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Once
the diagnosis of the fibroid tumors is established, other
treatment options for fibroid tumors include:
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Observation
The “wait and see”
approach is recommended for women who are not suffering symptoms
of fibroid disease and who have not developed anemia from heavy
menstrual bleeding. Since fibroids generally continue to grow
until menopause, women without symptoms should continue to
undergo regular gynecological follow up.
+ Medical
Therapy
There are a number of
drugs that can be used for the treatment of fibroids. Including:
- Birth-control pills
- Progestins (e.g., Megace)
- GnRH analogues (e.g., Lupron)
In addition, nonsteroidal anti-inflammatory drugs (e.g., Motrin)
can also be helpful in controlling many of the symptoms caused
by fibroids. GnRH agonists (e.g., Lupron ®) are most often used
as a temporizing measure to avoid transfusion. If these
therapies are unsuccessful, UFE or surgical approaches such as
endometrial ablation, myolysis, myomectomy or hysterectomy are
often performed.
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MR guided focused (ExAblate)
+ MR guided focused
Ultrasound (ExAblate)
A novel and non-invasive image-guided surgery
(with permission from
InSightec -
www.insightec.com)
Focused Ultrasound
The ultrasound is focused in a manner similar to how a magnifying
glass focuses light. The ultrasound waves are directed from a transducer
(a device that converts electrical energy into ultrasound energy) into a small
focal volume. During treatment, the beam of focused ultrasound energy
penetrates through soft tissue and produces well defined regions of protein
denaturation, irreversible cell damage, and coagulative necrosis, at specific
target locations. A single exposure of focused ultrasound energy is called
a “sonication.” Multiple sonications are necessary to ablate the targeted
tissue. Tight focusing is designed to limit the ablation to the targeted
location.
MR guidance
Prior to the treatment, anatomical
MR images, capable of showing the tumor and surrounding organs, are used to
position the patient and plan the treatment. As the treatment is
performed, the MR thermal mapping system displays the relative tissue
temperature as a color map superimposed on an anatomical MR image. This
allows the physician to observe temperature changes inside the body in real time
during treatment. Based on these observed temperature changes, the
physician can adjust treatment parameters accordingly to ensure safe and
effective thermal ablation. Following the treatment, anatomical MR images
are used to evaluate treatment outcome. T1 weighted images with Gadolinium
contrast agent is often used to determine which regions have become ablated
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Click for a larger image |
The patient lies in the prone position on a patient table inside the MRI
during the treatment.
(Courtesy of InSightec). |
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Focused ultrasound waves are directed towards the fibroid. During each
“sonification” (dose of focused ultrasound), a small volume of the fibroid
is ablated. After multiple sonifications the entire fibroid is ablated.
Focused ultrasound generates heat, ablating tissue only at the
focal point. The effect is similar to a magnifying glass used to focus the
sun’s energy on a single point
(Courtesy of InSightec).
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Click for a larger image |
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The figure on the left of a sagittal T2-weighted MR image clearly shows
the presence of multiple fibroids (red circles) in the uterus (blue
circle) in front of spine (arrow lines)
(Courtesy of InSightec).
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+ MR Guided Focused Ultrasound (ExAblate) clinical results
FDA approval is based on the results of a multi-national trial
conducted in 109 women with symptomatic uterine fibroids at seven medical
centers around the world. After six months, 92 % of the women
reported a significant improvement in fibroid related symptoms. The study
compared the results of ExAblate treatment with total abdominal hysterectomy.
Patients treated with the ExAblate missed 1.4 working days, on average compared
to an average of 18 days for the hysterectomy group. They returned to normal
activity in less than three days, compared to 17 days for the hysterectomy
group. Adverse events, while rare, included minor skin burns and a few instances
of nerve injury, all of which resolved within one year.
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A coronal view of pelvic MRI during ExAblate treatment shows the fibroid
(blue colored) being targeted for MRgFUS
(Courtesy of InSightec).
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Click for a larger image
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A coronal view of contrast enhanced pelvic MRI after ExAblate treatment on
the same patient above shows necrosis (dark area due to no blood supply
caused by the treatment) (Courtesy of InSightec).
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+ Benefits of ExAblate (MR guided Focused Ultrasound) Treatment
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Incisionless thermal
ablation of soft tissue.
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Integrated MR imaging
for treatment planning.
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Real time
visualization, monitoring, and control of treatment.
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No ionizing
radiation, means repeatable treatments.
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Many potential
applications.
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A sagittal view of pelvic MRI (T2-weighted) on another patient showed a
large fibroid in the uterus
(Courtesy of Sheba Medical Center, Tel Aviv, Israel)..
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Click for a larger image |
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A contrast enhance sagittal view of pelvic MRI on the same patient
one month after ExAblate treatment shows necrosis (dark area in the
uterus) of the fibroid with some shrinkage
(Courtesy of Sheba Medical Center, Tel Aviv, Israel).. |
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Another follow-up contrast enhanced pelvic MRI of the same patient above
(36 months after treatment) shows persistent necrosis (dark area due
to no blood supply) of the fibroid with further tumor shrinkage
(Courtesy of Sheba Medical Center, Tel Aviv, Israel). |
Click for a larger image |
+ Surgery
+ Myomectomy
Myomectomy is a
surgical procedure that involves removing the fibroids and
repairing the uterus as much as possible. Depending on the
location and size of the fibroids, myomectomy can be performed
through an incison made in the abdomen (Lapartomy),
through a laparoscope (Laparoscopic myomectomy), or through a
hysteroscope (Hysteroscopic myomectomy). The fibroids that are
located deep in the walls of uterus cannot be removed by
myomectomy. Fibroids may recur in 20-40% of cases, and
more surgery may be needed. Myomectomy is often recommended
for woman who wants to keep her uterus and maintain their
child bearing potential. However, myomectomy can cause
internal scarring resulting in infertility.
Although myomectomy has been the standard
therapy for women with fibroids who desire future fertility,
UFE can be considered as an option if myomectomy seems
unfavorable or patients strongly desire to avoid surgery.
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Hysterectomy
Hysterectomy, or
removal of the uterus, is a major surgical procedure, and is
performed through an incision in the abdomen or through the
vagina. General anesthesia is usually used for the operation
and the patient stays in the hospital for a few days after the
surgery. Hysterectomy is the most
frequent operation performed on woman.
After a hysterectomy, a woman no
longer has periods and is unable to become pregnant.
Hysterectomy for uterine fibroids should be reserved for
patients who do not respond to, who cannot tolerate medical
therapy, and who do not desire future fertility. For those
patients who desire future fertility, myomectomy or other
alternatives such as UFE should be considered .
+ Myolysis
Myolysis is a
laparoscopic procedure in which electric current is applied
repeatedly to each fibroid. This coagulates both the tumor and
its blood supply. The fibroid dies, shrinks in size and is
incapable of growing again. This approach is best used either
alone or in combination with laparoscopic myomectomy when
multiple fibroids are encountered.
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