| |  Outcomes after Uterine Artery Embolization for Pedunculated Subserosal Leiomyomas
From the SIR 2007 Annual Meeting. Received 21 July 2007; received in revised form 25 November 2007; accepted 27 November 2007. published online 17 March 2008. PurposeTo assess the safety and efficacy of uterine artery embolization (UAE) treatment of pedunculated subserosal leiomyomas. Materials and MethodsA review of patients undergoing UAE in a 30-month period (July 2004 to December 2006) was performed. Cases in which a pedunculated subserosal tumor (volume ≥14 cm3) was embolized were analyzed. The preprocedural volumes of the pedunculated tumor and uterus and the diameter and vascularity of the tumor and stalk were recorded. Posttreatment sizes of the pedunculated leiomyoma, stalk, and uterus were recorded, as was the presence or absence of complication(s). ResultsA total of 240 patients underwent embolization. Pedunculated subserosal leiomyomas were treated in 16 women, with a technical success rate of 100%. Preprocedural mean tumor and uterine volumes were 372 cm3 and 789 cm3, respectively. The mean stalk diameter was 2.7 cm (range, 0.8–7.8 cm). All pedunculated leiomyomas exhibited enhancement on contrast agent–enhanced magnetic resonance (MR) imaging (n = 13) or vascularity on Doppler ultrasonography (US; n = 3). Stalk vascularity was noted on MR imaging in 13 patients and was not assessed in the remaining three, who underwent US imaging. Imaging follow-up (mean, 5.9 months after UAE) demonstrated mean tumor volume reduction of 39.3% (95% confidence interval [CI], 28.2%–50.5%) and mean uterine volume reduction of 37.6% (95% CI, 26%–49.3%). There were no cases of continued tumor perfusion and no major complications. There was one minor complication of prolonged hospital stay (36 hours) for pain control. ConclusionUAE was successfully and safely performed for pedunculated subserosal leiomyomas, with a tumor volume reduction of 39% and no unique complications related to these lesions. UTERINE leiomyomas are common benign tumors that can cause pain, menorrhagia, and bulk symptoms (1). The vascular supply of uterine leiomyomas is primarily from the uterine arteries, and embolization of these vessels leads to tumor necrosis. First proposed in 1995 (2), uterine artery embolization (UAE) is now an established treatment modality for these tumors (3), with most studies reporting clinical success rates of approximately 90% (4, 5, 6). The presence of a pedunculated subserosal leiomyoma—defined as a uterine fibroid tumor with a stalk diameter at least 50% narrower than the diameter of the tumor (7)—is considered to be a relative contraindication to UAE (8, 9). Risks suggested to occur with embolization of pedunculated subserosal leiomyomas include torsion of the leiomyoma stalk, ischemic necrosis of the tumor, and separation of the tumor from the uterus requiring surgical intervention (8, 9, 10, 11, 12). Although there have been two cases reported in the literature of UAE complicated by a septic pedunculated subserosal leiomyoma requiring surgery including partial bowel resection (10, 11), the exact incidence of complications associated with embolic therapy for these lesions is unknown (12). The literature supporting the use of UAE for pedunculated subserosal leiomyomas is limited; a recent series (n = 12) (12), and a case report (n = 2) (13) have been published demonstrating effective treatment of pedunculated subserosal leiomyomas with UAE. Controversy persists regarding the safety and outcomes of UAE for this indication (8, 9). The purpose of this study was to retrospectively review the outcomes of UAE procedures performed for pedunculated subserosal leiomyomas at our institution; the goal was to provide more data on this topic. Quality of life outcomes after UAE were not assessed in this study. Materials and Methods  Patients and Baseline Imaging Institutional review board approval was granted for this retrospective study. The clinical and imaging records of 240 consecutive women who underwent UAE for symptomatic leiomyomas over a 30-month period (July 2004 to December 2006) were reviewed. All patients had baseline contrast agent–enhanced pelvic MR imaging and/or physician-supervised transvaginal ultrasonography (US). Cases in which at least one pedunculated subserosal leiomyoma with a volume of at least 14 cm3 on baseline imaging was embolized were identified and analyzed. Subserosal leiomyomas were defined as pedunculated if baseline imaging demonstrated a tumor stalk that was at least 50% narrower than the diameter of the tumor. In cases in which MR imaging and US were performed at baseline, measurements were obtained from the MR study. The baseline imaging studies were performed within 3 months of the embolization procedure. All patients were premenopausal and had no desire to preserve fertility. Embolization Technique and Patient Follow-up All UAE procedures were performed by fellowship-trained vascular and interventional radiologists. Patients were initially seen by specialists in obstetrics and gynecology before referral to an interventional radiologist. Patients were then assessed in clinic by the treating interventional radiologist before UAE. This included a review of the preprocedural imaging. UAE procedures were performed under moderate sedation with a combination of intravenous midazolam (0.5–2.0 mg; Sandoz, Boucherville, QC, Canada) and fentanyl (25–50 μg; Sandoz). Nursing staff were present during all procedures for patient monitoring, which included continuous electrocardiography and pulse oximetry. Percutaneous access was obtained via a right common femoral artery approach. The uterine arteries were selected with a Roberts uterine catheter (Cook, Bloomington, IN) or a C2 Glide catheter (4-F Cobra 2 Glidecath [Terumo, Tokyo, Japan] or 5-F C2 Beacon Tip [Cook]). Microcatheters were not employed. Flush aortography was not routinely performed. Pelvic and uterine arterial anatomy was delineated with digital subtraction arteriograms obtained with the catheter tips in the internal iliac and uterine arteries. All embolization procedures were performed with polyvinyl alcohol particles (335–500-μm; Contour; Boston Scientific, Natick, Massachusetts). Termination of embolization occurred when stasis in the uterine arteries was identified, with evidence of a standing column of contrast medium in the horizontal portion of each vessel. Hemostasis was obtained with manual compression. After UAE, patients were admitted overnight for observation and patient-controlled anesthesia. Patients were subsequently discharged home with oral analgesia. Initial follow-up was conducted at 3 months with a postprocedural transvaginal US examination, a contrast agent–enhanced MR study, and a clinic visit for all patients. Additional follow-up was performed according to patient preference and requirements; some patients were seen again in the clinic at 6 months and 1 year after UAE, with repeat imaging. Data Collection In cases in which subserosal leiomyomas were treated, the following pretreatment parameters were recorded: patient age, presenting symptoms, uterine volume, quantity of uterine leiomyomas, location and volume of dominant uterine leiomyoma, volume of pedunculated subserosal leiomyoma, diameter of pedunculated subserosal leiomyoma stalk, and presence or absence of vascularity in the tumor stalk. Leiomyoma quantity and location were defined according to the reporting standards for UAE for the treatment of uterine leiomyomas (7). Volumes were obtained according to the formula for a prolate ellipse (14). If a patient had more than one pedunculated subserosal leiomyoma, the measurements of the largest one were used. After UAE, volume of the uterus, volume of the pedunculated subserosal leiomyoma, diameter of the tumor stalk, and the presence or absence of tumor perfusion on contrast agent–enhanced MR imaging were ascertained. Additionally, the presence or absence of major or minor complications was recorded. Major and minor complications were defined according to the reporting standards for UAE for the treatment of uterine leiomyomas (7). In cases in which MR imaging and US were performed on follow-up, measurements were obtained from the MR examinations. In cases in which more than one MR imaging study was performed, measurements were obtained from the latest examination. Statistical Analysis Ninety-five percent confidence intervals were generated for the mean uterine volume reduction, the mean pedunculated subserosal leiomyoma volume reduction, and the mean reduction in the diameter of the tumor stalk after UAE according to the SDs of continuous variables. A paired Student t test was used to determine if there was a significant difference between the average diameter of the tumor stalk before and after UAE. A P value of less than .05 was considered significant. All statistical analyses were performed with SAS software (SAS, Cary, North Carolina). Results Over the 30-month period, 240 consecutive women were treated with UAE for symptomatic leiomyomas. Sixteen women had at least one pedunculated subserosal leiomyoma (volume ≥14 cm3) that was treated with UAE. In this study population, the average age was 42.9 years. Presenting symptoms included menorrhagia in 87.5% (n = 14), pain in 75% (n = 12), and bulk and/or pressure including urinary frequency in 81.3% (n = 13). Pretreatment Findings Most women underwent preprocedural MR imaging (81.3%; n = 13). The remaining three underwent preprocedural imaging with US only. Before embolization, the average uterine volume was 789 cm3. One half of the women (n = 8) had two to five leiomyomas; the remaining 50% (n = 8) had more than five leiomyomas. There were no cases of a single dominant leiomyoma. The largest (ie, dominant) leiomyoma was pedunculated subserosal in 62.5% of cases (n = 10), transmural in 18.8% (n = 3), broad-based submucosal or mixed intramural/submucosal in 6.3% (n = 1), intramural in 6.3% (n = 1), and broad-based subserosal in 6.3% (n = 1). The average volume of the dominant leiomyoma was 522 cm3. The average volume of pedunculated subserosal leiomyomas was 372 cm3. The mean diameter of the stalk of the pedunculated subserosal leiomyomas was 2.7 cm (range, 0.8–7.8 cm). There were six patients with stalk diameters less than 2 cm (range, 0.8–1.9 cm). Perfusion of the stalk was identified in all patients who underwent preprocedural MR imaging (n = 13). In the remaining three patients who underwent imaging with US alone before UAE, the vascularity of the stalk was not assessed. Postembolization Findings All women underwent imaging follow-up with contrast agent–enhanced pelvic MR, which was performed at a mean of 5.9 months after UAE. In this cohort, the average length of clinical follow-up was 10.0 months. Average uterine volume measured on imaging studies after UAE was 424 cm3, corresponding to a mean uterine volume reduction of 37.6% (95% CI, 26%–49.3%). The average volume of the pedunculated subserosal leiomyomas on imaging studies after UAE was 271 cm3, corresponding to a mean leiomyoma volume reduction of 39.3% (95% CI, 28.2%–50.5%). The average stalk diameter after UAE was 2.4 cm (range, 0.8–5.6 cm), corresponding to a mean reduction in stalk diameter of 6.2% (95% CI, 2.7%–9.8%). The measured reduction in average stalk diameter after embolization approached but did not reach significance (P = .07; Figure 1, Figure 2). There were no cases of persistent perfusion of the dominant leiomyoma or pedunculated subserosal leiomyomas on follow-up contrast agent–enhanced MR imaging. No major complications were identified. There were no cases of torsion of the leiomyoma stalk, separation of the leiomyoma from the uterus, or sepsis. There was a single minor complication: a prolonged hospital stay (36 hours) was required in one patient for pain control. The etiology of this patient's prolonged postprocedural pain is unknown; her leiomyoma had a volume of 383 cm3 before UAE, which is very close to the mean pretreatment leiomyoma volume observed in this series (372 cm3). Discussion A recent series (n = 12) by Katsumori et al (12) demonstrates the safety and effectiveness of UAE for pedunculated subserosal leiomyomas with a stalk diameter of at least 2 cm. There are also published case reports demonstrating effective treatment of large pedunculated subserosal leiomyomas with UAE followed by myomectomy (13). However, there is persistent apprehension regarding the safety and outcomes after UAE for pedunculated leiomyomas (8, 9). Our observational results suggest that UAE is safe and effective for the treatment of pedunculated subserosal leiomyomas. We did not observe any unique or previously suggested complications related to these lesions (8, 9, 10, 11, 12). Specifically, there were no cases of torsion of the tumor stalk, separation of the tumor from the uterus, or sepsis. There were also no cases of continued perfusion of the tumor on follow-up contrast agent–enhanced MR imaging at a mean of 5.9 months after UAE. There was a single minor complication in our cohort. One patient required a prolonged hospital stay (36 hours) for pain control; in our institutions, patients are usually admitted for less than 24 hours after UAE for pain control. After UAE, pain and cramping severe enough to warrant hospital admission (24–48 hours) is very common. This phenomenon can occur with any type of leiomyoma and is not unique to pedunculated subserosal lesions (7, 15). Results from the Fibroid Registry for Outcomes Data (15) indicate that readmission for pain control can be seen in as many as 2.4% of women after UAE, with this being the most common adverse event related to the procedure. The pretreatment characteristics of the pedunculated subserosal leiomyomas treated in our cohort were similar to those observed in the only other published series (n = 12) of pedunculated subserosal leiomyomas treated with UAE (12). In our cohort, the average volume of the pedunculated subserosal leiomyomas before embolization was 372 cm3 and the mean stalk size was 2.7 cm (range, 0.8–7.8 cm). This compares with 279 cm3 and 3.1 cm (range. 2.0–5.5 cm), respectively, in the other published series (12). In our cohort, follow-up imaging at a mean of 5.9 months demonstrated a mean uterine volume reduction of 37.6% (95% CI, 26%–49.3%) and a mean pedunculated subserosal volume reduction of 39.3% (95% CI, 28.2%–50.5%). These results are similar to the results reported by Katsumori et al (12) in which a mean tumor volume reduction of 41% (95% CI, 29.7%–53.0%) was observed at 4 months. Additionally, as observed in our study, the series of Katsumori et al (12) did not report any major complications after UAE for pedunculated subserosal leiomyomas. After UAE there was a slight reduction in the mean diameter of the pedunculated tumor stalk. Mean diameter decreased by 6.2% (95% CI, 2.7%–9.8%). This result approached but did not reach significance (P = .07). Again, this finding is similar to those in the other published series (12) in which no significant difference in stalk diameter was seen at 4 months and 1 year after embolization. There are a number of limitations to this study. This review is retrospective and it is possible that some patients with particularly unfavorable anatomy on pretreatment imaging (eg, a long, thin stalk) could have been excluded without our knowledge. Additionally, posttreatment follow-up questionnaires and menstrual bleeding quantification scales were not assessed, as this was not the purpose of the study. The length of clinical follow-up was relatively short. Longer follow-up intervals are needed to exclude long-term complications such as continued growth of the subserosal leiomyoma (16) or possible development of peritoneal adhesions (10, 11). Given the fact that there are at least two reported cases of complications arising from UAE for pedunculated subserosal leiomyomas (10, 11), a larger series may be required to definitively demonstrate the safety of this procedure for pedunculated subserosal lesions. From a practical standpoint, the authors of this study believe that this information should be conveyed to patients when informed consent is obtained. A larger series would also be needed to determine if there are safe limits with respect to the size of the pedunculated subserosal leiomyoma or the width of the stalk. In the other published series of pedunculated subserosal leiomyomas treated with UAE (12), lesions with stalk diameters of less than 2 cm were excluded. In our cohort, there were six tumors with a stalk diameter of less than 2 cm (range, 0.8–1.9 cm). In conclusion, despite being limited by its retrospective nature and small sample size, this study suggests the safety and effectiveness of UAE for pedunculated subserosal leiomyomas. Mean tumor volumes were reduced by 39% and there were no unique complications related to these lesions. References 1. 1Lumsden MA, Wallace EM. Clinical presentation of uterine fibroids. Baillieres Clin Obstet Gynaecol. 1998;12:177–195. MEDLINE |
CrossRef
2. 2Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolization to treat uterine myomata. Lancet. 1995;346:671–672. Abstract |
CrossRef
3. 3White AM, Spies JB. Uterine fibroid embolization. Tech Vasc Interv Radiol. 2006;9:2–6. Abstract | Full Text |
Full-Text PDF (102 KB)
|
CrossRef
4. 4Pron G, Bennett J, Common A, et al. The Ontario Uterine Fibroid Embolization Trial (Part 2: uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids). Fertil Steril. 2003;79:120–127. Abstract | Full Text |
Full-Text PDF (168 KB)
|
CrossRef
5. 5Spies JB, Ascher SA, Roth AR, et al. Uterine artery embolization for leiomyomata. Obstet Gynecol. 2001;98:29–34. MEDLINE |
CrossRef
6. 6Walker WJ, Pelage J. Uterine artery embolization for symptomatic fibroids: clinical results in 400 women with imaging follow up. Br J Obstet Gynaecol. 2002;109:1262–1272. 7. 7Goodwin SC, Bonilla SC, Sacks D, et al. Reporting standards for uterine artery embolization for the treatment of uterine leiomyomata. J Vasc Interv Radiol. 2003;14(suppl):S457–S476. 8. 8Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol. 2004;15:115–120. Full Text |
Full-Text PDF (78 KB)
9. 9Walker WJ, Pelage JP, Sutton C. Fibroid embolization. Clin Radiol. 2002;57:325–331.
Full-Text PDF (182 KB)
|
CrossRef
10. 10Braude P, Reidy J, Nott V, Taylor A, Forman R. Embolization of uterine leiomyomata: current concepts in management. Hum Reprod Update. 2000;6:603–608. MEDLINE |
CrossRef
11. 11Ravina JH, Aymard A, Cirau-Vigneron N, et al. Embolisation arterielle particulaire: un nouveau traitement des haemorragies des leiomyomers uterins. Press Med. 1998;27:299–303. 12. 12Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol. 2005;184:399–402. 13. 13Paxton BE, Lee JM, Kim HS. Treatment of intrauterine and large pedunculated subserosal leiomyomata with sequential uterine artery embolization and myomectomy. J Vasc Interv Radiol. 2006;17:1947–1950. Abstract | Full Text |
Full-Text PDF (1116 KB)
14. 14Ghai S, Rajan DK, Benjamin MS, Asch MR, Ghai S. Uterine artery embolization for leiomyomas: pre- and postprocedural evaluation with US. Radiographics. 2005;25:1159–1176.
CrossRef
15. 15Worthington-Kirsch R, Spies J, Myers E, et al. The Fibroid Registry for Outcomes Data (FIBROID) for uterine artery embolization: short-term outcomes. Obstet Gynecol. 2005;106:52–59. MEDLINE 16. 16Stringer NH, DeWhite A, Park J, et al. Laproscopic myomectomy after failure of uterine artery embolization. J Am Assoc Gynecol Laparosc. 2001;8:583–586. Abstract | Full Text |
Full-Text PDF (527 KB)
|
CrossRef
a Departments of Medical Imaging, North York General Hospital, University of Toronto, 4001 Leslie Street, Toronto Ontario, Canada M2K 1E1 b University Health Network and Mount Sinai Hospital, University of Toronto, 4001 Leslie Street, Toronto Ontario, Canada M2K 1E1.  Address correspondence to R.M.
None of the authors have identified a conflict of interest. PII: S1051-0443(07)01968-9 doi:10.1016/j.jvir.2007.11.022 © 2008 SIR. Published by Elsevier Inc. All rights reserved. | |
|
FULL TEXT01968-9/journalimage?img=PIIS1051044307019689.gr1.lrg.gif&fig=fig1&kwhquery=&issn=1051-0443&ishighres=false&allhighres=false&free=yes','journalimage');)
01968-9/journalimage?img=PIIS1051044307019689.gr2.lrg.gif&fig=fig2&kwhquery=&issn=1051-0443&ishighres=false&allhighres=false&free=yes','journalimage');)