(4)MRガイド下集束超音波療法(MRgFUS)による子宮筋腫の治療と管理(<特集>第59回シンポジウム1「子宮筋腫の発育制御とその管理」)
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Uterine leiomyoma is the most common pelvic tumor in women. Although hysterectomy has long been the standard treatment for uterine myoma, some uterus-preserving alternatives are available today. Among these, magnetic resonance-guided focused ultrasound surgery(MRgFUS) is a minimally-invasive procedure that uses high intensity ultrasound waves to ablate tissue. The present study investigates the efficacy of MRgFUS in the treatment of uterine myoma and the histopathological features on extirpated myoma tissue, when alternative surgical treatment is requisite. The Ethics Committee of Shinsuma Hospital approved the treatment of uterine myoma by MRgFUS, and written informed consent was obtained from all of the patients in compliance with the principles of good clinical practice. Between June 2004 and March 2007, 81 premenopausal patients with 125 myomas confirmed by T2-weighted MRI were treated by MRgFUS. The myomas were classified into 3 types based on signal intensity of T2-weighted images : type I, low intensity ; type II, intermediate intensity and type III, high intensity. The ablation (the non-perfused ratio of gadolinium injection) was about 55%in type I and type II, and 38% in type III. There was no correlation between the ablation ratio and the location or the size of the myoma. The uterine muscle was spared ablation when 2 combined myomas were treated as one tumor, suggesting that the vascularity was richer in the uterine muscle layer than in the myoma. Sufficient ablation of the myoma near the Os sacrum is not able to attain immediately after the treatment ; however, in several cases a complete nonperfusion margin was observed 3 or 6 months after the treatment. These cases yield very satisfactory results and it is meaningful to search for the reason why such good results were induced. Alternative treatment such as hysterectomy, myomectomy, TCR or UAE was indicated for 13.6% of the patients. Here, we demonstrate a case of leiomyosarcoma disclosed after MRgFUS and display T2-weighted schemas of myoma and leiomyosarcoma before and 6 months after treatment, attesting to the essentiality of follow-up after the procedure. MRgFUS was of little effect in cases of cellular leiomyoma in which regrowth of leiomyoma cells was observed at the periphery of the myoma. Necl-2 and COX-2 were positive in cellular leiomyoma tissue, as are myogenic stem cells in skeletal muscle. Moreover, numerous mast cells and abundant vascularity was found in cellular leiomyomas. These results suggest that cellular leiomyoma and myoma with hypervascularity or degenerative changes are resistant to MRgFUS treatment.
- 2007-09-01
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