The Focused Ultrasound Myoma Outcome Study (FUMOS); a retrospective cohort study on long-term outcomes of MR-HIFU therapy.

OBJECTIVES: Since 2004, uterine fibroids have been treated with MR-HIFU, but there are persevering doubts on long-term efficacy to date. In the Focused Ultrasound Myoma Outcome Study (FUMOS), we evaluated long-term outcomes after MR-HIFU therapy, primarily to assess the reintervention rate. METHODS: Data was retrospectively collected from 123 patients treated with MR-HIFU at our hospital from 2010 to 2017. Follow-up duration and baseline (MRI) characteristics were retrieved from medical records. Treatment failures, adverse events, and the nonperfused volume percentage (NPV%) were determined. Patients received a questionnaire about reinterventions, recovery time, satisfaction, and pregnancy outcomes. Restrictive treatment protocols were compared with unrestrictive (aiming for complete ablation) treatments. Subgroups were analyzed based on the achieved NPV < 50 or ≥ 50%. RESULTS: Treatment failures occurred in 12.1% and the number of adverse events was 13.7%. Implementation of an unrestrictive treatment protocol significantly (p = 0.006) increased the mean NPV% from 37.4% [24.3-53.0] to 57.4% [33.5-76.5]. At 63.5 ± 29.0 months follow-up, the overall reintervention rate was 33.3% (n = 87). All reinterventions were performed within 34 months follow-up, but within 21 months in the unrestrictive group. The reintervention rate significantly (p = 0.002) decreased from 48.8% in the restrictive group (n = 43; follow-up 87.5 ± 7.3 months) to 18.2% in the unrestrictive group (n = 44; follow-up 40.0 ± 22.1 months). The median recovery time was 2.0 [1.0-7.0] days. Treatment satisfaction rate was 72.4% and 4/11 women completed family planning after MR-HIFU. CONCLUSIONS: The unrestrictive treatment protocol significantly increased the NPV%. Unrestrictive MR-HIFU treatments led to acceptable reintervention rates comparable to other reimbursed uterine-sparing treatments, and no reinterventions were reported beyond 21 months follow-up. KEY POINTS: • All reinterventions were performed within 34 months follow-up, but in the unrestrictive treatment protocol group, no reinterventions were reported beyond 21 months follow-up. • The NPV% was negatively associated with the risk of reintervention; thus, operators should aim for complete ablation during MR-guided HIFU therapy of uterine fibroids. • Unrestrictive treatments have led to acceptable reintervention rates after MR-guided HIFU therapy compared to other reimbursed uterine-sparing treatments.

HISTOPATHOLOGIC FINDINGS IN WOMEN UNDERGOING HYSTEROSCOPIC RESECTION OF ENDOMETRIAL POLYPS AND UTERINE MYOMAS.

The aim of our study was to determine the prevalence of endometrial premalignant and malignant lesions in women undergoing hysteroscopy and to identify anthropologic factors related to the presence of malignancy. Data on 3470 women with submucosal myomas or endometrial polyps suspected on ultrasound were retrospectively analyzed. Hysteroscopy was performed in all these women in order to make a more precise diagnosis. Histologic analysis of endometrial samples obtained during hysteroscopy was used to confirm the diagnosis. Statistical analysis was performed using the SPSS 20.0.0 software. The mean age of study women was 49.1±13.3 years. The number of procedures performed due to the referral diagnosis of endometrial or submucosal myoma significantly increased over the 16-year study period. A significantly higher number of women had a benign histopathologic diagnosis. Histologic analysis revealed malignancy in 67 women. The youngest woman and oldest woman with malignant findings was aged 32 and 75, respectively. A significantly higher number of women with atypical hyperplasia and malignancy were in menopause. A comparable number of women with different histologic findings lived in urban and rural areas. There were a significantly larger proportion of widows among women with the histologic diagnosis of atypical hyperplasia or malignancy. The prevalence rate of malignancy in women having undergone hysteroscopy for polyps and myoma found by ultrasound was 1.93%. Postmenopausal status and older age were associated with an increased risk of malignancies, but premalignant changes and malignancies were also found in young and premenopausal women. Therefore, diagnostic hysteroscopy can be recommended in women of all age groups.

Multimodal imaging for diagnosis and management of parasitic peritoneal myoma with myxoid degeneration after laparoscopic-assisted myomectomy with electric power morcellation.

A 45-year-old multipara woman was referred due to the rapid enlargement of an asymptomatic pelvic mass that was detected during a regular check up. She had undergone laparoscopic-assisted myomectomy 15 years previously. At the time, the uncontained extraction of an intraligamental myoma with electric power morcellation had been performed. Multimodal imaging revealed a heterogeneous mass in the vesicouterine pouch that was found to be supplied by the left gastro-omental and superior vesical arteries. Although malignancy could not be completely denied, parasitic peritoneal myoma with myxoid degeneration was the most probable diagnosis. Single-port laparoscopic excision of the peritoneal mass was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The excised peritoneal mass was placed into a retrieval bag and extracted through the vagina. The pathological diagnosis was a parasitic peritoneal myoma with myxoid degeneration. The postoperative course was uneventful, and there was no recurrence of parasitic myoma in the 1-year follow up after surgery.

Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation.

BACKGROUND: Iatrogenic parasitic myomas (PMs), caused by intra-corporeal power morcellation during laparoscopy is gradually increasing. However, the pathogenesis and medical treatment of PMs remain largely unelucidated. METHODS: Laparoscopically-induced PM xenografted mouse model was conducted by xenografting human uterine myoma fragments into the abdominal cavity of SCID mice and hormonal manipulation was performed using this mouse model to demonstrate the role of oestrogen in the development of implanted PMs. Immunohistochemistry of oestrogen receptor α (ERα), progesterone receptor (PR), vimentin, vascular endothelial growth factor (VEGF), microvessel density (MVD) and Ki-67 index was performed and compared. RESULTS: In the patient with PMs, ERα, PR, angiogenesis and proliferative property expression were upregulated in PM lesions compared to uterine myomas. In the laparoscopically-induced PM mouse model, implanted myomas had more steroid receptor expressions, angiogenesis and proliferative property compared with pre-xenografted or non-implanted myoma. Depletion of oestrogen in the ovariectomized (OVX) mice decreased laparoscopically-induced PM implantations. In comparison, the implantations of PMs were increased with additional E2 supplement. Hormonal manipulation in the PM mouse model, including AI, GnRHa and SERM groups, were compared and AI significantly decreased the implantations, steroid receptor, angiogenesis, cell density, and proliferative index of PMs compared with control group. Furthermore, GnRHa significantly decreased VEGF and MVD expressions compared with control group. CONCLUSIONS: These data highlight the crucial role of oestrogen in the development of laparoscopically-induced PMs and suggest that hormone manipulation may be a potential therapeutic agent. TRIAL REGISTRATION: This protocol was approved by the Human and Animal Institutional Review Board of Taipei Veterans General Hospital ( VGHIRB No 2014-10-002C on Nov. 17th, 2014; IACUC 2014-119 on Aug. 22nd, 2014).

Incarceration of gravid uterus by growing subserosal myoma: case report.

Incarceration of gravid uterus is a rare condition, occurring in one in 3,000 to 10,000 pregnancies during second trimester. Incarceration of uterus can cause several complications, such as uterine rupture, labor dystocia, and uncontrollable postpartum hemorrhage. Early diagnosis is important to prevent these complications, but there are no standard treatments of incarceration of gravid uterus. The authors present a case report of incarceration of gravid uterus caused by growing subserosal myoma, which was treated with myomectomy during second trimester.

Hysteroscopy in women with abnormal uterine bleeding: a meta-analysis on four major endometrial pathologies.

PURPOSE: To determine the accuracy of hysteroscopy in diagnosing endometrial cancer, hyperplasia, polyps and submucous myomas. METHODS: Relevant articles were retrieved from the MEDLINE and the Cochrane Library (1986-2011). Studies were selected blindly. Results for diagnostic accuracy were extracted to form separate 2 × 2 tables (for endometrial cancer, hyperplasia, polyps and submucous myomas). A summary sensitivity and specificity point reflected the average accuracy observed. Summary ROCs (SROCs) were also calculated according to the HSROC model. RESULTS: For endometrial cancer, the estimated sensitivity was 82.6% (95% CR 66.9-91.8%) and the specificity was 99.7% (95% CR 98.1-99.9%). For endometrial hyperplasia, sensitivity was 75.2% (95% CR 55.4-88.1 %), while specificity was 91.5% (95% CR 85.7-95.0%). For endometrial polyps, sensitivity was 95.4% (95% CR 87.4-98.4%) and specificity was 96.4% (95% CR 93.7-98.0%). Finally, for submucous myomas, sensitivity was estimated to 97.0% (95% CR 89.8-99.2%) and specificity to 98.9% (95% CR 93.3-99.8%). CONCLUSIONS: Diagnostic accuracy for hysteroscopy is high for endometrial cancer, polyps and submucous myomas, but only moderate for endometrial hyperplasia.

[Urinary retention secoundary to cervical myoma large items]. / Retención urinaria secundaria a mioma cervical de grandes elementos.

OBJECTIVES: To describe the clinical-diagnostic importance of cystic appearance of a cervical myoma large elements result produced secondary METHOD: We described a case of a 40-year-old with abdominal discomfort producing difficulty walking, dyspareunia, urinary retention seven months of evolution. The USG diagnosis was a cystic mass consistent with a right ovarian cyst. The surgical abdominal total hysterectomy is performed. RESULTS: Histopathological study of approximately 1 3x6 cm uterus with myoma fund of approximately 4 cm and myoma level cervical posterior surface of 15x12 cm.

Fibroadenoma of the vulva--simultaneous with breast fibroadenomas and uterine myoma.

PURPOSE: To present a rare case of multiple fibroadenomas in breast and vulva and myomas in the uterus. In addition, to show the usefulness of receptor detection as a basis for the indication of antiestrogens. CASE: A 30-year-old patient presenting with a history of mammary fibroadenomas since the age of 16 years and uterine myomas since the age of 25 years. From age 26 to 29 years, she was operated on 3 times for fibroadenomas of the vulva. On the third time, she presented with 8 vulvar fibroadenomas. On this last occasion, a low expression of estrogen receptors was identified, together with a high expression of progesterone receptors (ER/PR pharmDx; Dako). Tamoxifen was indicated at 10 mg/d during the luteal phase of the menstrual cycle for 12 months. After 18 months from initiation of the treatment, the patient was found free of tumors in the vulva, with mammary tumor regression and a nonhomogeneous diffuse uterine myometrium. CONCLUSIONS: The presence of solid benign-type tumors in the vulva associated with mammary fibroadenomas and uterine myomas leads one to suspect the fibroadenomas. The histopathological diagnosis and the identification of the hormonal receptors are important for control purposes and therapeutic indications.

"See and treat" hysteroscopy after missed abortion.

A prospective study was conducted on the incidence of intrauterine pathology after missed abortion diagnosed and treated by hysteroscopy. A hysteroscopy was performed in 100 women four to 12 weeks after a dilatation and curettage for missed abortions. Uterine malformations were found in 12 patients, intrauterine adhesions in seven and submucous myoma in two cases. As a side finding four cases of asymptomatic retained products of conception were found. Most cases of the intrauterine pathology were treated instantly by hysteroscopy, "see and treat" regimen was preferred. Post-missed abortion-hysteroscopy is a simple and useful method for early diagnosis and treatment of congenital and acquired intrauterine pathology.

Uterine fibroids treatment: do we have new valid alternative? Experiencing the combination of vitamin D plus epigallocatechin gallate in childbearing age affected women.

OBJECTIVE: Uterine myomas are the most common benign tumors in females, and at least 25% of affected patients experience symptoms severe enough to need treatment, like heavy hemorrhage, pelvic pain, and infertility. Currently, a non-invasive approach is preferred in women of childbearing age who desire pregnancy. The aim of our study was to determine the effect of oral supplementation with a combination of vitamin D plus epigallocatechin gallate (EGCG) and vitamin B6 in women with myomas. PATIENTS AND METHODS: Between April and December 2020, we enrolled 95 women of childbearing age, afferent to our hospital, displaying at least one myoma with a diameter <4 cm. Patients were divided in two groups: 41 women were treated daily with two tablets of 25 µg vitamin D + 150 mg EGCG + 5 mg vitamin B6 for 4 months; 54 women, representing the control group, received no treatment. Total volume and vascularization of myomas were analyzed ultrasonographically. Bleeding and pelvic pain was also evaluated, as well as patients' quality of life and health through questionnaire Short Form Health Survey (SF-36) and Patient Global Impression of improvement (PGI-I). RESULTS: After treatment myomas' total volume and peripherical vascularization significantly decreased respectively by 37.9% (p<0.001) and 7.7%. On the other hand, we observed an increase in myomas' volume by 5.5 % and of peripherical vascularization by 5% in the control group. The treated group reported an improvement in SF-36 (p<0.001) and PGI-I (85.4%) questionnaire scores. CONCLUSIONS: We demonstrated, in young women who want to preserve fertility, that the combined supplementation of vitamin D, EGCG, and vitamin B6 reduced myomas' volume and improved patients' quality of life, without side effects.

Hysteroscopic removal of intrauterine contraceptive device embedded within submucous myoma.

We report that an intrauterine contraceptive device (IUCD) embedded within intrauterine tumour (submucous myoma) in a postmenopausal woman was misdiagnosed, definitively diagnosed and successfully removed with hysteroscopic resection. Hysteroscopy and hysteroscopic resection of the submucous myoma with IUCD should be reserved as a minimally invasive, safe and reliable treatment method, and can avoid a laparotomy and hysterotomy. This is believed to be the first reported case of such an occurrence.

Benefit of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography findings.

Patients with unexplained infertility following standard infertility screening tests usually undergo timing therapy that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation, or intrauterine insemination. If the treatment is unsuccessful, diagnostic laparoscopy is performed. However, with recent improvements in the assisted reproductive technology (ART), there has been a growing tendency that bypasses diagnostic laparoscopy and proceeds directly to ART. Therefore, the value of diagnostic laparoscopy in current fertility practice is under debate. In the present study, we evaluated the usefulness of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography (HSG) findings. Between January 1997 and December 2006, 57 infertile patients with normal HSG findings underwent diagnostic laparoscopy at Kinki University Hospital. In 46 (80.7%) of these patients, diagnostic laparoscopy revealed pathologic abnormalities. Specifically, endometriosis and peritubal and/or perifimbrial adhesions were found in 36 (63.2%) and 5 (8.8%) of the patients, respectively. In 8 patients (14.0%), the management plan was switched to ART because of severe tubal diseases. Among the 57 patients, 29 pregnancies (50.9%) were achieved, including 6 ART-mediated pregnancies. We conclude that diagnostic laparoscopy is beneficial for patients with unexplained infertility and normal HSG findings. Indeed, by diagnostic laparoscopy, we are able to detect the cause(s) of infertility in the pelvic cavity and to design a suitable management plan, which could lead to postoperative pregnancy. Therefore, because of the potential diagnostic and therapeutic benefits, patients with unexplained infertility and normal HSG findings should undergo diagnostic laparoscopy prior to ART.

[The gynecological TURP syndrome. Severe hyponatremia and pulmonary edema during hysteroscopy]. / Das gynäkologische "TUR-Syndrom". Schwere Hyponatriämie und Lungenödem während operativer Hysteroskopie.

Fluid overload and dilutional hyponatremia are rare but typical complications of endoscopic transurethral resection of the prostate gland (TURP syndrome). Less commonly, this complication caused by excessive absorption of hypotonic, electrolyte-free non-conductive distention solution, may also occur during endoscopic surgery of the uterus, e.g. operative hysteroscopy. A case report is presented of a 44-year-old woman scheduled for operative hysteroscopy for intracavital myoma under general anaesthesia, suffering from severe absorption syndrome leading to hyponatremia of 106 mEq/l and pulmonary edema necessitating subsequent admission to ICU. Anatomical and physiological as well as technical aspects of this syndrome are discussed. Recommendations for anesthesiology management are offered and a possible treatment of acute hyponatremia is discussed.

Uterine myoma: a condition amenable to medical therapy?

BACKGROUND: Uterine myomas are the most common benign tumors of the female reproductive tract. Of the different treatment methods available, medical therapy may be a less invasive choice. OBJECTIVE: To review the literature on medical treatments that are available or being developed for women with uterine myomas. METHODS: Literature review of articles pertaining to medical therapeutic strategies of uterine myomas. (Articles were searched by means of a computerized PubMed and Cochrane Library search with the following keywords: uterine myomas, leiomyomata, fibroids, and medical treatment.) RESULTS/CONCLUSION: At present, many drugs are available in routine clinical practice, some of which are under investigation. This review will explore the recent advances in medical treatment for the management of uterine myomas.

Endometrial stromal nodule with smooth muscle differentiation.

Uterine tumors composed of a prominent component of smooth muscle and endometrial stroma (so-called stromomyoma) are distinctly uncommon. This article describes the morphological features of one such tumor discovered as an incidental finding in a hysterectomy specimen of a 49-year-old lady with a clinical diagnosis of dysfunctional uterine bleeding. Morphological and immunohistochemical (IHC) evaluation were performed and a final diagnosis of endometrial stromal nodule with smooth muscle differentiation was rendered.

A Case Report of a Left Atrial Mass: The Importance of a Detailed Physical Exam.

Cardiac myxomas are rare clinical findings. They are frequently found in the left atrium and more commonly affect women. Clinical presentation can vary widely and symptoms can be vague and non-specific. We present a case of a 67-year-old woman presenting with 3 weeks of progressive heart failure symptoms that failed to respond to oral diuretic therapy. On physical exam, she was found to have a diastolic murmur, rumble and an early diastolic plop. Transthoracic echocardiogram revealed a 5.6 cm × 2.5 cm × 4.3 cm left atrial mass attached to the mitral valve causing left atrial outflow obstruction. The patient subsequently underwent surgical resection of the mass with resolution of symptoms immediately thereafter. Lack of recognition of this pathologic process as a cause of heart failure symptoms and lack of a quality physical exam can lead to a delay in diagnosis and treatment.

Treatment patterns for women with new episodes of uterine myomas in an insured population in the US.

INTRODUCTION: Uterine myomas are the most common benign tumors in reproductive-aged women and a leading reason for gynecologist visits and hysterectomies in the United States. This study examines the treatment patterns of insured women with new episodes of uterine myomas. MATERIALS AND METHODS: We used administrative claims from a proprietary research database to evaluate services (inpatient, outpatient, and prescription claims) incurred from January 1, 2001 to December 31, 2003. We identified women with CPT or ICD-9-CM codes suggestive of myoma and described treatment patterns for all women with a new episode of myoma and those with abnormal bleeding. RESULTS: The primary study group included 35 329 women with new episodes of care and at least three months of data before and after their index date for myoma. Most women (82.9%) had no code for diagnostic testing in the three months before or after the first myoma marker. Of 14 434 women with one year of follow-up, 26.1% had surgery and 24.7% were treated pharmacologically (oral contraceptives, progestins, or gonadotropin-releasing hormone agonists). Over half (55.1%) of women were untreated, including 45% of those with an ICD-9 code that indicated abnormal bleeding. CONCLUSIONS: Women with new myoma episodes rarely had codes for confirmatory diagnostic tests. Many women with myomas go untreated for at least a year. This is true even for those with evidence of abnormal bleeding. Myoma care may be improved through the introduction of new, safe, and effective therapies.