Uterine Fibroid Uterine Fibroid EmbolizationEmbolization

T a y l o r H a n d l e y - MS IVT a y l o r H a n d l e y - MS IVTexas Tech University School of MedicineTexas Tech University School of Medicine

Uterine Leiomyomata Uterine Leiomyomata (Fibroids)(Fibroids) Benign smooth muscle tumors of the Benign smooth muscle tumors of the

uterus uterus Roughly 50% of women afflicted with Roughly 50% of women afflicted with

fibroids by menopausal agefibroids by menopausal age– Black 2x > White/Asian womenBlack 2x > White/Asian women– Most commonly in 35-49 y/o womenMost commonly in 35-49 y/o women

One-half of women with fibroids have One-half of women with fibroids have significant symptomssignificant symptoms

Symptoms include: menometrorrhagia, Symptoms include: menometrorrhagia, pelvic pain, pelvic fullness, abdominal pelvic pain, pelvic fullness, abdominal distension, urinary urgency, constipation, distension, urinary urgency, constipation, bowel obstruction, hydronephrosisbowel obstruction, hydronephrosis

Uterine FibroidsUterine Fibroids

Because fibroids are estrogen-Because fibroids are estrogen-dependent, they usually resolve dependent, they usually resolve following menopausefollowing menopause

Responsible for over 200,000 Responsible for over 200,000 hysterectomies annuallyhysterectomies annually

Other current treatment options Other current treatment options include myomectomy, electrocautery include myomectomy, electrocautery coagulation (myolysis), hormonal coagulation (myolysis), hormonal therapy, and UFEtherapy, and UFE

Shortcomings of Shortcomings of Current TreatmentCurrent Treatment Current surgical options (hysterectomy, Current surgical options (hysterectomy,

myomectomy, myolysis) all require myomectomy, myolysis) all require general anesthesia general anesthesia

Associated with significant hospital stays Associated with significant hospital stays and recovery timesand recovery times

Myomectomy is less invasive but has Myomectomy is less invasive but has recurrence rate of recurrence rate of 10% per year 10% per year for 5 for 5 years following the procedureyears following the procedure

Hormonal therapy relatively as effective Hormonal therapy relatively as effective as an adjunctive treatment, but fibroids as an adjunctive treatment, but fibroids quickly recur following hormone quickly recur following hormone cessationcessation

Uterine Fibroid Uterine Fibroid Embolization (UFE)Embolization (UFE)

Proven to be a very effective alternative Proven to be a very effective alternative for some women with symptomatic for some women with symptomatic uterine fibroidsuterine fibroids

Less invasive procedure involving:Less invasive procedure involving:– Conscious sedation versus general Conscious sedation versus general

anesthesiaanesthesia– Shorter hospital stays Shorter hospital stays – More rapid recovery time, less More rapid recovery time, less

morbidity/fewer complicationsmorbidity/fewer complications Comparative clinical trials discussed laterComparative clinical trials discussed later

History of UFEHistory of UFE

Fibroids (hypervascular benign tumors) were Fibroids (hypervascular benign tumors) were noted to noted to spontaneously spontaneously infarct and subsequently infarct and subsequently undergo involution/volume reductionundergo involution/volume reduction

UFE – with UFE – with iatrogeniciatrogenic infarction – thought to infarction – thought to achieve the same resultachieve the same result

Selective embolization of uterine arteries has Selective embolization of uterine arteries has been used since 1970’s for gynecologic been used since 1970’s for gynecologic malignancies and hemorrhage-control in pelvic malignancies and hemorrhage-control in pelvic traumatrauma

Ravina et al. first used polyvinyl alcohol (PVA) in Ravina et al. first used polyvinyl alcohol (PVA) in UFE reported in 1994 (France) with excellent UFE reported in 1994 (France) with excellent resultsresults

Other Uses of Other Uses of EmbolotherapyEmbolotherapy

Control of abnormal uterine bleeding Control of abnormal uterine bleeding due to GYN malignancies, ectopic due to GYN malignancies, ectopic pregnancies, post-partum hemorrhagepregnancies, post-partum hemorrhage

Reduction of tumor vascularity prior to Reduction of tumor vascularity prior to surgical excision (renal cell CA, spinal surgical excision (renal cell CA, spinal tumors)tumors)

Palliative treatment of end-stage CA Palliative treatment of end-stage CA patients (e.g. abdominal pain from patients (e.g. abdominal pain from inoperable liver tumors, etc.)inoperable liver tumors, etc.)

Types of FibroidsTypes of Fibroids

Massive pedunculated Massive pedunculated submucosal fibroid submucosal fibroid (gross specimen (gross specimen following hysterectomy)following hysterectomy)

Submucosal FibroidsSubmucosal Fibroids– Assoc. with heavy and prolonged Assoc. with heavy and prolonged

menstrual periods, freq. miscarriagesmenstrual periods, freq. miscarriages– May prolapse into the cervixMay prolapse into the cervix

Intramural FibroidsIntramural Fibroids– Associated with mass-related sxs Associated with mass-related sxs

such as abdominal distention or such as abdominal distention or urinary frequency (bladder urinary frequency (bladder compression)compression)

Subserosal FibroidsSubserosal Fibroids– Frequently pedunculatedFrequently pedunculated– May grow into the uterine ligamentsMay grow into the uterine ligaments– Frequent mass sxsFrequent mass sxs

Presenting Fibroid Presenting Fibroid SymptomsSymptoms

Abnormal uterine bleedingAbnormal uterine bleeding– Especially true of submucosal fibroids just deep to Especially true of submucosal fibroids just deep to

endometriumendometrium Pelvic painPelvic pain

– From intramural degeneration or torsion of From intramural degeneration or torsion of intramural fibroidintramural fibroid

Pelvic pressurePelvic pressure Abdominal distensionAbdominal distension Genitourinary dysfunctionGenitourinary dysfunction

– Urinary frequency due to bladder compressionUrinary frequency due to bladder compression– Hydronephrosis due to ureteral obstructionHydronephrosis due to ureteral obstruction

InfertilityInfertility Pedal edema, constipation, intestinal Pedal edema, constipation, intestinal

obstructionobstruction

Pre-procedure Pre-procedure EvaluationEvaluation

Essential Essential to have a thorough gynecologic to have a thorough gynecologic evaluation, must rule out endometrial evaluation, must rule out endometrial hyperplasia and malignancyhyperplasia and malignancy– Pap smear within 6 months of procedure Pap smear within 6 months of procedure – Endometrial biopsy (in pts presenting with Endometrial biopsy (in pts presenting with

menorrhagia) within 12 monthsmenorrhagia) within 12 months Serum B-hCG to rule out pregnancySerum B-hCG to rule out pregnancy Current Ultrasound or MRI to document Current Ultrasound or MRI to document

size/location of fibroid/ssize/location of fibroid/s If pt on hormonal therapy (GnRH agonist), If pt on hormonal therapy (GnRH agonist),

must withhold agent for 12 weeks prior to must withhold agent for 12 weeks prior to procedureprocedure

The Ideal Patient for The Ideal Patient for UFEUFE

Pre-menopausal pt Pre-menopausal pt not not desiring desiring fertility fertility

Post-menopausal pt with failure of Post-menopausal pt with failure of spontaneous regressionspontaneous regression

Pt has failed medical managementPt has failed medical management Fibroid is of moderate size (3-7cm)Fibroid is of moderate size (3-7cm) Absolute contraindication to Absolute contraindication to

surgery (including pt preference)surgery (including pt preference)

Poor Candidates for Poor Candidates for UFEUFE

Pt with minimal sxs, or sxs easily Pt with minimal sxs, or sxs easily controlled w/ medical mgmtcontrolled w/ medical mgmt

Pt desires fertility, amenable to Pt desires fertility, amenable to myomectomymyomectomy

Primary complaint of spontaneous Primary complaint of spontaneous ABAB

Isolated pedunculated submucosal Isolated pedunculated submucosal fibroidfibroid

Pt requires other pelvic surgeryPt requires other pelvic surgery

ContraindicationsContraindications

AbsoluteAbsolute– PregnancyPregnancy– Known/suspected pelvic infection or Known/suspected pelvic infection or

bacteremiabacteremia RelativeRelative

– Coagulopathy, renal failure, contrast allergyCoagulopathy, renal failure, contrast allergy– Peripheral vascular occlusive diseasePeripheral vascular occlusive disease– Pt currently on hormonal therapy (e.g. Pt currently on hormonal therapy (e.g.

Lupron)Lupron)

Imaging of FibroidsImaging of Fibroids Ultrasound Ultrasound

– Effective at excluding other uterine pathology, Effective at excluding other uterine pathology, documentation of size/locationdocumentation of size/location

– Results dependent on pts body habitus, operator skillResults dependent on pts body habitus, operator skill MRIMRI

– Preferred imaging modalityPreferred imaging modality– Excellent documentation of exact size, location, and Excellent documentation of exact size, location, and

internal characteristics of fibroidinternal characteristics of fibroid– Mizukami Mizukami et al. report possible prognostic et al. report possible prognostic

significance of T2-weighted images: better outcome significance of T2-weighted images: better outcome in pts whose fibroids have intermediate/high signal in pts whose fibroids have intermediate/high signal intensityintensity

– Best method of excluding adenomyosisBest method of excluding adenomyosis– Excellent in documenting volume reduction after Excellent in documenting volume reduction after

embolizationembolization Fibroids usually show decreased signal intensity in T1 Fibroids usually show decreased signal intensity in T1

and T2 images after embolizationand T2 images after embolization

Axial T1-weighted imageAxial T1-weighted image

Describe the type and location Describe the type and location of the fibroid…of the fibroid…Sagittal T2-weighted MRISagittal T2-weighted MRI

3cm Intramural Fibroid in the 3cm Intramural Fibroid in the Posterior, Lower Uterine Posterior, Lower Uterine

SegmentSegment

45 y/o 45 y/o female female with with

abdominal abdominal distention distention

: : Incidentally-Incidentally-

found found calcified calcified uterine uterine fibroidfibroid

UFE : Procedural UFE : Procedural BasicsBasics1)1) Conscious sedation is used +/- Foley Conscious sedation is used +/- Foley

catheter, prophylactic Abx (Cefazolin 1 catheter, prophylactic Abx (Cefazolin 1 gm IV)gm IV)

2)2) Femoral artery accessed with 4-5 Fr Femoral artery accessed with 4-5 Fr cathetercatheter

3)3) Flush catheter advanced to abdominal Flush catheter advanced to abdominal aorta and pelvic angiogram aorta and pelvic angiogram performed. performed. Important to identify not Important to identify not only the uterine arteries, but also only the uterine arteries, but also other collateral supplies to the other collateral supplies to the myomatous uterus (e.g. ovarian aa., myomatous uterus (e.g. ovarian aa., lumbar aa.)lumbar aa.)

PelvicArteriogram 1

3 4

5 6 7 8

2

2

910

11

12

Identify these

Arteries!13

PelvicArteriogram 1

3 4

5 6 7 8

2

2

910

11

12

1- Abdominal Aorta2- Lumbar aa.3- R Common Iliac A.4- LCIA5- R Ext Iliac Art6- R Int Iliac Art (Hypogastric)7- LIIA8- LEIA9- Anterior Division, L Hypogastric A.10 – Posterior Division L Hypogastric A.11- Iliolumbar A.12- Superior Gluteal A13- Median Sacral A

13

4)4) The uterine arteries are identified and The uterine arteries are identified and selectively catheterizedselectively catheterized

The R. Uterine Artery arising from the anterior division of the Int.Iliac Artery. Its terminal branches, the spiral arteries, appear dilated, tortuous, and laterally displaced in the presence of fibroids.

1

21- Catheter tip positioned in Ant. Div. of R Hypogastric A.2- Origin of R. Uterine A.

Selective Injection of Uterine Selective Injection of Uterine ArteriesArteries

Note the uterine artery supplying the

hypervascular benign tumor

5)5) An embolic agent (PVA or An embolic agent (PVA or Embospheres) of appropriate diameter Embospheres) of appropriate diameter is injected into the uterine arteries to is injected into the uterine arteries to induce thrombosis. induce thrombosis. BilateralBilateral embolization of uterine arteries is embolization of uterine arteries is essential.essential.

6) Embolization should be continued 6) Embolization should be continued until there is sluggish flow in the until there is sluggish flow in the uterine artery with elimination of the uterine artery with elimination of the fibroid blushfibroid blush

7) Post-embolization pelvic angiography should 7) Post-embolization pelvic angiography should be performed to document arterial occlusionbe performed to document arterial occlusion

Pre-embolization Post - embolization

The Post-Embolization The Post-Embolization SyndromeSyndrome

Affects most patients and lasts 2-Affects most patients and lasts 2-7 days after procedure7 days after procedure

Pelvic pain / cramping (usually Pelvic pain / cramping (usually peaks at 12-24 hrs post-embo)peaks at 12-24 hrs post-embo)

Nausea/vomitingNausea/vomiting Low-grade feverLow-grade fever General malaiseGeneral malaise

Post-Embolization Post-Embolization ManagementManagement

Have PCA pump available Have PCA pump available immediatelyimmediately following procedure for pain controlfollowing procedure for pain control

Most facilities admit pt for one night for Most facilities admit pt for one night for pain controlpain control

Outpatient protocols involve:Outpatient protocols involve:– Opioid analgesics (Oxycodone 10-20mg q12 Opioid analgesics (Oxycodone 10-20mg q12

hr)hr)– NSAIDs (Celebrex 100mg q12 hr x 7 days, NSAIDs (Celebrex 100mg q12 hr x 7 days,

followed by Ibuprofen)followed by Ibuprofen)– Antinausea medication (prochlorperazine) Antinausea medication (prochlorperazine)

Patient FollowupPatient Followup

Patient should follow-up with PCP Patient should follow-up with PCP within 1 monthwithin 1 month

Follow-up imaging should occur at Follow-up imaging should occur at 3, 6, and 12 months after the 3, 6, and 12 months after the procedure to document resultsprocedure to document results

Potential Potential ComplicationsComplications Premature menopause 2-5%Premature menopause 2-5% Expulsion of fibroid < 2%Expulsion of fibroid < 2% SepsisSepsis < 1% < 1% Emergent hysterectomy < 1%Emergent hysterectomy < 1% Death < 1%Death < 1%

Clinical Results of UFEClinical Results of UFE Spies et al. (2001) followed 200 UFE pts Spies et al. (2001) followed 200 UFE pts

with written questionnaires and follow-with written questionnaires and follow-up imagingup imaging– Improved bleeding sxs in 90% of pts at 12 Improved bleeding sxs in 90% of pts at 12

monthsmonths– Also significant improvement in mass sxs, Also significant improvement in mass sxs,

and patient satisfactionand patient satisfaction– The stability of symptom improvement did The stability of symptom improvement did

not not change over the follow-up time of 2 change over the follow-up time of 2 yearsyears

– Mean fibroid volume reduction of 44% over Mean fibroid volume reduction of 44% over 3 months and 58% over 12 months3 months and 58% over 12 months

Spies et al. 2001. “Uterine artery embolization for leiomyomata.” Obstetrics & Gynecology. 98(1):29-34.

Al-Fozan et al. (2002) compared Al-Fozan et al. (2002) compared inpatient hospital costsinpatient hospital costs for 545 for 545 women with uterine fibroids treated women with uterine fibroids treated with either myomectomy, total with either myomectomy, total abdominal hysterectomy, vaginal abdominal hysterectomy, vaginal hysterectomy or UFEhysterectomy or UFE– UFE assoc with the shortest hospital stayUFE assoc with the shortest hospital stay– In-hospital cost of UFE was the leastIn-hospital cost of UFE was the least

UFE cost $1,007 (Canadian)UFE cost $1,007 (Canadian) Vaginal hysterectomy cost $1,515Vaginal hysterectomy cost $1,515 Abdominal myomectomy $1,781Abdominal myomectomy $1,781 Abdominal hysterectomy $1,933Abdominal hysterectomy $1,933Al-Fozan et al. 2002. “Cost analysis of myomectomy, hysterectomy, and uterine artery embolization.” American Journal of Obstetrics and Gynecology. 187(5):1401-1404.

Spies et al. (2002) analyzed Spies et al. (2002) analyzed baseline variables of 200 pts to baseline variables of 200 pts to determine if they influenced determine if they influenced clinical success of UFEclinical success of UFE– Smaller baseline leiomyoma size and Smaller baseline leiomyoma size and

submucosal location are more likely submucosal location are more likely to result in a positive imaging to result in a positive imaging outcomeoutcome

– There are limited associations b/w There are limited associations b/w other baseline variables and other baseline variables and symptom change or imaging symptom change or imaging outcomeoutcomeSpies et al. 2002. “Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome.” Radiology. 222:45-52.

Smith et al. (2004) studied 64 Smith et al. (2004) studied 64 women to evaluate changes in women to evaluate changes in fibroid-specific symptom severity fibroid-specific symptom severity and health-related quality of life and health-related quality of life after UFE.after UFE.– Questionnaires given to women Questionnaires given to women

undergoing UFE mean of 32 months undergoing UFE mean of 32 months after procedureafter procedure

– Symptom severity scores decreased by Symptom severity scores decreased by a mean of 32%a mean of 32%

– HRQOL scores increased by a mean of HRQOL scores increased by a mean of 36%36%

Smith et al. 2004. “Patient satisfaction and disease specific quality of life after uterine artery embolization.” American Journal of Obstetrics and Gynecology. 190(6):1697-1705.

Al-Fozan et al. 2002. “Cost analysis of myomectomy, hysterectomy, and uterine artery embolization” American Journal of Obstetrics and Gynecology. 187(5):1401-1404.

Andrews, RT. 2001 “Andrews, RT. 2001 “Uterine artery embolization as a definitive treatmentUterine artery embolization as a definitive treatment for for uterine leiomyomata (fibroids).”uterine leiomyomata (fibroids).”

Kaufman, JA. 2004. Kaufman, JA. 2004. Vascular and Interventional RadiologyVascular and Interventional Radiology. St. Louis: Mosby.. St. Louis: Mosby.

Siskin, GP. 2004. “Uterine Fibroid Embolization.” Online. Available Siskin, GP. 2004. “Uterine Fibroid Embolization.” Online. Available http://www.emedicine.com/radio/topic837.htm

Smith et al. 2004. “Patient satisfaction and disease specific quality of life after uterine artery embolization.” American Journal of Obstetrics and Gynecology. 190(6):1697-1705.

Spies et al. 2002. “Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome.” Radiology. 222:45-52.

Spies et al. 2001. “Uterine artery embolization for leiomyomata.” Obstetrics & Gynecology. 98(1):29-34.

Bibliography

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