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University of California at Los Angeles School of Medicine Los
Angeles, CA 90024
Century City Hospital Los Angeles, CA 90067 and colleagues
We read with interest the article by Sisken et al. [1]. Since publishing the first United States series on uterine artery embolizations [2], our group has treated more than 550 patients with uterine myomata. Twenty-three of these patients (4.2%) underwent hysterectomy because all other treatments had failed. Of these women, 39% had significant adenomyosis in the surgical specimen. Many of these patients presented as failures of treatment several years after uterine fibroid embolization.
We caution against optimistic interpretation of early results. Why? Embolization will stop uterine bleeding for any number of conditions [3]. Nine (60%) of 15 patients in the research of Sisken et al. [1] had evidence of adenomyosis and myomata. The two diseases have identical symptoms: Which pathologic process of the two was responding to treatment? One patient had superficial adenomyosis without evidence of myomata. Do we know from preoperative evaluation that this was not a patient suffering from hormonal imbalance, for whom uterine fibroid embolization would have been inappropriate?
We further caution against reliance on imaging alone to make the diagnosis of adenomyosis, or adenomyoma, before treatment. Although the first author of this letter is not a radiologist, he has witnessed several qualified specialists disagree about a patient on the basis of sonography, CT, and MR imaging. We perform a deep myometrial biopsy, a technique suggested by McCausland and McCausland [4], as part of our preoperative evaluation in all patients [5]. We have found marked disparity between any of the imaging modalities and the pathologic specimen.
Adenomyosis has, to date, failed to respond to various forms of alternate treatments to hysterectomy, such as endometrial ablation [4, 6]. When the cure for this poorly understood disease, short of extirpation of the uterus, is found, we will applaud, loudly. We fear that uterine fibroid embolization is not the bullet, alas.
References
Albany Medical College Albany, NY 12208
University of Pittsburgh Medical Center Pittsburgh, PA
15213
Albany Medical College Albany, NY 12208
We thank McLucas et al. for their insightful comments regarding our article, "Uterine Artery Embolization for the Treatment of Adenomyosis: Clinical Response and Evaluation with MR Imaging" [1]. McLucas et al. are understandably concerned about broadly recommending uterine artery embolization as a primary treatment for adenomyosis. They base these concerns on reports of failure of uterine fibroid embolization in patients with documented adenomyosis and on the difficulty in definitively diagnosing adenomyosis with currently available imaging techniques. We have acknowledged the reports of treatment failure in our original article and continue to acknowledge that it is possible that adenomyosis may place some patients at increased risk for treatment failure after embolization [2, 3].
The practical issue at hand is that, on a day-to-day basis, we are frequently faced with the decision of whether to offer embolization to our patients. It goes without saying that most physicians would prefer to offer this procedure to patients in whom success is likely. Most physicians do not currently use deep myometrial biopsy, which is part of the protocol used by McLucas et al., when evaluating patients for a uterine fibroid embolization procedure. The current standard of care mandates that the decision for treatment be based on a history and physical examination, imaging findings (pelvic sonography, MR imaging, or both), and, in select cases, a superficial endometrial biopsy. We agree that the results of the workup before embolization may be less than straightforward. As discussed extensively in our article [1], adenomyosis and fibroids frequently coexist, symptoms produced by these entities are often similar, and the imaging diagnosis of adenomyosis, in particular, may sometimes be difficult.
Nonetheless, we think that the positive experience of both the small population included in our article [1] and a follow-up cohort of 12 patients has made it appropriate to discuss embolization as an option for patients whose MR imaging findings are suggestive of adenomyosis. We agree that when both fibroids and adenomyosis are present in a patient, it is impossible to know which entity is responsible for the presenting symptoms and, therefore, impossible to know which entity is being effectively addressed by embolization in the event of treatment success. In the same manner, however, it is impossible to attribute treatment failure after embolization merely to the presence of adenomyosis on pathologic evaluation of a hysterectomy specimen. Variability in embolization technique, arterial anatomic variation, and ovarian arterial collateral flow are just a few examples of other potential causes of treatment failure after uterine fibroid embolization [3,4,5]. Adenomyosis is only one potential cause on that list, as confirmed by the fact that 61% of treatment failures found by McLucas et al. did not have adenomyosis at pathologic examination.
We agree that a small percentage of patients who continue to be symptomatic after embolization may have background adenomyosis. On the other hand, our preliminary experience has led us to believe that many symptomatic patients who are diagnosed with adenomyosis on the basis of MR imaging might indeed benefit from embolization. At the least, the results of our study indicate that MR imaging—diagnosed adenomyosis should no longer be considered a contraindication for embolization. Larger clinical trials that include women with fibroids, women with adenomyosis, and women with both entities are needed to determine who most benefits from embolization.
References
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  G. Tropeano, S. Amoroso, and G. Scambia Non-surgical management of uterine fibroids Hum. Reprod. Update, May 1, 2008; 14(3): 259 - 274. [Abstract] [Full Text] [PDF]
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 T T Zacharia and M J O'Neill Prevalence and distribution of adnexal findings suggesting endometriosis in patients with MR diagnosis of adenomyosis. Br. J. Radiol., April 1, 2006; 79(940): 303 - 307. [Abstract] [Full Text] [PDF]
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 B. McLucas, R. Perrella, and R. C. Jha Adenomyosis: MRI of the Uterus Treated with Uterine Artery Embolization Am. J. Roentgenol., April 1, 2004; 182(4): 1084 - 1085. [Full Text] [PDF]
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