Jpn J Intervent Radiol Vol.31 No.3 2016

State of the Art
Update of UAE for Uterine Myoma

An Introduction
Hiroshi Miura

1. Clinical Overview of Uterine Myoma

Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
Akihiko Wakatsuki

Uterine myomas are one of the most common gynecological problems; they are present in 20-30% of women aged over 40 years. A uterine myoma is a benign tumor that develops from the smooth muscle of the uterus. They are classified according to the location in the uterus: intramural myomas are located within the wall of the uterus; subserosal myomas are located under the peritoneal surface; and submucosal myomas are located under the endometrium. Clinical Symptoms
Major symptoms of uterine myomas are hypermenorrhea, abdominal pain, and anemia. Symptoms depend on the location and size of the uterine myoma. Diagnosis of uterine myomas is primarily based on a pelvic examination, but some imaging tests are also useful. Treatment
Treatment may be needed if a uterine myoma is causing problems. Treatment options include hormone therapy, surgery, and uterine artery embolization (UAE). Hormone therapy uses gonadotropin-releasing hormone agonists (GnRHa), low dose estrogen-progestin (LEP), or levonorgestrel-releasing intrauterine system (LNG-IUS). Surgical treatment options are hysterectomy, myomectomy (abdominal or laparoscopic), and transcervical resection. UAE is a nonsurgical treatment option for premenopausal women with myoma-related symptoms who wish to retain their uterus.

Key words

  • Uterine myoma
  • Low dose estrogen-progestin(LEP)
  • Gonadotropin-releasing hormone agonists(GnRHa)
  • Laparoscopic myomectomy

2. Preoperative Imaging Evaluation of UAE

Department of Radiology, Showa University School of Medicine
Takehiko Gokan, Shouei Sai, Norifumi Hosaka, Noritaka Seino

Magnetic resonance (MR) imaging is the most accurate imaging technique for detection and evaluation of uterine leiomyomas. Therefore, MR imaging is the imaging modality of choice before uterine artery embolization (UAE). Advantage of MR imaging over other imaging modalities include a large field of view, high contrast resolution, improved anatomic detail, and the ability to detect other pelvic pathologies. MR angiography also has a useful role in the evaluation of pelvic vascular anatomy. MR imaging allows diagnosis of leiomyoma with a high level of confidence. However, we should keep in mind that definite differential diagnosis of uterine sarcomas and benign leiomyoma with MR imaging still has some limitation.

Key words

  • Uterus
  • Leiomyoma
  • MRI

3. Technique of Uterine Fibroid Embolization

Department of Radiology, Aichi Medical University
Yuichiro Izumi, Shuji Ikeda, Akira Kitagawa, Toyohiro Ota, Tsuneo Ishiguchi

In this ar ticle we describe the technique of uterine ar ter y embolization (UAE) of symptomatic uterine leiomyomas. The UAE procedure is performed via the bilateral common femoral arteries. A 4F sheath is placed, followed by a 4F pigtail catheter, which is positioned above the level of the renal arteries, and aortography is performed for anatomical evaluation of the pelvic and ovarian arteries. Bilateral internal iliac arteries are catheterized with 4F angledtip catheters using the crossover technique. 2.7F high-flow type microcatheters are advanced to the ascending branches of the uterine arteries. Simultaneous bilateral iliac and uterine angiograms are performed using a flow-dividing three-port stopcock. Microspheres should be injected under free flow. We use Embosphere for UAE. First, 500-700μm of Embosphere is used. If flow persists after injection of 2 vials of 500-700μm, we change to 700-900μm. The endpoint of embolization is occlusion of flow to leiomyomas, with slow flow remaining in the main uterine artery.

Key words

  • Uterine artery embolization
  • Uterine leiomyoma
  • Microsphere embolization

4. UAE Outcomes

Department of Radiology, Saiseikai Shiga Hospital
Tetsuya Katsumori

Uterine artery embolization (UAE) has been recognized as a safe and effective alternative to major surgery, i.e. hysterectomy and myomectomy for symptomatic uterine leiomyoma, based on strong scientific evidence. This minimally invasive treatment provides the following outcomes comparing to major surgery; (i) less blood loss, (ii) shorter hospital stay, (iii) quicker recovery to work, (iv) similar rate of improvement in symptoms and quality-of-life in the long-term, (v) higher rate of re-intervention. Interventional radiologists performing UAE are required to understand not only the procedure but also imaging and clinical outcomes including complications during the follow-up period.

  • Uterine artery embolization
  • Leiomyoma
  • Outcomes
  • MRI

5. Guidelines of Uterine Arterial Embolization for Uterine Leiomyoma

Department of Diagnostic Radiology, National Cancer Center Hospital
Miyuki Sone

Uterine artery embolization (UAE) for symptomatic uterine leiomyoma has been addressed in guidelines worldwide; however, evidence-based guidelines providing recommendations based on rating the cer tainty in the evidence with the modern methodology does not yet exist for UAE. The Japanese Society of Inter ventional Radiology has developed and published practice guidelines for interventional procedures since 2008 and is now developing guidelines for UAE using the latest methodology of clinical practice guidelines. In this article, the characteristics of guidelines for UAE in diverse countries and the recent trend of the methodology of the development of guidelines are addressed.

  • Uterine artery embolization
  • Uterine leiomyoma
  • Guideline

Original Article

Evaluation of CT-guided Lung Biopsy : Conventional CT-guided Biopsy Versus CT Fluoroscopy-guided Biopsy

Department of Radiology and Clinical Pathology1), Tottori prefectural Central Hospital
Kazuhiko Nakamura, Eiji Matsusue, Yoshio Fujihara, Shu Nakamoto1)
Department of Radiology, Tottori University School of Medicine
Naoko Mukuda, Akira Adachi

We evaluated the diagnostic accuracy and complication rates for CT-guided cutting needle biopsy of pulmonary lesions performed with or without fluoroscopic guidance. The evaluation of the outcome was performed retrospectively for 283 lesions by conventional CT-guided method (group 1) and 293 lesions by CT fluoroscopy-guided method (group 2). Biopsies were performed using 18-G cutting needle in all lesions. Diagnostic yield, including sensitivity and specificity for the diagnosis of malignancy, accuracy and complication rates were calculated. The sensitivity, specificity and accuracy were respectively 93.6%, 98.2% and 95.4% in group 1 and 93.3%, 100% and 95.2% (p=1.00) in group 2. The pneumothorax rate and requirement of drainage rate were respectively 28.8% and 2.2% in group 1 and 29.8% (p=0.85) and 1.0% (p=0.18) in group 2. Intrapulmonary hemorrhage and hemoptysis were occurred in respectively 15.9% and 4.4% of group 1 and 31.8% (p=0.000014) and 2.4% (p=0.16) of group 2. Therefore diagnostic accuracy and complication rates for CT-guided cutting needle biopsy of pulmonary lesions with or without fluoroscopic guidance were not significantly different between the two groups. CT fluoroscopy-guided lung biopsy is a useful diagnostic modality, but should be used on a case-by-case basis because of the associated radiation exposure.

Key words

  • Lung tumor
  • CT-guided biopsy
  • CT fluoroscopy