Contribution of contrast-enhanced ultrasound with Sonovue to describe the microvascularization of uterine fibroid tumors before and after uterine artery embolization

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Abstract

Objective

The principal objective of this study was to use contrast-enhanced ultrasonography to describe the characteristics of fibroid microvascularization before and after embolization.

Study design

Forty women had contrast-enhanced ultrasonography with Sonovue® injections before uterine artery embolization, the day afterwards, and at 6–12 months afterwards. An MRI was also performed before and after the procedure.

Results

Two thirds of the fibroids took up the contrast product before the myometrium did, and 45.8% were vascularized along the peripheral rim of the fibroid, compared with 41.6% with a principal pedicle and from the center in three (12.6%). After embolization at day one (D1), the myometrium was fully enhanced, that is, perfusion of the myometrium was plainly visible, in 25 cases (69.4%; n = 36), partially enhanced in eight (22.2%), and totally avascular in three (8.4%). Analysis of the failures according to imaging criteria the day after embolization (D1) showed failure in seven women, with partial enhancement for six, and total for one. In the imaging at 6 months (M6), contrast ultrasonography showed failure for three women, with enhancement of the largest fibroid. This enhancement was total in two cases and partial (40%) in one. There were five failures according to MRI at M6, with partial enhancement. Only two of these failures were simultaneously failures according to the contrast-enhanced ultrasonography. There were five clinical failures, two consistent with the imaging at 6 months and four predictable on D1.

Conclusion

Contrast-enhanced ultrasonography is feasible and useful to understand fibroid vascularization and for monitoring embolization; its correlation with MRI is good, its concordance less so.

Introduction

Because of the good clinical results reported (85–90% at 5 years), uterine artery embolization (UAE) has emerged as the principal alternative to surgery [1], [2], [3], [4], [5], [6], [7]; UAE represents 40% of the treatment for fibroid in our institution.

Within the fibroid, vascularization is centripetal [8], [9], and the central area is the most sensitive to spontaneous ischemic accidents (which explains the necrobiosis of some fibroids). The failure of power Doppler to show fibroid microvascularization adequately presents two persistent limitations for the early assessment of embolization results: difficulties both in the early and inexpensive assessment of radiologic response to treatment and in determining the vascular factors that predict this response.

MRI with gadolinium injection allows a good assessment and is considered a reference method, but it is not always available and remains expensive [1].

Sonography with the peripheral injection of a second-generation ultrasound contrast product (Sonovue®) can now characterize tumor vascularization and makes it possible to map its microvessels with precision.

The principal objective of this study was to use contrast-enhanced ultrasonography to describe the characteristics of fibroid microvascularization before and the day after embolization.

The secondary objectives were: to determine the radiologic predictive factors and the concordance of MRI and contrast-enhanced ultrasonography for successful embolization.

Section snippets

Material and methods

This prospective study took place at Tours University Hospital Center from 2008 to 2011. It included 40 women aged at least 18 years with at least one symptomatic uterine fibroid (size between 6 and 9 cm) for which embolization was planned. Approval from our institution's review board and local ethics committee was obtained and written consent signed by the patients.

The exclusion criteria were: intracavitary uterine mass suggestive of submucous fibroid type 0 or 1, polyps or endometrial cancer,

Results

The women's mean age was 44 ± 6 years, and their mean BMI 25.2 ± 5.5. All women had hormone therapy, which failed, and two had already had a myomectomy that was followed by the reappearance of symptoms.

Nine vials of particles, on average, were used per patient, all particle sizes combined.

The interviews (history and symptoms) taken before the procedure and then at 6–12 months showed a clear improvement in all symptoms. Of the 40 women studied, five were lost to follow-up and could not be questioned

Comment

First reported in 1995 in France [3], uterine artery embolization for the treatment of fibroids has developed slowly in Europe improved by the guidelines recently published [1].

Contrast-enhanced ultrasound based on vascular exploration appeared to us to be a promising technique for assessing the probability of success for fibroid treatment and determining its predictive factors.

Our study made it possible to describe the microvascularization of fibroids and the vascular kinetics of fibroids

Conflict of interest

There is no conflict of interest with Bracco as Pr Tranquart was not working for Bracco at the time of the study, and our study was financed completely by public funds.

Condensation

Contrast-enhanced ultrasound is feasible and useful to understand fibroid vascularization and for monitoring embolization; its correlation with MRI is good, its concordance less so.

Acknowledgments

To Mrs. Jo Cahn for English translation and to the CIT Technique Innovation Center of Tours France for financial management

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