Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center: A Retrospective Cohort Study.

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE.

Delirium and Coronavirus Disease 2019: Looking Back, Moving Forward.

During the coronavirus disease 2019 pandemic, crisis changes in clinical care increased rates of delirium in the intensive care unit (ICU). Deep sedation, unfamiliar environments with visitor restrictions, and such factors due to high workload and health system strain contributed to the occurrence of delirium doubling in the ICU. As the pandemic wanes, health care systems and ICU leadership must emphasize post-pandemic recovery, integrating lessons learned about delirium management, evidence-based care, and family involvement. Strategies to empower clinicians, creatively deliver care, and integrate families pave the way forward for a more holistic approach to patient care in the post-pandemic era.

Patient Experiences With a Multidisciplinary Fibroid Program.

STUDY OBJECTIVE: Although medical, interventional, and surgical treatment options for fibroids have expanded over the last decade, many patients are not thoroughly counseled about all available therapies. Patients desire a more comprehensive approach with shared decision-making tailored to their health goals. The aim of this study is to assess patient knowledge regarding treatment options before and after consultation with a multidisciplinary fibroid center. DESIGN: Prospective survey study. SETTING: Academic medical center in New York, NY. PATIENTS AND PARTICIPANTS: Patients who presented for initial consultation with a multidisciplinary fibroid program from July 2021 through January 2022. INTERVENTIONS: Patients were offered same-day office consultation with a minimally invasive gynecologic surgeon (MIGS) followed by a telemedicine visit with an interventional radiologist (IR) within 3 weeks of the appointment request. Collaborative discussions were held between providers regarding patient care. Patients were asked to complete the survey following both appointments. Data was collected regarding demographics, prior evaluation of fibroids, knowledge about treatment options, and overall experience. RESULTS: A total of 102 patients completed the survey (response rate 77%). A majority (55.9%) had known about their fibroids for at least 2 years. Most patients sought out the fibroid program for a 2nd (28.4%), 3rd (22.5%) or 4th (7.8%) opinion. Notably, 35.3% of patients who had previously been seen by an obstetrician-gynecologist (OB/GYN) were not offered any treatment. Of those who had been offered treatment, 24.5% were counseled on medical management with oral contraceptives, 28.4% on surgical options, and 5.9% on uterine artery embolization. Nearly all patients (86.3%) endorsed that they would not have sought 2 separate consultations had it not been for the program. Patients were overall well-informed after their experience, with 95.1% reporting they were more knowledgeable about their options and none reporting the 2 separate consults created more confusion for them. CONCLUSION: Many patients with symptomatic fibroids seeking secondary opinions have not been adequately counseled on fibroid management options. A collaborative approach to fibroid management better educates patients, provides an opportunity to be thoroughly counseled by the specialists performing either surgical or interventional procedures, and increases patient knowledge about fibroid treatment options.

MRI-guided focused ultrasound focal therapy for patients with intermediate-risk prostate cancer: a phase 2b, multicentre study.

BACKGROUND: Men with grade group 2 or 3 prostate cancer are often considered ineligible for active surveillance; some patients with grade group 2 prostate cancer who are managed with active surveillance will have early disease progression requiring radical therapy. This study aimed to investigate whether MRI-guided focused ultrasound focal therapy can safely reduce treatment burden for patients with localised grade group 2 or 3 intermediate-risk prostate cancer. METHODS: In this single-arm, multicentre, phase 2b study conducted at eight health-care centres in the USA, we recruited men aged 50 years and older with unilateral, MRI-visible, primary, intermediate-risk, previously untreated prostate adenocarcinoma (prostate-specific antigen ≤20 ng/mL, grade group 2 or 3; tumour classification ≤T2) confirmed on combined biopsy (combining MRI-targeted and systematic biopsies). MRI-guided focused ultrasound energy, sequentially titrated to temperatures sufficient for tissue ablation (about 60-70°C), was delivered to the index lesion and a planned margin of 5 mm or more of normal tissue, using real-time magnetic resonance thermometry for intraoperative monitoring. Co-primary outcomes were oncological outcomes (absence of grade group 2 and higher cancer in the treated area at 6-month and 24-month combined biopsy; when 24-month biopsy data were not available and grade group 2 or higher cancer had occurred in the treated area at 6 months, the 6-month biopsy results were included in the final analysis) and safety (adverse events up to 24 months) in all patients enrolled in the study. This study is registered with ClinicalTrials.gov, NCT01657942, and is no longer recruiting. FINDINGS: Between May 4, 2017, and Dec 21, 2018, we assessed 194 patients for eligibility and treated 101 patients with MRI-guided focused ultrasound. Median age was 63 years (IQR 58-67) and median concentration of prostate-specific antigen was 5·7 ng/mL (IQR 4·2-7·5). Most cancers were grade group 2 (79 [78%] of 101). At 24 months, 78 (88% [95% CI 79-94]) of 89 men had no evidence of grade group 2 or higher prostate cancer in the treated area. No grade 4 or grade 5 treatment-related adverse events were reported, and only one grade 3 adverse event (urinary tract infection) was reported. There were no treatment-related deaths. INTERPRETATION: 24-month biopsy outcomes show that MRI-guided focused ultrasound focal therapy is safe and effectively treats grade group 2 or 3 prostate cancer. These results support focal therapy for select patients and its use in comparative trials to determine if a tissue-preserving approach is effective in delaying or eliminating the need for radical whole-gland treatment in the long term. FUNDING: Insightec and the National Cancer Institute.

Intraprocedural uterine position reorientation during uterine fibroid embolization: a case report.

Uterine Fibroid Embolization is an effective method of treating uterine fibroids as an alternative to surgery. Positional changes of the uterus secondary to pregnancy, pelvic surgery, urinary retention, endometriosis and fibroids have all been reported, however, no literature has specifically described the uterus incidentally changing position during uterine fibroid embolization. We present a unique case of uterine reorientation during a uterine fibroid embolization procedure.

Percutaneous evacuation of anterior abdominal wall hematomas using catheter-based mechanical thrombectomy.

Post-operative hematoma is a common surgical complication, often treated conservatively. However, persistent, recurrent or symptomatic hematomas may require percutaneous or surgical drainage. The authors present two cases of persistent post-surgical hematomas which were successfully evacuated in a single-setting using a percutaneous mechanical thrombectomy system.

Varicocele Embolization: Patient Selection: Preprocedure Workup, and Technical Considerations.

Varicocele refers to an abnormally dilated and tortuous pampiniform venous plexus within the spermatic cord. The prevalence of varicocele is reported to be approximately 15% in the general male population. Its incidence increases with age and has a higher incidence in infertile men. Varicocele treatment (surgical or interventional) is considered one of the most common therapies of reversible infertility in men. Percutaneous embolization offers nonsurgical, minimally invasive option for the treatment of varicoceles, requiring only minimal sedation. In this article, the authors review the clinical and technical details of percutaneous varicocele embolization with a summary of currently available evidence.

Combination uterine artery embolization and hysteroscopic resection for a symptomatic uterine leiomyoma: A collaborative single-session approach for better patient care.

Uterine artery embolization (UAE) for symptomatic uterine fibroids is accompanied by transcervical fibroid expulsion in 3-15% of cases. It can be a source of significant patient distress, may require reintervention for removal, and is the most common reason for hospital readmission following UAE. Conversely, the success of hysteroscopic resection decreases with increasing fibroid size while the risk of complications increases. Because certain fibroid features identifiable on preoperative imaging predict need for eventual hysteroscopic resection, it is possible to prospectively identify such patients and employ an alternative management strategy. We present such an approach, illustrated in the case of a woman with a pedunculated broad-based uterine fibroid successfully managed via combination UAE and immediate hysteroscopic resection.

Incidental sonographic detection of bladder cancer in a woman with large uterine fibroids: significance and lessons learned.

Uterine leiomyomas are the most common solid pelvic tumors in pre-menopausal women and typically present with abnormal uterine bleeding and/or symptoms of mass effect. A potential consequence of the space-occupying nature of these lesions is the decreased sensitivity for the detection of adjacent pelvic pathology, which can be particularly problematic given the overlap in symptoms between fibroids and other pelvic disease. We present the case of a woman with a large uterine fibroid who had multiple imaging evaluations before undergoing uterine fibroid embolization and on immediate follow-up sonography was discovered to have early-stage bladder cancer.

Integrative Molecular Analysis of Patients With Advanced and Metastatic Cancer.

PURPOSE: We developed a precision medicine program for patients with advanced cancer using integrative whole-exome sequencing and transcriptome analysis. PATIENTS AND METHODS: Five hundred fifteen patients with locally advanced/metastatic solid tumors were prospectively enrolled, and paired tumor/normal sequencing was performed. Seven hundred fifty-nine tumors from 515 patients were evaluated. RESULTS: Most frequent tumor types were prostate (19.4%), brain (16.5%), bladder (15.4%), and kidney cancer (9.2%). Most frequently altered genes were TP53 (33%), CDKN2A (11%), APC (10%), KTM2D (8%), PTEN (8%), and BRCA2 (8%). Pathogenic germline alterations were present in 10.7% of patients, most frequently CHEK2 (1.9%), BRCA1 (1.5%), BRCA2 (1.5%), and MSH6 (1.4%). Novel gene fusions were identified, including a RBM47-CDK12 fusion in a metastatic prostate cancer sample. The rate of clinically relevant alterations was 39% by whole-exome sequencing, which was improved by 16% by adding RNA sequencing. In patients with more than one sequenced tumor sample (n = 146), 84.62% of actionable mutations were concordant. CONCLUSION: Integrative analysis may uncover informative alterations for an advanced pan-cancer patient population. These alterations are consistent in spatially and temporally heterogeneous samples.

Percutaneous drainage of an infected endometrioma.

Endometrioma superinfection is uncommon and poorly described in the literature. This rarity has precluded agreement on optimal management, with most authors treating these lesions as endometriomas rather than abscesses and thus recommending laparoscopic or open cystectomy or oophorectomy. We present a minimally-invasive alternative, illustrated in the case of an infected endometrioma which was successfully managed via image-guided percutaneous drainage.

Percutaneous Orthotopic IVC Construction in a Pediatric Patient with Symptomatic IVC Agenesis.

Inferior vena cava agenesis is an uncommon condition usually attributed to embryologic dysgenesis. When symptomatic, unprovoked deep venous thrombosis and/or lower extremity venous congestion are the most frequent manifestations. Its rarity has precluded consensus regarding appropriate management. Symptomatic chronic venous congestion requires surgical construction of auxiliary venous pathways, which may involve substantial morbidity, prolonged recovery and extensive scarring. We report successful minimally invasive management via percutaneous endovascular orthotopic inferior vena cava construction in a pediatric patient, thereby obviating the need for surgery and its associated morbidity. LEVEL OF EVIDENCE: Level IV, case study.

Bone biopsy protocol for advanced prostate cancer in the era of precision medicine.

BACKGROUND: Metastatic biopsies are increasingly being performed in patients with advanced prostate cancer to search for actionable targets and/or to identify emerging resistance mechanisms. Due to a predominance of bone metastases and their sclerotic nature, obtaining sufficient tissue for clinical and genomic studies is challenging. METHODS: Patients with prostate cancer bone metastases were enrolled between February 2013 and March 2017 on an institutional review board-approved protocol for prospective image-guided bone biopsy. Bone biopsies and blood clots were collected fresh. Compact bone was subjected to formalin with a decalcifying agent for diagnosis; bone marrow and blood clots were frozen in optimum cutting temperature formulation for next-generation sequencing. Frozen slides were cut from optimum cutting temperature cryomolds and evaluated for tumor histology and purity. Tissue was macrodissected for DNA and RNA extraction, and whole-exome sequencing and RNA sequencing were performed. RESULTS: Seventy bone biopsies from 64 patients were performed. Diagnostic material confirming prostate cancer was successful in 60 of 70 cases (85.7%). The median DNA/RNA yield was 25.5 ng/µL and 16.2 ng/µL, respectively. Whole-exome sequencing was performed successfully in 49 of 60 cases (81.7%), with additional RNA sequencing performed in 20 of 60 cases (33.3%). Recurrent alterations were as expected, including those involving the AR, PTEN, TP53, BRCA2, and SPOP genes. CONCLUSIONS: This prostate cancer bone biopsy protocol ensures a valuable source for high-quality DNA and RNA for tumor sequencing and may be used to detect actionable alterations and resistance mechanisms in patients with bone metastases. Cancer 2018;124:1008-15. © 2017 American Cancer Society.