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GnRH agonist pre-treatment before MR-HIFU fibroid treatment

Case Study
Prof. Kim, Young-sun, M.D. Samsung Medical Center • Korea, Republic of
Keserci, Bilgin Philips Healthcare • Korea, Republic of

Patient history

39 year-old unmarried female. 158 cm tall and a weight of 52 kg.

Diagnosed with uterine fibroids with chief complaints of menorrahagia for one year. Patient complained of requiring 15 pads per day, with changing them once an hour and had a hemoglobin level of 4.5 mg/dL.

One year ago, patient underwent a laparoscopic myomectomy. Symptoms were not resolved from this procedure.

MR examination

 T2-weighted planning image
T2-weighted planning image

Patient presented with a submucosal pedunculated fibroid of 6.3 cm in diameter. 

Full ablation of the fibroid was expected to be a challenge, both due to the depth of the fibroid and partial vascularity, as observed on DCE-MRI. In addition, it was very important to reach the posterior aspects of the fibroid, as this was contributing to patient symptoms.

GnRH analog pre-treatment* was recommended to reduce fibroid volume and provide a potential reduction in vascularity. Patient was given a standard two rounds of Luprolide acetate. MR-HIFU therapy was scheduled 16 days after the second injection.

Fibroid shrinkage was effective from the pre-treatment with GnRH analog. Fibroid diameter decreased from 6.3 cm to 4.6 cm.

Note - clinician has observed in previous treatments that the timing of therapy post-GnRH analog treatment is important, and should follow very close after hormonal therapy.

MR-HIFU treatment

Sonalleve MR-HIFU V1 system with R2.1L1 version software was used.

T2 weighted planning images

 A small bowel loop is positioned directly in front of the fibroid, as observed in the sagittal scan. Bladder has been filled to attempt to shift the bowel and provide a clear acoustic window. Rectum has been filled to push the fibroid forward.
A small bowel loop is positioned directly in front of the fibroid, as observed in the sagittal scan.
Bladder has been filled to attempt to shift the bowel and provide a clear acoustic window.
Rectum has been filled to push the fibroid forward.

The bowel loop was observed directly in the beam path on treatment day.

Multiple manipulation techniques were applied to attempt to push the bowel up out of the acoustic window (above).

Eventually the bladder was substaintally filled to allow for a clear acoustic window (below). Patient tolerated this through therapy despite some discomfort.

Note - care should be taken when sonicating through the bladder to assure beam path does not intersect substaintally with Foley catheter.
 T2-weighted planning image and visualization of acoustic window
T2-weighted planning image and visualization of acoustic window


Following positioning to move the bowel from the ultrasound energy path, the bladder was filled to enable an acoustic window.

MR-HIFU therapy

 T2-weighted planning images showing treatment cell placement
T2-weighted planning images showing treatment cell placement

A total of 33, 8 mm treatment cells were used for therapy.

Procedure times:
Total MR room time: 3 hours, 5 minutes

Preparation time: 1 hour, 5 minutes*

Procedure time: 1 hour, 51 minutes

Note, it is atypical to have such substaintal patient manipulation in a therapy session, yet due to the patient compliance this time enabled an effective patient therapy.

Post-treatment MR images

 T1-weighted, contrast-enhanced post-treatment sagittal image T1-weighted, contrast-enhanced post-treatment coronal image
T1-weighted, contrast-enhanced post-treatment sagittal image
T1-weighted, contrast-enhanced post-treatment coronal image

Results

Non-perfused volume (NPV) was 87% of total fibroid volume. NPV was calculated slice-by-slice from the T1w-contrast enhanced image acquired immediately following treatment.

Case considerations and lessons learned

Urinary bladder filling is beneficial for the following reasons:
  • It may be used to displace the small bowel loops out of the sonication path
  • It can improve the MR-HIFU window 

 

GnRH agonists may enhance outcomes when used in conjunction with MR-HIFU.

Patient symptoms should be the primary factor when determining volume and region to ablate. In submucosal fibroids with menorrhagia-related symptoms the emphasis of therapy should be on the submucosal region.

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)
* This webinar is for international use only. Not for US.


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

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