An MRI pictorial review of uterine fibroid expulsion after uterine artery embolisation

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1 An MRI pictorial review of uterine fibroid expulsion after uterine artery embolisation Poster No.: C-1893 Congress: ECR 2017 Type: Educational Exhibit Authors: E. Y. Auyoung, L. Ratnam, R. Das, S. Ameli-Renani, L. Mailli; London/UK Keywords: Neoplasia, Education and training, Treatment effects, Embolisation, MR, Management, Interventional vascular, Genital / Reproductive system female DOI: /ecr2017/C-1893 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Learning objectives 1) To recognise characteristic features on MR images of expelled uterine fibroids after uterine artery embolisation (UAE). 2) To assess potential predictive markers of uterine fibroid expulsion on pre-embolisation MR images. 3) To describe clinical consequences of uterine fibroid expulsion. Background Uterine fibroids are benign monoclonal tumours of smooth muscle cells and fibrous tissue arising from the uterine myometrium. They are the most common pelvic tumor in women, occurring in up to 77% of women of child-bearing age [1]. (The pathophysiology is not well understood, but it is thought that genetic, environmental, and molecular factors lead to the formation of fibroids via two distinct components: (a) the transformation of normal myocytes into abnormal myoctes and (b) the growth of the abnormal myocytes via clonal expansion into clinically apparent tumours [2]. Although some fibroids may be asymptomatic, others may cause debilitating symptoms such as abnormal uterine bleeding, urinary incontinence, pelvic pain, and reproductive problems.) A crucial component of uterine fibroid assessment, treatment planning, and follow-up is imaging. The imaging modality of choice is multi-planar MRI due to its high tissue contrast resolution, multiplanarity, and reproducibility [3]. Using these images, we can differentiate the diagnosis from other myometrial pathologies, localise and measure the fibroid, as well as classify the fibroid based on its relation to the layers of the uterine wall (subserosal, submucosal, intramural, or endocavitary). Symptomatic fibroids have been classically removed surgically by hysterectomy or myomectomy, however, UAE is an efficacious and less invasive alternative to surgery [4]. UAE targets the end arterial branches that perfuse the fibroids resulting in infarction, coagulative necrosis, and eventual shrinkage of the fibroids [5]. Compared with surgical intervention, UAE is associated with fewer and less severe complications. Of these complications, the most common and of particular interest to this study is uterine fibroid expulsion [6]. Expulsion of uterine fibroids is often associated with pain, bleeding and infection that can result in repeat hospital admissions, further management and patient dissatisfaction. Page 2 of 12

3 Findings and procedure details We retrospectively reviewed post-uae MR images of patients referred to our institution for UAE of symptomatic fibroids. Images that revealed evidence of partially or completely expelled fibroids were selected and their pre-uae MR images were reviewed to document and correlate fibroid characteristics with the post-uae MR images. Furthermore, the patient's post-uae clinical documentation was noted. Our study consisted of 12 patients with an average age of 44 (range: 34-52). In these patients, 13 fibroids were determined to have been either partially expelled (n=5) or completely expelled (n=8) of which, we identified 9 intramural fibroids, 3 endocavitary fibroids, and 1 submucosal fibroid. All endocavitary fibroids (Fig. 5, 11, 12) were found to be fully expelled and 44% of the intramural fibroids were partially expelled. The average pre-uae maximum fibroid dimension was 9.5 cm (range: cm) and the average fibroid volume reduction was 95% (range: %). The average infarction rate was 96%. The post-uae MR images of the partially expelled fibroids (Fig. 1-5) reveals a clear reduction in fibroid volume and an area of high signal intensity between the fibroid and the endometrial cavity. This communicating channel is a snapshot of the process of fibroid expulsion with part of the fibroid merging with the endometrial cavity. We are able to see this process in full in Figure 6 with the communicating channel evident in Figure 6b taken 6 months post-uae and the lack of the fibroid in question in Figure 6c taken 1 year postuae. Analysis of MR images of completely expelled fibroids (Fig 5-12) reveals the lack of the fibroid in question. In its place however, there may be scar tissue (Fig 7-10), identified by low signal intensity within the discontinued endometrial lining (endometrial gap). All patients had similar clinical presentations of abdominal pain, heavy bleeding and/ or malodorous discharge starting as early as 1week post-embolisation to 3 months post-embolisation. These symptoms persisted between 4 months and 9 months postembolisation, with 8 patients reporting symptoms resolving between 6-7 months postuae. One patient did not report any symptoms, although on imaging the fibroid was fully expelled. Two patients developed an infection during the post-embolisation period and required hospitalisation. Images for this section: Page 3 of 12

4 Fig. 1: (a) Pre-UAE T2-weighted MR image showing an intramural fibroid with a maximum dimension of 10 cm. (b) 6 months post-uae T2-weighted MR image showing the previously described intramural fibroid partially expelled with a 2 cm opening into the endometrial cavity as identified by the arrow. Page 4 of 12

5 Fig. 2: (a) Pre-UAE T2-weighted MR image showing a submucosal fibroid with a maximum dimension of 7.8 cm. (b) 6 months post-uae T2-weighted MR image displaying the same submucosal fibroid now partially expelled with a channel opening into the endometrial cavity measuring 1.9 cm as indicated by the arrow. Fig. 3: (a) Pre-UAE T2-weighted MR image revealing an intramural fibroid with a maximum dimension of 6.4 cm. (b) 6 months post-uae T2-weighted MR image showing the same intramural fibroid now partially expelled with a channel opening into the endometrial cavity of 1 cm as identified by the arrow. Page 5 of 12

6 Fig. 4: (a) Pre-UAE T2-weighted MR image showing an intramural fibroid with a maximal dimension of 15.6 cm. (b) 6 months post-uae T2-weighted MR image revealing the same intramural fibroid partially expelled with an opening into the endometrial cavity of 1 cm as indicated by the arrow. Page 6 of 12

7 Fig. 5: (a) Pre-UAE T2-weighted MR image displaying an intramural fibroid and an endocavitary fibroid. (b) 6 months post-uae T2-weighted MR image showing the intramural fibroid partially expelled with an opening into the endometrial cavity of 2 cm as demonstrated by the arrow. The endocavitary fibroid has been completely expelled. Fig. 6: (a) Pre-UAE T2-weighted MR image displaying an intramural fibroid with a maximum dimension of 10 cm. (b) 6 months post-uae T2-weighted MR image revealing the intramural fibroid now reduced in size and with an opening into the endometrial cavity of 1 cm identified by the arrow. (c) 12 months post-uae T2-weighted MR image showing that the intramural fibroid has been completely expelled. Page 7 of 12

8 Fig. 7: (a) Pre-UAE T2-weighted MR image revealing an intramural fibroid with cystic degeneration and a maximum dimension of 8.2 cm. (b) 6 months post-uae T2-weighted MR image showing that the intramural fibroid has been completely expelled. As indicated by the arrow, there is scar tissue from the fibroid and an endometrial gap of 1.8 cm visible. Page 8 of 12

9 Fig. 8: (a) Pre-UAE T2-weighted MR image revealing an intramural fibroid with a maximum dimension of 11.7 cm. (b) 6 months post-uae T2-weighted MR image showing that the intramural fibroid has been completely expelled. As indicated by the arrow, there is scar tissue and an endometrial gap of 1.4 cm visible. Fig. 9: (a) Pre-UAE T2-weighted MR image revealing an intramural fibroid with a maximum dimension of 7 cm. (b) 6 months post-uae T2-weighted MR image showing that the intramural fibroid has been completely expelled. As indicated by the arrow, there is scar tissue and an endometrial gap of 0.6 cm visible. Page 9 of 12

10 Fig. 10: (a) Pre-UAE T2-weighted MR image revealing an intramural fibroid with a maximum dimension of 17.4 cm. (b) 6 months post-uae T2-weighted MR image showing that the intramural fibroid has been completely expelled. As indicated by the arrow, there is scar tissue measuring 1.1 cm long and an endometrial gap of 1.4 cm. Page 10 of 12

11 Fig. 11: (a) Pre-UAE T2-weighted MR image revealing an endocavitary fibroid with a maximum dimension of 9.5 cm. (b) 6 months post-uae T2-weighted MR image showing that the endocavitary fibroid has been completely expelled. There is no scar tissue that developed in this case. Fig. 12: (a) Pre-UAE T2-weighted MR image revealing an endocavitary fibroid with a stalk and maximum dimension of 9.8 cm. (b) 6 months post-uae T2-weighted MR image showing that the endocavitary fibroid has been completely expelled. There is no scar tissue that developed in this case. Page 11 of 12

12 Conclusion Characteristics of uterine fibroid expulsion can be identifed on 6 months post-uae MR images. Pre-UAE MRI features of uterine fibroids, such as its localisation and size, can be predictors of fibroid expulsion. This probability should be conveyed to women together with its associated clinical consequences. Furthermore, although still uncertain, the postuae endometrial changes left from these fibroids may have potential fertility implications. Personal information Dr Leto Mailli MD, Master, PhD, MSc, EBIR Interventional Radiology Consultant St. George's University Hospital, NHS Foundation Trust leto.mailli@stgeorges.nhs.uk References Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril Apr;87(4): Stewart EA. Uterine fibroids. Lancet Jan;357(9252): Testa AC, Legge AD, Bonatti M, Manfredi R, Scambia G. Imaging techniques for evaluation of uterine myomas. Best Pract Res Clin Obstet Gynaecol Jul;34:27-53 Hehenkamp WJK, Volkers NA, Birnie E, Reekers JA, Ankum WM. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy -- results from the randomized clinical embolisation versus hysterectomy (EMMY) trial. Radiology Mar;246(3): Goodwin SC, Spies JB. Uterine fibroid embolization. N Engl J Med Aug;361(7): Spies JB, Spector A, Roth AR, et al. Complications After Uterine Artery Embolization for Leiomyomas. Obstet Gynaecol Nov;100(5 Pt 1): Page 12 of 12

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