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Thursday, January 17, 2019

High Epithelial Cell Adhesion Molecule–Positive Circulating Tumor Cell Count Predicts Poor Survival of Patients with Unresectable Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization 


Summary


The detection of peripheral blood circulating tumor cells (CTCs) has been used to develop the association between recurrence and prognosis after surgical resection or liver transplantation in patients with hepatocellular carcinoma (HCC). Through a prospective analysis, the authors sought to assess the role of epithelial cell adhesion molecule (EpCAM)–positive CTC count in predicting survival outcomes of chemoembolization in patients with unresectable HCC. 89 patients with a pathologic or clinical diagnosis of HCC had peripheral blood samples analyzed through the CellSearch system for EpCAM positive CTCs 1-2 days prior to chemoembolization and were stratified into three groups for analysis (0-1 CTC, 2-5 CTCs, and ≥ 6 CTCs) based on the Cox proportional-hazards model. Chemoembolization was performed using oxaliplatin, pirarubicin, and fluorouridine; disease progression was evaluated per modified Response Evaluation Criteria In Solid Tumors as identified by 2 senior radiologists who were blinded to the clinical information.

After controlling for Child-Pugh class, ECOG status, presence of vascular invasion, number of tumors, tumor size, and AFP, the authors found that a CTC was an independent predictor of overall survival (OS) in patients with HCC treated with chemoembolization (P = .049). The risk of death in the high-level and moderate-level groups was 2.819 fold (P = .016) and 1.301 fold (P = .477) higher, respectively, than in the low-level group. The median OS times of patients with high, middle, and low CTC levels were 5.3 months, 10.5 months, and 19 months, respectively (P < .001). Analysis regarding progression free survival (PFS) showed that the risk of progression was 4.745 fold greater (P <.0001) in the high-level group and 1.525 fold greater (P =.201) in the moderate-level group compared with the low level group. High EpCAM-positive CTC counts appear to be associated with poor survival of patients with unresectable HCC treated with chemoembolization.



Table

Note–Groups 0, 1, and 2 represent low level group (CTC count 0/1), moderate level group (CTC count 2–5), and high level group (CTC count ≥ 6). Variable CTC was compared vs group 0 in Cox analysis.

AFP = a-fetoprotein; CTC = circulating tumor cell; ECOG = Eastern Cooperative Oncology Group; HR = hazard ratio; OS = overall survival; PS = performance status.

*Refers to imaging diagnosis, not pathologic diagnosis.

Commentary


The results of the present study are in accordance with previous studies with regard to EpCAM-positive CTC counts correlating with tumor recurrence and survival, particularly in patients with high-level counts (CTC ≥ 6). The association between higher CTC counts and malignant features of HCC including satellite foci, vascular invasion, and poorly differentiated tumors is the suggested explanation for these findings.

However, the findings of the study must be interpreted with caution as 63 of the included patients had previously received treatment with 50 of those patients undergoing previous chemoembolization. The variation between primary chemoembolization and repeat chemoembolization on CTC counts and patient responsiveness is unknown. Further, the implications of added cost and potential for false positive results (0.6 %– 5.3%) must be considered when implementing this prognostic tool. As CTC counts seem to correlate with malignant HCC features and late BCLC stage, the value added by this test to prognostication for unresectable HCC beyond that already established by previous staging/imaging findings appears limited. Despite these reservations, using CTCs to detect and predict the responsiveness of various oncologic treatments appears to be a promising field of investigation.

Click here for abstract

Shen J, Wang W-S, Zhu X-L, Ni C-F. High Epithelial Cell Adhesion Molecule–Positive Circulating Tumor Cell Count Predicts Poor Survival of Patients with Unresectable Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization. Journal of Vascular and Interventional Radiology [Internet]. 2018 Nov 1;0(0).

Post Author:
Jacob Bundy, MD, MPH
PGY-1
Department of Surgery
University of Michigan Health System
@JBundyRad

Monday, January 14, 2019

Irinotecan-Eluting 75-150-µm Embolics Lobar Chemoembolization in Patients with Colorectal Cancer Liver Metastases: A Prospective Single-Center Phase I Study 


Summary


Interventional oncologists have long been involved in treatment of hepatic metastatic disease from colorectal cancer, offering ablation, radioemboliztion, and bland/chemoembolization. Given the propensity of disease, colorectal cancer is number three cause of cancer related death in the US with 60% of patients developing liver metastases at some point, this remains a great interest to IO’s despite transarterial therapy being third line therapy at best. This single center prospective trial evaluates feasibility and safety of using a smaller embolic bead, 75-150 µm, with irinotecan, an established chemotherapeutic for patients who have failed 5-FU therapies While the primary end-points are relatively modest, the group also evaluated treatment efficacy, irinotecan pharmacokinetics, and angiogenesis biomarkers. Ultimately, 14 patients with liver dominant colorectal cancer metastatic disease who had progressed through at least 1 line of systemic therapy were treated. Treatment cycles were 6 weeks, and a patient could be treated twice prior to initial follow up imaging. A maximum of 4 treatment cycles were performed. Retreatment was based on presence of new disease, progression of disease, or stable disease on follow up imaging. The study used 1 vial of LC Bead M1 loaded with 100 mg of irinotecan infused in a lobar manner. Embolization was stopped prior to complete dose delivery if 2-5 heart beat stasis was achieved.

Feasibility was defined as the ability to deliver the entire dose to 80% of the patients. Procedural complications and 30-day adverse events were recorded to determine safety. All 32 embolizations in the 14 patients were completed with delivery of the entire dose each time. There were no procedural complications. The most common 30-day adverse event was abdominal pain, seen in 50% of the patients, with 28.6% qualifying as a severe (grade 3-4). Median overall survival from the first treatment was 18.1 months with 1 year survival of 65%. By EASL criteria, 3 patients had partial response, 4 patients had stable disease, and 6 patients had progression.



Figure 1. (a) Partial response demonstrated in 2 patients based on EASL criteria. On contrast-based imaging (venous phase), the tumor measurements before and after transarterial chemoembolization were, respectively, 3.44 x 3.11 cm and 1.90 x 2.49 cm for patient 1 (71 year old male) and 3.99 x 3.68 cm and 1.47 and 1.37 cm for patient 2 (58 year old male). (b) Kaplan-Meier curves demonstrating MOS and 1-year survival.

Commentary


While chemoembolization, specifically with irinotecan, has been relatively well studied from 2006 to present, both as third line or salvage treatment and in conjunction with systemic chemotherapy, there has been little research involving smaller sized beads. The advantages of smaller embolics include more distal penetration into the tumor bed and ability for more uniform coverage throughout the target zone. Despite the small number of patients, this data supports the existing data that chemoembolization using 75-150 µm embolics is indeed safe and feasible. Obviously, this study is limited do to sample size, short follow up interval, and hetereogenous pre-existing and subsequent cancer therapies. While this adds to our literature supporting safety of transarterial chemoembolization for colorectal metstatic disease, many questions still remain. There is still no clear position for transarterial chemoembolization nor transarterial radioembolization in the armamentarium for treatment of mestastatic colorectal cancer. Should these be considered third line, fourth line, or salvage therapy? Is radiation or chemoembolic superior? What size embolic is ideal for chemoembolization? Clearly, more research needs to be performed in this realm, especially to compete with systemic chemotherapy trials and seemingly endless supply of novel chemotherapeutics emerging on the market.

Click here for abstract

Fereydooni A, Letzen B, Ghani M, et al. Irinotecan-Eluting 75-150-µm Embolics Lobar Chemoembolization in Patients with Colorectal Cancer Liver Metastases: A Prospective Single-Center Phase I Study. J Vasc Interv Radiol. 2018. Oct 15.

Post Author:
David M Mauro, MD
Assistant Professor
Department of Radiology
Vascular and Interventional Radiology
University of North Carolina
@DavidMauroMD

Thursday, January 10, 2019

Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable—Results of 72 Consecutive Patients


Summary


Research from the University Hospital of Zurich (Switzerland) recently evaluated the outcome of elective/emergent endovascular repair of isolated iliac artery aneurysms (IIAAs) as the first treatment option. A retrospective study was conducted including 72 patients with 85 IIAAs. Treatment strategy included coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. The following arterial segments were involved: common iliac (63 patients; 74.1%), internal iliac (21 patients; 24.7%), and external iliac (1 patient; 1.2%). Mean diameter was 5 cm (range, 2.5–11 cm). Emergent repair was performed in 19 patients due to rupture (26.4%). Mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0–14.2 y). Primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group). In-hospital mortality rate was 1.4%. Total of 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall re-intervention rate was 16.7%. Primary patency rate was 98.6%. 22 deaths occurred (30.6%), but only 2 aneurysm-related deaths (2.8%). The authors concluded that primary endovascular repair of IIAAs shows excellent results and should be considered the first-line therapy for IIAAs. Surgical backup should be available in emergent cases. 



Fig: Anatomic classification of IIAA.

Commentary


This paper reinforces the important role of endovascular approach for arterial aneurysms, specifically for rare cases of isolated iliac artery aneurysms. The low incidence of this entity should not undermine its significance since it can lead to major complications such as rupture, which is associated with high morbidity and mortality. Therefore, it is recommended to treat aneurysms > 3cm. However, even for elective cases, surgical repair can have up to a 10% mortality rate, given the deep location of the iliac arteries within the pelvis. The present retrospective study demonstrated that endovascular repair was safe and effective for both elective and emergent cases even after long term follow-up (median of 4.3 years). There was a low conversion rate (4.6%) to open repair and they all occurred in emergent cases. This is not surprising given the severe clinical presentation of this patient population. Therefore, surgical back up is definitely recommended in these cases as mentioned by the authors. The initial critical presentation also explains the higher incidence of in-hospital major complications and increased length of admission for those emergent cases presenting with rupture. The standardized endovascular way to treat those aneurysms according to the location as performed by the research definitely helps replication of the results and solidification of the endovascular approach as the first line treatment for this condition.

Click here for abstract

Post Author:
Ricardo Yamada, MD
Assistant Professor
Department of Radiology
Division of Vascular and Interventional Radiology
Medical University of South Carolina

Tuesday, January 8, 2019

Endovascular Denervation: a new approach for cancer pain relief 


Summary


Debilitating pain is a common issue that affects cancer patients, and while medical treatment may improve the symptoms, there are significant side efectssuch as nausea, addiction, constipation etc. Celiac pleuxus neurolysis (CPN) has been performed by percutaneously injecting ethanol or phenol around the celiac plexus, however complications such as nerve damage, pneumothorax, hematoma, etc. More recently Endoscopy has been used to guide celiac plexus neurolysis and while it has been effective there have been major side effects such as bleeding, abscess, bowel perforation etc.

The authors sought out toe evaluate the feasibility of patients Endovascular denervation (EDN) to treat pain caused by pancreatic cancer, cervical cancer, cholangiocarcinoma and esophageal cancer. The authors included patients with abdominal cancer that had a VAS >6, ages 25-75 and had a greater than 1 month survival expectation. The primary end point was pain relief as measured with VAS, secondary end points included, QOL assesment, narcotic intake and safety. During the procedure the patient has a surface electrode placd on the back, an aortogram is performed and through an 8 French sheath a 6 electrode catheter is placed proximal to the celiac artery and close to the SMA. The procedure was done under moderate anesthesia, and the denervation was performed for 120 seconds and 60 degrees. Six different points of ablation were treated in that region.

The seven patients included had a VAS score greater than 7 and experienced pain relief at 1, 2 , 4, 8 and 12 weeks. The average VAS score was reduced by greater than 3 points in all patients. The average QOL score increased by 25, with improvement in sleep and more enjoyment in activities. Narcotic use also decreased after EDN, and no major complications were observed.

The authors hypothesize that the radiofrequency energy delivered through the aorta may cause celiac plexus block and improve abdominal pain. The authors mention that the results are similar to CT or EUS guided CPL and quote pain relief in 10-24% when used alone and 80-90% when used in combination with other options. In the group presented by the authors pain relief lead to significant increase in QOL scores, with decreased narcotic use and improved sleep, with no major complications.

The study is limited by the small sample size, the lack of a control group and the difficulty in quantifying a subjective measure like pain.



Figure- Anortogram showing the origin of the celiac and SMA(a), followed by deployment of the electrode near the celiac (b) and the SMA (c)

Commentary


The authors show that endovascular CPN might be an alternative to CT CPL and potentially technically easier and with less complications. Technically the procedure seems straight forward and the results promising. Patients had a decrease in pain scores, improved QOL scores and decreased narcotic intake. The discussion mentions similar outcomes when compared to CT and EUS CPN, however the data presented for the other studies (pain relief efficacy) is not similar to what the authors presented, similar to the pain relief duration. The study could benefit from a longer follow up, and to compare it to a group of patients that were treated either with CT or EUS CPN.

Click here for abstract

Zhang Q, Guo JH, Zhu HD, Zhong YM, Pan T, Yin HQ, Dong YH, Teng GJ. Endovascular Denervation: A New Approach for Cancer Pain Relief? J Vasc Interv Radiol. 2018 Nov 7. pii: S1051-0443(18)31415-5. doi: 10.1016/j.jvir.2018.08.008. [Epub ahead of print] PubMed PMID: 30414719.

Post Author
Carlos J. Guevara, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Sciences, Houston
@UTHouston_IR
@CarlosGuevaraIR

Friday, December 21, 2018

Regorafenib for patients with hepatocellular carcinoma who progressed on sorafenib treatment (RESOURCE): a randomized, double-blind, placebo-controlled, phase 3 trial


Summary:


Hepatocellular carcinoma (HCC) locoregional treatment includes surgical resection, transplantation, ablation and chemoembolization. For those patients who are not candidates for such treatment, medical management with the oral multikinase inhibitor sorafenib, can provide improvement in overall survival. This study aimed to evaluate the safety and efficacy of regorafenib, for patients in whom HCC has progressed during treatment with sorafenib.

Across 152 centers and 21 countries, 573 patients with progression of HCC on sorafenib were enrolled in a randomized 2:1 regorafenib to placebo, double-blind, placebo-controlled phase 3 clinical trial. The primary endpoint was overall survival analyzed by intention to treat. Median overall survival was 10.6 months (95% CI 9.1 – 12.1) with regorafenib and 7.8 months (6.3 – 8.8) with placebo. Median progression-free survival was 3.1 months (2.8 – 4.2) with regorafenib and 1.5 months (1.4 – 1.6) with placebo by mRECIST criteria; median time to progression of 3.2 months (2.9 – 4.2) and 1.5 months (1.4 – 1.6) respectively. The safety profile of regorafenib in HCC is consistent with the use of this medication in other malignancies. The most common reason for discontinuation of regorafenib was disease progression (60%, 83% in the control group).

This study concludes that regorafenib provides a clinical improvement in overall survival in patients with progression of HCC while on sorafenib. Two patients had a complete tumor response by mRECIST criteria. This suggests that the sequential use of two multikinase inhibitors with partially overlapping target profiles can provide benefit to this patient population.



Figure 2. Kaplan-Meier analysis of overall survival (A), progression-free survival (mRECIST; B), and time to progression (mRECIST; C)

Commentary:


Regorafenib offers a viable option for patients who have failed sorafenib and has the potential to add to the current treatment armamentarium. Multiple clinical trials with second line therapies including TACE (Kudo et al., GIDEON trial, Zhang et al.), HAIC (SIRIUS trial, Terashima et al., Shao et al.) and alternative medications (Llovet et al., Zhu et al.) have demonstrated variable benefit depending on the treatment timing or drug.

The STAB Study Phase II data, recently published by Sato et al. indicates a similar class of patients (Child-Pugh class A with Barcelona Stage C disease) may benefit from concurrent TACE with sorafenib therapy with a mean overall and progression free survival of 17.3 and 5.4 months respectively, longer than those with regorafenib therapy. While this patient population was chemotherapy-naïve, it offers a potential treatment option for those patients on sorafenib prior to treatment failure. The introduction of regorafenib has the potential to change IR treatment for refractory HCC as concurrent regorafenib-TACE or alternative IR therapies may become a viable option in the future.


Bruix J, Qin S, Merle P, et al. Regorafenib for patients with hepatocellular carcinoma who progressed on sorafenib treatment (RESOURCE): a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet. 2017; 389: 56-66.

Post Author:
Nicole A. Keefe, MD
Resident Physician
Department of Radiology and Medical Imaging
University of Virginia
@NikkiKeefe

Friday, December 14, 2018

Patient and Facility Demographics Related Outcomes in Early-Stage Non-Small Cell Lung Cancer Treated with Radiofrequency Ablation: A National Cancer Database Analysis 


Summary


The role of patient demographics and facility volume play with regards to survival after surgery for NSCLC has been established in multiple prior studies. However, while survival data is available for radiofrequency (RF) ablation of NSCLC, the impact of patient demographics and facility volume is not known in these patients undergoing RF ablation.

The purpose of this investigation was to evaluate the effect that these factors have on OS after RF ablation in early-stage NSCLC using the National Cancer Database (NCDB). The investigators performed a retrospective cohort study of all patients diagnosed with NSCLC from 2004 to 2014. Patients with metastatic and or nodal disease were excluded (T1aN0M0 and T1bN0M0). Additionally, patients who received chemotherapy or radiation at any time were excluded. The final cohort was a total of 967 patients. Patient demographic factors incorporated into the analysis included insurance status, income, education level and residence type. Facility demographic variables evaluated included facility type (community cancer program, comprehensive community cancer program, academic/research program, or integrated network cancer program) and facility volume. Patients were separated into those treated at high-volume centers (HVCs) and those who were not (non-HVC). After propensity score-weighted analysis of a matched cohort of 574 patients, the significant improvement in OS persisted with 1-, 3-, and 5-year OS of 89.4%, 51.2%, and 27.7%, respectively, in the HVC group, compared to 85.2%, 42.0, and 19.6%, respectively, in the non-HVC group (P=.015). Worse OS after RF ablation was significantly associated with increasing age and higher T-classification.



Commentary


This study suggests there is a significant survival benefit in patients treated with RF ablation for NSCLC in higher volume institutions. What to do with this knowledge remains the question. Additionally, more work will need to be done to look further at the specific variables accounting for this difference, apart from the higher volumes done at these centers. With all things equal, ablative technologies for NSCLC can then be pitted head to head with the current standard of care.

Click here for abstract

Lam, Alexander, et al. Patient and Facility Demographics Related Outcomes in Early-Stage Non-Small Cell Lung Cancer Treated with Radiofrequency Ablation: A National Cancer Database Analysis. Journal of Vascular and Interventional Radiology. November, 2018. Volume 29, Issue 11, 1535–1541.

Post Author: 
Zagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti

Thursday, December 13, 2018

From the SIR Residents and Fellows Section (SIRRFS) Teaching Topic: Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis


de Bruijn AM, Smink M, Lohle PN, Huirne JA, Twisk JW, Wong C, Schoonmade L, Hehenkamp WJ. Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis. Journal of Vascular and Interventional Radiology. 2017 Oct 9.

Click here for abstract

This evidence-based review article evaluated the effect of uterine artery embolization (UAE) on symptom reduction in adenomyosis with respect to length of follow-up (< 12 months or >12 months) and whether patients had pure (adenomyosis alone) or combined (adenomyosis and fibroids) disease. The meta-analysis supported that uterine artery embolization (UAE) for both pure and combined adenomyosis resulted in significant short-term and long-term symptom improvement. There were limitations in that no randomized controlled trials were available, many included studies were retrospectively evaluated, many studies had a small sample size, and many studies offered vague description of methodology. As well, the sample size of most included studies was not sufficient to draw solid conclusions. This called for future trials to use standardized outcomes and validated questionnaires to render outcomes that can be extrapolated in systematic reviews.


Figure. Improvement of clinical symptoms (%).

Clinical Pearls


What is the pathophysiology of adenomyosis?

Adenomyosis defined as heterotopic endometrium in the myometrium and has diffuse, segmental, superficial, and deep forms. It is typically considered a disease of multiparous women in the late reproductive years. Though the etiology is still not well known, adenomyosis is thought to occur from either endomyometrial invagination of the endometrium or de novo from mullerian rests. There is also evidence that the junctional zone (JZ), which separates the subendometrial myometrium from the outer myometrium (appears as a dark band on T2WI), plays a role, as disease in the JZ predisposes to secondary infiltration of endomyometrial elements. Aside from older, multiparous women, JZ distortion can also be found in young, nulliparous women with heavy periods. A JZ > 12 mm is highly predictive of disease and < 8 mm essentially excludes it. Six studies in the meta-analysis reported a JZ reduction of 13.7%-38% after UAE. Smeets et al reported a thicker JZ at baseline to be a possible predictor of UAE failure in patients with adenomyosis. Patients who underwent hysterectomy owing to persisting symptoms compared with patients with clinical improvement showed a statistically significant thicker JZ at baseline (P = .028) and during 3 months (P = .034) of follow-up. Nijenhuis et al reported the mean JZ thickness at baseline not to be significantly thicker in groups with insufficient response (P = .17); however, it was statistically significant thicker in 4 patients needing additional therapy (P = .004).

What other gynecological pathologies are associated with adenomyosis?

Concurrent benign, estrogen-dependent gynecologic pathology, namely leiomyoma and endometriosis, is often present, increasing operative risks for major gynecologic surgery. There is also a known association between recurrent fetal loss and adenomyosis, though there is no direct evidence that adenomyosis is a risk factor for spontaneous abortion. The authors of this study state that in addition to the use of standardized outcomes and validated questionnaires, future trials should focus on fertility results in patients with symptomatic adenomyosis. Only two of the thirty-four studies in their meta-analysis reported fertility outcomes in terms of pregnancy outcome after UAE. Kim et al reported on 5 pregnancies. Two of these patients underwent elective abortion owing to unwanted pregnancies. The remaining three patients carried to term and showed no signs of uteroplacental vascular insufficiency or abnormal uterine contraction during labor or postpartum. The pregnancies resulted in 2 vaginal deliveries and 1 elective cesarean delivery because of previous cesarean delivery. The average weight of neonates was 3.2 kg (range, 3.1–3.4 kg). Yao et al described 1 pregnancy after UAE reporting termination of the pregnancy after 26 weeks. The reason for termination was not reported. Of 99 patients, 6 (6%) became pregnant after UAE. There is a paucity of high-quality data documenting the ability to conceive following UAE. Studies have reported between 48-59% live birth pregnancy rates, although the data is limited and influenced by age and current fertility status. Based on limited data, a discussion should take place with the patient about her fertility goals and a referral to a reproductive endocrinologist may also be helpful.

Why are symptoms of adenomyosis?

Though adenomyosis may be asymptomatic, it typically produces the symptoms of dysmenorrhea, dyspareunia, and chronic pelvic pain. These are also the most common symptoms of the other estrogen-dependent, benign gynecologic pathologies of endometriosis, leiomyoma, and endometrial polyp, which makes delineation of the symptoms profile difficult if the processes are concurrent. The included studies in this meta-analysis reported improvement of clinical symptoms in 83.1% (872 of 1,049) of patients. Only five of the thirty-four studies used the standardized Uterine Fibroid Symptom and Quality of Life (UFS-QOL; Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol 2002; 99:290–300) questionnaire to evaluate health-related quality of life (HRQOL) and symptom severity. This use of this questionnaire should be used in future trials to render outcomes that can be extrapolated in systematic reviews.

Question to Consider


What are complications of UAE?

There were 20 studies that reported on complications in 615 patients. Abdominal pain occurring directly following the procedure until 2 weeks after the procedure was described in 361 of 413 patients (87.4%). Persistent amenorrhea was reported in 28 of 445 patients (6.3%) in 13 studies. All of these patients were > 40 years of age. A pseudoaneurysm was reported, which was treated with a thrombin injection. Spontaneous expulsion of leiomyomata was reported in ten patients. Endometritis was suspected in four patients. These patients were treated with broad-spectrum antibiotics. Deep venous thrombosis of the calf occurred in one patient; however, this patient did not require anticoagulation therapy. No deaths or other complications occurred.

For pain control, patient controlled analgesia with IV morphine, meperidine, hydromorphone, or fentanyl is effective. Some interventionalists prefer epidural or oral administration of narcotics. UAE patients often suffer nausea post-procedure and require either prophylactic administration or, as needed, delivery of antiemetic such as odansetron. Anti-inflammatory agents such as IV ketorolac or oral ibuprofen periprocedurally or postoperatively are commonly used. Some physicians prefer administering steroids pre-procedurally, as well, to help limit post-embolization symptoms.

The risk of infection in UAE is low with reported rates of 0.2-1% of patients. Infection usually occurs in a delayed fashion, one to two weeks after the procedure. There have been several cases of fatal sepsis occurring after UAE in patients who did not receive prophylactic antibiotics. Currently, SIR recommends prophylaxis with a single dose of 1 mg Cefazolin IV as a common choice to cover typical organisms causing infection, including skin flora and E. Coli

1. Genc M, Genc B, Cengiz H. Adenomyosis and accompanying gynecological pathologies. Arch Gynecol Obstet 2015; 291:877–881.
Brosens JJ, de Souza NM, Barker FG. Uterine junctional zone: function and disease. Lancet 1995; 346:558.

3. Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol 2002; 99:290–300.

4. LoVerme W, James M, Ho Ahn S. “Patient Evaluation: Genitourinary System.” Patient Care in Vascular and Interventional Radiology. Third Edition. Society of Interventional Radiology, 2016. 99-111. Print.

Post Author:
Rajat Chand
Radiology Resident
John H. Stroger, Jr. Hospital of Cook County