Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

DE | EN | RU

References

  1. Stewart EA. Uterine fibroids. Lancet 2001; 357: 293–298
  2. Freed MM, Spies JB. Uterine artery embolization for fibroids: a review of current outcomes. Semin. Reprod. Med 2010; 28: 235–241
  3. Van der Kooij SM, Bipat S, Hehenkamp WJK, et al. Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis. Am. J. Obstet. Gynecol. 2011; 205: 317.e1–18
  4. Kröncke T, David M. Uterusarterienembolisation (UAE) zur Myombehandlung: Ergebnisse des 4. radiologisch-gynäkologischen Expertentreffens. Röfo 2013; 185: 461–463
  5. Kirby JM, Burrows D, Haider E, et al. Utility of MRI before and after uterine fibroid embolization: why to do it and what to look for. Cardiovasc Intervent Radiol 2011; 34: 705–716
  6. Katsumori T, Kasahara T, Tsuchida Y, et al. Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids. Int J Gynaecol Obstet 2008; 103: 217–221
  7. Yousefi S, Czeyda-Pommersheim F, White AM, et al. Repeat uterine artery embolization: indications and technical findings. J Vasc Interv Radiol 2006; 17: 1923–1929
  8. Scheurig-Muenkler C, Lembcke A, Froeling V, et al. Uterine artery embolization for symptomatic fibroids: long-term changes in disease specific symptoms and quality of life. Hum Reprod. 2011; 26(8):2036-42.
  9. Scheurig-Muenkler C, Koesters C, Powerski MJ, et al. Clinical Long-term Outcome after Uterine Artery Embolization: Sustained Symptom Control and Improvement of Quality of Life. J Vasc Interv Radiol. 2013; 24(6):765-71
  10. Kroencke TJ, Scheurig C, Poellinger A, et al. Uterine Artery Embolization for Leiomyomas: Percentage of Infarction Predicts Clinical Outcome. Radiology. 2010; 255(3):834-41.
  11. Froeling V, Meckelburg K, Schreiter NF, et al. Outcome of uterine artery embolization versus MR-guided high-intensity focused ultrasound treatment for uterine fibroids: Long-term results. Eur J Radiol. 2013
  12. Habilitationsschrift von PD Dr. Thomas J Kröncke zum Thema: Die Uterusarterienembolisation (UAE): Ein neues Verfahren zur Behandlung des symptomatischen Uterus myomatosus. Technische Durchführung, klinische Ergebnisse und peri-interventionelle Bildgebung. 2008
  13. Habilitationsschrift von PD Dr. Christian Scheurig-Münkler zum Thema: Die Uterusarterienembolisation (UAE) in der Behandlung symptomatischer Gebärmuttermyome und der Adenomyosis uteri - Klinischer Langzeitverlauf und Einflussfaktoren auf den Therapieerfolg. 2014

Uterine Artery Embolization (UAE) for Symptomatic Uterine Fibroids

 

Uterine leiomyomas, or fibroids, are the most common benign tumors in women of childbearing age. They can be found in 50% to 77% of women. Fibroids are firm muscular nodules that grow in the wall of the uterus (womb) and displace the normal muscle layer (myometrium). Although they can become quite large, uterine fibroids cause symptoms in only about 25% of the women who have them. Most women with symptomatic fibroids start having problems between 30 and 50 years of age. Typical problems include heavy and long menstrual periods. In severe cases, the resulting blood loss can cause anemia (lower than normal count of red blood cells) with fatigue and lack of stamina. Other common symptoms are an increased urge to urinate and difficult bowel movements. In women with several or large uterine fibroids, the resulting enlargement of the womb may be seen as a noticeable swelling in the lower abdomen.

 

When fibroids cause no symptoms and are diagnosed by chance, no treatment is necessary. Mild symptoms usually improve when the woman starts taking the pill or gets an intrauterine contraceptive device (IUD). If the symptoms are so severe that they cannot be controlled with medication, hysterectomy (surgical removal of the womb) is still the most widely recommended and performed treatment. Uterine artery embolization (UAE) is an alternative, minimally invasive option for these women. UAE spares the uterus, and many scientific studies performed over the last 20 years have shown that UAE is safe and effective. The first UAE in Germany was performed at the Charité in 2000.

 

How Does Uterine Artery Embolization Work?

 

The interventional radiologist makes a small incision (cut) in the right groin (about 2 mm), through which a thin catheter is inserted into the femoral artery and guided toward the uterus. This catheter serves to introduce an even thinner catheter (about 1 mm in diameter), which is maneuvered into the uterine artery. The radiologist uses X-ray guidance and injects contrast medium to monitor the procedure and to check the catheter position. When the catheter is in place, tiny plastic particles are released into the bloodstream. Because fibroids have a rich supply of blood vessels, the particles flow to the fibroids first, where they clog the vessels and block further blood flow. This way, the fibroid is cut off from nutrients supplied with the blood and starts to shrink. Blood flow to the normal uterine muscle layer is not affected by the embolic particles. Research has shown that successful long-term outcome with complete elimination of symptoms or marked improvement is achieved in 75% to 80% of the women treated with UAE. Women undergoing fibroid embolization are not exposed to the risks of general anesthesia, which is not required for this minimally invasive procedure. Medications given before, during, and after embolization will minimize pain and ensure maximum comfort during and after treatment.

 

Who are Candidates for Uterine Artery Embolization?

 

Nearly all women with symptomatic fibroids can undergo uterine artery embolization. However, UAE should not be performed if a malignant tumor is suspected or in women who are pregnant or have an active genital inflammation. If a woman wishes to have children in the future, uterus-sparing surgical options should be contemplated first. Our interventional radiologists work closely with the fibroid clinic of the Department of Gynecology and Obstetrics of the Charité to provide comprehensive counseling and to identify the best treatment strategy for each case. In general, the location of fibroids within the uterus, their number and size or type, and the severity of symptoms have only little effect on the outcome of UAE. Several diagnostic tests are required to evaluate a woman before fibroid embolization, including a pregnancy test, a pelvic examination, and blood work. A magnetic resonance imaging (MRI) examination is needed to determine the exact size, site, and number of fibroids and their blood supply. The MR images also allow the radiologist to identify possible reasons (contraindications) that may preclude UAE treatment. In addition, a Pap smear is obtained to screen for cervical cancer.

 

What are Complications and Side Effects of Uterine Artery Embolization?

 

There are a few complications, but they are usually mild. In 3% to 4% of women, lower abdominal pain may persist for some time and can require medical treatment. Another undesired effect of UAE, observed in about 4% of women, is premature onset of menopause (end of menstrual periods). This mostly occurs in older women close to natural menopause. It is very rare in younger women. Some women will notice vaginal discharge or the passage of small pieces of fibroid tissue during the first menstrual periods after fibroid embolization (3% – 8 %) or develop a genital infection (2% – 3%). Permanent damage or impairment is not to be expected after UAE. With meticulous preparation and the use of modern equipment, the radiation exposure during UAE is very low. It is comparable to the radiation dose of 2 abdominal CT scans – a common medical imaging procedure.

 

Aftercare

 

UAE typically requires a hospital stay of 3 to 5 days. Adequate pain control is important to keep patients comfortable during treatment and the first week after fibroid embolization. The medication needed to manage the pain associated with UAE is initially given by infusion and then switched to tablets on the second day. Depending on the severity of pain, oral pain medication can be continued for about a week. Pain and other problems should not persist beyond that time. It takes a few weeks before the final outcome can be evaluated. If there is no improvement within three months, the cause must be found. In most cases, an MRI examination will be done for assessment.

 

  • Contact:

Ms Steffi Gerlach

Minimally Invasive Tumor Therapy (MITT)

Charité, Campus Virchow-Klinikum

Department of Radiology

Augustenburger Platz 1

13353 Berlin, Germany

Phone: +49 (0)30/450-527235

Fax: +49 (0)30/450-553928

minimal-invasive-ambulanz@charite.de oder mia@charite.de

 

Case Example

 

The images presented here were obtained in a woman with heavy menstrual periods and a large uterine fibroid (leiomyoma). A magnetic resonance imaging (MRI) examination performed before uterine artery embolization (UAE) clearly depicts the fibroid and allows good evaluation. Figure a depicts the uterus and the fibroid (white asterisk) from the side. The bright structure below the uterus is the urinary bladder (black arrow). This MR image shows the close relationship of the uterus to the urinary bladder and illustrates why a large uterine fibroid can press on the bladder and cause problems with urination. Figure b is an MR image showing the appearance of the womb and urinary bladder after administration of contrast medium. In this image, the entire uterus with the fibroid (black asterisk) appears bright, which reflects the rich blood supply of the fibroid and the uterus. During fibroid embolization, contrast medium is injected directly into the uterine artery through the catheter placed for administration of the embolic particles. The contrast medium fills the arteries supplying the fibroid and makes them more visible (Figure c, black arrow). These arteries are then blocked with small particles. After particle administration, the fibroid arteries are no longer visible (Figure d), indicating successful embolization with interruption of blood flow to the fibroid. Soon after UAE, the patient experienced complete resolution of all her symptoms. A follow-up MRI performed about 1 year after UAE (Figures e and f) shows that the fibroid is now much smaller and, after contrast medium administration, appears much darker than the surrounding uterine muscle tissue. This appearance confirms that permanent interruption of the blood supply to the fibroid has been achieved. (Figures from: Kröncke TJ et al. Transarterielle Embolisation bei Uterus myomatosus: klinische Erfolgsrate und kernspintomographische Ergebnisse. Rofo. 2005 Jan;177(1):89-98)