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Comparison of first and second UAE for symptomatic uterine leiomyomas
JVIR
’
Scientific Session
Sunday
3:36 PM
Abstract No. 33
Comparison of first and second UAE for symptomatic uterine leiomyomas T. Katsumori1, H. Miura1, Y. Tsuji2, Y. Masuda1, T. Nishimura1; 1Saiseikai Shiga Hospital, Shiga, Japan; 2 Saiseikai Shiga Hospital, Shiga, Shiga Purpose: To compare the outcomes between first and second uterine artery embolization (UAE) for symptomatic uterine leiomyomas. Materials: This is a single-institute, retrospective study approved by the IRB. Between December 1997 and August 2015, 403 consecutive women with symptomatic uterine leiomyomas underwent UAE at our institute. Eleven of them underwent first and second UAE at our institute. Technical, MRI, and clinical outcomes were compared between first and second UAE. Primary endpoint was tumor infarction rate on contrast-enhanced MRI after UAE in both groups. Secondary endpoints were differences in angiographic findings, embolization, adverse events, and short-term clinical outcomes. Results: First UAE achieved technical and clinical success, with duration of symptom control that continued for more than 4 years in all women. Second UAE was successfully performed for recurrent uterine leiomyomas in the same women. The mean ages of the patients when they underwent first and second UAE were 37.7±4.6 y and 45.8±4.3y, respectively. Contrast-enhanced MRI one week after UAE demonstrated that the tumor infarction rates were significantly lower in the second UAE group, with a mean of 69.8±33.9% (range, 5 to 100%), compared to a mean of 95.1±6.3% (range, 80 to 100%) in the first UAE group (p¼0.034). Both uterine arteries (UA) were patent in all patients in the first UAE group, whereas one UA was occluded and one UA was not feeding the uterine tumor in the second UAE group (p¼0.49). There were significantly more collateral vessels (1.27/patient) in the second UAE group than those (0.18/patient) in the first UAE group (p¼0.045). Number of embolized collateral vessels were 0.09/patient in the first UAE group and 0.27/patient in the second UAE group (p¼0.341). No
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significant differences in uterine and dominant tumor reduction rates and symptom control 4 months after UAE were observed. Conclusions: Second UAE is efficient, but not as effective as first UAE in tumor infarction on contrast-enhanced MRI, which can affect mid- and long-term outcomes. Despite recanalization of most UA, more collateral vessels were observed in second UAE compared to those in first UAE.
3:45 PM
Abstract No. 34
How useful is adjunctive ketorolac for managing pain following uterine fibroid embolization?
M. McDermott1, E. Aaltonen2; 1New York University, New York, NY; 2NYU, New York, NY Purpose: To evaluate the adjunctive use of ketorolac, an intravenous (IV) anti-inflammatory medication, for managing pain following uterine fibroid embolization (UFE). Materials: This was a retrospective review of 59 patients who underwent UFE at a single institution over a 24-month period. Ketorolac administration and patient controlled analgesia (PCA) pump usage data were reviewed and cumulative ketorolac and IV opioid doses were recorded. Patient reported post-UFE pain on a 0-10 scale was also recorded. Statistical analysis using Mann-Whitney U, Pearson’s correlation, and multiple regression was then performed to determine effect of adjunctive ketorolac on PCA pump use and post-UFE pain score. Results: Pain management regimens following UFE often utilize a combination of IV opioid PCA with adjunctive IV ketorolac. In this study, 100% of patients received IV opioids via PCA and 83.1% (49/59) of patients received at least one 30 mg dose of ketorolac during the post-procedure period. Higher doses of ketorolac were not associated with reduced PCA pump use or lower pain scores. Instead, ketorolac dose had a moderate positive correlation with IV opioid dose (R¼0.417, p¼0.001) and a weak positive correlation with pain score (R¼0.280, p¼0.031). For example, higher doses of ketorolac (490 mg) were associated with increased PCA pump use and significantly higher IV opioid doses, 52.1 mg vs 26.8 mg (Mann-Whitney U¼569.5, p¼0.007). Ketorolac had no significant effect on pain scores, 5.0 vs 4.7 (ANOVA F¼0.629, p¼0.431) with univariate analysis. To control for the effect of PCA pump use and evaluate for a potential small but significant association of ketorolac with post-UFE pain, multiple regression analysis was performed and demonstrated statistical significance (F¼5.17, p¼0.009, R2¼0.156). However, ketorolac did not contribute significantly to the model (p¼0.263), whereas IV opioid dose did (p¼0.027). Conclusions: Although it is often recommended that intravenous anti-inflammatory medications such as ketorolac should be used after UFE as an adjunct to IV opioid PCA, this study suggests that this medication has no significant effect on post-UFE pain control. References 1. Spencer EB, Stratil P, Mizones H. Clinical and Periprocedural Pain Management for Uterine Artery Embolization. Seminars in Interventional Radiology. 2013;30(4):354-363. http://dx.doi.org/10.1055/s-0033-1359729. 2. Pron G, Mocarski E, Bennet J, et al. Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial. J Vasc Interv Radiol. 2003;14:1243-1250.
SUNDAY: Scientific Sessions
pathology reports and images available for review. The MRI reevaluation suggested 5 of these were highly likely to be malignant. Of those 5, 3 were confirmed malignant (0.35% of initial cohort), with the others benign. There was one uterine leiomyosarcoma, one adenosarcoma and one endometrioid carcinoma. The imaging re-evaluation did not miss any malignancies among the other 13 suspicious cases. However, among the 845 without suspicious MRI findings, there was at least one patient with a missed diagnosis of uterine leiomyosarcoma discovered 5 months after UAE. This observed frequency of uterine malignancy of 4 in 866 or 0.46% falls within the range of current FDA estimates of 0.2-0.29% for uterine malignancy among those presenting with symptomatic fibroids. MRI correctly diagnosed malignancies preoperatively in 3 of the 4 cases and to our knowledge only one malignancy was not detected prior to UAE (0.11%). Conclusions: Among our patients presenting for UAE, uterine malignancy was rare (0.46%), with the majority detected with MRI prior to UAE. MRI imaging may help detect uterine malignancy and reduce the risk of missed malignancy among patients with symptomatic uterine fibroids.
’
’
Scientific Session
Sunday
3:36 PM
Abstract No. 33
Comparison of first and second UAE for symptomatic uterine leiomyomas T. Katsumori1, H. Miura1, Y. Tsuji2, Y. Masuda1, T. Nishimura1; 1Saiseikai Shiga Hospital, Shiga, Japan; 2 Saiseikai Shiga Hospital, Shiga, Shiga Purpose: To compare the outcomes between first and second uterine artery embolization (UAE) for symptomatic uterine leiomyomas. Materials: This is a single-institute, retrospective study approved by the IRB. Between December 1997 and August 2015, 403 consecutive women with symptomatic uterine leiomyomas underwent UAE at our institute. Eleven of them underwent first and second UAE at our institute. Technical, MRI, and clinical outcomes were compared between first and second UAE. Primary endpoint was tumor infarction rate on contrast-enhanced MRI after UAE in both groups. Secondary endpoints were differences in angiographic findings, embolization, adverse events, and short-term clinical outcomes. Results: First UAE achieved technical and clinical success, with duration of symptom control that continued for more than 4 years in all women. Second UAE was successfully performed for recurrent uterine leiomyomas in the same women. The mean ages of the patients when they underwent first and second UAE were 37.7±4.6 y and 45.8±4.3y, respectively. Contrast-enhanced MRI one week after UAE demonstrated that the tumor infarction rates were significantly lower in the second UAE group, with a mean of 69.8±33.9% (range, 5 to 100%), compared to a mean of 95.1±6.3% (range, 80 to 100%) in the first UAE group (p¼0.034). Both uterine arteries (UA) were patent in all patients in the first UAE group, whereas one UA was occluded and one UA was not feeding the uterine tumor in the second UAE group (p¼0.49). There were significantly more collateral vessels (1.27/patient) in the second UAE group than those (0.18/patient) in the first UAE group (p¼0.045). Number of embolized collateral vessels were 0.09/patient in the first UAE group and 0.27/patient in the second UAE group (p¼0.341). No
S19
significant differences in uterine and dominant tumor reduction rates and symptom control 4 months after UAE were observed. Conclusions: Second UAE is efficient, but not as effective as first UAE in tumor infarction on contrast-enhanced MRI, which can affect mid- and long-term outcomes. Despite recanalization of most UA, more collateral vessels were observed in second UAE compared to those in first UAE.
3:45 PM
Abstract No. 34
How useful is adjunctive ketorolac for managing pain following uterine fibroid embolization?
M. McDermott1, E. Aaltonen2; 1New York University, New York, NY; 2NYU, New York, NY Purpose: To evaluate the adjunctive use of ketorolac, an intravenous (IV) anti-inflammatory medication, for managing pain following uterine fibroid embolization (UFE). Materials: This was a retrospective review of 59 patients who underwent UFE at a single institution over a 24-month period. Ketorolac administration and patient controlled analgesia (PCA) pump usage data were reviewed and cumulative ketorolac and IV opioid doses were recorded. Patient reported post-UFE pain on a 0-10 scale was also recorded. Statistical analysis using Mann-Whitney U, Pearson’s correlation, and multiple regression was then performed to determine effect of adjunctive ketorolac on PCA pump use and post-UFE pain score. Results: Pain management regimens following UFE often utilize a combination of IV opioid PCA with adjunctive IV ketorolac. In this study, 100% of patients received IV opioids via PCA and 83.1% (49/59) of patients received at least one 30 mg dose of ketorolac during the post-procedure period. Higher doses of ketorolac were not associated with reduced PCA pump use or lower pain scores. Instead, ketorolac dose had a moderate positive correlation with IV opioid dose (R¼0.417, p¼0.001) and a weak positive correlation with pain score (R¼0.280, p¼0.031). For example, higher doses of ketorolac (490 mg) were associated with increased PCA pump use and significantly higher IV opioid doses, 52.1 mg vs 26.8 mg (Mann-Whitney U¼569.5, p¼0.007). Ketorolac had no significant effect on pain scores, 5.0 vs 4.7 (ANOVA F¼0.629, p¼0.431) with univariate analysis. To control for the effect of PCA pump use and evaluate for a potential small but significant association of ketorolac with post-UFE pain, multiple regression analysis was performed and demonstrated statistical significance (F¼5.17, p¼0.009, R2¼0.156). However, ketorolac did not contribute significantly to the model (p¼0.263), whereas IV opioid dose did (p¼0.027). Conclusions: Although it is often recommended that intravenous anti-inflammatory medications such as ketorolac should be used after UFE as an adjunct to IV opioid PCA, this study suggests that this medication has no significant effect on post-UFE pain control. References 1. Spencer EB, Stratil P, Mizones H. Clinical and Periprocedural Pain Management for Uterine Artery Embolization. Seminars in Interventional Radiology. 2013;30(4):354-363. http://dx.doi.org/10.1055/s-0033-1359729. 2. Pron G, Mocarski E, Bennet J, et al. Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial. J Vasc Interv Radiol. 2003;14:1243-1250.
SUNDAY: Scientific Sessions
pathology reports and images available for review. The MRI reevaluation suggested 5 of these were highly likely to be malignant. Of those 5, 3 were confirmed malignant (0.35% of initial cohort), with the others benign. There was one uterine leiomyosarcoma, one adenosarcoma and one endometrioid carcinoma. The imaging re-evaluation did not miss any malignancies among the other 13 suspicious cases. However, among the 845 without suspicious MRI findings, there was at least one patient with a missed diagnosis of uterine leiomyosarcoma discovered 5 months after UAE. This observed frequency of uterine malignancy of 4 in 866 or 0.46% falls within the range of current FDA estimates of 0.2-0.29% for uterine malignancy among those presenting with symptomatic fibroids. MRI correctly diagnosed malignancies preoperatively in 3 of the 4 cases and to our knowledge only one malignancy was not detected prior to UAE (0.11%). Conclusions: Among our patients presenting for UAE, uterine malignancy was rare (0.46%), with the majority detected with MRI prior to UAE. MRI imaging may help detect uterine malignancy and reduce the risk of missed malignancy among patients with symptomatic uterine fibroids.
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