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Gadolinium-Enhanced MR Imaging in the Evaluation of Uterine Fibroids Treated with Uterine Artery Embolization

¹ All authors: Department of Radiology, Saiseikai Shiga Hospital, Ohashi 2-4-1, Ritto-cho, Kurita-gun, Shiga, 520-3046, Japan.

Received November 17, 2000; accepted after revision February 7, 2001.

 
Address correspondence to T. Katsumori.

Abstract

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OBJECTIVE. The purpose of this study was to determine whether tumor volume reduction can be predicted by the infarction rate of uterine fibroids as seen on gadolinium-enhanced MR images obtained immediately after uterine artery embolization.

MATERIALS AND METHODS. In our study, 36 women with symptomatic uterine fibroids successfully underwent uterine artery embolization. Unenhanced and enhanced MR imaging was performed before the procedure and repeated at 1 week, 4 months, and 1 year after the procedure. We retrospectively reviewed enhanced MR images of uterine fibroids after uterine artery embolization. At 4 months after uterine artery embolization, we compared the rate of tumor volume reduction in patients with completely infarcted dominant fibroids with the rate of tumor volume reduction in patients with partially infarcted fibroids.

RESULTS. Enhanced MR images obtained 1 week after uterine artery embolization revealed that 100% infarction rates of the dominant uterine fibroids were achieved in 33 women (92%), and 70-90% infarction rates were seen in the remaining three (8%). They also revealed that of a total of 204 fibroids in these patients, 100% infarction was achieved in 199 fibroids (98%). Enhanced MR images obtained 4 months after uterine artery embolization showed that tumor volume reduction of the completely infarcted dominant fibroids (n = 23) was 60% ± 18%, whereas that of the partially infarcted fibroids (n = 5) was 35% ± 27% (p = 0.0367).

CONCLUSION. Gadolinium-enhanced MR imaging is a useful diagnostic technique for uterine fibroids after uterine artery embolization because it assesses the degree of infarction in the embolized fibroids, which corresponds to the subsequent tumor volume reduction.

Introduction

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Uterine fibroids are among the most common benign tumors of the female pelvis [1]. Recently, uterine artery embolization of uterine fibroids has been reported as a useful alternative to major surgery and hormone therapy because this procedure can contribute to an improvement in clinical symptoms and a reduction in tumor volume [2,3,4,5,6,7,8,9,10,11,12,13,14,15]. In the literature on using uterine artery embolization for treating uterine fibroids, the improvement of clinical symptoms was assessed by questionnaire, and the tumor and uterine volume reductions were measured radiologically on sonography or MR imaging [2,3,4,5,6,7,8,9,10,11,12,13,14,15]. To the best of our knowledge, there are few reports in the literature on enhanced MR imaging of uterine fibroids performed after uterine artery embolization [11, 13,14,15]. The purpose of our study was to clarify gadolinium-enhanced MR imaging findings of uterine fibroids after uterine artery embolization and to determine whether the fibroid infarction rate on enhanced MR imaging immediately after the procedure can predict subsequent tumor volume reduction.

Materials and Methods

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Our retrospective study included 36 women with uterine fibroids who successfully underwent uterine artery embolization. The women ranged in age from 37 to 52 years (mean age, 44.1 years). All of the women were premenopausal and had clinical symptoms including menorrhagia, uterine bleeding, pelvic pain, and bulk-related symptoms that could not be controlled by oral medication. In each patient, the total number of fibroids larger than 10 mm in diameter was assessed on a baseline MR image. Before uterine artery embolization, all of the women were examined by local gynecologists and diagnosed with uterine fibroids. Most of the women (29/36) had undergone an initial course of drug therapy that was unsuccessful. They were all recommended by local gynecologists to have hysterectomy and myomectomy, but all refused it. All but three had no desire for future pregnancies. One woman had undergone a myomectomy. They all were informed of the benefits and risks of uterine artery embolization. Oral and written informed consent was obtained from the women and their families. The follow-up periods after uterine artery embolization ranged from 1 to 32 months (mean, 10.3 months). Of the 36 women, 10 were followed up for 1-4 months; 14, for 4-12 months; and 12, for more than 1 year.

In all of the women, angiography was performed through the right femoral artery under local anesthesia. After a 5-French loop catheter (KSF7; Clinical Supply, Gifu, Japan) was inserted into the left proximal uterine artery, a microcatheter (Sniper; Clinical Supply) was coaxially advanced to the distal left uterine artery, under a mapping on pelvic arteriogram. Then gelatin sponge particles approximately 500-1000 µm in diameter, mixed with antibiotics (cefazolin sodium, 1 g; Fujisawa, Osaka, Japan), contrast medium, and saline were infused into the artery at fluoroscopy. Next, the same 5-French catheter was inserted into the right uterine artery, and the same procedure was performed. The gelatin-sponge particles used in uterine artery embolization were made from gelatin sponge sheets (Spongel; Yamanouchi, Tokyo, Japan) by the operators. First, the sheet was cut into thin slices with a scalpel. After compressing the slice to make it paperlike, we cut it into small fragments with small scissors. The size of the compressed particles was approximately 500-1000 µm.

In four of 36 women, a microcatheter was not used. The average time of the procedure was 54.2 min (range, 25-110 min). The mean fluoroscopy time was 16.6 min (range, 7-31 min). We used low-frequency pulsed fluoroscopy in all patients. Postprocedural cramping was treated with conscious sedation, including intramuscular injection of 2 mg of morphine (butorphanol tartrate; Burisutoru Miyazu Sukuizu, Tokyo, Japan), an IV infusion of 15 mg of pentazocine, 1-2 mg of midazolam, and an intramuscular and IV infusion of hydrochloride that were combined as necessary. Antibiotics (cefazolin sodium) were administered IV at a dose of 1 g twice daily for 2 days, and thereafter ofloxacin (Daiichiseiyaku, Tokyo, Japan) was administered orally at a dose of 100 mg twice daily for another 2 days. No patients underwent repeated embolization during the follow-up period.

MR imaging was performed using a 1.0-T system (Magnetom Impact; Siemens Medical Systems, Erlangen, Germany) and a CP-body coil. Axial and sagittal MR imaging were performed before uterine artery embolization and at 1 week, 4 months, and 1 year after uterine artery embolization. T1-weighted images were obtained before and after contrast administration using breath-hold two-dimensional fast low-angle shot sequences (TR/TE, 165/5.0; field of view, 30 cm; matrix, 256 x 154; section thickness, 10 mm; intersection gap, 2 mm). T2-weighted images were obtained before and after contrast administration using breath-hold fast spin-echo sequences (3685/128; echo train, 23; field of view, 30 cm; matrix, 256 x 138; section thickness, 10 mm; intersection gap, 2 mm). Enhanced MR imaging was performed approximately 2 min after IV infusion of 10 mL of gadolinium (Magnevist; Schering, Berlin, Germany).

We have made it a rule to perform MR imaging before and after uterine artery embolization in our hospital. None of the 36 women who underwent the procedure were excluded from our study. MR imaging before the procedure was performed in all 36 women. However, eight of the 36 women underwent preprocedural MR imaging without contrast administration at other hospitals using different MR units and parameters.

We defined tumor enhancement as when the intensity of the tumor was greater on the enhanced MR image than on the previously obtained unenhanced MR image. Follow-up MR imaging with contrast administration was performed in our hospital at approximately 1 week after uterine artery embolization in all 36 women, after 4 months in 26 of the 36 women, and after 1 year in 12 of the 36 women. The same two radiologists assessed all MR images for consensus. We diagnosed uterine and potential coexisting diseases of the pelvis from the baseline MR images. Fibroids larger than 10 mm in diameter were assessed in our study; in each patient, the tumor with the largest diameter was defined as the dominant fibroid. The largest diameter of the dominant fibroid in each patient, the dominant fibroid's location, the total number of fibroids larger than 10 mm in diameter in all patients, the number of fibroids per patient, and the uterine volume were calculated from baseline MR images. We calculated uterine volume using the formula of a prolate ellipse (length x depth x width x 0.5233).

On the enhanced MR imaging 1 week after uterine artery embolization, we assessed the infarction rates of fibroids larger than 10 mm in diameter and determined whether the myometrium was enhanced. We defined tumor infarction as when the intensity of the tumor did not change on the MR image after enhancement compared with that on the MR image before enhancement. The infarction rates of fibroids were calculated on the basis of multiple measurements of maximum fibroid diameter from the postprocedural enhanced MR image, which was obtained by taking a sagittal slice at the level of the maximum diameter of the tumor. The dominant-tumor reduction rate, uterine-volume reduction rate, and residual enhanced component in the embolized fibroid were assessed on the follow-up enhanced MR images at 4 months and at 1 year after uterine artery embolization (Figs. 1A,1B,1C,1D and 2A,2B,2C,2D).

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —43-year-old woman with large submucosal fibroid. Enhanced T1-weighted MR image obtained before uterine artery embolization shows large submucosal fibroid (asterisk) 11 cm in maximum diameter. Uterine volume is 1286 cm3.

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —43-year-old woman with large submucosal fibroid. Enhanced T1-weighted MR image obtained 7 days after embolization shows fibroid was not enhanced, but muscular layer of uterus (arrow) enhanced.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —43-year-old woman with large submucosal fibroid. Enhanced T1-weighted MR image obtained 4 months after uterine artery embolization shows uterine fibroid decreased to 9 cm in maximum diameter (46% tumor volume reduction) and was not enhancing. Muscular layer of uterus is enhanced.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —43-year-old woman with large submucosal fibroid. Enhanced T1-weighted MR image obtained 1 year after uterine artery embolization shows fibroid and uterus both decreased. Tumor reduction rate was 56%, and uterus-volume reduction rate was 58%.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —47-year-old woman with intramural fibroid. Enhanced T1-weighted MR image obtained before uterine artery embolization shows intramural fibroid 9 cm in maximum diameter. Uterine volume is 750 cm3.

View larger version (176K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —47-year-old woman with intramural fibroid. Enhanced T1-weighted MR image obtained 7 days after uterine artery embolization shows 70% of fibroid region did not enhance and 30% enhanced.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —47-year-old woman with intramural fibroid. Enhanced T1-weighted MR image obtained 4 months after uterine artery embolization shows nonenhancing area of uterine fibroid decreased, whereas enhanced area increased compared with B. Overall, tumor decreased slightly. Tumor volume reduction rate was 22%. Muscular layer of uterus is still enhanced.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —47-year-old woman with intramural fibroid. Enhanced T1-weighted MR image obtained 11 months after uterine artery embolization shows tumor size was almost the same as in C. Tumor reduction rate was 27%, and uterus-volume reduction rate was 18%.

We compared tumor volume reduction rates at 4 months after uterine artery embolization in the women with completely infarcted dominant fibroids with the rates of tumor volume reduction in the women with partially infarcted fibroids. Statistical analysis was performed using the Mann-Whitney test to compare the groups. A probability value of less than 5% (p < 0.05) was considered significant.

Results

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All 36 of the women underwent baseline MR imaging and were diagnosed with uterine fibroids. Their MR images showed that the maximum diameter of a dominant fibroid ranged from 2 to 14 cm (mean, 7.2 cm) and that 11 of 36 women had a single fibroid and 25 of 36 women had two or more fibroids. The dominant fibroid was located in the submucosal area in 13 women, in the intramural area in 19 women, and in the subserosal area in four women. A total of 204 fibroids greater than 10 mm in diameter was found in the patient population. The number of fibroids per woman ranged from 1 to 20 (mean, 5.7 fibroids). The uterine volume measured on MR imaging before uterine artery embolization ranged from 180 to 1864 cm³ (mean, 803 cm³) (Table 1). Of 36 women, 28 had no other gynecologic disease of the pelvic cavity, but five had adenomyosis and three had ovarian endometrial cysts that were confirmed on MR imaging before the procedure.

MR images obtained with contrast administration before uterine artery embolization showed that a large number of fibroids were well enhanced without avascular regions. However, in the 28 women for whom enhanced MR imaging was performed before uterine artery embolization, we found that one fibroid showed no enhancement in one woman with multiple fibroids, and six fibroids showed partially enhanced areas in six women (Table 1).

Enhanced MR images obtained 1 week after uterine artery embolization showed that 100% infarction rates of the dominant fibroids were achieved in 33 (91.7%) of the 36 women, and 70-90% infarction rates were seen in the remaining three women (8.3%). Enhanced MR images showed that 199 (97.6%) of 204 fibroids in our study showed 100% infarction (Table 2), whereas one large submucosal fibroid, one large intramural fibroid, and three subserosal fibroids showed less than 100% infarction. In all 36 women, MR images showed that the myometrium was well enhanced.

Enhanced MR images obtained 4 months after uterine artery embolization showed that the enhanced area in the dominant fibroids increased slightly in volume in three women, although all dominant tumors decreased in size. At 4 months, the tumor-volume reduction rate of the dominant fibroid averaged 58% (range, 22-100%) and the uterine-volume reduction rate averaged 44% (range, 16-62%) (Table 2). Enhanced MR images obtained 4 months after uterine artery embolization showed that tumor-volume reduction of the completely infarcted dominant fibroids (n = 23) was 60% ± 18%, whereas that of the partially infarcted fibroids (n = 5) was 35% ± 27% (p = 0.0367) (Table 3). MR imaging also revealed that the one fibroid that had not been enhanced on MR imaging before uterine artery embolization did not change in size.

At 1 year, the tumor-volume reduction rate of the dominant fibroid averaged 68% (range, 27-90%) and the uterine-volume reduction rate averaged 58% (range, 21-77%) (Table 2).

Embolization of bilateral uterine arteries was successfully performed without complications in all 36 of the women. No major complications arose during the follow-up period.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
We performed MR imaging with contrast material before and after uterine artery embolization. Postprocedural MR imaging with contrast administration is useful because it can give objective and clear information, not only on the reduction in tumor volume, but also on the non-enhancing area in the tumor that is suggestive of infarction. The purpose of performing MR imaging with contrast administration 1 week after uterine artery embolization was to assess both the initial therapeutic results in regard to infarction rates of the embolized fibroids and the potential complications related to the procedure. Our results showed that the mean tumor-volume reduction of the completely infarcted dominant fibroids was significantly greater than that of the partially infarcted fibroids at 4 months after uterine artery embolization. This finding indicates that the tumor volume reduction tends to be better for the completely infarcted fibroids. Thus, we believe that enhanced MR images obtained after uterine artery embolization provide useful information on the infarction rate of the fibroids, which corresponds to the tumor-volume reduction rate. Moreover, when the post-procedural enhanced MR imaging reveals that large areas of the embolized fibroids remain enhanced, the tumor-volume reduction rates might be lower. If the residual enhanced area of the fibroids is found to be responsible for the remaining clinical symptoms, we believe that postprocedural enhanced MR imaging can give helpful information about indications for additional treatments, including repeated uterine artery embolization and surgery.

In our series, we used gelatin-sponge particles alone as the embolic material that we regarded as a temporary agent, as described in articles using animal experiments [16,17,18,19,20]. Therefore, although it is unclear how gelatin-sponge particles affect human uterine arteries, it is possibile that bilateral uterine arteries might begin to recanalize within 1-2 weeks after uterine artery embolization. However, post-procedural enhanced MR images showed that most uterine fibroids that had been enhanced on the preprocedural MR imaging were not enhanced afterward. This finding suggests that uterine artery embolization induced nonenhancement in most regions of the uterine fibroids and thus acute infarction, within at least 1 week after uterine artery embolization, leading to tumor volume reduction [13]. In a few patients, the MR images also showed that a small area of the uterine fibroid was enhanced; this finding suggests that the enhanced area may receive its blood supply from the collateral circulation or that all arteries supplying the fibroids may not be completely occluded by uterine artery embolization, or both.

We do not know whether the residual enhanced area in embolized fibroids will eventually regrow. To our knowledge, there are no reports in the literature that any fibroids successfully treated with uterine artery embolization have regrown; research to date suggests that they do not [2,3,4,5,6,7,8,9,10,11,12]. In our series, MR imaging showed that no tumors had regrown during the follow-up period. Further investigation is necessary to determine whether fibroids with a residual enhanced component will regrow in the future.

In all 36 of the women in our study, all contrast-enhanced MR images after uterine artery embolization showed that the myometrium was well enhanced. This finding indicates that the blood flow to the myometrium is preserved from collateral circulation after uterine artery embolization without any infarction. MR imaging after uterine artery embolization is also helpful because it can accurately detect potential complications related to the procedure, such as an abscess or infarction of the myometrium.

Preprocedural MR imaging is important as a baseline for comparison with postprocedural MR imaging. It has a high accuracy in differentially diagnosing between fibroids and other uterine diseases such as adenomyosis and other potential lesions in the pelvis [11]. Burn et al. [14] and Jha et al. [15] reported that preprocedural unenhanced MR imaging was also helpful in predicting subsequent responses to uterine artery embolization.

We performed uterine artery embolization with only gelatin-sponge particles in all women. If uterine artery embolization is performed with polyvinyl-alcohol particles, as reported in most of the literature [2,3,4,5,6,7,8,9,10,11,12], it is possibile that different MR imaging findings might be obtained.

Our initial study is limited because the patient population was small and the follow-up period was short. Nevertheless, we believe that gadolinium-enhanced MR imaging is a useful diagnostic technique with which to assess the infarction rates of uterine fibroids treated with uterine artery embolization, and that these infarction rates correspond to the subsequent reduction in tumor volume.

Acknowledgments
 
We thank Shirou Inoue and Shinsuke Watanabe of Saiseikai Shiga Hospital for their kind support. We also thank Akihiko Hino and Tadao K. Kobayashi of Saiseikai Shiga Hospital for their kind assistance in preparing the manuscript.

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