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Commentary |
1 Department of Radiology, CG 201, Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007-2113. Address correspondence to J. B. Spies
Received December 7, 2005; accepted after revision December 19, 2005.
Address correspondence to J. B. Spies
(spiesj{at}gunet.georgetown.edu).
Keywords: hysterectomy • interventional radiology • leiomyoma • uterine artery embolization • UFE • uterine fibroid embolization
Uterine artery embolization for leiomyomas (popularly known as uterine fibroid embolization or UFE) has come a long way since the first U.S. report by Goodwin et al. in 1997 [1]. A brief search of the literature yielded over 300 scientific articles published on uterine embolization since then and it is estimated by the Society of Interventional Radiology that over 12,000 of these procedures are performed in the U.S. each year. The procedure has been recognized as safe and effective (in the short term at least) by the American College of Obstetricians and Gynecologists [2]. UFE is now accepted as an effective fibroid therapy, in large part due to the efforts of investigators who have studied the procedure and its outcome and who have published those results.
In this issue of the AJR, Katsumori and coworkers add to that knowledge base and continue their excellent work documenting the clinical effectiveness of the gelatin sponge as an embolic agent for fibroid embolization [3]. Following up on their previous reports documenting the short-term clinical and imaging outcome from embolization [4, 5], the authors detail the long-term outcome from embolization—with nearly 100 patients treated and 80 followed for up to 60 months (mean, 37.4 months). The excellent cumulative symptom rate at 5 years of 89.5% shows that uterine embolization using this embolic agent is highly effective and durable.
This article is particularly important because it presents long-term data. Only two prior studies in the English-language literature, one by our group [6] and another by Broder et al. [7], have presented data on outcomes of uterine embolization at 3 years posttherapy or beyond and the article by Katsumori et al. [3] is only the second with data collected out to 5 years. This contribution to our understanding of the procedure represents a confirmation that it is durable and that UFE can compete with other uterine-sparing therapies as an effective alternative to hysterectomy.
As Pelage et al. [8] have previously shown, the key to successful long-term outcome and prevention of recurrence is the infarction of all or nearly all the fibroid tissue present at the time of the embolization. The most likely reason for short- and midterm recurrence is regrowth of uninfarcted fibroid tissue. In general, the greater the amount of tissue that is uninfarcted, the sooner the recurrence is likely to occur. Importantly, Pelage's work showed that the symptom recurrence might occur long before the fibroid grows back to its original size. The amount of shrinkage that occurs after embolization is much less important than the degree to which the fibroid infarcts. The best means of assessing the extent of fibroid infarction is contrast-enhanced MRI.
This article [3] is also important because it provides confirmation that the gelatin sponge is an effective embolic agent, although the type of gelatin sponge (Spongel, Yamanouchi) used is not currently available in the United States. Its painstaking hand preparation as a moderate size particle (500-100 µm size) is not the same as the pledgets or slurry commonly used in this country. Nevertheless, their study is consistent with those previously published that show the effectiveness of tris-acryl gelatin microspheres and particulate polyvinyl alcohol sponge in infarcting fibroids [9] and confirms that this material prepared in the manner used by these Japanese investigators is an effective material for this procedure.
The study by Katsumori et al. [3] helps confirm that UFE is no longer an experimental procedure; it clearly is an effective and safe means of treating uterine fibroids and, in many ways, is better characterized than more traditional treatments. I am hopeful that those performing hysterectomy, myomectomy, and other fibroid therapies will take note of the care that these authors have used in this evaluation. It is a useful model for all of us to emulate.
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