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Efficacy of High Intensity Focused Ultrasound Treatment for Cystic Adenomyosis: a Report of Four Cases

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Efficacy of High Intensity Focused Ultrasound Treatment for Cystic Adenomyosis: a Report of Four Cases 3749 Original Article Efficacy of high intensity focused ultrasound treatment for cystic adenomyosis: a report of four cases Xiao-Jing Zhou1#, Zhi-Ming Zhao2, Peng Liu1#, Cong-Ying Zhao1, Yu-Jie Lin3, Ying Liu1, Min Wang4, Cai Tian1, Hai-Yan Li1, Chen-Xiao Hou1, Xiu-Min Li5, Zhi-Yu Zhao6, Ying-Jie Zhou1 1Seven Section of Department of Gynaecology, the Second Hospital of Hebei Medical University, Shijiazhuang, China; 2Department of Reproductive Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, China; 3Department of Ultrasound, the Ninth Hospital of Xingtai City (the Hospital of Julu County), Xingtai, China; 4Department of Ultrasound, Tang County Hospital of Traditional Chinese Medicine, Tang County, China; 5Department of Ultrasound, Dingzhou Traditional Chinese Medicine Hospital, Dingzhou, China; 6Department of Gynecology, Zhengding Maternal and Child Health Hospital, Zhengding, China Contributions: (I) Conception and design: YJ Zhou; (II) Administrative support: YJ Zhou; (III) Provision of study materials or patients: YJ Zhou, XJ Zhou; (IV) Collection and assembly of data: P Liu, CY Zhao, Y Liu, C Tian, HY Li, CX Hou ; (V) Data analysis and interpretation: ZM Zhao ; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. #These authors contributed equally to this work. Correspondence to: Ying-Jie Zhou, MD. Seven Section of Department of Gynecology of the Second Hospital of Hebei Medical University, No.215 of Heping Xi Lu, Xinhua District, Shijiazhuang 050000, China. Email: [email protected]. Background: Cystic adenomyosis is a particular type of adenomyosis, High intensity focused ultrasound (HIFU), as a non-invasive method, has also been used to treat adenomyosis. The purpose of this study was to investigate the efficacy, safety, and feasibility of HIFU for the treatment of cystic adenomyosis. Methods: Diagnosis of cystic adenomyosis was obtained through trans-vaginal ultrasound and magnetic resonance imaging (MRI). Ultrasound-guided HIFU ablation was performed under conscious sedation. The patients were evaluated by the comparison of pre-HIFU and post-HIFU imaging, as well as the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire subscales, consisting of Symptom Severity Score (SSS) and Heath Related Quality of Life (HRQL). Results: HIFU was effective in treating cystic adenomyosis. No complications were observed in the four patients who were successfully treated with HIFU. Compared to preoperative symptoms and patient satisfaction, symptoms at the first follow-up observed significant improvements, with no dysmenorrhea and high health-related quality of life. During the outpatient follow-up of one month, three months, and six months postoperation, the four patients were still without dysmenorrhea and were highly satisfied with the HIFU ablation. Conclusions: HIFU, as a non-invasive treatment, supplies a safe and effective possibility for the treatment of cystic adenomyosis. Keywords: High intensity focused ultrasound (HIFU); cystic adenomyosis; non-invasive; treatment; Uterine Fibroid Symptom and Quality of Life questionnaire subscales (UFS-QOL questionnaire subscales) Submitted Jul 14, 2020. Accepted for publication Oct 27, 2020. doi: 10.21037/apm-20-1599 View this article at: http://dx.doi.org/10.21037/apm-20-1599 Introduction cyst is larger than 5 mm. Patients usually have moderate to severe dysmenorrhea, which may be primary or secondary Cystic adenomyosis or cystic adenomyoma is a particular to other menstrual disorders. Cystic degeneration of an type of adenomyosis that manifests cystic growth in the adenomyoma first was described in the world by Parulekar adenomyotic lesion (1). The maximum diameter of the in 1990 (2). And in the year of 1996, Tamura et al. first © Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2020;9(6):3742-3749 | http://dx.doi.org/10.21037/apm-20-1599 Annals of Palliative Medicine, Vol 9, No 6 November 2020 3743 reported the case of an adenomyotic cyst of the uterus in AME Case Series reporting checklist (available at http:// a 16-year-old girl (3). The pathogenesis is still unclear. dx.doi.org/10.21037/apm-20-1599). There are two main points of view, (I) congenital diseases; some parts of the Mullerian duct are damaged during Methods the development process, and the parts remain. After the menarche, the residual Mullerian duct epithelial cells This study was conducted following the declaration of under the action of estrogen periodically hemorrhages Helsinki (as revised in 2013) and was approved by the and form the cystic cavity. Thus, dysmenorrhea occurs Ethics Committee of the Second Hospital of Hebei Medical due to increased pressure in the cyst. (II) Iatrogenic University (No. 2019-R024). Written informed consent was diseases; patients have different types of uterine operation obtained from all participants. history before the onset, the lesions may be related to the surgical operation site, clinical manifestations often appear Clinical data after uterine operation history, and trauma may be the inducement. Severe dysmenorrhea often characterizes this Four cystic adenomyosis patients with severe dysmenorrhea, population, which is difficult to control with drugs (4). aged from 20 to 34 years old, underwent HIFU treatment It is easily misdiagnosed as female obstructive genital between January 2012 and January 2015 in the Second malformation and uterine fibroid degeneration. Due to Hospital of Hebei Medical University. A thorough history, misdiagnosis and delay treatment, the quality of life and including age (at the time of treatment), age at onset of gestation potential of adolescents and young women are symptoms, marital status, fertility, delivery method, the affected. Currently, the treatment methods for cystic severity of dysmenorrhea, and other menstrual disorders, adenomyosis is to remove the lesion and protect the was obtained. All patients underwent ultrasonography reproductive function. Treatment methods should be and magnetic resonance imaging (MRI) to determine determined according to the patient’s age, fertility status, the exact location and size of the lesion and its relation clinical symptoms, among many others; however, the most to the uterine cavity. The preoperative and postoperative important is medication. Clinically used for conventional symptoms and patient satisfaction were evaluated using adenomyosis, treatment drugs are applicable, including the Uterine Fibroid Symptom and Quality of Life (UFS- nonsteroidal anti-inflammatory drugs (NSAIDs). It is an QOL) questionnaire subscales, consisting of Symptom only temporary relief of symptoms, and it is easy to relapse Severity Score (SSS) and Heath Related Quality of Life after stopping the drug. The effect of treatment was not (HRQL) (15). All patients were admitted to the hospital satisfactory. (III) Surgical treatment, the most important due to progressive dysmenorrhea with inadequate response and effective method, including open surgical resection, to medical management, which affected their quality of life. laparoscopic resection of the lesions, and excision of No apparent abnormalities were found in the detection of the lesions under hysteroscopy (5-8). Although partial routine blood, routine urine, biochemistry, coagulation, uterine resection can effectively alleviate the symptoms of and cervical liquid-based smears. Baseline patient profiles dysmenorrhea, it is difficult for patients to accept it due to and imaging findings were presented in Table 1. Figure 1 sizeable surgical trauma and postoperative complications. describes the MRI features of the lesions and their relation High intensity focused ultrasound (HIFU), as a non- to the uterine cavity. invasive method, can be used to kill the target tissues without damaging surrounding structures effectively. The Devices previous studies have shown that HIFU is safe and effective in treating patients with solid tumors, superior to other Philips iU22 color Doppler ultrasonic diagnostic apparatus methods, including no radiation damage, less pain, and (iU22; Philips Healthcare, Hamburg, Germany) was applied rapid recovery after treatment (9-12). Recently, HIFU has for trans-vaginal ultrasound examination with a trans- also been used to treat adenomyosis (13,14). However, no vaginal probe frequency of 9 Hz. Simultaneously, the blood study has reported on the feasibility of HIFU treatment for flow signal distribution of the lesions was detected by color cystic adenomyosis. In this study, it reported four cases of Doppler flow imaging (CDFI) apparatus, and the ultrasonic patients with cystic adenomyosis treated with HIFU. diagnosis was obtained. We present the following article in accordance with the A Philips Achieva 3.0T magnetic resonance imaging © Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2020;9(6):3742-3749 | http://dx.doi.org/10.21037/apm-20-1599 3744 Zhou et al. Efficacy of HIFU treatment for cystic adenomyosis Table 1 Baseline characteristics, clinical symptoms, and imaging and follow-up findings Variable Case 1 Case 2 Case 3 Case 4 Age (years) 29 34 20 22 Severe Severe Severe Severe Main symptom dysmenorrhea dysmenorrhea dysmenorrhea dysmenorrhea Age at onset of symptoms (years) 17 28 15 13 Menorrhagia (yes/no) Yes No No No History of marriage (yes/no) Yes Yes No No Reproductive history (yes/no) No Yes Yes No Mode of delivery – Cesarean section – – History of abortion (yes/no) No No Yes No Lesion size, cm3 2.5×2.0×2.2 3.2×3.4×3.0 3.6×4.0×3.0 2.0×2.0×2.0
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