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Effective MR-HIFU therapy of two uterine fibroids with aid of patient positioning

Case Study
van den Bosch, Maurice, M.D., Ph.D. University Medical Center Utrecht • Netherlands
Ikink, Marlijne, M.D. University Medical Center Utrecht • Netherlands

Patient history

46-year-old female with no future wish for children. BMI 23.1 kg/m2. 

Complaints of menorrhagia, bloating and frequent urination. Current treatment with progestin intra-uterine device (mirena). Baseline Symptom Severity Score (tSSS) of 40.6 points and Health Related Quality of Life (HRQoL) of 94.8 points. 

Request for help: She desired uterine sparing therapy.

MR imaging

MRI was done on Sonalleve MR-HIFU V2 system with R3.1L1 version software.

Planning images before treatment

 Fibroid A: 150 mL volume, 6.8 cm diameter Fibroid B: 50 mL volume, 5.8 cm diameter
Fibroid A: 150 mL volume, 6.8 cm diameter
Fibroid B: 50 mL volume, 5.8 cm diameter


The T2-weighted image shows the uterus in midposition and two subserosal uterine fibroids.

Fibroid diameters are 6.8 cm (Fibroid A: 150 mL) and 5.8 cm (Fibroid B: 50 mL). Bladder compression is clearly visible on the axial images.  

Both fibroids were defined as Type I fibroids, hypo-intense on T2W Imaging1.

Contrast-enhanced T1-weighted images were acquired during examination, following the administration of intravenous contrast agent (Gadovist®).

1Funaki et. al.
Magnetic resonance-guided focused ultrasound surgery for uterine fibroids: relationship between the therapeutic effects and signal intensity of preexisting T2-weighted magnetic resonance images. 
American Journal of Obstetrics and Gynecology, 2007, Vol 196,(2), 184.e1-184.e6)

MR-HIFU treatment

A total of 26 treatment cells of 12 and 16 mm, including 5 test shots, were used with a power level range of 80-120 Watts (1.2 MHz frequency). Treatment was started with 16 mm treatment cells at the most central parts of the fibroid, while the smaller cells were used to treat the outer part of the fibroid. 

Procedure times
Total MR room time: 4 hours 
Sonication time: 1 hours, 56 minutes

Note that MR room time is defined as the time between the moment the patient enters the MR room and the moment she exits. Sonication time is defined as the time from the start of the first sonication to the end of the last sonication.

Case considerations

The long MR room time was due to having booked a full 4 hours rather than requirements of the treatment itself. In fact, this case was quite rapid as two subserosal uterine fibroids were treated with separate planning target volumes. Patient re-positioning was performed during therapy, enabling access to both fibroids. This was all achieved within 2 hours 30 minutes total procedure time.

Post-treatment MR images

The following images are T1-weighted, contrast-enhanced post-treatment sagittal images.
 Fibroid A: 150 mL volume, 6.8 cm diameter Fibroid B: 50 mL volume, 5.8 cm diameter
Fibroid A: 150 mL volume, 6.8 cm diameter
Fibroid B: 50 mL volume, 5.8 cm diameter

Results

Immediately after treatment, a contrast enhanced-T1-weighted MR scan was acquired to visualize the treatment result. Non-perfused volume (NPV) was calculated in the Achieva console using the sum-by-slice method. 

Fibroid A: 45ml / 150ml = 0.30 (30%)
Fibroid B: 10ml / 50ml = 0.20 (20%)
NPV / total fibroid volume = NPV ratio

Note that the objective in this treatment was to address the symptomatic fibroids.

Outcomes and follow-up

3-months follow-up MR scan:
Fibroid A with dimensions of 6.5 x 5.5 cm (110 mL), corresponds to 27% fibroid volume reduction.
Fibroid B with dimensions of 3.5 x 5 cm (25 mL) corresponds to 50% volume reduction. 
Patient is symptom-free (tSSS = zero points)

6-months follow-up MR scan: 
Fibroid A with dimensions of 5.5 cm in three orthogonal planes, corresponds to 40% fibroid volume reduction. 
Fibroid B remained the same as the 3-month follow-up MR Scan with dimensions of 3.5 x 5 cm (25 mL) corresponds to 50% volume reduction. 

Patient reported a normalized menstrual cycle with a significant symptom improvement overall of 40.6 points. Patient felt very satisfied with her therapy experience.


 T2-weighted image - 6 month follow-up
T2-weighted image - 6 month follow-up
Note: Results from case studies are not predictive of results in other cases. Case results may vary.

*NetForum case studies provide information about procedures performed by Philips users, yet Philips takes no responsibility for non-device content (medicine used, positioning preparation, etc)


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Sep 26, 2012

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Case Study
Sonalleve MR-HIFU
Body, fibroid, Interventional, Uterine fibroid, Uterus, Women's health
 

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