高强度聚焦超声治疗子宫肌瘤的初步观察

目的:探讨高强度聚焦超声(简称HIFU)治疗子宫肌瘤的临床疗效及安全性。方法:利用HIFU在人体内部的可聚焦特性,对82例子宫肌瘤予以治疗,在治疗后3月、6个月随访观察患者临床症状,体征和瘤体的超声影像学变化。结果:总有效率96.4%(79例),治愈率37.8%(31例)。疗效显著率55%(45例)。结论:HIFU用于临床治疗子宫肌瘤,是一种安全有效的微创治疗方法。     

子宫黏膜下肌瘤高强度聚焦超声治疗

子宫肌瘤是育龄期妇女最常见生殖系统肿瘤,其中10%～15%为子宫黏膜下肌瘤。子宫黏膜下肌瘤的治疗方式包括传统开腹手术、宫腔镜、腹腔镜、子宫动脉栓塞术、高强度聚焦超声（HIFU）治疗等。每种治疗方式有其独特适应证和禁忌证,HIFU治疗因其非侵入性、治疗精确可控等优点,越来越多地用于子宫黏膜下肌瘤的治疗。     

High-intensity focused ultrasound for the targeted destruction of uterine tissues: experiences from a pilot study using a mobile HIFU unit

Background High intensity focused ultrasound (HIFU) is a novel method which offers the non-invasive ablation of tissues without harming overlying organs or skin. It has been introduced successfully in urology for the ablation of prostatic hyperplasia and seems to be promising in the treatment of uterine fibroids. In this study we aimed to examine the feasibility and possible side effects of HIFU treatment of uterine tissues using an experimental mobile HIFU unit with ultrasound guidance. Methods For these experiments, a 1.07 MHz ultrasound source was used which allows treatment depths between 0 and 10 cm. In 12 patients scheduled to have abdominal hysterectomy, 5–60 impulses of HIFU were applied through the intact skin upon uterine tissues directly prior to the surgical procedure. Tissue intensities lay between 3,200 and 6,300 W/cm2 and a fixed pulse length of 4 s was used. Results No side effects were encountered other than one first-degree skin burn and the treatment was well tolerated. Histology showed clearly demarcated coagulative necrosis in the targeted tissues. Treatment was concluded in less than 45 min for each patient. Conclusion Focused ultrasound is an effective method to selectively destroy tissue within the uterus and the transabdominal access route is very feasible. This study shows that a mobile ultrasound source can be used safely and effectively to destroy uterine tissues, such as fibroids, without major side effects.     

Cost-effectiveness of magnetic resonance-guided focused ultrasound surgery for treatment of uterine fibroids

Objective  To estimate the cost-effectiveness of a treatment strategy for symptomatic uterine fibroids, which starts with Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) as compared with current practice comprising uterine artery embolisation, myomectomy and hysterectomy.
Design  Cost-utility analysis based on a Markov model.
Setting  National Health Service (NHS) Trusts in England and Wales.
Population  Women for whom surgical treatment for uterine fibroids is being considered.
Methods  The parameters of the Markov model of the treatment of uterine fibroids are drawn from a series of clinical studies of MRgFUS, and from the clinical effectiveness literature. Health-related quality of life is measured using the 6D. Costs are estimated from the perspective of the NHS. The impact of uncertainty is examined using deterministic and probabilistic sensitivity analysis.
Main outcome measures  Incremental cost-effectiveness measured by cost per quality-adjusted life-year (QALY) gained.
Results  The base-case results imply a cost saving and a small QALY gain per woman as a result of an MRgFUS treatment strategy. The cost per QALY gained is sensitive to cost of MRgFUS relative to other treatments, the age of the woman and the nonperfused volume relative to the total fibroids volume.
Conclusions  A treatment strategy for symptomatic uterine fibroids starting with MRgFUS is likely to be cost-effective.     

Acute renal insufficiency and thrombocytopenia after high-intensity focused ultrasound (HIFU) ablation for uterine myomas

ObjectiveUltrasound-guided high-intensity focused ultrasound (USg-HIFU) has emerged in recent years as the new treatment modality for uterine myomas and adenomyosis with the advantages of being non-invasive, safe and effective. As its utility increases, adverse reactions emerge and deserve clinicians’ attention for experience accrual. We herein report a case who suffered from acute renal insufficiency and thrombocytopenia immediately after receiving HIFU for uterine myomas.Case reportA 38-year-old nulliparous healthy female received HIFU for huge uterine myoma that caused heavy vaginal bleeding and chronic anemia. The procedure went smoothly but the patient immediately suffered from oliguria and dark-colored urine. With conservative management and aggressive hydration, her condition had improved spontaneously after 1 week without leaving any long-term sequelae. Myoma size reduced by 70% 3 months post-treatment and her bleeding problems significantly improved.ConclusionThis is the first report of post-HIFU acute renal failure and thrombocytopenia. Thermal injuries, drug toxicity and mechanical obstruction of ureters are some plausible explanations for speculations.     

Subjective effect of magnetic resonance-guided focused ultrasound surgery for uterine fibroids

AIM: We treated 69 patients with symptomatic uterine fibroids using a magnetic resonance-guided focused ultrasound surgery (MRgFUS) system. Our objective was to determine the clinical outcome of MRgFUS, focusing on symptom improvement, with emphasis on the time and extent of improvement. METHODS: Patients who would have been otherwise offered conventional surgery were considered for eligibility. They were asked to report their symptom severities before and after treatment on the same query form. The questionnaire, given 6 months after treatment, included a question asking when the patients' symptoms started to improve. Their fibroids were classified into three types according to the signal intensity on T2-weighted magnetic resonance images: type 1, low intensity as skeletal muscle, type 2, intermediate intensity, lower than myometrium but higher than skeletal muscle; and type 3, high intensity, the same as or higher than myometrium. RESULTS: No severe adverse events occurred in any of the patients. Seven patients required alternative treatment after MRgFUS, with five of them having type 3 fibroids. Mean symptom scores were all reduced after MRgFUS, regardless of the symptom types. Frequent urination improved first, while heavy bleeding took longer to resolve than the other symptoms. CONCLUSION: MRgFUS is an effective and safe method for treating symptomatic uterine fibroids, especially for type 1 and type 2 fibroids. Type 3 fibroids, however, are difficult to treat using the current MRgFUS system.     

超声消融治疗子宫黏膜下肌瘤的安全性和疗效评价

目的 探讨超声消融治疗突入宫腔体积＜50%的子宫黏膜下肌瘤的安全性及疗效.方法 前瞻性选择2006年10月至2009年9月在解放军总医院妇产科就诊有明显临床症状的、经MRI确诊的突出官腔体积＜50%的子宫黏膜下肌瘤患者66例(68个肌瘤),行超声引导下的聚焦超声消融治疗,记录消融治疗过程中及消融治疗后出现的不良反应;消融治疗后即刻采用超声造影评价消融治疗的疗效,消融治疗后第3、6、12和24个月,超声评价肌瘤体积变化;采用子宫肌瘤相关症状评分表(SSS)和月经期症状评分表评估症状变化.结果 共66例患者的68个黏膜下肌瘤消融治疗前肌瘤平均体积为(151±134)cm3,消融治疗后即刻超声造影中无灌注区平均体积为(114±104)cm3,肌瘤体积消融率为(77±16)%.所有患者均顺利完成治疗,随访时间为6～44个月,中位随访时间24个月,至今未出现显著并发症.消融治疗后有52%(34/66)的患者出现阴道排液症状,均于消融治疗3～4个月经周期后自行恢复正常.消融治疗后第3、6、12和24个月时,SSS评分与消融治疗前比较,分别降低20.9%、38.0%、45.1%、47.1%;月经期症状评分与消融治疗前比较,分别降低42.0%、63.8%、64.2%、68.8%,分别与治疗前比较,差异均有统计学意义(P＜0.05),坏死肌瘤逐渐吸收缩小,肌瘤体积较消融治疗前平均缩小44.7%、66.0%、77.7%和89.8%.结论 超声消融治疗突入宫腔体积＜50%的子宫黏膜下肌瘤安全、有效,黏膜下肌瘤相关症状改善显著.

Abstract：

Objective To evaluate the efficacy and safety of focused ultrasound ablation in the treatment of submucosal fibroids which broke into uterine cavity less than 50%. Methods From Oct. 2006 to Sept. 2009, 66 patients with 69 submucosal fibroids broke into uterine cavity less than 50% diagnosed by MRI in Chinese People's Liberation Army General Hospital were enrolled in this study. They were treated by ultrasound-guided focused ultrasound ablation in the outpatient department, which using the contrast enhanced ultrasonography to assess the efficacy after ablation immediately, to measure reduction of fibroids volume and record adverse effect before and after ultrasound ablation. At 3, 6, 12 and 24 months after treatment, ablation outcome and fibroids volumes were evaluated by contrast ultrasound. The changes of clinical symptom were evaluated by the symptom severity score ( SSS) of the uterine fibroid quality-of-life instrument( UFS-QOL). Results The average volume of fibroids in 66 patients with 68 submucosal fibroids were (151 ±134) cm3 before treatment and (114 ± 104) cm3 no enhanced regional after treatment. The ablation rate of target fibroids was (77 ±16)%. All patients completed this treatment successfully, they were followed up for 6 - 44 months, the median follow-up time was 24 months. No serious complication was observed. However, there were 52% (34/66) patients presented vaginal discharge after ablation, it disappeared gradually after 3 to 4 menstrual cycles. The SSS and the menstrual period symptom scores were significantly lower than that before ablation at the follow-up of 3,6, 12 and 24 months, the rates were 20. 9% , 38. 0% , 45. 1% , 47. 1% and 42. 0% , 63. 8% , 64. 2% , 68. 8% , which all reached statistical difference (P ＜ 0. 05 ). The necrotic fibroids were absorbed gradually, the reduction rates of fibroid volume were 44. 7% ,66. 0% ,77. 7% and 89. 8% . Conclusion It was safe and efficacy that focused ultrasound ablation was used in treatment of submucosal fibroids which broke into the uterine less than 50%.     

Patient suitability for magnetic resonance guided focused ultrasound surgery of uterine fibroids

Objective

To assess selection criteria used to determine eligibility for magnetic resonance-guided focused ultrasound surgery (MRgFUS) for the treatment of symptomatic uterine fibroids; to assess the percentage of patients suitable for MRgFUS.

Study design

A retrospective analysis of 144 patients seeking minimally invasive treatment options for symptomatic uterine fibroids at a single treatment center. Clinical eligibility for MRgFUS was assessed at a gynecology clinic by a Gynecology research fellow trained in the procedure and suitability was assessed by magnetic resonance imaging. Several techniques were used to mitigate against factors that are contra-indications for MRgFUS.

Results

100% of patients interested in MRgFUS were deemed clinically eligible for the procedure and 74% were deemed technically suitable to proceed with treatment.

Conclusions

Mitigation techniques allow for less restrictive MRgFUS selection criteria for treatment for symptomatic uterine fibroids. These less restrictive criteria are expected to expand the pool of patients for whom MRgFUS is a viable treatment option for uterine fibroid symptoms.     

High-intensity focused ultrasound treatment for non-neoplastic epithelial disorders of the vulva

Objective

To assess the efficacy of high-intensity focused ultrasound (HIFU) treatment in patients with non-neoplastic epithelial disorders of the vulva.

Method

We reviewed 41 cases of lichen sclerosus, 38 cases of squamous cell hyperplasia, and 17 mixed cases treated by HIFU from April 2004 to July 2008 at the Women's Hospital of Zhejiang University School of Medicine. Biopsy specimens were assessed with light microscopy before and after treatment.

Results

Pruritus and signs of vulvar lesions were dramatically improved following HIFU treatment, without severe complications, and 90.23% of the patients were cured or had their symptoms improved 6 months after treatment. On light microscopy, pigmentation and epithelial structures were recovered and dermal lymphocytic infiltration was reduced. The response rates were lower and complication rates higher among lichen sclerosus than among squamous cell hyperplasia cases (P < 0.05 for both).

Conclusion

Treatment with HIFU may be safe and effective in cases of vulvar dystrophy.     

Magnetic resonance imaging-guided focused ultrasound surgery for symptomatic uterine fibroids: estimation of treatment efficacy using thermal dose calculations

Objective

To study the correlation between the predicted thermal dose volume (TDV) and the actual ablation volumes in MR-guided focused ultrasound surgery (MRgFUS) for symptomatic uterine fibroids, and to follow up the outcome for 12 months post-treatment.

Study design

Phase-difference fast spoiled gradient-echo MR images were used to analyze thermal change during the energy deliveries of MRgFUS in 60 consecutive patients treated for symptomatic uterine fibroids. The TDV obtained through analysis of these MR images was compared with the non-perfused volume (NPV) measured on post-treatment contrast enhanced T1-weighted images. Final values of TDV ratio and NPV ratio were obtained by dividing these values by original fibroid volume. Patients were followed for 12 months post-treatment to assess symptomatic relief using the symptom severity score (SSS).

Results

Treatments in which we managed to reach a TDV ratio larger than 27% of the treated fibroid yielded a ratio of NPV to TDV of 1.1 ± 0.5, indicating accurate control of the non-invasive procedure. Patient symptoms, as measured by the SSS, continuously decreased from a mean baseline score of 50 ± 22 to 19 ± 12 (P < 0.0001) 12 months post-treatment.

Conclusions

At large treatment volumes (exceeding 27% TDV ratio), thermal dose estimates correspond very closely to non-perfused volumes measured immediately post treatment. These large treatment volumes result in continuous clinical improvement throughout the first 12 months after MRgFUS.     

Successful in vitro fertilization pregnancy following magnetic resonance-guided focused ultrasound surgery for uterine fibroids

We describe an in vitro fertilization (IVF) pregnancy and delivery after magnetic resonance-guided focused ultrasound (MRgFUS) for a symptomatic uterine fibroid. A 45-year-old para 0 + 1, with four previous failed IVF treatments underwent MRgFUS for a single anterior wall fibroid causing intra-cavitary distortion and conceived after the first IVF cycle 10 months following the procedure. The patient received shared antenatal care. She was admitted in spontaneous labor at term but delivered by emergency cesarean section a healthy male infant. We describe the first IVF pregnancy following MRgFUS for a symptomatic fibroid.     

Ulipristal acetate for uterine fibroids: a systematic review and meta-analysis

Ulipristal acetate (UA), a selective progesterone modulator, has been approved for short-term therapy for symptomatic fibroids. We decided to undertake a systematic review of the best available evidence and draw a more definitive conclusion regarding the efficacy of UA for the management of uterine fibroids. The outcomes included symptomatic relief, quality of life-related parameters, reduction in fibroid size, side effects and recurrence rate. We included four randomised controlled trials which consisted of three trials which compared UA with placebo, and one trial compared it with gonadotropin-releasing hormone analogues for symptomatic relief. The three trials comparing UA with placebo reported significant improvement in symptoms related to excessive uterine bleeding as evidenced by the attainment of amenorrhea or reduction in pictorial blood assessment chart. However, due to the heterogeneity of the available data, a meta-analysis was possible only for one the outcomes – attainment of amenorrhea which indicated improvement in symptoms [57.88 (19.81–169.16); p?相似文献   

Outcome of unintended pregnancy after ultrasound-guided high-intensity focused ultrasound ablation of uterine fibroids

ObjectiveTo evaluate the safety of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation of uterine fibroids among women with unintentional pregnancy within 1 year of therapy.MethodsA retrospective analysis was conducted of 435 women who underwent USgHIFU therapy at Chongqing Medical University, China, between October 1, 2006, and October 1, 2009.ResultsUnplanned pregnancy was reported by 24 women within 1 year of USgHIFU ablation; 8 of these women had desired pregnancy before undergoing treatment. A total of 27 fibroids were detected, 24 of which were treated (mean volume 65.9 ± 58.8 cm³). Pregnancy was continued by 7 women without any complications. One pregnant woman who had desired pregnancy before therapy underwent an induced abortion owing to concerns about the effects of USgHIFU on the fetus. Fourteen women without pregnancy intention before USgHIFU therapy chose to undergo induced abortion; 2 women experienced spontaneous abortion. No adhesion occurred after USgHIFU therapy. Furthermore, USgHIFU, labor, and abortion had no effect on subsequent menstruation or sexual activities.ConclusionPregnancy within 1 year after USgHIFU ablation of uterine fibroids appears safe; however, large scale studies are required to confirm these data.     

Effect of high-intensity focused ultrasound on sexual function in the treatment of uterine fibroids: comparison to conventional myomectomy

Background

Uterine fibroids are the most common benign tumors in women. As a new minimally invasive clinical technology, high-intensity focused ultrasound (HIFU) has been widely applied to the treatment of uterine fibroids, but no study using objective criteria has evaluated the effect of HIFU on sexual function.

Methods

A total of 100 premenopausal patients were enrolled in this randomized clinical trial (RCT). The brief index of sexual functioning (BISF-W) was used to evaluate changes in sexual function. Differences in the outcome were calculated for each individual before treatment and at 3 and 6 months after treatment, and changes were compared between the HIFU group (HIFUG) and the myomectomy group (MYG).

Results

Preoperative BISF-W scores were similar in both groups (P < 0.05). No significant differences were found between the two groups at 3 and 6 month after treatment. Within the groups, patients reported less arousal and less problems at 3 month compared to baseline. There was a trend toward improved sexual satisfaction and overall quality of sexual life in both groups 6 months after treatment compared with the baseline, although it failed to reach statistical significance except for the dimensions of relational satisfaction and problems affecting sexuality.

Conclusions

Sexual function improved on average to some degree after both HIFU and conventional myomectomy.