Speaking at the meeting of the Society of Interventional Radiology (SIR) in Toronto this year, Gary Siskin highlighted the importance of patient consultation and evaluation prior to uterine artery embolisation (UAE). He said that it was important to ask if the patient had fibroids and if they had troubling symptoms, then ascertain if those symptoms can be linked to the fibroids and if UAE would help.
In terms of imaging the fibroids, Siskin said: "I prefer MRI to evaluate patients prior to UAE... I believe that if you are recommending an organ-sparing procedure, you must get the best look at the uterus that you can." Using this technology can show you other, 'interesting' findings such as adenomyosis, he added. "In these cases, UAE is a controversial treatment choice," he cautioned. Recent results have been favourable but recurrence rates will likely be higher. However, "It deserves to be discussed as a potential treatment." Other things that might be identified from an MRI include pedunculated fibroids and necrotic calcified devascularised fibroids.
When enquiring about the patient's symptoms, the interventionalist needs to ask about abnormal bleeding, menstrual cramping, abdominal distension, frequency of urination, and if there is any pain during sex. If there are none of these symptoms, proceed with care, Siskin said. "As a rule, I generally do not offer UAE to patients without fibroid-related symptoms. But there are exceptions, particularly if there has been recent growth and you cannot see the ovaries on the ultrasound."
Women with particularly large fibroids may also be unsuitable for UAE, with dubious long-term success. "The key to treating patients with large fibroids is setting reasonable expectations," he commented.
On the question of fertility, Siskin advised that UAE should not be the first procedure offered to asymptomatic patients with fibroids and infertility. While myomectomy has demonstrated benefit in terms of improving the rates of conception and lowering miscarriages issues, there are no such data yet for UAE. If a woman wants to preserve her fertility, she should be treated as if she were an 'infertility' patient, he said. "Give her a consultation for myomectomy, and only consider UAE if she is a poor candidate for myomectomy."
The most important thing, he continued, is to make sure that the patient is informed about all the benefits and risks of each option. "We must acknowledge that we do not yet know enough about UAE and future fertility to make many definitive statements other than 'women have become pregnant after UAE'," said Siskin.
Siskin also presented a round-up of new treatment options available that the interventionalist should be familiar with. These include cryo-, radiofrequency and laser ablation, which "can be performed with MR or with laparoscopic guidance". However, supporting data are still from small cohorts over the short term. Other options include MR-guided focused ultrasound, which has more supporting data following the publication of a 12-month follow-up study of 109 patients, which showed that 71% of patients had a decrease of at least ten points in symptom severity scores at six months and mean time to return to work was one day. (Stewart et al, Fertility and Sterility 2006).
"In conclusion," said Siskin, "UAE works. Most people with symptomatic fibroids are candidates for the procedure and imaging with MRI is a good thing to do prior to UAE." The last conclusion is independently elaborated by Dr Krönke in a separate UAE study.
UAE aftercare
Following Siskin at SIR, James Spies, professor and chairman of the department of radiology at Georgetown University Hospital (Washington, DC) spoke about post procedure management. Usually conducted on an out-patient basis, UAE can typically lead to moderate to intense pain for 2-6 hours after embolisation, and that physicians should be ready to administer remedies. Other after effects include (in roughly this order of likeliness) nausea, itching and hypertension.
However, observed Spies, there is small chance that UAE might result in myometrial injury, particularly if pain persists. "It is often difficult to identify those patients who will have a benign course from those who are in trouble," he said. Spies recommended daily or bi-daily calls to the patient, an examination early on in the process, MRI if there is no resolution and to always be suspicious. "Remember, you know more about this process than her gynaecologist," he added.
Spies then spoke about the FIBROID registry, which plans to follow patients' outcomes for up to 36 months. Initially, 3,166 women at 72 sites have been included, 1,701 of whom have been followed for 12 months so far. Most patients have shown "striking, marked improvement", remaining stable from six to 12 months, he said. Few interventions or hospitalisations have been needed, but poorer outcomes were associated with larger dominant fibroids, fewer fibroids, unilateral embolisation, younger patients and smokers.
He concluded: "The FIBROID registry represents the largest clinical outcomes study ever undertaken for a fibroid therapy. This is a remarkable achievement given that there was no funding support for investigators or sites."
Other UAE news
In a separate talk, Spies noted that "UAE with tris-acryl gelatin microspheres resulted in marked durable improvement in menstrual bleeding." Based on the outcomes of a Ruta menorrhagia questionnaire, 57% of patients at baseline said they had heavy menstrual bleeding, but at three years only 2% reported heavy bleeding. Health-related quality of life as measured by the SF-12 survey was similarly improved after three years in both the physical and mental domains, he added.
In a second study, Spies and co-authors tracked the economic outcomes of UAE. They compared health resource use and medical costs of UAE (125 patients included) versus hysterectomy (2,836) or myomectomy (704) in 2002.
They found that UAE patients had significantly more in-patient hospitalisations, hospital out-patient visits, and physician office visits up to one year post-procedure. The median procedure cost for UAE was $5,968, while for hysterectomy it was $7,707 and $7,299 for myomectomy. Although the median cost was lowest for UAE, the sum total of all costs over 12 months was the same for all three procedures, the authors stated.
While the finances may be the same, UAE does offer other advantages, according to a third study by interventionalists from Pochon-gun, South Korea. They reported on clinical outcomes in 29 UAE patients after four years of follow-up. They found that the mean volume reduction rates of predominant fibroids were 62.5% at three and a half months and 27.7% at four years. Also at four years, the majority of patients reported marked symptom improvement for menorrhagia (16 of 19 cases), dysmenorrhea (seven of seven), and bulk-related symptoms (seven of 14).
Gelatin sponges
Japanese researchers have conducted a UAE study with gelatin sponge particles, concluding that they can provide long-term relief from symptoms with few complications. PVA particles, which are used most commonly in UAE, are not commercially available in Japan (Katsumori et al, American Journal of Roentgenology March 2006).
For this study, the researchers collected data from 96 women up to five years post-procedure. All but one patient underwent bilateral UAE with 500-1,000um gelatin sponge particles, with a technical success rate of 99%. According to post-UAE contrast-enhanced MRI, 89% of the largest fibroids were completely infarcted. The cumulative symptom control rates were 96.9% at one year, 94.5% at two years, and 89.5% at five years. The cumulative rates of overall failure were 4.2% at one year, 6.5% at two years, and 12.7% at years three through five.
"Our results suggest that UAE using gelatin sponge particles alone for symptomatic uterine fibroids provides long-term symptom control in most patients because the cumulative rates of symptom control were 89.5% at both three and five years," Katsumori's group wrote. Echoing Siskin's talk, the group noted that future studies will have to look at such issues as fibroid regrowth and fertility. In this study, 13 women who attempted to get pregnant post-UAE were unable to do so, while two women who did not express a desire for pregnancy did become pregnant (both miscarried).
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