Leiomyomas,
also known as fibroids or myomas,
are the most common gynecologic neoplasm,
occurring in 20%–30% of women of reproductive age.
(1) Fibroids are composed of smooth muscle with varying amounts of fibrous connective tissue.
Fibroids are benign and,
the most part of them, asymptomatic.
Unfortunately,
patients with fibroids can suffer symptoms such as menorrhagia,
dysmenorrhea,
urinary frequency,
pelvic and back pain,
dyspareunia,
constipation,
or bulk-related symptoms.
The symptomatic patients are suitable to be treated with medical or Surgical treatments.
For well over a decade,
uterine fibroid embolization (UFE) has been proven as an effective minimally invasive treatment for symptomatic patients.
(1)
The Uterine Fibroid Embolization (UFE) is a well known and effective method of treating symptomatic fibroids.
This percutaneous minimal technique selectively catheterizing both uterine arteries,
where microspheres are injected to occlude the distal arterioles that vascularize the fibroids.
It causes necrosis of the tumours,
decreasing patients’ symptoms and eventually decreasing tumours’ size.
Multiples articles in the literature had shown very good results of the technique,
without observing statistical differences with miomectomy or hysterectomy.
Therefore,
it is a good option for women who wish to avoid surgery,
are poorly surgical candidates,
or wish to retain their uterus (1)
Ultrasonography (US scan) remains the Gold standard diagnostic imaging technique for patients with suspicious of symptomatic uterine fibroids.
However,
magnetic resonance (MRI) imaging is the most accurate imaging technique for detection and evaluation of them.
Even MRI is more extensive than US,
it can show both uterine artery origins,
its variants and a possible ovarian artery fibroid vascular supply,
decreasing patient’s and operator’s radiation dose during the procedure.
It is also superior to differentiate adenomyosis and leiomyomas.
Therefore,
it has become the modality of choice for diagnosis and follow up of patients treated with UAE.
The evaluation in gray scale and with color Doppler has low sensitivity in the detection of alterations in microvascularization.
The use of intravenous ultrasound contrast (in our case,
Sonovue),
is a simple technique,
not nephrotoxic and without the adverse effects of iodinated contrasts and ionizing radiation,
which provides information on the vascularization of the fibroid in real time,
in addition to allow better definition of the boundaries of the tumour thus improving the diagnostic yield.
(10)
The aim of this study is to evaluate the powerful of post-UAE iv contrast US scan vs post- iv contrast MRI scan in order to detect the success and complications of the per cutaneous technique.
Contrast Enhanced Ultrasound (CEUS)
There are several contrast enhanced ultrasound (CEUS) drugs licensed in Europe,
such as Levovist®,
Optison®,
Sonovue®,
Definity®.
In our case,
SonoVue was the drug used,
which is currently the CEUS most frequently used.
It is a high molecular weight gas,
whose microbubbles contain sulfur hexafluoride stabilized with several surfactants (phospholipids and palmitic acid).
The average diameter of the microbubbles is 2.5 microns and 90% is less than 8 microns.
It remains viable in the vial for 6 h after preparing it.
The usual dose is 2.4 ml when administered intravenously.
(2) (3).
Ultrasound scans with Sonovue pre- and post UAE were performed with a Siemens ultrasound,
B-mode with pulse inversion and a low-frequency convex probe (up to 5Mhz).
Follow up c-US scans were performed one month after the percutaneous procedure was done.
Differences in the size of the biggest tumours and the lack or persistence of myomas’ contrast enhancement were recorded.
If contrast enhancement of the lesions persisted,
they were classified as 1) Peripheral enhancement,
2) Partial enhancement,
but less than 50% 3) Partial enhancement,
but more than 50%,
4) Avascular.
Preservation of uterus vascularity was also checked.
We considered a successful treatment by imaging if a lack of tumour enhancement and a preservation of uterus vascularity was observed.
The decrease of tumours’ size compared with the pre treatment c-US scan was not necessary to evaluate the success of UAE.
These ultrasounds were performed and reported by trained radiologists of the interventional radiology department.
Those radiologists did not know the result of the pelvic MRI and vice versa.
Pelvic MRI with contrast.
In our case we used a 1.5 T Siemens MRI machine,
and all the MRIs were performed under the same protocol,
which included turbo-spin echo and fat saturation sequences in T2 and 2D FLASH with dynamic sequential study,
post intravenous gadolinium injection (0.1 mmol / kg) in the sagittal and axial planes and,
in some cases coronal plane was also included.
During Pre UAE c-MRI,
size,
number and location of fibroids were reported (only transmural and transmural myomas with submucosal component were embolized in our case).
Uterine arteries anatomy and the possible ovarian artery hypertrophy and involvement were also described.
Follow-up c- MRI was performed in the majority of patients between the 1st and 2nd month post UAE procedure.
Differences in the size of the biggest tumours and the lack or persistence of myomas’ contrast enhancement were recorded.
If contrast enhancement of the lesions persisted,
they were classified as 1) Peripheral enhancement,
2) Partial enhancement less than 50% 3) Partial enhancement,
but more than 50%,
4) Avascular.
The preservation of uterus vascularity was also checked.
We considered a successful treatment by imaging if a lack of tumour enhancement.
The decrease of tumours’ size compared with the pre treatment c-MRI was not necessary to evaluate the success of UAE.
Once more,
these MRI were reported by consultant interventional radiologists.
Those radiologists did not know the result of the pelvic c-US scan findings