) and progesterone receptor (PR) in the fibroid tissue specimens.

RESULTS

The mean SMC counts in the HIFU and control groups were 337.68/field and 328.52/field respectively. The mean collagen content in the HIFU group and control group were 46.06% and 41.69% respectively. The mean microvessel counts in the HIFU group and control group were 13.66/field and 14.08/field respectively. The mean ER scores in the HIFU and control groups were 6.9 and 7.47 respectively, and the mean PR scores were 7.3 and 7.56 respectively. Overall, there were no significant differences in the SMC counts, collagen content, microvascular counts, and the ER and PR expression levels between the HIFU group and control group (p > 0.05).

CONCLUSIONS

HIFU ablation has no effect on the pathological characteristics of local recurrent fibroid tissue, and is an ideal non-invasive treatment option.

A retrospective analysis of single-port laparoscopy in myoma management

Objective

This study assesses the effectiveness and safety of single-port laparoscopic myomectomy (SPLM) versus conventional laparoscopic myomectomy (CLM).

Methods

We conducted a retrospective case-control study at a university tertiary hospital, involving 262 patients treated from July 2020 to December 2022. Participants were divided into two groups: 132 underwent SPLM and 130 underwent CLM.

Results

The two groups were comparable in terms of age, body mass index, parity, delivery history, preoperative anemia, number of myomas, and size of the largest myoma. The SPLM group showed a significant reduction in operation time (average 93 min) and estimated blood loss (average 50 ml) compared to the CLM group (average 118.5 min and 100 ml, respectively). Subgroup analysis based on the size, location, and number of myomas further highlighted the advantages of SPLM, particularly for patients with large (diameter ≥8 cm) or multiple myomas (number ≥4). Patient satisfaction was also notably higher in the SPLM group.

Conclusions

Single-port laparoscopic myomectomy offers a highly effective, safer, and patient-preferred option for the surgical management of fibroids, especially in cases of large or multiple myomas. These findings suggest that SPLM could become the preferred surgical approach for complex fibroid cases, promising less trauma and quicker recovery for patients.

Risk assessment and prediction of occult uterine sarcoma in patients with presumed uterine fibroids before high-intensity focused ultrasound treatment

OBJECTIVE

To develop a diagnostic model for predicting occult uterine sarcoma in patients with presumed uterine fibroids.

MATERIALS AND METHODS

We retrospectively reviewed 41631 patients with presumed uterine fibroids who presented for HIFU treatment in 13 hospitals between November 2008 and October 2023. Of these patients, 27 with occult uterine sarcoma and 54 with uterine fibroids were enrolled. Univariate analysis and multivariate logistics regression analysis were used to determine the independent risk factors for the diagnosis of occult uterine sarcoma. A prediction model was constructed based on the coefficients of the risk factors.

RESULTS

The multivariate analysis revealed abnormal vaginal bleeding, ill-defined boundary of tumor, hyperintensity on T2WI, and central unenhanced areas as independent risk factors. A scoring system was created to assess for occult uterine sarcoma risk. The score for abnormal vaginal bleeding was 56. The score for ill-defined lesion boundary was 90. The scores for lesions with hypointensity, isointensity signal/heterogeneous signal intensity, and hyperintensity on T2WI were 0, 42, and 93, respectively. The scores for lesions without enhancement on the mass margin, uniform enhancement of tumor, and no enhancement in the center of tumor were 0, 20, and 100, respectively. Patients with a higher total score implied a higher likelihood of a diagnosis of occult uterine sarcoma than that of patients with a lower score. The established model showed good predictive efficacy.

CONCLUSIONS

Our results demonstrated that the diagnostic prediction model can be used to evaluate the risk of uterine sarcoma in patients with presumed uterine fibroids.

Predicting the Prognosis of HIFU Ablation of Uterine Fibroids Using a Deep Learning-Based 3D Super-Resolution DWI Radiomics Model: A Multicenter Study

RATIONALE AND OBJECTIVES

To assess the feasibility and efficacy of a deep learning-based three-dimensional (3D) super-resolution diffusion-weighted imaging (DWI) radiomics model in predicting the prognosis of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids.

METHODS

This retrospective study included 360 patients with uterine fibroids who received HIFU treatment, including Center A (training set: N = 240; internal testing set: N = 60) and Center B (external testing set: N = 60) and were classified as having a favorable or unfavorable prognosis based on the postoperative non-perfusion volume ratio. A deep transfer learning approach was used to construct super-resolution DWI (SR-DWI) based on conventional high-resolution DWI (HR-DWI), and 1198 radiomics features were extracted from manually segmented regions of interest in both image types. Following data preprocessing and feature selection, radiomics models were constructed for HR-DWI and SR-DWI using Support Vector Machine (SVM), Random Forest (RF), and Light Gradient Boosting Machine (LightGBM) algorithms, with performance evaluated using area under the curve (AUC) and decision curves.

RESULT

All DWI radiomics models demonstrated superior AUC in predicting HIFU ablated uterine fibroids prognosis compared to expert radiologists (AUC: 0.706, 95% CI: 0.647-0.748). When utilizing different machine learning algorithms, the HR-DWI model achieved AUC values of 0.805 (95% CI: 0.679-0.931) with SVM, 0.797 (95% CI: 0.672-0.921) with RF, and 0.770 (95% CI: 0.631-0.908) with LightGBM. Meanwhile, the SR-DWI model outperformed the HR-DWI model (P < 0.05) across all algorithms, with AUC values of 0.868 (95% CI: 0.775-0.960) with SVM, 0.824 (95% CI: 0.715-0.934) with RF, and 0.821 (95% CI: 0.709-0.933) with LightGBM. And decision curve analysis further confirmed the good clinical value of the models.

CONCLUSION

Deep learning-based 3D SR-DWI radiomics model demonstrated favorable feasibility and effectiveness in predicting the prognosis of HIFU ablated uterine fibroids, which was superior to HR-DWI model and assessment by expert radiologists.

Complications and adverse events of high-intensity focused ultrasound in its application to gynecological field - a systematic review and meta-analysis

OBJECTIVE

To analyze and summarize the types, incidence rates and relevant influencing factors of adverse events (AEs) after high-intensity focused ultrasound ablation of gynecological diseases and provide reference and basis for handling such events in clinical practice.

METHOD

We searched PubMed, Cochrane Library, Web of Science and Embase databases to retrieve all literature since its establishment until February 2024. We evaluated the quality of included literature and publication bias and conducted a meta-analysis of single group rates for various AEs using Stata 17.0.

RESULTS

This systematic review finally included 41 articles. We summarized 34 kinds of AEs in 7 aspects and conducted a single group rate meta-analysis and sub-group analysis of 16 kinds of AEs. Among the common AEs of High-Intensity Focused Ultrasound (HIFU), the incidence of lower abdominal pain/pelvic pain is 36.1% (95% CI: 24.3%∼48.8%), vaginal bleeding is 20.6% (95% CI: 13.9%∼28.0%), vaginal discharge is 14.0% (95% CI: 9.6%∼19.1%), myoma discharge is 24% (95% CI: 14.6%∼34.8%), buttock pain is 10.8% (95% CI: 6.0%∼16.5%) and sacral pain is 10% (95% CI: 8.8%∼11.2%). Serious complications include uterine rupture, necrotic tissue obstruction requiring surgical intervention, third degree skin burns and persistent lower limb pain or movement disorders.

CONCLUSION

The common AEs after HIFU surgery are mostly mild and controllable, and the incidence of serious complications is extremely low. By reasonable prevention and active intervention, these events can be further reduced, making it a safe and effective treatment method. It is a good choice for patients who crave noninvasive treatment or have other surgical contraindications.

Risk factors affecting long-term efficacy of ultrasound-guided high-intensity focused ultrasound treatment for multiple uterine fibroids

OBJECTIVES

To investigate the long-term efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for multiple uterine fibroids and the factors associated with recurrence.

MATERIALS AND METHODS

Five hundred and forty-nine patients with multiple uterine fibroids treated with USgHIFU from June 2017 to June 2019 were retrospectively analyzed. The Pictorial Blood Loss Assessment Chart (PBAC) was used to assess menstrual blood loss. The patients were asked to undergo pre- and post-USgHIFU magnetic resonance imaging (MRI) and complete routine follow-up after USgHIFU. Cox regression analysis was used to investigate the risk factors associated with recurrence.

RESULTS

The median number of fibroids per patient was 3 (interquartile range: 3-4), and a total of 1371 fibroids were treated. Among them, 446 patients completed 3 years follow-up. Recurrence, defined as PBAC score above or equal to 100 and/or the residual fibroid volume increased by 10%, was detected in 90 patients within 3 years after USgHIFU, with a cumulative recurrence rate of 20.2% (90/446). The multi-factor Cox analysis showed that age was a protective factor for recurrence. Younger patients have a greater chance of recurrence than older patients. Mixed hyperintensity of fibroids on T2WI and treatment intensity were risk factors for recurrence. Patients with hyperintense uterine fibroids and treated with lower treatment intensity were more likely to experience recurrence than other patients after USgHIFU. No major adverse effects occurred.

CONCLUSIONS

USgHIFU can be used to treat multiple uterine fibroids safely and effectively. The age, T2WI signal intensity and treatment intensity are factors related to recurrence.

Current and Emerging Treatment Options for Uterine Fibroids

Uterine fibroids are the most common benign neoplasm of the female reproductive tract in reproductive age women. Their prevalence is age dependent and can be detected in up to 80% of women by the age of 50 years. Patients affected by uterine fibroids may experience a significant physical, emotional, social, and financial toll as well as losses in their quality of life. Unfortunately, curative hysterectomy abolishes future pregnancy potential, while uterine-sparing surgical and radiologic alternatives are variously associated with reduced long-term reproductive function and/or high tumor recurrence rates. Recently, pharmacological treatment against uterine fibroids have been widely considered by patients to limit uterine fibroid-associated symptoms such as heavy menstrual bleeding. This hormonal therapy seemed effective through blocking the stimulatory effects of gonadal steroid hormones on uterine fibroid growth. However, they are contraindicated in women actively pursuing pregnancy and otherwise effective only during use, which is limited because of long-term safety and other concerns. Accordingly, there is an urgent unmet need for safe, durable, and fertility-compatible non-surgical treatment options for uterine fibroids. In this review article, we cover the current pharmacological treatments for uterine fibroids including their comparable efficacy and side effects as well as emerging safe natural compounds with promising anti-uterine fibroid effects.

Efficacy and Safety of Ultrasound-Guided High-Intensity Focused Ultrasound Ablation in Women With Multiple Uterine Fibroids: An Exploratory Study

OBJECTIVE

The aim of the work described here was to explore the clinical efficacy and safety of ultrasound-guided high-intensity focused ultrasound (USg-HIFU) treatment in women with multiple fibroids and identify the characteristic parameters predicting USg-HIFU efficacy in multiple fibroids.

METHODS

From February 2021 to August 2022, 138 patients with multiple fibroids (group A comprising 125 patients with two to four fibroids and 13 patients with five or more fibroids) and 149 patients with solitary fibroids (group B) were included. HIFU treatment information, efficacy comparisons and adverse events were recorded. A nomogram model of the characteristic parameters used to predict the efficacy of USg-HIFU in multiple fibroids was established.

RESULTS

After USg-HIFU treatment, the statistical comparison of pre-operative versus post-operative symptom scores and fibroid volume in the two groups indicated obvious symptom relief and substantial shrinkage of fibroid volume (all p values <0.001). Nevertheless, group A required more energy and longer treatment and sonication times to achieve a 70% non-perfused volume (NPV) ratio, and had a lower energy efficiency factor than group B (all p values <0.05). No severe complications were observed in either group. The nomogram model included fibroid volume, fibroid location and signal intensity on T2-weighted imaging (T2WI). The area under the receiver operating characteristic curve and the accuracy of the model were 0.698 and 0.686, respectively.

CONCLUSION

USg-HIFU appears to be an effective and safe treatment option for multiple fibroids. Knowledge of the fibroid volume, location and signal intensity on T2WI may help determine the efficacy of USg-HIFU in multiple fibroids.

High-Intensity Focused Ultrasound Ablation of Uterine Fibroids: A Review

Leiomyomas, or uterine fibroids, are growths consisting of muscle and tissue that develop in or on the uterine wall. The most frequent benign uterine tumours in women of reproductive age are thought to be fibroids. Dysmenorrhea, spotting, hypermenorrhoea, abdominal pain, pressure on surrounding organs, and issues with micturition and defecation are among the symptoms that are often present. Fibroids can form as a single nodule or as a cluster. Uterine fibroids, especially large submucosal and intramural uterine fibroids, can cause obstacles to implantation and lead to pregnancy loss. Uterine fibroids can be treated without surgery and with little downtime using focused ultrasound. There is published research showing that women can conceive and have healthy children after therapy, thus protecting fertility. The ablation of uterine fibroids by high-intensity focused ultrasound (HIFU) is successful since the volume of the fibroids is significantly reduced.

An interpretable MRI-based radiomics model predicting the prognosis of high-intensity focused ultrasound ablation of uterine fibroids

BACKGROUND

Accurate preoperative assessment of the efficacy of high-intensity focused ultrasound (HIFU) ablation for uterine fibroids is essential for good treatment results. The aim of this study was to develop robust radiomics models for predicting the prognosis of HIFU-treated uterine fibroids and to explain the internal predictive process of the model using Shapley additive explanations (SHAP).

METHODS

This retrospective study included 300 patients with uterine fibroids who received HIFU and were classified as having a favorable or unfavorable prognosis based on the postoperative nonperfusion volume ratio. Patients were divided into a training set (N = 240) and a test set (N = 60). The 1295 radiomics features were extracted from T2-weighted imaging (T2WI) and contrast-enhanced T1-weighted imaging (CE-T1WI) scans. After data preprocessing and feature filtering, radiomics models were constructed by extreme gradient boosting and light gradient boosting machine (LightGBM), and the optimal performance was obtained by Bayesian optimization. Finally, the SHAP approach was used to explain the internal prediction process.

RESULTS

The models constructed using LightGBM had the best performance, and the AUCs of the T2WI and CE-T1WI models were 87.2 (95% CI = 87.1-87.5) and 84.8 (95% CI = 84.6-85.7), respectively. The use of SHAP technology can help physicians understand the impact of radiomic features on the predicted outcomes of the model from a global and individual perspective.

CONCLUSION

Multiparametric radiomic models have shown their robustness in predicting HIFU prognosis. Radiomic features can be a potential source of biomarkers to support preoperative assessment of HIFU treatment and improve the understanding of uterine fibroid heterogeneity.

CLINICAL RELEVANCE STATEMENT

An interpretable radiomics model can help clinicians to effectively predict the prognosis of HIFU treatment for uterine fibroids. The heterogeneity of fibroids can be characterized by various radiomics features and the application of SHAP can be used to visually explain the prediction process of radiomics models.

An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus

Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.

Long-term outcomes of ultrasound guided high intensity focused ultrasound ablation for patients with uterine fibroids classified by T2WI: a multicenter retrospective study

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.

Therapeutic dose and long-term efficacy of high-intensity focused ultrasound ablation for different types of uterine fibroids based on signal intensity on T2-weighted MR images

OBJECTIVE

To investigate the therapeutic dose and long-term efficacy of high-intensity focused ultrasound (HIFU) ablation for different types of uterine fibroids based on signal intensity on T2-weighted MR images (T2WI).

MATERIALS AND METHODS

Four hundred and one patients with a solitary uterine fibroid treated with HIFU were classified into four groups consisting of extremely hypointense, hypointense, isointense and hyperintense fibroids. Each group was further classified into two subtypes: homogeneous and heterogeneous, based on signal homogeneity of fibroids. The therapeutic dose and long-term follow-up results were compared.

RESULTS

There were significant differences in treatment time, sonication time, treatment intensity, total treatment dosage, treatment efficiency, energy-efficiency factor (EEF) and non-perfused volume (NPV) ratio among the four groups (p<.05). The average NPV ratio achieved in patients with extremely hypointense, hypointense, isointense and hyperintense fibroids was 75.2 ± 14.6%, 71.1 ± 15.6%, 68.2 ± 17.3% and 67.8 ± 16.6%, respectively; the re-intervention rates at 36 months after HIFU were 8.4%, 10.3%, 12.5% and 6.1%, respectively. Sonication time, treatment intensity and total energy for heterogeneous fibroids were greater than that for homogeneous fibroids in patients with extremely hypointense fibroids (p<.05). The treatment time for heterogeneous fibroids was significantly longer than that for homogeneous fibroids in patients with isointense fibroids (p<.05). Multivariate ordered logistic regression analysis showed that the ablation volume of fibroids and treatment time were related to NPV ratio (p<.05).

CONCLUSION

Every group of patients obtained satisfactory long-term results. Hyperintense fibroids are difficult to treat by HIFU. Heterogeneous fibroids are more difficult to treat with HIFU than homogeneity fibroids.

Prediction of postoperative reintervention risk for uterine fibroids using clinical-imaging features and T2WI radiomics before high-intensity focused ultrasound ablation

OBJECTIVE

To predict the risk of postoperative reintervention for uterine fibroids using clinical-imaging features and T2WI radiomics before high-intensity focused ultrasound (HIFU) ablation.

METHODS

Among patients with uterine fibroids treated with HIFU from 2019 to 2021, 180 were selected per the inclusion and exclusion criteria (42 reintervention and 138 non-reintervention). All patients were randomly assigned to either the training (n = 125) or validation (n = 55) cohorts. Multivariate analysis was used to determine independent clinical-imaging features of reintervention risk. The Relief and LASSO algorithm were used to select optimal radiomics features. Random forest was used to construct the clinical-imaging model based on independent clinical-imaging features, the radiomics model based on optimal radiomics features, and the combined model incorporating the above features. An independent test cohort of 45 patients with uterine fibroids tested these models. The integrated discrimination index (IDI) was used to compare the discrimination performance of these models.

RESULTS

Age (p < .001), fibroid volume (p = .001) and fibroid enhancement degree (p = .001) were identified as independent clinical-imaging features. The combined model had AUCs of 0.821 (95% CI: 0.712-0.931) and 0.818 (95% CI: 0.694-0.943) in the validation and independent test cohorts, respectively. The predictive performance of the combined model was 27.8% (independent test cohort, p < .001) and 29.5% (independent test cohort, p = .001) better than the clinical-imaging and radiomics models, respectively.

CONCLUSION

The combined model can effectively predict the risk of postoperative reintervention for uterine fibroids before HIFU ablation. It is expected to help clinicians to develop accurate, personalized treatment and management plans. Future studies will need to be prospectively validated.

Improvement of fibroid-associated symptoms and quality of life after US-guided high-intensity focused ultrasound (HIFU) of uterine fibroids

Uterine fibroids are the most common benign uterine tumors and can cause various severe symptoms as abnormal menstrual bleeding or pelvic pain. Therefore, the primary objective in the treatment of uterine fibroids is a sufficient symptom relief. Ultrasound (US)-guided High-intensity focused ultrasound (HIFU) is an effective non-invasive treatment strategy for ablation of uterine fibroids that can achieve a significant tumor volume reduction. The aim of the study is to evaluate if US-guided HIFU treatment can reduce fibroid-associated symptoms leading to an improvement of health-related quality of life. Fifty-five women with symptomatic uterine fibroids underwent US-guided HIFU ablation. Clinical evaluation was performed on the basis of the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) at baseline, 6 weeks, 3, 6, 9 and 12 months after HIFU. Imaging follow-up included contrast-enhanced ultrasound (CEUS) and contrast-enhanced MRI. A significant reduction of the Symptom Severity Scale (SSS) was observed between 6 weeks and 12 months after HIFU (49.9 ± 19.4 at baseline vs. 42.2 ± 20.1 at 6 weeks and 23.6 ± 12.7 at 12 months after treatment, p < 0.001) correlating with a significant improvement (p < 0.001) of Health-related Quality of Life (HRQL) (52.5 ± 22.7 at baseline vs. 59.8 ± 22 at 6 weeks and 77.9 ± 17.3 at 12 months after treatment). Significant postinterventional improvement was observed in every subscale of HRQL. In the majority of patients, only minor, short-lasting and self-limiting side effects were observed, e.g. soft tissue edema of the anterior lower abdominal wall in the acoustic pathway or transient moderate lower abdominal pain as during menstruation. One patient with a very large fibroid experienced strong short-lasting pain after the procedure; two patients experienced post-procedurally a transient sciatic nerve irritation. US-guided HIFU of uterine fibroids reduces disease-related symptoms and improves health-related quality of life.

Management of unresectable and recurrent intra-abdominal desmoid tumors treated with ultrasound-guided high-intensity focused ultrasound: A retrospective single-center study

To assess the efficacy and safety of ultrasound (US)-guided high-intensity focused ultrasound (HIFU) ablation for treatment of unresectable and recurrent intra-abdominal desmoid tumors. From June 2014 to March 2020, 15 patients with consecutive unresectable and recurrent diseases that pathologically proven to be intra-abdominal desmoid tumors had undergone the treatment of US-guided HIFU ablation. All patients underwent contrast-enhanced magnetic resonance imaging before and after HIFU treatment. Nonperfused volume ratio was used to evaluate the effect of HIFU therapy. Intraprocedural and postprocedural adverse effects and complications are recorded to assess the safety of the therapy. Outcome of HIFU ablation has been investigated through serial contrast-enhanced imaging examinations during follow up. Out of 15 patients 14 of them have successfully completed the whole therapy, 1 patient is ineffective and gives up further treatment. The mean nonperfused volume ratio is 71.1% (95% confidence interval, 3% to 88.2%). During a mean follow up of 29 months (range from 8 to 61 months), the mean tumor volume was reduced by 59% (95% confidence interval, +49% to -100%). No tumor spreads along the treated area in all patients except one. Complications have occurred in 5 patients (33.3%), including bowel rupture (1 case), intra-abdominal abscess (1 case), slight injury to the femoral nerve (1 case), and bone injury (2 cases), the bowel rupture patient underwent surgery; the others have been cured during the follow up. US-guided HIFU ablation is an effective treatment modality for patients suffered from unresectable and recurrent intra-abdominal desmoid tumors.

Therapeutic Outcome of MR-Guided High-Intensity Focused Ultrasound (MR-HIFU) in Solitary versus Multiple Uterine Fibroids

MR-guided high-intensity focused ultrasound (MR-HIFU) is an effective method for treating symptomatic uterine fibroids, especially solitary lesions. The aim of our study was to compare the clinical and morphological outcomes of patients who underwent MR-HIFU due to solitary fibroid (SF) or multiple fibroids (MFs) in a prospective clinical trial. We prospectively included 21 consecutive patients with SF (10) and MF (11) eligible for MR-guided HIFU. The morphological data were assessed using mint Lesion™ for MRI. The clinical data were determined using the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire before and 6 months after treatment. Unpaired and paired Wilcoxon-test and t-tests were applied, and Pearson’s coefficient was used for correlation analysis. A p-value of 0.05 was considered statistically significant. The volume of treated fibroids significantly decreased in both the SF (mean baseline: 118.6 cm³; mean 6-month follow-up: 64.6 cm³) and MF (107.2 cm³; 55.1 cm³) groups. The UFS-QOL showed clinical symptoms significantly improved for patients in both the SF and MF groups regarding concern, activities, energy/mood, and control. The short-term outcome for the treatment of symptomatic fibroids in myomatous uterus by MR-guided HIFU is clinically similar to that of solitary fibroids.

Should Ultrasound-Guided High Frequency Focused Ultrasound Be Considered as an Alternative Non-Surgical Treatment of Uterine Fibroids in Non-Asiatic Countries? An Opinion Paper

Minimally invasive interventions for myomata treatment have gained acceptance due to the possibility of preserving fertility with reduced trauma induced by laparotomy as way of entrance. There are insufficient data regarding outcomes of high intensity focused ultrasound (HIFU) in non-Asiatic women. Therefore, we revised the available evidence to present an expert opinion that could support physicians, patients and policy-makers for considering this approach in other populations. We revisited systematic reviews, randomized controlled trials and cohort studies from January 2018 to August 2021 using PubMed and Google scholar, regarding short and long term outcomes after ablation with focused ultrasound waves. In total, 33 studies, including 114,810 adult patients showed that outcomes of this approach depend on several parameters directly related with resistance to thermal ablation, especially fibroid size and vascularization. Two studies report satisfactory outcomes in Afro-American women. In accordance to the technique used, fibroid volume reduction showed to be higher in fibroids <300 cm3 after ultrasound guided HIFU than after MRI guided. Compared to myomectomy and uterine artery embolization, HIFU seems to have shorter hospital stay, higher pregnancy rates and similar adverse events rates, with skin burn being the most reported. Symptoms and quality of life improvement is similar to myomectomy but lower than embolization, however reintervention rate is higher after HIFU. Lacks evidence about long-term sarcoma risk after ablation. Available evidence shows that HIFU can be considered as a uterine sparing treatment for women of different ethnicities suffering of uterine myomatosis, especially for those wishing to preserve their fertility.

Comparison of thermal ablative methods and myomectomy for the treatment of fibroids: a systematic review and meta-analysis

OBJECTIVE

To examine the effectiveness and safety of thermal ablative methods and myomectomy for the treatment of uterine fibroids.

MATERIALS AND METHODS

We searched EMBASE, PubMed, the Cochrane Central Register of Controlled Trials, Scopus, CINAHL, ClinicalTrials.gov and Web of Science databases through April 2021. Clinical trials comparing the thermal ablative methods and myomectomy for the treatment of uterine fibroids were included.

RESULTS

Thirteen studies including 4205 patients were eligible. The thermal ablative treatment group was associated with less major adverse events (only ultrasound guided high-intensity focused ultrasound) (RR, 0.111 [95% CI, 0.070-0.175], p=.0), shorter duration of hospital stays in observational studies (-0.1497 day, [95% CI, -1.593 to -0.321], p=.0) and in randomized controlled trials (RCTs) (-0.844 day, [95% CI, -0.1.142 to -0.546], p=.0), higher uterine fibroid symptom (UFS) score after operation (0.252 [95% CI, 0.165-0.339]; p=.0), transformed symptom severity (tSS) score after operation (0.515 [95% CI, 0.355-0.674]; p=.0) and quality of life (QoL) score after operation (0.188 [95% CI, 0.093-0.283]; p=.0) in comparison with myomectomy group. No statistically significant difference was found between the thermal ablative treatment group and myomectomy group with respect to reintervention rate and pregnancy rate.

CONCLUSION

The current data available demonstrate that thermal ablative methods were not inferior to myomectomy in the treatment of uterine fibroids. The findings in this study need to be further confirmed by large RCTs.

Ultrasound-Guided High-Intensity Focused Ultrasound for Devascularization of Uterine Fibroid: A Feasibility Study

This study aimed to establish the feasibility of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for devascularization of uterine fibroids. Ultrasound color Doppler flow imaging (CDFI) and B-mode imaging were used to target fibroid vascularity. The vessels were covered and ablated by high-intensity focused ultrasound spots. In this study, 42 fibroids with a volume of 66.98 ± 4.00 cm³ were treated. No blood flow was detected by post-treatment CDFI in 40 fibroids. The 6-mo non-perfusion volume rate was 75.23% ± 34.77% (n = 40). The mean shrinkage in fibroid volume was 38.20% and 43.89%, respectively, at 1 and 6 mo after treatment (p < 0.001). The uterine fibroid symptom and quality of life scores were reduced by 9.43% at 1 mo and 26.66% at 6-mo after treatment (p < 0.001). No serious adverse event was observed. This study demonstrates the feasibility of USgHIFU-induced fibroid devascularization, and more studies are required for the evaluation of safety and efficacy.

MRI features and clinical outcomes of unexpected uterine sarcomas in patients who underwent high-intensity focused ultrasound ablation for presumed uterine fibroids

OBJECTIVE

To investigate the MRI features and clinical outcomes of unexpected uterine sarcomas in patients after high-intensity focused ultrasound (HIFU) ablation for presumed uterine fibroids.

MATERIALS AND METHODS

15,759 consecutive patients who came for HIFU treatment, from November 2008 to September 2019, for presumed uterine fibroids were retrospectively reviewed. All the patients had completed a pre-HIFU MRI. All MRI images were independently analyzed and interpreted by two radiologists in every center.

RESULTS

According to the T2WI MRI features of hyperintensity, accompanied by irregular margins, necrosis or cystic degeneration, multi-lobulated lesion with internal septation, 46 patients were suspected to be uterine sarcomas before HIFU. Eleven patients were histologically diagnosed as uterine sarcomas after laparotomy. Among the 15713 patients who received HIFU treatment for presumed uterine fibroids, 8 patients were found to have occult recurrence during the follow-up period, and 6 were confirmed histologically as uterine sarcomas after laparotomy. The incidence rate of uterine sarcomas was 0.108% (17/15759). Among them, 12 cases were low-grade endometrial stromal sarcoma (LG-ESS) and 5 cases were uterine leiomyosarcoma (LMS). No histological dissemination of the sarcoma was detected in patients with unexpected uterine sarcomas.

CONCLUSION

Although some MRI features of uterine sarcomas and uterine fibroids overlapped, MRI is valuable in distinguishing between uterine fibroids and uterine sarcomas. HIFU does not seem to cause histological dissemination of the sarcoma, but follow-up visits should be strictly adhered to in order to detect unexpected uterine sarcomas at an early stage and to treat them in a timely manner.

The safety and ablation efficacy of ultrasound-guided high-intensity focused ultrasound ablation for desmoid tumors

OBJECTIVE

To evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for desmoid tumors (DTs).

METHOD

A total of 111 patients with histologically proven DTs were included and treated by USgHIFU ablation. Adverse events were continuously evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 until 3 months after treatment. The incidence of non-perfused areas within the treated tumors, non-perfused volume rate (NPVR) and tumor volume reduction were evaluated using contrast-enhanced MRI before and one week and 3 months after the procedure.

RESULTS

The enrolled patients (32 male, 79 female, mean age 29.5 ± 1.0 years) with 145 DTs (118 extra-abdominal, 16 abdominal wall, 11 intra-abdominal; median maximum diameter: 9.6 cm, range: 3-34.5 cm) underwent 188 sessions of HIFU ablation, and the mean number of ablations was 1.7 (range, 1-7) per patient. In majority of cases (143/145 cases, 98.6%), no serious adverse events were observed. There was no significant difference in the incidence of adverse events between patients who received a single treatment and those who received multiple treatments. Non-perfused area was observed within every treated tumor, and the median NPVR was 84.9% (range, 1.9-100%). The tumor volume reduction rate was 36.1 ± 4.2% at 3 months after treatment.

CONCLUSION

USgHIFU ablation, as a noninvasive and easily repeatable local treatment, is a promising treatment for DTs.

Uterine Fibroids: Assessing Unmet Needs from Bench to Bedside

Uterine fibroids (leiomyomas) are noncancerous growths that can have deleterious effects on the health and quality of life for millions of women. Attempts to better understand the factors that influence prevalence and disparities associated with fibroids have been made; however, significant knowledge gaps continue to persist, which hinder care for individuals living with fibroids. The Society for Women's Health Research convened an interdisciplinary Uterine Fibroids Working Group to review the current state of knowledge about uterine fibroids and recommend areas in which to prioritize efforts to address research gaps and improve diagnosis, treatment, and access to care for patients with this chronic disease. Throughout a 2-day roundtable meeting, participants discussed updates on key literature, research, clinical practice, and public health data on uterine fibroids. Overarching themes and recommendations were identified and determined by consensus agreement of the participants at the conclusion of the meeting. Systematic studies of the etiology and pathology of uterine fibroids are needed to address important knowledge gaps and unmet clinical needs regarding the multifaceted management of fibroids and their effects on overall health and quality of life. The Working Group recommends addressing key deficits within the spheres of research, clinical care, and federal policy. Immediate needs include increasing research investment, improving fibroid assessment using pelvic imaging, implementing longitudinal study designs, addressing factors that contribute to disease disparities (especially among women of color), developing fertility-friendly treatment options, expanding awareness and education beyond gynecologic specialists, and advancing personalized patient care through shared decision-making approaches.

High-intensity focused ultrasound (HIFU) ablation versus surgical interventions for the treatment of symptomatic uterine fibroids: a meta-analysis

OBJECTIVES

To compare the treatment success and safety of ultrasound- and MR-guided high-intensity focused ultrasound (HIFU) with surgery for treating symptomatic uterine fibroids.

METHODS

We searched studies comparing HIFU with surgery for fibroids in different databases from January 2000 to July 2020. The mean difference (MD) or relative risk (RR) with 95% confidence interval (CI) for different outcome parameters was synthesized.

RESULTS

We included 10 studies involving 4450 women. Compared with the surgery group, the decrease in uterine fibroid severity score at 6- and 12-month follow-up was higher in the HIFU group (MD - 4.16, 95% CI - 7.39 to - 0.94, and MD - 2.44, 95% CI - 3.67 to - 1.20, p < 0.05). The increase in quality-of-life (QoL) score at 6- and 12-month follow-up was higher in the HIFU group (MD 2.13, 95% CI 0.86 to 3.14, and MD 2.34, 95% CI 0.82 to 3.85, p < 0.05). The duration of hospital stay and the time to return to work was shorter in the HIFU group (MD - 3.41 days, 95% CI - 5.11 to - 1.70, and MD - 11.61 days, 95% CI - 19.73 to - 3.50, p < 0.05). The incidence of significant complications was lower in the HIFU group (RR 0.33, 95% CI 0.13 to 0.81, p < 0.05). The differences in the outcomes of adverse events, symptom recurrence, re-intervention, and pregnancy were not statistically significant (p > 0.05).

CONCLUSIONS

HIFU is superior to surgery in terms of symptomatic relief, improvement in QoL, recovery, and significant complications. However, HIFU showed comparable effects to surgery regarding the incidence of adverse events, symptom recurrence, re-intervention, and pregnancy.

KEY POINTS

• HIFU ablation is superior to surgery in terms of symptomatic relief, improvement in QoL, recovery, and significant complications. • HIFU has comparable effects to surgery in terms of symptom recurrence rate, re-intervention rate, and pregnancy rate, indicating that HIFU is a promising non-invasive therapy that seems not to raise the risk of recurrence and re-intervention or deteriorate fertility compared to surgical approaches in women with fibroids. • There is still a lack of good-quality comparative data and further randomized studies are necessary to provide sufficient and reliable data, especially on re-intervention rate and pregnancy outcome.

Magnetic resonance imaging parameters in predicting the ablative efficiency of high-intensity focused ultrasound for uterine fibroids

OBJECTIVE

To evaluate the role of quantitative MRI parameters in predicting HIFU ablation results for uterine fibroids.

MATERIAL AND METHODS

A total of 245 patients with uterine fibroids who underwent HIFU treatment in Chongqing Haifu Hospital were reviewed retrospectively. The patients were divided into two groups according to the non-perfused volume (NPV) ratio which was either higher or lower than 80%. The MRI parameters were measured, and a logistical regression analysis was performed to investigate the potential predictors associated with the NPV ratio. Receiver operating characteristics (ROC) analysis was used to determine the cut off value for MRI parameters in predicting a high NPV ratio.

RESULTS

The subcutaneous fat thickness in the group of patients with an NPV ratio over 80% was significantly thinner than that in the group of patients with an NPV ratio less than 80% (15 mm versus 21 mm). The signal intensity ratio of fibroids to skeletal muscle on T2WI was significantly lower in the group of patients with an NPV ratio over 80% compared with the group with an NPV ratio lower than 80% (2.46 versus 3.23). The signal intensity ratio of fibroid to skeletal muscle correlated negatively with the NPV ratio and positively with the energy efficiency factor (EEF). The cut off value of signal intensity ratio of fibroid to muscle for predicting the NPV ratio over 80% is 3.045.

CONCLUSION

The signal intensity ratio of fibroid to skeletal muscle on T2WI can be used as a factor for predicting the effectiveness of HIFU ablation of uterine fibroids.

High-intensity focused ultrasound ablation in the treatment of recurrent ovary cancer and metastatic pelvic tumors: a feasibility study

OBJECTIVE

To explore the feasibility of high-intensity focused ultrasound (HIFU) ablation for treating metastatic pelvic tumors and recurrent ovary cancer.

MATERIALS AND METHODS

Eight patients with metastatic pelvic tumors or recurrent ovary cancer were enrolled in this study. Among them, 5 patients had ovarian cancer, 1 had cervical cancer, 1 had endometrial cancer, and 1 had rectal cancer. Six of them received abdominal surgical operation for their primary cancer, no one received radiotherapy. HIFU treatment was performed under conscious sedation. Vital signs were monitored during the procedure, and adverse effects were recorded. Postoperative follow-up was performed to observe pain relief and the improvement of the patient's quality of life.

RESULTS

The median age of the patients was 54 (range: 33-76) years, with a total of 12 lesions. The average volume of the lesions was 238.0 cm³. Six patients completed 12 months follow-up. Postoperative pain relief rate was 60% (3/5), and the quality of life improved in the short term. The main adverse effect of HIFU was pain in the treated area, with the pain score lower than 4, and all of which was self-relieved within 1 day after HIFU treatment. No serious complications such as skin burn, intestinal perforation, and nerve injury occurred.

CONCLUSION

HIFU is feasible for the treatment of metastatic pelvic tumors or recurrent ovary cancer without serious complications. Therefore, HIFU seems a promising treatment for recurrent ovary cancer, metastatic pelvic tumors from cervical cancer, endometrial cancer, and rectal cancer.

Comparison of High-Intensity Focused Ultrasound and Conventional Surgery for Patients with Uterine Myomas: A Systematic Review and Meta-Analysis

OBJECTIVE

Uterine myomas are one of the most common gynecologic tumors in premenopausal women. The conventional surgical treatments are myomectomy and hysterectomy, but high-intensity focused ultrasound (HIFU) is a new noninvasive treatment creating no surgical wound. The aim of this study was to evaluate the effectiveness and safety of HIFU treatment compared with conventional surgery for patients with uterine myomas.

DATA SOURCES

PubMed, Embase, and the Cochrane Library were searched for studies published before January 2021.

METHODS OF STUDY SELECTION

Studies comparing the outcome of HIFU and conventional surgery-myomectomy and hysterectomy-for patients with uterine myomas were included. We conducted meta-analyses by using a random effects model. Uterine myoma symptom score and quality-of-life score were analyzed using the mean difference (MD). The recovery time and frequency of major adverse events were also evaluated.

TABULATION, INTEGRATION, AND RESULTS

Ten studies were included. HIFU relieved uterine myoma symptoms significantly when compared with conventional surgery at 6 (MD -1.61; 95% confidence interval [CI], -2.88 to -0.33) and 12 (MD -2.44; 95% CI, -3.68 to -1.20) months after treatment. Similarly, HIFU group improve the quality-of-life score significantly at 6 (MD 2.14; 95% CI, 0.86-3.42) and 12 (MD 2.34; 95% CI, 0.82-3.86) months after treatment when compared with the surgery group.

CONCLUSION

HIFU could be an effective and safe treatment option for patients with uterine myomas. However, one of its side effects, skin burns, requires further research and discussion. Additional studies involving more randomized controlled trials are warranted.