Incidence and changes in endometrial-leiomyoma fistula following uterine artery embolization: a single-center retrospective analysis.

OBJECTIVES: To investigate whether the number and size of endometrial-leiomyoma fistulas (ELFs) change following uterine artery embolization (UAE) for leiomyoma and the correlation between ELFs and vaginal discharge (VD). MATERIALS & METHODS: This study was a retrospective analysis of 100 patients who underwent UAE at a single institution between May 2016 and March 2021. They all underwent MRI at baseline, 4 months, and 1 year after UAE. The number and size of the ELFs were compared with the MRI images each time. The ELF tumor characteristics and the correlation between the ELFs and VD were assessed. Additional gynecologic interventions due to VD associated with ELFs were evaluated. RESULTS: No ELF was observed at baseline. Ten ELFs were noted in nine patients at 4 months, and 35 ELFs were noted in 32 patients 1 year after UAE. The ELFs significantly increased over time (p = 0.004, baseline vs. 4 months; p < 0.001, 4 months vs. 1 year). The ELF size did not significantly change over time (p = 0.941). The tumors developing ELFs after UAE were mainly located at the submucosal or intramural area contacting the endometrium at baseline, with a mean size of 7.1 (2.6) cm. Nineteen patients (19%) had VD 1 year after UAE. There was no significant correlation between VD and the number of ELFs (p = 0.80). No patients underwent additional gynecologic interventions due to VD associated with ELFs. CONCLUSION: ELFs increased in number and did not disappear over time after UAE in most tumors. CLINICAL RELEVANCE STATEMENT: Despite the MR imaging findings, within the limited data of this study, ELFs were not seemingly associated with clinical symptoms, including VD. KEY POINTS: • Endometrial-leiomyoma fistula (ELF) is a complication of uterine artery embolization (UAE). • ELFs increased in number over time after UAE and did not disappear in most tumors. • Most tumors developing ELFs after UAE were located near/contacted the endometrium and were larger.

Timing of Uterine Artery Embolization for Leiomyoma during the Menstrual Cycle.

PURPOSE: To investigate differences in outcomes of uterine artery embolization (UAE) for leiomyoma when performed during different phases of the menstrual cycle. MATERIALS AND METHODS: In this single-institution retrospective analysis, 111 premenopausal patients (median [range] age, 44 [33-52] years) undergoing UAE for symptomatic leiomyoma between June 2014 and February 2020 were included. Twenty-one patients underwent UAE in the menstrual phase (the early follicular phase), 27 in the late follicular phase, and 63 in the luteal phase. Baseline characteristics and technical and peri-procedural outcomes were compared among groups. Leiomyoma infarction on contrast-enhanced magnetic resonance imaging 1 week after UAE and 4-month outcomes, including changes in the Uterine Fibroid Symptom and Quality of Life questionnaire scores, the volume reduction rates of the uterus and largest leiomyoma, follicle stimulating hormone values, adverse events, and amenorrhea, were compared among groups. RESULTS: A 4-month follow-up was completed for all patients. No significant differences were observed among groups in baseline characteristics or technical and peri-procedural outcomes. There were no significant differences in the multivariate-adjusted 1-week infarction rates of all leiomyoma volumes (P = .161) or multivariate-adjusted 4-month outcomes, including changes in the Uterine Fibroid Symptom and Quality of Life questionnaire symptoms and total scores (P = .864 and P = .798, respectively), the volume reduction rates of the uterus and the largest leiomyoma (P = .865 and P = .965, respectively), and follicle stimulating hormone values (P = .186) among the groups. No significant differences were noted in the 4-month adverse events (P = .260) or amenorrhea (P = .793) among the groups. CONCLUSIONS: The present study demonstrated no significant differences in the outcomes of UAE for leiomyoma when performed during different phases of the menstrual cycle.

Intra-Arterial Lidocaine Administration for Anesthesia after Uterine Artery Embolization with Trisacryl Gelatin Microspheres for Leiomyoma.

PURPOSE: To evaluate whether administration of lidocaine into the uterine artery for anesthesia immediately after uterine artery embolization (UAE) with trisacryl gelatin microspheres (TAGM) for leiomyoma is safe and effective. MATERIALS AND METHODS: In a single-institution retrospective study, 100 patients underwent UAE using TAGM with a pruned tree endpoint between June 2014 and April 2019. The first 50 patients (control group) underwent UAE without lidocaine; in the second 50 patients (study group), lidocaine was administered into the uterine artery immediately after UAE. Baseline characteristics and technical and periprocedural outcomes were compared. Visual analog scale (VAS) scores 0, 3, 6, 9, 12, and 18 hours after UAE were compared between the groups with repeated measures analysis of variance. Each multivariate-adjusted VAS score < 24 hours was compared with analysis of covariance. RESULTS: No significant differences were observed in baseline characteristics or technical and periprocedural outcomes, including the volume of morphine used (P = .415), between the groups. No significant differences were found in crude or multivariate-adjusted VAS scores at each time point < 24 hours. Only the multivariate-adjusted VAS score 3 hours after UAE was 0.7 lower in the study group (mean ± SE, 2.2 ± 0.3 vs 2.9 ± 0.3); however, no significant difference was noted (P = .070). No adverse events associated with lidocaine were detected. CONCLUSIONS: Intra-arterial lidocaine administration immediately after UAE with TAGM for leiomyoma was safe, but did not contribute to significant reductions in pain or volume of narcotic agent administered.

Insufficient Leiomyoma Infarction in Uterine Artery Embolization: Relationship with Tumor Location.

PURPOSE: To evaluate which leiomyoma location in the uterus predicts insufficient tumor infarction after uterine artery embolization (UAE). MATERIALS AND METHODS: In this single-institution retrospective study, 45 patients (mean age, 43.4 y ± 4.1) underwent UAE for leiomyomas using trisacryl gelatin microspheres alone with "pruned-tree" endpoint performed by qualified interventional radiologists between October 2015 and July 2017. Technical outcomes and complications were assessed. All patients underwent unenhanced and enhanced MR imaging before and after UAE. A total of 476 tumors of ≥ 1 cm observed in all patients were evaluated. Multivariate generalized linear mixed model analysis was performed to investigate relationships between insufficient tumor infarction (< 90%) on contrast-enhanced MR imaging after UAE and baseline factors, including tumor location in the long-axis, front-back, and inner-outer directions and tumor size. RESULTS: All patients successfully underwent UAE with no major complications. Multivariate analysis revealed that there was a higher likelihood of insufficient infarction of tumors at the cervix (odds ratio [OR] 80.45; 95% confidence interval [CI] 9.97, 649.09; P < .001) and lower body (OR 4.31; 95% CI 2.52, 7.38; P < .001) than at the upper body and of tumors at the front than at the back wall (OR 2.20; 95% CI 1.32, 3.67; P = .002). Tumor size (OR 0.71; 95% CI 0.61, 0.82; P < .001) was a significant factor, whereas tumor location in the inner-outer direction was not. CONCLUSIONS: Insufficient leiomyoma infarction after UAE was more likely to involve tumors at the cervix, lower body, or front wall of the uterus or smaller tumors.

Volume of embolic agents in uterine artery embolization for leiomyoma: relation to baseline MRI.

PURPOSE: To assess whether pre-procedural MRI findings predict the volume of tris-acryl gelatin microspheres (TAGM) used in uterine artery embolization (UAE) for leiomyomas. MATERIAL AND METHODS: This was a retrospective, single-institution study. Between June 2014 and December 2017, 73 patients with leiomyomas underwent UAE with TAGM alone. Univariate and multivariate analyses were performed to assess the relationships between the volume of TAGM and baseline parameters. Technical outcomes, tumor infarction on post-procedural contrast-enhanced MRI, and complications were evaluated. RESULTS: Technical success was achieved in all patients. Infarction of ≥90% of the total leiomyoma volume was observed in 93% (67/72) of patients. No major complications were noted. The mean (SD) volume of 500- to 700-µm particles used in all (73/73) patients was 10.3 ± 4.6 ml. The multivariate analysis revealed that uterine volume (p = .034) correlated with the 500- to 700-µm TAGM volume. Seven hundred- to 900-µm particles were added for 70% (51/73) of patients at a mean (SD) volume of 3.6 ± 4.6 ml. The dominant tumor volume (p = .028) correlated with the 700- to 900-µm TAGM volume. CONCLUSION: The dominant tumor or uterine volume on pre-procedural MRI was directly associated with the volume of TAGM required for embolization of leiomyomas.

[Subarachnoid Hemorrhage of Unknown Origin at Initial Imaging Investigation].

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

First Versus Second Uterine Artery Embolization for Symptomatic Leiomyoma.

OBJECTIVE: The purpose of this study was to compare the outcomes of second uterine artery embolization (UAE) with those of first UAE for symptomatic uterine leiomyoma. MATERIALS AND METHODS: In this single-institution retrospective study, between December 1997 and May 2016 first UAE was performed on 423 consecutively registered patients and second UAE on 11 consecutively registered patients to treat leiomyoma. The primary endpoint was infarction of all tumor tissue as seen at postprocedural contrast-enhanced MRI. The secondary endpoints were angiographic findings, embolization, MRI, and clinical outcomes 1 year after UAE. The outcomes were compared between the two groups. Multivariable linear regression analysis was performed to assess independent correlations with tumor infarction. RESULTS: Most of the baseline demographic features and technical outcomes in the two groups were similar. In the second UAE group, all but one uterine artery was reopened. More collateral vessels were observed at the second UAE (1.1/patient versus 0.23/patient, p = 0.043). Contrast-enhanced MRI after UAE revealed that the tumor infarction rate was significantly lower in the second UAE group (69.8 ± 33.9% vs 96.8 ± 9.0%, p = 0.025). The difference remained significant after adjustments for possible confounders (p < 0.001). Whether UAE was a first or a second procedure was significantly associated with tumor infarction rate (p < 0.001). The uterine volume reduction rate 1 year after UAE was significantly lower in the second UAE group (33.4 ± 18.1% versus 46.9 ± 16.6%, p = 0.008). No other 1-year outcomes were significantly different between the groups. CONCLUSION: Second UAE was effective but inferior to first UAE in that it resulted in less tumor infarction at contrast-enhanced MRI and had a lower uterine volume reduction rate.

Tris-acryl gelatin microspheres versus gelatin sponge particles in uterine artery embolization for leiomyoma.

Background Tris-acryl gelatin microspheres (TAGM) and gelatin sponge particles (GS) have been used in uterine artery embolization (UAE) for leiomyoma. No direct comparisons of both embolic agents have been reported. Purpose To compare the outcomes of UAE with TAGM with those of UAE with GS for uterine leiomyoma. Material and Methods This was a non-randomized, single-institute, non-inferiority study. Between July 2008 and August 2015, 67 consecutive patients with symptomatic leiomyoma underwent UAE. GS was used for the first 49 patients and TAGM was used for the following 18 patients. The primary endpoint was tumor infarction on contrast-enhanced magnetic resonance imaging (MRI) 1 week after UAE. The secondary endpoints were changes in symptoms and quality-of-life scores with UFS-QOL questionnaires at 4 months, and adverse events (AEs) in the 4 months after UAE. Results The baseline characteristics of both groups were similar. Complete or nearly complete tumor infarction (≥90%) was achieved in 94.4% (17/18) of the TAGM group and 93.6% (44/47) of the GS group. This difference (0.8%; 95% CI, -11.9% to 13.5%) indicated the non-inferiority of the TAGM group to the GS group, with a pre-specified non-inferiority margin of 20%. No significant differences were observed in improvements in symptoms or quality-of-life scores at 4 months ( P = 0.56 and P = 0.19) or in 4-month AEs ( P = 0.29). Conclusion The outcomes of UAE with TAGM were comparable to those of UAE with GS, suggesting that both embolic agents are acceptable for the treatment of leiomyoma.

Hemoptysis due to a lung metastasis of renal cell carcinoma: A case report.

A 53-year-old man with a history of surgery for renal cancer was referred to our hospital due to massive hemoptysis. Contrast-enhanced CT revealed a well-enhanced pulmonary nodule suggestive of a tumor (diameter of 16 mm), which was considered a causal lesion. Bronchial artery embolization was successfully performed and subsequently hemoptysis disappeared. However, hemoptysis recurred 6 months later, and the tumor was surgically resected. Pathological examination revealed the resected tumor was a lung metastasis of renal cell carcinoma, which directly invaded into pulmonary bronchus. Hemoptysis secondary to lung metastasis of renal cell carcinoma has rarely been reported in the literature.

Sunitinib maleate administration before percutaneous CT-guided cryoablation for large renal cell carcinoma: A case report.

A 60-year-old woman taking anti-platelet drugs was referred to the hospital for the treatment of advanced renal cell carcinoma. CT revealed that the tumor had a diameter of 5 cm and hyper-vascularity. Percutaneous CT-guided cryoablation (CA) was indicated. Since preprocedural arterial embolization failed to provide sufficient embolic effects, sunitinib maleate was administered. It provided good tumor devascularization and volume reduction, which corresponded to downstage. Therefore, the administration contributed to successfully performing subsequent percutaneous CT-guided CA with no serious hemorrhagic complications. Sunitinib maleate may be an alternative to conventional treatments before CA for renal cell carcinoma.

Uro-lymphatic fistula associated with urolithiasis: A case report.

Uro-lymphatic fistulas are rare, and involve communication between the renal collecting system and the lymphatic system. The disorder is usually caused by the obstruction of lymphatic vessels due to several diseases, leading to chyluria. Here, we report the case of a patient with a uro-lymphatic fistula, considered to be associated with urolithiasis.

Posterior lumbar subcutaneous edema as the rare sign of IgA vasculitis (Henoch-Schönlein purpura): A case of a child.

Posterior lumbar subcutaneous edema (PLSE) is often found on MRI in adults with obesity or various lumbar conditions. We report a case of a 6-year-old boy with IgA vasculitis (Henoch-Schönlein purpura) along with PSLE observed on CT and MRI. The finding is markedly rare in patients with IgA vasculitis, with only limited cases previously reported in the literature. The edema was symmetrically localized along the erector spine muscle with a smooth margin. These findings differed from the irregularly accumulated edema observed in some adult cases. PLSE should not be overlooked as a nonspecific finding. When symmetrical and circumscribed PLSE is found in children, IgA vasculitis should be added to differential diagnosis in PLSE.

Transcatheter arterial embolization for a symptomatic Tarlov cyst with hemorrhage due to an underlying arteriovenous fistula.

Symptomatic sacral perineural cysts (Tarlov cysts) accompanied by intra-cyst hemorrhage are rare. The treatment strategies have not been established. We report a 57-year-old woman with severe back pain due to a Tarlov cyst accompanying intracyst hemorrhage. Computed tomography angiography revealed an arteriovenous fistula (AVF) at the area surrounding the cyst. The patient underwent transcatheter arterial embolization for the AVF. Thereafter, the hematoma and cyst decreased in size, and clinical symptoms markedly improved with no additional surgery. Transcatheter arterial embolization may be an effective alternative to surgery for Tarlov cysts with vascular disease, including AVF.

An unusual presentation of usual-type endocervical adenocarcinoma with lobular endocervical glandular hyperplasia: A case report.

Uterine cervical hematoma is rare. A 51-year-old woman underwent pelvic magnetic resonance imaging (MRI) for uterine tumor survey. A large hematoma with cystic and solid lesions was observed in the uterine cervix. Follow-up MRI after 5 days revealed that the hematoma had decreased in volume. Pathological examination after surgery suggested there was usual-type endocervical adenocarcinoma (UEA) in the lower cervix and lobular endocervical glandular hyperplasia (LEGH) in the upper cervix, along with the cervical hematoma. The findings of this case suggest that the uterine cervical hematoma was secondary to either UEA or LEGH.

Definitive Radiotherapy for Penoscrotal Extramammary Paget's Disease: A Case Report with Long-Term Follow-Up.

Penoscrotal extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma in older male patients, and no effective nonsurgical treatment strategies are currently available. The aim of this study was to report the usefulness of external radiotherapy (RT) for penoscrotal EMPD in an inoperable elderly patient. This report presents the treatment of an 89-year-old man with widespread penoscrotal EMPD. A multidisciplinary treatment team decided on radical RT. The patient received a radiation dose of 61.8 Gy in 30 fractions through electron and photon beams. His treatment tolerance was good, and no severe toxicity had been observed up the last follow-up. At 6.5 years after the RT, the patient showed no evidence of recurrence. Definitive RT resulted in excellent disease control and minimal toxicity; thus, it could be a promising nonsurgical therapeutic option for penoscrotal EMPD, even in extremely elderly individuals.

Organized Chronic Subdural Hematoma Treated with Middle Meningeal Artery Embolization and Small Craniotomy: Two Case Reports.

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

Ice Ball Cracks on CT During Cryoablation for Renal Tumors: A Retrospective Analysis.

PURPOSE: To evaluate the frequency of ice ball cracks on CT during cryoablation of renal tumors and assess the severity of hemorrhagic complications associated with this finding. MATERIALS AND METHODS: Between March 2014 and March 2019, 130 patients underwent CT-guided cryoablation using cryoprobes with a diameter of 1.5 mm for 138 renal tumors (mean diameter, 23.6 mm; standard deviation [SD], 7.5; range, 8.3-43). Two blinded board-certified radiologists retrospectively reviewed the presence of cracks on CT obtained during the procedure. The incidence of major hemorrhage and changes in hemoglobin levels after cryoablation were examined. Factors influencing the appearance of ice ball cracks were assessed with multivariate analyses. RESULTS: Cracks were observed in 25 of the138 procedures (18%). Inter-reader reliabilities with kappa statistics were 0.90 and 0.84 for first and second freeze sessions, respectively. There were no major hemorrhagic events requiring blood transfusion or arterial embolization. Mean (± SD) decreases in hemoglobin levels between pre- and postoperative day 1 were 1.15 ± 0.86 g/dl in the cracks group and 1.01 ± 0.80 g/dl in the no cracks group with no significant difference (p = 0.14). Multivariate analyses identified a higher number of cryoprobes (odds ratio, 4.1; 95% confidence interval [CI] 1.7-11; p = 0.001) and no hydrodissection (odds ratio 6.7; 95% CI 2.1-28; p < 0.001) as factors associated with ice ball cracks. CONCLUSION: Ice ball cracks were frequently observed on CT during cryoablation for renal tumors and were seemingly self-limiting events requiring no intervention.

Susceptibility weighted MRI after uterine artery embolization for leiomyoma.

PURPOSE: To evaluate whether susceptibility-weighted MR imaging (SWI) findings are associated with tumor infarction on contrast-enhanced MRI (CE-MRI) after uterine artery embolization (UAE) for leiomyoma. METHODS: This was a single institution, retrospective study. Between February 2016 and April 2017, 27 consecutive patients underwent UAE and completed SWI and CE-MRI before and 1 week after UAE. Two blinded readers independently reviewed the MRI of 261 tumors ≥1 cm in all patients. We evaluated the relationship between the hypointense peripheral rim observed on the tumor surface on post-procedural SWI and the infarction rates (≥90%, <90%) of each tumor based on post-procedural CE-MRI. Inter-reader correlation coefficients (ICC) and the sensitivity and specificity of the rim were measured. RESULTS: Substantial inter-reader agreement was noted in post-procedural SWI interpretations (ICC = 0.681, 95% CI; 0.547, 0.771). The rim was observed in 66.7% (174/261) of tumors by reader 1 and 55.9% (146/261) of tumors by reader 2 on post-procedural SWI. Correlations were observed between the rim and ≥90% tumor infarction by readers 1 and 2 (Spearman's coefficient = 0.474 and 0.438, p < 0.001 and p < 0.001, respectively). The sensitivity and specificity of the rim to tumor infarction were 77.2 and 82.6% (reader 1), and 65.8 and 100% (reader 2), respectively. CONCLUSIONS: The present study demonstrated that the hypointense peripheral rim was observed on some leiomyomas on SWI immediately after UAE. The rim correlated with tumor infarction on post-procedural CE-MRI. This SWI finding was helpful for evaluating embolic effects on leiomyomas in the acute phase after UAE.