Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization

Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement

Internal iliac artery (IIA) balloon occlusion catheters have been commonly inserted to decrease the risk of postpartum hemorrhage in placenta accreta spectrum disorders; however, there has been mixed success in clinical studies. Placement of an infrarenal aortic balloon has shown more consistent effectiveness in recent studies. A possible reason for this is collateral arterial supply to the placenta from external iliac artery branches. Retrospective chart review was conducted of angiography images during prophylactic IIA balloon occlusion catheter insertion over a 7-year period. Sixty-two individual cases were identified. Digital subtraction angiography (DSA) was performed in 32 (52%) cases, and 20 (62%) showed collateral blood supply from branches of the external iliac arteries, namely the round ligament artery. In conclusion, a high proportion of placenta accreta spectrum cases have arterial blood supply from branches of the external iliac artery, which may explain the discrepancy in effectiveness seen between IIA and infrarenal aortic sites of balloon occlusion catheter placement.

Long-term Efficacy of Fibroid Devascularization with Ultrasound-Guided High-Intensity Focused Ultrasound

RATIONALE AND OBJECTIVES

High-intensity focused ultrasound (HIFU) has been increasingly used for treatment of uterine leiomyoma. The superiority of HIFU therapy targeting uterine leiomyoma blood vessels, however, still needs to be further explored. This study aims to evaluate the long-term efficacy of fibroid devascularization with ultrasound-guided HIFU (USgHIFU) and the effects of treatment on the ovarian reserve and endometrial injury.

MATERIALS AND METHODS

Fibroid devascularization was assessed with the Adler grade obtained by color Doppler flow imaging and power Doppler imaging (PDI). The targeted vessels were covered and then sonicated by HIFU focal spots. The patients were followed up at 1 month, 3 months, 6 months, 1 year, 2 years and 3 years after treatment. Adverse effects and complications were recorded. The non-perfusion volume rate (NPVR), fibroid volume shrinkage rate (FVSR), Adler Grade, symptom severity score (SSS) and uterine fibroid symptom and quality of life (UFS-QOL) were evaluated. Adverse events (AEs) were recorded. In Center 1, the enrolled patients completed the anti-Müllerian hormone (AMH) test before and at 6 months after treatment.

RESULTS

A total of 117 eligible patients were consecutively enrolled to receive interventions and follow-up evaluations of the three centers from January 2019 to May 2023. The 1-month and 6-month NPVRs were 66.60% ± 33.14% and 51.12% ± 39.84%, respectively. The mean FVSRs at 1 month and 6 months after treatment were 38.20% and 43.89%, respectively. No significant difference was observed in AMH levels before and after treatment (p > 0.05). No irreversible endometrial injury was observed in MR images after HIFU treatment. No significant difference was observed in both 1-month and 6-month FVSRs among Center 1, 2 and 3 (p > 0.05). No severe AEs occurred. For long-term outcomes, significant differences were observed in Adler grade, FV, FVSR, SSS, reduction in SSS and UFS-QOL before and after treatment (p < 0.001) whereas no significant difference was observed in Adler grade among 3 months, 1 year, 2 years and 3 years after treatment (p > 0.05). The SSSs were reduced by 33.42% at 1 year, 42.32% at 2 years and 52.46% at 3 years after treatment.

CONCLUSION

For patients with uterine fibroids, USgHIFU-induced devascularization is a safe and effective treatment option. It has little effect on ovarian function and the endometrial injury is reversible, which could be attractive for patients who plan to become pregnant.

Bipedalism and the dawn of uterine fibroids

The high prevalence and burden of uterine fibroids in women raises questions about the origin of these benign growths. Here, we propose that fibroids should be understood in the context of human evolution, specifically the advent of bipedal locomotion in the hominin lineage. Over the ≥7 million years since our arboreal ancestors left their trees, skeletal adaptations ensued, affecting the pelvis, limbs, hands, and feet. By 3.2 million years ago, our ancestors were fully bipedal. A key evolutionary advantage of bipedalism was the freedom to use hands to carry and prepare food and create and use tools which, in turn, led to further evolutionary changes such as brain enlargement (encephalization), including a dramatic increase in the size of the neocortex. Pelvic realignment resulted in narrowing and transformation of the birth canal from a simple cylinder to a convoluted structure with misaligned pelvic inlet, mid-pelvis, and pelvic outlet planes. Neonatal head circumference has increased, greatly complicating parturition in early and modern humans, up to and including our own species. To overcome the so-called obstetric dilemma provoked by bipedal locomotion and encephalization, various compensatory adaptations have occurred affecting human neonatal development. These include adaptations limiting neonatal size, namely altricial birth (delivery of infants at an early neurodevelopmental stage, relative to other primates) and mid-gestation skeletal growth deceleration. Another key adaptation was hyperplasia of the myometrium, specifically the neomyometrium (the outer two-thirds of the myometrium, corresponding to 90% of the uterine musculature), allowing the uterus to more forcefully push the baby through the pelvis during a lengthy parturition. We propose that this hyperplasia of smooth muscle tissue set the stage for highly prevalent uterine fibroids. These fibroids are therefore a consequence of the obstetric dilemma and, ultimately, of the evolution of bipedalism in our hominin ancestors.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids of Different Sizes: A Single Center Experience

The present study aimed to evaluate the clinical and radiological 1-year outcomes of uterine artery embolization (UAE) performed in a selected population of women with symptomatic myomas and who do not wish to conceive. Between January 2004 and January 2018, a total of 62 patients with pre-menopausal status and with no wish to conceive in the future underwent UAE for the treatment of symptomatic fibroids. All the patients underwent magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TV-US) before and after the procedure at 1-year follow-up. Clinical and radiological parameters were recorded, stratifying the population into 3 groups according to the size of the dominant myoma (group 1: <50 mm; group 2: ≥50 and ≤80 mm; group 3: >80 mm). Mean fibroid diameter was significantly reduced (42.6% ± 21.6%) at 1-year follow-up, with excellent improvements in terms of both symptoms and quality of life. No significant difference was observed regarding baseline dimension and the number of myomas. No major complications were reported (2.5%). The present study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids in pre-menopausal women with no desire to conceive.

Leiomyomata, neonatal anthropometry, and pregnancy outcomes in singleton pregnancies

PURPOSE

To investigate the relationship of fibroids in pregnancy, preterm birth, and neonatal anthropometry.

METHODS

Pregnant women (n = 2578) in the National Institute of Child Health and Human Development Fetal Growth Studies-Singletons cohort had up to six ultrasounds across pregnancy. Sonographers recorded fibroid number and volume of the three largest fibroids. Trained personnel measured neonatal anthropometry. Linear and logistic regression compared neonatal anthropometry and pregnancy outcomes among pregnancies with versus without fibroids. Causal mediation analysis evaluated preterm birth as a mediator.

RESULTS

Average birthweight did not differ by fibroid status. However, compared with pregnancies without fibroids, neonates from pregnancies with single fibroids had 0.3- (95% confidence interval [CI], 0.0, 0.5) cm larger head circumferences; those with multiple fibroids had 0.3- (95% CI, 0.0, 0.6) cm larger arm circumferences; and those with small fibroid volume had 0.7- (95% CI, 0.3, 1.2) cm larger head, 0.4- (95% CI, 0.0, 0.8) cm larger arm, and 0.7- (95% CI, 0.1, 1.3) cm larger thigh circumferences. Presence versus absence of fibroids was associated with 1.73-2.65 times higher odds of preterm birth. Differences in preterm birth did not explain fibroid-anthropometry results.

CONCLUSIONS

We found no evidence that fibroids negatively impacted fetal growth; instead, fibroids were associated with increased head, arm, and thigh circumferences.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00912132.

Pressure-Induced Fibroid Ischemia: First-In-Human Experience with a Novel Device for Laparoscopic Treatment of Symptomatic Uterine Fibroids

The purpose of this study was to assess the feasibility of use of a novel uterine fibroid treatment device hypothesized to cause fibroid infarction by increasing intra-tumoral pressure. Between August 2019 and January 2020, 21 uterine fibroids were treated in 16 symptomatic pre-menopausal black women. Pelvic magnetic resonance imaging was performed before the procedure, a day after the procedure and at 1, 3, 6, and 12 months. The subjects were also followed for clinical outcomes and quality of life up to 12 months at a single investigational site. At 3 months, the mean reduction in the fibroid volume was 36.3% (P = .002). Incremental reduction in volume peaked at the end of the follow-up, at the 12-month mark (60.4%; P = .008). There were no procedures in which the users failed to perform laparoscopic pressure suturing of fibroids with the pressure-induced fibroid ischemia device. Improvement in the quality of life was evident in the Health-Related Quality of Life total, Energy/Mood, Control, and Sexual Function domains of the Uterine Fibroid Symptom and Quality of Life questionnaire at 3 months post-procedure. Unanticipated risks were not identified. Serious adverse events were not identified. The initial clinical assessment of the pressure-induced fibroid ischemia device supports feasibility of the approach and does not reveal serious safety concerns. Trial is currently being registered retrospectively (This was a feasibility study and therefore registration was not mandatory).

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases

BACKGROUND

Uterine leiomyomata have been loosely associated with intrauterine fetal demise (IUFD), largely attributed to fetal growth restriction from cavitary distortion. We present two cases of IUFD in patients with non-distorting leiomyomata and pathologic placental findings of maternal vascular malperfusion (MVM) and fetal vascular malperfusion (FVM).

CASE REPORT

Case 1 details a 28w3d IUFD associated with large leiomyomata (largest 11.9 × 7.6 × 9.7 cm), post-partum deep vein thrombosis, and severe pre-eclampsia histologic features. Case 2 details a 25w2d IUFD associated with smaller leiomyomata (largest 3.1 × 3.0 × 3.3 cm). Both placentas demonstrated MVM, including parenchymal thrombi and accelerated villous maturity, and FVM, including avascular stem villi.

DISCUSSION

As the placentas in both cases demonstrated findings consistent with altered placental perfusion, we posit that leiomyomata in these cases may have been associated with both maternal and fetal vascular malperfusion, ultimately contributing to fetal demise.

Combination of microspheres and gadoteridol for the determination of non-target ovarian embolization during uterine artery embolization. A case series

Background. Uterine myoma is the most common benign tumor of the pelvic organs in women. One of the effective therapies for myomas is uterine artery embolization (UAE), which can be associated with unintended ovarian embolization. However, there is no certainty about the effect of unintended ovarian embolization on fertility and ovarian function since no precise evidence-based ways of identifying unintended embolization have been described. Aim. To develop a highly accurate method for identifying unintended ovarian embolization during UAE. Materials and methods. A series of clinical cases of the utilization of combined embolization material based on the paramagnetic contrast agent gadoteridol and saturable HepaSphere microspheres are presented. Results. On admission, patients underwent magnetic resonance imaging (MRI) of the pelvic organs with contrast enhancement. After UAE with this combined embolization material, another pelvic MRI without contrast enhancement was performed on the in-hospital day 2. In the first clinical case, no hyperintensive zones were detected in the ovarian stroma. However, in the second case, a previously undetected hyperintensive signal up to 6 mm in diameter was seen in the stroma of the left ovary by repeat MRI. Conclusion. Using this combined material during UAE significantly increases the accuracy of possible unintended ovarian embolization detection as soon as in the early postoperative period.

Effectiveness of transarterial embolisation for intractable postpartum haemorrhage in a disseminated intravascular coagulation state, despite emergency hysterectomy

PURPOSE

We evaluated the effectiveness of transarterial embolization (TAE) for intractable postpartum hemorrhage in patients with disseminated intravascular coagulation (DIC) despite emergency hysterectomy.

MATERIALS AND METHODS

We retrospectively assessed TAE performed after emergency hysterectomy in 15 patients between July 2008 and January 2022. Underlying condition, technical success, clinical success, angiographic findings, laboratory findings, pregnancy-modified DIC score (The International Society on Thrombosis and Haemostasis), blood transfusion, ICU (Intensive care unit) admission day, hospital day, in-hospital mortality, and long-term sequelae were evaluated.

RESULTS

All patients were diagnosed with DIC before embolization, with a 43.9 mean DIC score. All patients showed positive angiographic findings for active bleeding. Thirty-eight bleeding arteries were confirmed. The remnant uterine artery (n=25) was the most common focus of persistent bleeding, followed by the cervicovaginal artery (n=6), pudendal artery (n=3), obturator artery (n=2), vesical artery (n=1), and unspecified artery from the internal iliac artery (n=1). Technical and clinical success rates were 100% (15/15) and 93.3% (14/15), respectively. Mean nadir hemoglobin (Hb) level before embolization was 4.9 g/dL. All patients underwent massive transfusion before embolization (mean 33.2 packs of RBC). Postoperatively, a smaller amount of blood was transfused than before the procedure (mean 10.6 packs of RBC). Mean nadir Hb level after embolization was 8.2 g/dL. There was one instance each of in-hospital death, hypoxic brain damage, and ischemic acute kidney injury.

CONCLUSION

Despite hysterectomy for postpartum bleeding, there could be multiple residual or uncontrolled bleeding foci, especially in case of DIC, for which TAE could be an effective treatment.

Contralateral and Ipsilateral Arterial Vasculature of the Human Uterus: The Pilot Results of an Anatomical Study

Arterial blood to the human uterus is provided by a pair of uterine arteries (UA) and supported by terminal branches of ovarian (OA) and vaginal arteries (VA). Literature reports the existence of ipsilateral and contralateral anastomoses between these arteries and the UA, but data on the prevalence of such anastomoses are discrepant. The aim of this trial is to study whether contralateral and ipsilateral anastomoses exist. We studied nine human uterine specimens, which were obtained from (i) human cadavers (n = 6), (ii) uterine transplant recipients (n = 2), and (iii) one altruistic uterine donor (n = 1). We injected India ink into the graft through the UA of each specimen (n = 8) or OA (n = 1). We semiquantitatively observed and evaluated the extent of the injection on horizontal, vertical, and transmural levels. The dye permeated beyond the midline in 9/9 (100 %) cases. Near-complete/complete permeation to the contralateral side was observed in 6/9 (66 %) cases. The dye permeated ipsilaterally throughout all uterine levels in 8/8 cases (100 %) of UA injection. The entire wall of the myometrium was permeated in 2/9 (22 %) cases. In 7/9 (78 %) cases, the wall of the myometrium was permeated less than halfway through. In conclusions, the preliminary results of this study prove the existence of ipsilateral and contralateral anastomoses. Complete transmural injection was observed in only 22 % of cases; however, this finding does not provide information about the functional capacity of these anastomoses. More data and studies are necessary to make definitive conclusions.

Association between uterine fibroids and antimüllerian hormone concentrations among African American women

OBJECTIVE

To evaluate the extent to which uterine fibroids are associated with antimüllerian hormone (AMH) concentrations.

DESIGN

Cross-sectional study.

SETTING

Baseline data from the Study of the Environment, Lifestyle, and Fibroids, which is a 5-year longitudinal study of African American women.

PATIENT(S)

A total of 1,643 women aged 23-35 years without a known history of fibroids.

EXPOSURE

Fibroid presence.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was percent difference in the mean AMH concentration between participants with fibroids and those without fibroids. The secondary outcomes were percent differences in the mean AMH concentrations in participants with different numbers, sizes, types, and positions of fibroids and the percent difference in the mean AMH concentration in participants with different uterine volumes.

RESULT(S)

At least 1 fibroid was identified on ultrasound in 362 (22%) participants. There was a small difference in the mean AMH concentrations in participants with fibroids (age-adjusted model: -4.6%, 95% confidence interval (CI): -14.5% to 6.5%; multivariable model: -4.6%, 95% CI: -14.4% to 6.3%). The mean AMH concentrations were found to decrease with increasing fibroid number. Although differences in AMH concentrations were not statistically significant, compared with no fibroids, the mean percent differences in AMH concentrations for 1, 2-3, and ≥4 fibroids were -1.2% (95% CI: -13.2% to 12.5%), -7.1% (95% CI: -23.3% to 12.5%), and -17.5% (95% CI: -38.2% to 10.0%), respectively. There were no consistent associations between AMH concentrations and fibroid location, size, or uterine volume.

CONCLUSION(S)

The presence of fibroids was not materially associated with AMH concentrations. Other than a monotonic inverse relationship between fibroid number and AMH concentrations, no other fibroid characteristics were consistently or appreciably associated, although associations were imprecise.

Arterial spin labeling assessment of myometrial perfusion changes in patients with uterine fibroid and its impact on fertility

Background

Fibroids are the most common uterine tumor in the reproductive age group. These tumors although benign, their relation to infertility is still controversial. The purpose of this study is to assess the fibroid impact on fertility using arterial spin labeling (ASL) technique.

Results

This prospective study included 40 cases (30 female patients having uterine fibroid and 10 age- and sex-matched control cases). The 30 patients were divided according to their fertility into 2 subgroups: fertile (n = 15) and infertile (n = 15). All cases underwent pelvic magnetic resonance imaging (MRI) examination with ASL technique. The perfusion values were measured in the uterine walls, fibroids, and in the gluteus maximus muscle as control. ASL demonstrated non-significant difference in the perfusion between anterior and posterior uterine walls in the control cases and revealed significant difference in the perfusion between fibroid positive and fibroid negative uterine walls in patients with uterine fibroid (p value < 0.04). Perfusion values of the fertile and infertile subgroups showed no statistically significant difference.

Conclusion

Arterial spin labeling is an evolving technique that can be used to evaluate the myometrial perfusion changes in patients with uterine fibroid without using contrast media. Uterine fibroids were associated with decreased perfusion but with no statistically significant impact on fertility.

Ovarian arteries embolization in women with persistent symptoms following uterine arteries embolization for uterus fibroids

PURPOSE

In patients with persisting symptoms after uterine arteries embolization (UAE), ovarian arteries embolization (OAE) may play a role to improve symptoms and decrease subsequent surgery rates. In a retrospective cohort, we aimed to investigate the efficacy and safety of OAE in females with recurrent or persistent symptoms following UAE.

METHODS

We performed a retrospective analysis of prospectively collected cases at a single reference academic hospital; we identified patients who benefited from OAE for persisting symptoms following UAE from 2008 to 2021. Outcome variables included the rates of subsequent surgery, a quality-of-life questionnaire with the UFS-QOL tool, the MRI reduction in uterine and fibroids volumes and the fibroid devascularization rate.

RESULTS

Among 1300 women treated with UAE during the study period, 18 eventually received OAE and were included (mean age 44 ± 4.3 SD). There was no OAE procedural complication. There was a decrease in uterine volume and a complete devascularization of the dominant fibroid in 10/11 (90.9%) patients who underwent 12 months MRI. Three women underwent subsequent hysterectomy. Among 10/18 patients who answered the quality-of-life questionnaire after a mean follow-up of 70 months, eight reported an improvement or stability of symptoms.

CONCLUSION

OAE for persisting symptoms after UAE was associated with improvement or stability of quality-of-life in most study subjects and less than a fifth of the cohort underwent hysterectomy after OAE. This study highlights the role of OAE as an adjunct to UAE.

Imaging evaluation of uterine arteries in potential living donors for uterus transplantation: a comparative study of MRA, CTA, and DSA

OBJECTIVE

To evaluate uterine arteries (UA) of potential living donors for uterus transplantation (UTx) by comparison of CT angiography (CTA), digital subtraction angiography (DSA), and MR angiography (MRA) with care taken to minimize radiation doses.

METHODS

Prospective donors for a clinical UTx trial were included. CTA, DSA, and MRA measurements in three predefined segments of the UAs were evaluated. Radiation doses were estimated and 1-year graft survival was recorded.

RESULTS

Twelve potential donors (age 37-62 years) were investigated. There was no difference in visualized average UA lumen diameter when comparing CTA (mean 2.0 mm, SD 0.4), DSA (mean 2.1 mm, SD 0.6), and MRA (mean 2.0 mm, SD 0.3). MRA was not able to fully evaluate 10 (43%) out of 23 UA that proved to be patent on DSA. One UA was not identified by any of the modalities, and three MRA-absent UAs were identified by both CTA and DSA. The estimated mean effective dose was lower for DSA (5.1 mSv, SD 2.8) than CTA (7.1 mSv, SD 2.0), but not significantly (p value = 0.06). Three potential donors were excluded due to UA pathology and one due to adenomyosis. Eight donors underwent hysterectomy, with 1-year graft survival in six women.

CONCLUSION

MRI including MRA should be the initial modality to examine potential UTx donors to acquire valuable details of uterine anatomy, and if UAs are fully visualized, there is no need for further angiographic methods with radiation. If UAs are not visualized by MRA, CTA may be performed and in selective cases with addition of the invasive modality DSA.

KEY POINTS

• For uterine transplantation, pelvic MRI with MRA provides information of the uterine structure and of the diameters of uterine arteries in living donors. • Failure of MRA to demonstrate uterine arteries could be followed by CTA which will visualize the uterine arteries in a majority of cases. If MRA and additional CTA provide inconclusive results, the uterine arteries should be further evaluated by DSA. • Information of CTA can be used in the angio-system for DSA settings to minimize the radiation and contrast media doses.

Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls

Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.

Uterine fibroid vascularization: from morphological evidence to clinical implications

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.

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.

Vascular biology of uterine fibroids: connecting fibroids and vascular disorders

Fibroids are benign tumors caused by the proliferation of myometrial smooth muscle cells in the uterus that can lead to symptoms such as abdominal pain, constipation, urinary retention, and infertility. While traditionally thought of as a disease process intrinsic to the uterus, accumulating evidence suggests that fibroid growth may be linked with the systemic vasculature system, although cell-intrinsic factors are certainly of principal importance in their inception. Fibroids are associated with essential hypertension and preeclampsia, as well as atherosclerosis, for reasons that are becoming increasingly elucidated. Factors such as the renin-angiotensin-aldosterone system, estrogen, and endothelial dysfunction all likely play a role in fibroid pathogenesis. In this review, we lay out a framework for reconceptualizing fibroids as a systemic vascular disorder, and discuss how pharmaceutical agents and other interventions targeting the vasculature may aid in the novel treatment of fibroids.

MRI-based pictorial review of the FIGO classification system for uterine fibroids

Uterine fibroids are the most common gynecologic neoplasm and contribute to significant morbidity, particularly when submucosal in location or large enough to cause bulk symptoms. Correctly classifying fibroids is essential for treatment planning and prevention of complications. Ultrasound is the first-line imaging modality for characterizing uterine fibroids. However, MRI allows for high-resolution, multiplanar visualization of leiomyomata that affords a more accurate assessment than ultrasound, particularly when fibroids are numerous. The FIGO system was developed in order to more uniformly and consistently describe and classify uterine fibroids. In this article, we review the MRI appearance of each of the FIGO classification types, detailing key features to report. Additionally, we present a proposed template for structured reporting of uterine fibroids based on the FIGO classification system.

Uterine Artery Embolization of Uterine Leiomyomas: Predictive MRI Features of Volumetric Response

OBJECTIVE. The purpose of this article was to evaluate MRI features of uterine leiomyomas that predict volumetric response after uterine artery embolization (UAE). MATERIALS AND METHODS. This retrospective study included 75 patients with 212 uterine leiomyomas who were successfully treated between August 2013 and December 2018. To predict uterine volumetric response, age, number of lesions, and baseline uterine volume were assessed. To predict leiomyoma volumetric response, a multivariate regression analysis was performed to evaluate six predictive factors: location, baseline leiomyoma volume, signal intensity on T1-weighted and T2-weighted MRI, heterogeneity of signal intensity on T2-weighted MRI, and vascularity on subtraction imaging (SI). A five-variable predictive ROC model was developed to evaluate the diagnostic accuracy of the signal intensity ratio on T2-weighted MRI, enhancement ratio, heterogeneity ratio on T2-weighted MRI, location, and baseline leiomyoma volume in predicting at least 40% leiomyoma volumetric response. RESULTS. Age, number of leiomyomas, and baseline uterine volume were not predictive of uterine volumetric response. A submucosal location was the best predictive factor of leiomyoma volumetric response, and it showed 32.2% more leiomyoma volumetric response compared with a nonsubmucosal location (p < .001). Hyperintensity on T2-weighted MRI was the second best predictive factor of leiomyoma volumetric response, and it showed 16.9% more volumetric response compared with hypointense leiomyomas (p = .013). A small baseline leiomyoma volume (< 58 cm³) was associated with 10.2% more leiomyoma volumetric response compared with larger leiomyomas (p = .01). Leiomyomas that were hyperintense on SI showed 7.9% more leiomyoma volumetric response compared with those that were hypointense (p = .014). The five-variable ROC model showed high diagnostic accuracy with an AUC of 0.85, sensitivity of 82%, and specificity of 71%. CONCLUSION. A submucosal location, hyperintensity on T2-weighted MRI, small baseline leiomyoma volume (< 58 cm³), and hyperintense leiomyoma on subtraction imaging are the main independent favorable predictors of leiomyoma volumetric response after UAE. An accurate predictive ROC model was developed that may help in selecting patients suitable for UAE. Quantitative assessment of heterogeneity on T2-weighted MRI showed promising results as a predictor of volumetric response, and further research in this area using texture analysis and radiomics is suggested.

Uterine Myomas: Endovascular Treatment

Uterine fibroids embolization is a safe and effective organ sparing treatment for fibroid-related symptoms based on a broad range of published evidence including randomized-controlled trials. Indication to treatment is usually the presence of symptomatic uterine fibroids. In this review, a systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was conducted, with a special focus on the indication to treatment, technique, procedural outcomes and pain control. All clinical trials published in English language, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered.

Contrast-Enhanced Ultrasound for Monitoring Non-surgical Treatments of Uterine Fibroids: A Systematic Review

Non-surgical treatment options for uterine fibroids are uterine artery embolization (UAE), high-intensity focused ultrasound ablation (HIFUA), and percutaneous microwave ablation (PMWA). Magnetic resonance imaging (MRI) is the reference standard imaging method before and after these procedures. Contrast-enhanced ultrasound (CEUS) has been studied as an alternative to MRI for evaluating the fibroids' characteristics and responses to non-surgical treatments. PubMed, Ovid MEDLINE and Scopus databases were searched for literature published from January 2000 through June 7, 2020, that investigated the application of CEUS as an adjunct to monitor UAE, HIFUA or PMWA in human uterine fibroid treatments. Two independent reviewers analyzed 128 publications, out of which 17 were included. Based on this systematic review, CEUS provides detailed data about fibroid volume and vascularization prior, during and post UAE, and it helps determine the endpoint of the procedure. HIFUA with intra-procedural CEUS has faster volume shrinkage over a shorter time period with less needed energy and provides early detection of residual tissue after HIFUA. CEUS and contrast-enhanced MRI have sufficient agreement to be used interchangeably in the clinic to evaluate the therapeutic effect of PMWA and HIFUA on fibroids.

Value of Dyna CT in guiding embolization during transarterial uterine artery embolization of fibroids

The present study aimed to assess the usefulness of Dyna CT during transarterial uterine artery embolization (UAE) of fibroids. A total of 65 patients with symptomatic submucosal and intramural fibroids scheduled for transarterial UAE at the First People's Hospital of Changhou between May 2016 and September 2018 were included. Dyna CT and routine digital subtraction angiography (DSA) were performed in all patients during angiographic embolization of the bilateral internal iliac arteries. The visualization qualities of uterine artery origin and fibroids, as imaged by Dyna CT, were compared with DSA anterior-posterior images. Dyna CT provided excellent 3-dimensional visualization of vascular structures of the bilateral internal iliac arteries and uterine artery origin. Dyna CT was primarily useful in patients with overlapped uterine arteries or complex vascular anatomies on DSA anterior-posterior images (Dyna CT 100% vs. DSA anterior-posterior 69.2%, P=0.03). However, stained fibroids were identified in 57/65 cases (87.7%) by Dyna CT, and in all of the cases (100%) by DSA anterior-posterior imaging (P=0.03). Dyna CT is not suitable for procedural evaluation when used alone for transarterial UAE of fibroids. However, Dyna CT is an excellent supplement to DSA anterior-posterior imaging, as it provides additional information to aid in treatment planning.

Role of Interventional Procedures in Obstetrics and Gynecology

Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.

Intraoperative transradial angiography augments safe hysterectomy for uterine fibroids in the setting of ambiguous arterial anatomy: a case report

Background

Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography.

Case presentation

A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient’s gynecologist decided to treat her with surgical resection, given the fibroid’s size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications.

Conclusions

Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.

Evaluation of Uterine Contractility by Magnetic Resonance Imaging in Women Undergoing Embolization of Uterine Fibroids

PURPOSE

To assess uterine contractility using ultrafast magnetic resonance imaging (cine MRI) before and after uterine fibroid embolization (UFE).

MATERIALS AND METHODS

This is a prospective study of uterine contractility in 26 patients (age 30-41 years) undergoing UFE for symptomatic uterine fibroids. Cine MRI was performed before and 6 months after UFE. Two radiologists evaluated uterine contractility and classified it as absent, ordered, or disordered. Patients were then grouped into three distinct patterns of progression: unchanged contractility (group A), modified contractility (B), and loss of contractility (C). These findings were then confronted with factors that might have interfered with uterine contractility pattern (uterine volume, location of dominant fibroid, fibroid/myometrium index, and fibroid necrosis pattern).

RESULTS

Of the 26 patients, 8 (30.7%) had no contractility before the procedure, while 18 (69.2%) exhibited some form of contractility (11 [61%] ordered, 7 [39%] disordered). All 8 patients who had no contractility at baseline exhibited contractility after UFE (5 ordered, 3 disordered). Of the 11 who had ordered contractility at baseline, 9 remained ordered and 2 lost contractility after UFE. Of the 7 with disordered contractility at baseline, 1 remained disordered, 5 progressed to ordered contractility, and 1 lost contractility. Overall, 10 patients (38%) had no change in contractility after UFE (group A), 13 (50%) had a positive change (group B), and 3 (11%) lost contractility (group C). The potential interference factors assessed had no statistically significant effect in any group.

CONCLUSION

In women of reproductive age with symptomatic fibroids, uterine contractility improved significantly after UFE.

LEVEL OF EVIDENCE

Level 3-non-randomized controlled cohort/follow-up study.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas

OBJECTIVE

The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas.

METHODS

Guidelines for imaging uterine leiomyomas were defined based on a survey distributed to all members of the working group, an expert consensus meeting at European Congress of Radiology (ECR) 2017 and a critical review of the literature.

RESULTS

The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed.

CONCLUSIONS

MRI offers an outstanding and reproducible map of the size, site and distribution of leiomyomas. A standardised imaging protocol and method of reporting ensures that the salient features are recognised. These imaging guidelines are based on the current practice among expert radiologists in the field of female pelvic imaging and also incorporate essentials of the current published MR literature of uterine leiomyomas.

KEY POINTS

• MRI allows comprehensive mapping of size and distribution of leiomyomas. • Basic MRI comprise T2W and T1W sequences centered to the uterus. • Standardized reporting ensures pivotal information on leiomyomas, the uterus and differential diagnosis. • MRI aids in differentiation of leiomyomas from other benign and malignant entities, including leiomyosarcoma.

Ultrasound-Guided Percutaneous Microwave Ablation for Subserosal Uterine Myomas

STUDY OBJECTIVE

To prospectively evaluate the clinical effectiveness and safety of ultrasound-guided percutaneous microwave ablation for symptomatic subserosal uterine myomas.

DESIGN

Prospective observational study (Canadian Task Force classification II-1).

SETTING

A teaching hospital (Department of Interventional Ultrasound, General Hospital of Chinese PLA, Beijing, China).

PATIENTS

Sixty-nine patients with symptomatic subserosal uterine myomas treated with ultrasound-guided percutaneous microwave ablation.

INTERVENTIONS

All 69 patients underwent ultrasound-guided percutaneous microwave ablation. The number of patients lost to follow-up at was 21 at 3 months, 34 at 6 months, and 35 at 12 months.

MEASUREMENTS AND MAIN RESULTS

The efficacy of treatment was evaluated based the mean myoma volume shrinkage rate and changes in Uterine Fibroid Symptom and Quality of Life Questionnaire scores at 3, 6, and 12 months after therapy. Treatment safety was evaluated based on the Society of Interventional Radiology practice guidelines. The mean patient age was 40.3 ± 4.9 years (range, 26-49 years). The mean myoma volume was 221.74 ± 153.18 cm³ before ablation, decreasing to 87.24 ± 45.93 cm³ at 3 months after ablation (p < .001), 46.68 ± 24.7 cm³ at 6 months after ablation (p < .001), and 38.05 ± 24.93 cm³ at 12 months after ablation (p <.001), respectively. Between pretreatment and 3-month follow-up, the mean symptom severity score decreased from 34.53 ± 3.83 to 12.74 ± 3.07 (p < .001), and the mean health-related quality of life score increased from 45.25 ± 10.97 to 78.48 ± 11.39 (p < .001). Both scores remained stable at the 6- and 12-month follow-up time points. No permanent injury or fatal complications were seen in this series.

CONCLUSION

Ultrasound-guided percutaneous microwave ablation of subserosal uterine myomas is a promising treatment method. Further studies with larger sample sizes and a control group are needed.

Doppler sonography of perifibroid and intrafibroid arteries of uterine leiomyomas

Objective

To sonographically evaluate the dominant fibroid nodule vascularity and flow velocity pattern of perifibroid and intrafibroid arteries.

Methods

We recruited 140 women with uterine fibroids. Their uteri were scanned to determine the vascularity of fibroid nodules and the Doppler indices of the fibroid arteries.

Results

The median volume of the dominant leiomyoma nodule was 133 cm³ (range=1.5-2,575 cm³). Eighty-three subjects (59.3%) had a dominant leiomyoma nodule volume of ≤200.0 cm³ while the volume of the dominant leiomyoma nodule was >200.0 cm³ in 57 (40.7%) subjects. The dominant fibroid nodule was vascular in 137 (97.9%) subjects and avascular in 3 (2.1%). All the perifibroid artery indices (except the end-diastolic velocity [EDV] and diastolic average ratio [DAR]) are significantly higher than those of the intrafibroid artery. The mean Doppler indices of perifibroid vs. intrafibroid arteries as follows: peak systolic velocity (PSV; 52.1 vs. 45.4 cm/s); EDV (21.1 vs. 22.4 cm/s); time-averaged maximum velocity (TAMX; 31.5 vs. 30.4 cm/s); time- averaged mean velocity (Tmean; 14.3 vs. 13.8 cm/s); pulsatility index (PI; 1.1 vs. 0.8); resistive index (RI; 0.6 vs. 0.5); systolic-diastolic ratio (SDR; 2.7 vs. 2.1); impedance index (ImI; 2.7 vs. 2.1); and DAR (0.66 vs. 0.74); P<0.001 for all indices.

Conclusion

The predominant pattern of fibroid vascularity is peripheral vascularity and the perifibroid artery indices (except EDV and DAR) are significantly higher than those of the intrafibroid artery. Recurrent fibroids in women with previous myomectomy had significantly higher intrafibroid PI, RI, SDR, and ImI than those without previous myomectomy.

Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center

OBJECTIVE

To evaluate effectiveness and safety of UFE as alternative to surgery, in treatment of uterine fibromatosis.

METHODS/MATERIALS

255 patients (aged 26-55) with symptomatic UF, indication for surgery, followed in our center (2000-2014), single or multiple fibroids, pain and/or functional/compressive disorders, underwent embolization: injection of PVA particles (150-900 μm) from distal portion of uterine arteries (ascending section). Primary end-point: flow-stop distally to injection site, disappearance of lesion design, preservation of flow in main trunk of UA. Secondary end-point: control of pain and functional/compressive disorders during follow-up (2-7 years).

RESULTS

Procedure was performed bilaterally in 250 patients (98%). Mean duration: 47 min (average fluoroscopy: 10:50 min). Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h). Follow-up at 2 years: resolution of menstrual disorders in 78% of patients and improvement in 14%; pain disappeared in 66%; significant improvement of menstrual flow and HCT/HB levels, decrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. Recurrence in 18 patients.

CONCLUSIONS

UFE represents an excellent alternative to surgical treatment: it is safe, tolerable and effective both in short and long term, with evident advantages in economic and social terms.

Minimally invasive procedures in the management of uterine fibroids

Uterine fibroids are benign uterine tumors. In women during the reproductive period, uterine fibroids occur in about 25%, whereas after this time, they are observed in more than 40% of women. In the majority of women (about 20-50%), such tumors do not cause discomfort and do not require treatment. Asymptomatic uterine fibroids usually undergo only regular medical control, whereas symptomatic fibroids are an indication for treatment. Current treatment methods include surgical, pharmacological and minimally invasive treatment. Among the current commonly used methods, there are minimally invasive treatment options, which include Uterine Artery Embolization (UAE), Magnetic Resonance Guided Ultrasound Surgery (MRgFUS), MR-guided High Intensity Focused Ultrasound (MR-HIFU) and Laparoscopic Uterine Artery Occlusion (LUAO). The minimally invasive Ultrasound-guided High Intensity Focused Ultrasound method (US-HIFU) is new, but still experimental. The use of MRgFUS/MR-HIFU for the thermoablative treatment of fibroids was approved by the FDA (Food and Drug Administration) in 2004. As a minimally invasive method, it enables preservation of the uterus and eliminates the need for general anesthesia. LUAO is based on the use of the vascular clip, which is placed on the uterine artery at the level of the internal iliac artery. This procedure is performed bilaterally.

The use of UAE in obstetrics and gynecology was first described in 1987 as an effective method in the treatment of hemorrhage, which allows avoiding surgical intervention and enables the uterus to be preserved. An appropriate qualification of patients is crucial for high clinical efficacy and prevention of complications after UAE. The candidates should be women with symptomatic uterine fibroids, without other pathologies within the pelvis, who do not plan to get pregnant in the future.

The variety of uterine fibroids as for the location, size, and symptoms they can evoke, has enforced a very individual approach to each patient, to begin with observation and regular gynecological control, through a number of pharmacological and minimally invasive treatment methods, and ending with the removal of the uterus. It gives the doctors the tools, which, if used properly, can manage uterine fibroids and fulfil the expectations of the patient.

Structured vs narrative reporting of pelvic MRI for fibroids: clarity and impact on treatment planning

OBJECTIVES

To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists.

METHODS

This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed.

RESULTS

More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p < 0.0001). Compared to narrative reports, gynaecologists and radiologists deemed structured reports both more helpful for surgical planning (p < 0.0001) (gynaecologists: 8.5 ± 1.2 vs. 5.7 ± 2.2; radiologists: 9.6 ± 0.6 vs. 6.0 ± 2.9) and easier to understand (p < 0.0001) (gynaecologists: 8.9 ± 1.1 vs. 5.8 ± 1.9; radiologists: 9.4 ± 1.3 vs. 6.3 ± 1.8).

CONCLUSION

Structured fibroid MRI reports miss fewer key features than narrative reports. Moreover, structured reports were described as more helpful for treatment planning and easier to understand.

KEY POINTS

• Structured reports missed only 1.2 ± 1.5 out of 19 key features, as compared to narrative reports that missed 7.3 ± 2.5 key features for planning of fibroid treatment. • Structured reports were more helpful and easier to understand by clinicians. • Structured template can provide essential information for fibroids treatment planning.

Pelvic Blood Flow Predicts Fibroid Volume and Embolic Required for Uterine Fibroid Embolization: A Pilot Study With 4D Flow MR Angiography

OBJECTIVE

We report here an initial experience using 4D flow MRI in pelvic imaging-specifically, in imaging uterine fibroids. We hypothesized that blood flow might correlate with fibroid volume and that quantifying blood flow might help to predict the amount of embolic required to achieve stasis at subsequent uterine fibroid embolization (UFE).

MATERIALS AND METHODS

Thirty-three patients with uterine fibroids and seven control subjects underwent pelvic MRI with 4D flow imaging. Of the patients with fibroids, 10 underwent 4D flow imaging before UFE and seven after UFE; in the remaining 16 patients with fibroids, UFE had yet to be performed. Four-dimensional flow measurements were performed using Arterys CV Flow. The flow fraction of the internal iliac artery was expressed as the ratio of internal iliac artery flow to external iliac artery flow and was compared between groups. The flow ratios between the internal iliac arteries on each side were calculated. Fibroid volume versus internal iliac flow fraction, embolic volume versus internal iliac flow fraction, and embolic volume ratio between sides versus the ratio of internal iliac artery flows between sides were compared.

RESULTS

The mean internal iliac flow fraction was significantly higher in the 26 patients who underwent imaging before UFE (mean ± standard error, 0.78 ± 0.06) than in the seven patients who underwent imaging after UFE (0.48 ± 0.07, p < 0.01) and in the seven control patients without fibroids (0.48 ± 0.08, p < 0.0001). The internal iliac flow fraction correlated well with fibroid volumes before UFE (r = 0.7754, p < 0.0001) and did not correlate with fibroid volumes after UFE (r = -0.3051, p = 0.51). The ratio of embolic required to achieve stasis between sides showed a modest correlation with the ratio of internal iliac flow (r = 0.6776, p = 0.03).

CONCLUSION

Internal iliac flow measured by 4D flow MRI correlates with fibroid volume and is predictive of the ratio of embolic required to achieve stasis on each side at subsequent UFE and may be useful for preprocedural evaluation of patients with uterine fibroids.

Preprocedural MRI and MRA in planning fibroid embolization

This pictorial review aims to discuss and illustrate the up-to-date use of preprocedural magnetic resonance imaging (MRI) in selecting patients and planning uterine artery embolization (UAE). The merits of magnetic resonance angiography (MRA) in demonstrating the pelvic vasculature to guide UAE are highlighted. MRI features of fibroids and their main differential diagnoses are presented. Fibroid characteristics, such as location, size, and enhancement, which may impact patient selection and outcome, are presented based on recent literature. Pelvic arterial anatomy relevant to UAE, including vascular variants are illustrated, with conventional angiography and MRA imaging correlation. MRA preprocedural determination of the optimal projection angles for uterine artery catheterization is straightforward and constitutes an important strategy to minimize ionizing radiation exposure during UAE. A reporting template for MRI/MRA preassessement of UAE for fibroid treatment is provided.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

MRI traceability of superparamagnetic iron oxide nanoparticle-embedded chitosan microspheres as an embolic material in rabbit uterus

PURPOSE

We aimed to compare polyvinyl alcohol (PVA) particles with calibrated superparamagnetic iron oxide (SPIO) nanoparticle-loaded chitosan microspheres in a rabbit model, specifically regarding the relative distribution of embolic agents within the uterus based on magnetic resonance imaging (MRI) and pathological evaluation.

METHODS

Twelve New Zealand white rabbits underwent uterine artery embolization using either standard PVA particles (45-150 µm or 350-500 µm) or calibrated SPIO-embedded chitosan microspheres (45-150 µm or 300-500 µm). MRI and histopathological findings were compared one week after embolization.

RESULTS

Calibrated SPIO-loaded chitosan microspheres 45-150 µm in size were detected on T2-weighted images. On histological analysis, calibrated SPIO-embedded chitosan microspheres were found in both myometrium and endometrium, whereas PVA particles were found only in the perimyometrium or extrauterine fat pads. A proportional relationship was noted between the calibrated SPIO-embedded chitosan microsphere size and the size of the occluded artery.

CONCLUSION

Calibrated SPIO-embedded chitosan microspheres induced greater segmental arterial occlusion than PVA particles and showed great potential as a new embolic material. SPIO-embedded chitosan microspheres can be used to follow distribution of embolic particles through MRI studies.

Tris-acryl gelatin microspheres versus gelatin sponge particles in uterine artery embolization for leiomyoma

Background

Tris-acryl gelatin microspheres (TAGM) and gelatin sponge particles (GS) have been used in uterine artery embolization (UAE) for leiomyoma. No direct comparisons of both embolic agents have been reported.

Purpose

To compare the outcomes of UAE with TAGM with those of UAE with GS for uterine leiomyoma.

Material and Methods

This was a non-randomized, single-institute, non-inferiority study. Between July 2008 and August 2015, 67 consecutive patients with symptomatic leiomyoma underwent UAE. GS was used for the first 49 patients and TAGM was used for the following 18 patients. The primary endpoint was tumor infarction on contrast-enhanced magnetic resonance imaging (MRI) 1 week after UAE. The secondary endpoints were changes in symptoms and quality-of-life scores with UFS-QOL questionnaires at 4 months, and adverse events (AEs) in the 4 months after UAE.

Results

The baseline characteristics of both groups were similar. Complete or nearly complete tumor infarction (≥90%) was achieved in 94.4% (17/18) of the TAGM group and 93.6% (44/47) of the GS group. This difference (0.8%; 95% CI, –11.9% to 13.5%) indicated the non-inferiority of the TAGM group to the GS group, with a pre-specified non-inferiority margin of 20%. No significant differences were observed in improvements in symptoms or quality-of-life scores at 4 months ( P = 0.56 and P = 0.19) or in 4-month AEs ( P = 0.29).

Conclusion

The outcomes of UAE with TAGM were comparable to those of UAE with GS, suggesting that both embolic agents are acceptable for the treatment of leiomyoma.

Unexpected Angiography Findings and Effects on Management

Despite progress in noninvasive imaging with computed tomography and magnetic resonance imaging, conventional angiography still contributes to the diagnostic workup of oncologic and other diseases. Arteriography can reveal tumors not evident on cross-sectional imaging, in addition to defining aberrant or unexpected arterial supply to targeted lesions. This additional and potentially unanticipated information can alter management decisions during interventional procedures.

Embolization of Inferior Mesenteric Artery for Intractable Intrapelvic and Vaginal Bleeding After Hysterectomy

Branches of the internal iliac artery or ovarian artery are the typical sources of pelvic hemorrhage. The inferior mesenteric artery has been rarely reported as the origin of pelvic bleeding. We present 2 cases of intractable intrapelvic and vaginal bleeding after hysterectomy. One patient underwent a hysterectomy because of uncontrolled postpartum hemorrhage and another underwent a vaginal hysterectomy to treat vaginal prolapse. Both patients were subjected to angiography to control continuous vaginal bleeding after hysterectomy. The angiography revealed that the bleeding originated from the inferior mesenteric artery. Selective embolization of the inferior mesenteric artery successfully controlled the intractable intrapelvic and vaginal bleeding without complications. The inferior mesenteric artery is a potential source of intractable intrapelvic and vaginal bleeding for patients with a lower genital tract injury.

Uterine artery embolization angiography and fertility related aspects

Purpose. Uterine artery embolization is a minimally invasive technique. It applies the principle of targeted anatomical structure devascularisation with utility in fibroid conservative therapy, including for future fertility preserving status. The objective of our paper represents a description and evaluation of angiography utility as a predictive method for fertility maintenance. Material and Methods. The angiography and ultrasound aspects obtained from a prospective study in which selected patients have undergone uterine artery embolization for fertility preservation are detailed. Results. The following angiography aspects have been detected: left- right shunt and utero-ovarian collaterals; these have been compared with the ultrasound aspects related to the fibroid evolution form a volumetric and Doppler ultrasound point of view. The angiographical description predicts the impact on post embolization fibroid evolution and upon fertility. An analysis is made in order to assess the way in which angiography can contribute to fertility alteration. Conclusions. The angiography aspects during embolization and the following ultrasound aspects can represent predictive factors as to fertility evolution after uterine artery embolization.

IGF-1 and VEGF can be used as prognostic indicators for patients with uterine fibroids treated with uterine artery embolization

The aim of the present study was to investigate the association between serum vascular endothelial growth factor (VEGF) and insulin-like growth factor 1 (IGF-1) levels and the prognosis of patients with uterine fibroids following uterine artery embolization (UAE) treatment. A total of 70 patients with uterine fibroids and 20 healthy controls were enrolled in this study between 2012 and 2014. The serum levels of IGF-1 and VEGF were measured using ELISA. Multiple-factor analysis was performed to assess the association between serum levels of IGF-1/VEGF and certain clinical characteristics, including size, location, number of uterine fibroids and adenomyosis. Progression-free survival curves were analyzed using the Kaplan-Meier method. The serum levels of IGF-1 and VEGF in patients with uterine fibroids prior to UAE treatment were significantly higher than those in controls (P<0.05). At 1 week after UAE treatment, the serum levels of IGF-1 and VEGF were significantly lower compared with those prior to UAE treatment. The serum levels of IGF-1 and VEGF at 1 or 3 months after UAE treatment were significantly higher than those at 1 week after UAE treatment. The serum levels of IGF-1 and VEGF were significantly correlated with the clinical characteristics of uterine fibroids (P<0.05). Lower levels of IGF-1 and VEGF in the serum following UAE treatment were associated with an enhanced progression-free survival of patients. In conclusion, the levels of IGF-1 and VEGF in the serum following UAE treatment can be used as indicators of prognosis in patients with uterine fibroids.