Urban Myths in Fibroids and UFE

Urban Myths in
Fibroids and UFE
Interventional Radiologist
Northwell Health Partners
Vice Chairman- Department of Radiology
Long Island Jewish Medical Center
Associate Professor
Hofstra Northwell School of Medicine
Attending Physician
Departments of Radiology, Surgery and Urology
David Siegel, M.D., FSIR
• Speakers Bureau: St. Jude Medical
“You can’t get pregnant after
UFE”
“The fibroids all come back in 4
or 5 years
“The pain is unbearable”
“There’s no way to know that
those tumors are not cancer”
“You won’t be able to have an
orgasm after UFE”
“You know, when that do that
embolization thing they kill
your ovaries too”
“ UFE will put you into
menopause”
“Since UFE causes menopause you
might as well have the
hysterectomy”
“You can’t treat submucosal fibroids”
“HIFU is Better”
“People die from this procedure”
“Birth defects are common in
children born after UFE”
“Sometimes those pellets get into the
wrong arteries and ruin your sex
life”
“You have the wrong kind of fibroids
for UFE”
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Cancer
Sexual function
Morphology
Menopause
Pregnancy
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“There’s no way to know that those
tumors are not cancer”
“Listen to me honey, your done
having kids. We’ll take out your
uterus with all those nasty fibroids
and we’ll take out your ovaries too,
that way you won’t get cancer”
• Cervical Cancer
• Endometrial Cancer
• Ovarian Cancer
• Uterine Sarcoma
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~40,00 new U.S. cases / year
Early 60’s Whites 2x> Blacks
Abnormal vaginal bleeding is
almost always present
Endometrial Bx
Routine?
>40 Y.O.
 Any irregular bleeding
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Cervical Cancer
Avg. age 40
Affects sexually active women >21 y.o.
PAP Screening
>40,000 U.S, CIN2/CIN3 pts./year
CIN 3  invasive cancer: estimated 10 -15 yrs
~10,000 new U.S. cases /year “underscreened”
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4th leading cause of death in females
1:57 women, increasing
U.S.: >25,00 new cases & 16,000 deaths/ yr.
Risk Factors: Family History, Nullparity, HRT
Li AJ. Giuntoli RL 2nd. Drake R. Byun SY. Rojas F.
Barbuto D. Klipfel N. Edmonds P. Miller DS. Karlan BY.
Ovarian preservation in stage I low-grade endometrial
stromal sarcomas. Obstetrics & Gynecology.
106(6):1304-8, 2005 Dec.
Piver MS. Prophylactic Oophorectomy: Reducing the
U.S. Death Rate from Epithelial Ovarian Cancer. A
Continuing Debate. Oncologist.1996;1(5):326-330.
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Represents sarcomatous
degeneration of a fibroid
Can mimic a fibroid
 ? Indistinct border on MRI ?
 ? >50% High T2 Signal
Postmenopausal and /or Rapid
Fibroid Growth
Persistant enhancement after UFE
Risk Of Sarcoma?
(2014fibroid morcellation)
Coffin,
Ascher and
SpiesGeorgetown
University
Hospital
FDA= 1 in 350
SIR 2016
ACOG 1 in 500
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Meta-analysis: Pritts EA, et al
Gynecol Surg. 2015 12:165-177.
1 in 8300
In Prospective Studies
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25/ 866 patients(2.9%)
suspected of malignancy on MRI.
4 proven Malignancies
• Malignancy correctly identified
in 3 of 4 cases by MRI
• Prevalence of malignancy at
time of consult was 4 in 866 or 1 in
216 (0.46%)
• Prevalence of malignancy
missed by MRI- 1 of 866 or 0.11
Remember………
No Tissue Diagnosis!
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High Quality Imaging
Routine Use Of MRI
Hysteroscopy
Gyn Exam, PAP, EMBx
X
Prophylactic
TAH +/- BSO
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“You won’t be able to have an orgasm
after UFE”
“Sometimes those pellets get into the
wrong arteries and ruin your sex life”
Arteries Related To Female Sexual Response
External Pudendal Artery
Ext. iliac artery
External genitalia, labia, clitoris
Internal Pudendal Artery
External genitalia, labia, clitoris
& lower vagina
Vaginal Artery (+/- proximal UA
branch)
V
UA
IP
Analogous to male inf. vesicle art
Supplies most of vagina
Uterine Artery
Cervicovaginal branch
Cervix & superior portion of vagina
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Uterine artery segments
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Descending
 no branches
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Transverse
 Cervicovaginal br.
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Ascending
 courses along the lateral
uterus
 muscular or “helicine”
branches
 terminal fundal branchesvariable OA
>>>>>
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Massive vault necrosis with bladder fistula after
uterine artery embolisation Amr H. El-Shalakany,
Mohammad H. Nasr El-Din, Gamal A. Wafa, Mohammad E.
Azzam, Ahmad El-Dorry British Journal of Gynecology
February 2003, Vol. 110 pp. 215-216
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Labial Necrosis After Uterine Artery Embolization
for Leiomyomata Thomas J. Yeagley, Jay Goldberg,
Thomas A. Klein,Joseph Bonn. Obstetrics and Gynecology
2002; 100:881-2
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Patch of necrosis that resolved spontaneously
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Single patient case report
41 y.o. UFE for Pain & menorrhagia
6 weeks- unable to achieve orgasm
12 weeks- regained ability to achieve clitoral but not internal
orgasm
? Cervicovaginal branch embolization uterovaginal plexus
ischemia of cervix?
loss of uterine contractions?
Personal Experience (?underreported) <6 cases / 1700
All transient= less than 6 months
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Thakar R, Manyonda I, Stanton SL, Clarkson P, Robinson G. Bladder, bowel
and sexual function after hysterectomy for benign conditions. Br J Obstet
Gynecol 1997; 104: 983–987.
Virtanen H, Makinen J, Tenho T, Kilholma P, Pitkanen Y, Hirvonen T. Effects
of abdominal hysterectomy on urinary and sexual symptoms. Br J Urol 1993;
72: 868–872.
Sloan D. The emotional and psychosexual aspects of hysterectomy. Am J
Obstet Gynecol 1978; 131: 598–605.
Master WH, Johnson WE. The uterus. In: Human sexual response, 1st ed.
Boston: Little, Brown, 1966; 111–126.
Richards DH. A post-hysterectomy syndrome. Lancet 1974; 2: 983–985.
Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal uterine
amputation vs. hysterectomy: effects on libido and orgasm. Acta Obstet
Gyncecol Scand 1983; 62: 147–152.
Zussman L, Zussman S, Sunley R, Bjornson E. Sexual response after
hysterectomy-oophorectomy: recent studies and reconsideration of
psychogenesis. Am J Obstet Gynecol 1981; 140: 725–729.
Neurological
Vascular
Hormonal
Anatomical
UFE
Surgical Therapy
--
nerve injury 2’ to dissection
Non target embolization
cervicovaginal embolization
Vascular ligation
esp. Pudendal
menopause
4WTSAP
? Loss of uterine contractions
Oophorectomy
Menopause
Hysterectomy
Loss of uterine contractions
• 141 women
• 2 surveys
• Sexual and Psychological well being
• Prior to and 3 months following UFE
• >30% increase in Sexual desire and acivity
• Decrease in sexual problems
• Orgasm, Lubrication and Pain
SIR 2016
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Patients from 5 centers
170 analyzed/264
enrolled
Improvement of all
aspects of sexual
function
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Desire, arousal,
satisfaction, lubrication,
orgasm and pain
Increase in FSFI=
Female Sexual Function Index
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in 78%Of Pts.
No reported ischemic
vaginal complications
--------------------------------------------------------------------------------------------------Personal conversation :Kovacsik and Lohle---No patients with loss of ability to achieve orgasm
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True Sexual
Dysfunction after
UFE is exceedingly
rare and almost
always transient
Women’s sex lives
are generally
enhanced after
UFE
Prospective studies
needed
“You can’t treat submucosal fibroids”
“You have the wrong kind of fibroids for
UFE”
??2CM
?? 6CM
??3CM
??CM
??4CM
Be prepared to deal with aborting fibroids at any time post procedure!
•IR 24 / 7 AVAILABILITY
•OB/GYN
–Variable Skill Set
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R P Berkowitz, F L Hutchins, R L Worthington-Kirsch, "Vaginal expulsion of
submucosal fibroids after uterine artery embolization: A report of three cases,"
The Journal of Reproductive Medicine 44 (April 1999) 373-376.
“Vaginal expulsion of submucosal fibroids can be viewed as a
side effect of the procedure”
S. Abbara, MD, J.B. Spies, A.R. Scialli, R.C. Jha, J.M. Lage, B. Nikolic,
“Transcervical Expulsion of a Fibroid as a Result of Uterine Artery Embolization
for Leiomyomata” JVIR April1999; 10(4): p.409-411
“transvaginal expulsion of embolized leiomyomata will be an
occasional sequela of the embolotherapy of fibroids”
Solitary or Dominant
Endocavitary Disease
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Ravina J, Ciraru-Vigneron N, Aymard A, Ferrand J, Merland J.
Uterine artery embolisation for fibroid disease: results of a 6 year
study. Min Invas Ther & Allied Technol 1999;8:441-447
 1 case (n=184) of post UFE “Aseptic
necrobiosis”
 Laparotomy –removal of necrotic 8cm
fibroid
 “Pedunculated subserous myomas should
be referred for conventional surgery”
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Payne JF, Haney AF. Serious complications of uterine artery
embolization for conservative treatment of fibroids. Fertil Steril.
2003;79(1):128–31.
 case report: bowel obstruction
 Laparotomy 14 days post UFE
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Katsumori T, Akazawa K, Mihara T. Uterine Artery Embolization for
Pedunculated Subserosal Fibroids. AJR 2005; 184:399-402
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12 pts/ 15 Pedunculated fibroids- NO COMPLICATIONS
Mean Fibroid Diameter=8.3cm ; Mean Stalk Diameter= 3.1cm
Complete fibroid devascularization 11/15 = 73%
Mean tumor volume reduction= 53% @1yr. Post UFE
100% symptom relief @ 2yrs
Margau R, Simons ME, Rajan DK, Hayeems EB, Sniderman KW, Tan K,
Beecroft R, Kachura JR. Outcomes after Uterine Artery Embolization for
Pedunculated Subserosal Leiomyomas. J Vasc interv Radiol 2008; 19:657-661
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16 pts with pedunculated fibroids- NO MAJOR COMPLICATIONS
(1pt 36hrs in hospital)
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Mean Fibroid Volume=372cm3 ; Mean Stalk Diameter= 2.7cm
Mean tumor volume reduction= 39.3% @6months Post UFE
100% symptom relief @ 2yrs
Symptomatic Pedunculated Subserosal Fibroids
Solitary symptomatic PSF
or
Dominant PSF in patient with bulk
symptoms only
Laparoscopic
Myomectomy
JVIR 2004
“ 50% rule”
“a subserosal leiomyoma that is
sufficiently pedunculated
(attachment point <50% of the
diameter ) can be at risk for
detachment from the uterus, a
situation that necessitates
surgical intervention”
JVIR 2014
Indeed, the early anecdotal concerns regarding the
safety and effectiveness of uterine embolization with
pedunculated leiomyomas with a narrow attachment
has not been borne out in subsequent larger
investigations, and symptomatic and safety outcomes
are similar to those in patients without this type of
this type of
leiomyoma should not be
considered a contraindication
to uterine embolization.
leiomyoma. Therefore,
Urban Myths in
Fibroids and UFE
Interventional Radiologist
Northwell Health Partners
Vice Chairman- Department of Radiology
Long Island Jewish Medical Center
Associate Professor
Hofstra Northwell School of Medicine
Attending Physician
Departments of Radiology, Surgery and Urology