At CIRSE (September 15–19, Lisbon, Portugal) in a presentation on uterine artery embolization for fibroids (UFE), James B Spies, Georgetown University School of Medicine, Washington DC, USA, discussed suitability of patients for the treatment.
In the presentation, Spies summarised the literature concerning uterine artery embolization as a treatment for fibroids and suggested that the suitability of UFE could be broken down into a three-part checklist: the presenting symptoms, uterine anatomy and patient preferences.
Patients with symptomatic fibroids usually have an increase in the length of the menstrual cycle and the number of heavy days of bleeding were indicated as suitable for uterine artery embolization, but patients with bleeding between menstruation should be considered for alternative diagnosis, such as endometrial polyps or hyperplasia. Similarly, heavy bleeding is caused by fibroids deep in the uterus, while serosal fibroids do not cause bleeding. Atypical pain that occurs daily and debilitating is unusual for fibroids and more likely may be due to endometriosis. The first step, then, is to correlate the symptoms the patient has and the fibroids that are present.
In terms of uterine anatomy, Spies outlined that fibroid placement (submucosal, intramural and subserosal) can be treated successfully. In the case of pendulculated sereosal fibroids, Spies said that, according to recent studies by Katsumori et al and Smeets et al, they were safe to treat with uterine artery embolization and there was no increase in complications and no decrease in outcomes. However, according to the presentation, other anatomic subgroups should be considered for different treatment. Patients with autoinfarcted fibroids and minimal fibroids should get conservative management. He expanded on this saying that the literature suggests that while most patients with symptomatic fibroids are candidates for UFE, those with larger fibroids, larger uteri, single vs. multiple fibroids, large submucosal fibroids and incompletely infracted fibroids after uterine artery embolization were more likely to require additional interventions. Also, cervical fibroids do not respond as reliably to uterine fibroid embolization as other fibroid locations, as they have poor vascularity and during treatment it is difficult to define a vascular supply.
In terms of patient preferences, according to Spies, UFE is best for patients who have finished their child-bearing stage of life, those who wish to retain the uterus, patients who have a poor surgical risk, patients who have undergone prior pelvic surgery and those who wish or need minimal recovery time. However, he added: “Ideally, the evaluation of patients interested in uterine embolization should be a collaborative effort between an interventional radiologist and a gynaecologist.”
Spies continued in saying that there are cases where other interventional treatments should be considered as first line treatment rather than uterine artery embolization. This included patients who are undergoing fertility treatment or are interested in pregnancy in the near future and should be considered for myomectomy, patients who require a durable solution to fibroids should investigate the possibility of hysterectomy and patients with resectable submucosal fibroids where hysteroscopic resection may be more appropriate.
In his conclusion Spies said that: “proper patient selection is important for the best outcomes and it is important to look at the patient and the images to avoid pitfalls in patient selection.”