PMC5434313_01
Case 1: (a) sagittal T1-w with fat saturation acquired after intravenous injection of paramagnetic contrast medium showing the two small fibroids (white arrows) located in the near field that were not directly treated but that became nonperfused too after the treatment; two bigger fibroids treated are visible too; (b) a follow-up MRI (T1-w with fat saturation acquired after intravenous injection of paramagnetic contrast medium) showing a normal vascularization of the two small fibroids.
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fig3
This case illustrates that smaller fibroids located in the near field and not directly treated may show as nonperfused fibroids after treatment (white arrows in Figure 3(a)). A possible hypothesis to explain this finding may lie in damage to feeding vessels shared between targeted fibroid and nontargeted fibroids or, more likely, to a transient vasospasm of the feeding vessels of nontargeted fibroids, since, in a subsequent MRI follow-up, the untargeted fibroids showed back a normal vascularization (black arrows in Figure 3(b)).
PMC5434313_02
Case 2: sagittal T2-w intraoperative scan showing the targeted fibroid (asterisk) and full bladder (B) with urinary catheter present. Bowels obstructing the beam path were mitigated using a custom sliced (dashed line) gel pad (GP) and rectal filling with ultrasound gel (R). Curved arrow mimics the dislocation of the bowel loops. This treatment was successfully performed through the full bladder.
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fig4
The screening MRI showed multiple small fibroids, at least 11, of which there was only one treatable (size: 5 cm; volume: 51.50 cc) intramural fibroid, homogenously hypointense on T2-w images (asterisk in Figure 4), involving the right side of the fundus of the uterus with an heterogeneous enhancement on postcontrast T1-w images. Bowel obstructing the beam path was mitigated using a custom sliced 45 mm thick cylindrical gel pad (a circular segment equal to about one-sixth of the diameter was sliced off from the cranial part; see dashed line in Figure 4); furthermore, rectum was filled with about 300 cc of US gel and bladder with about 350 cc of saline. Bowel loops were able to be displaced superiorly and out of the beam pathway (curved arrow in Figure 4). The treatment was performed through the full bladder (B in Figure 4) demonstrating how even challenging cases can be treated if the physician succeeds to find a way to expose the ROT.
PMC5434313_03
Case 3: (a) screening coronal T2-w showing the bigger intramural fibroid on the right wall of the uterus, the small intracavitary submucosal fibroid on the mid left (white arrow), and one more small intramural fibroid on the left wall of the uterus; (b) axial T1-w acquired after intravenous injection of paramagnetic contrast medium acquired at the end of the treatment showing treated fibroids as nonenhancing round lesions (white arrow on the small intracavitary submucosal fibroid); (c) in a follow-up MRI, the small intracavitary submucosal fibroid was no more appreciable; the white arrow shows the "empty" uterine cavity after spontaneous vaginal expulsion.
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fig5
MRI of the pelvis showed two fibroids, both hypointense on T2-w images; the largest one (diameter 7.3 cm; volume 164.07 cc) was intramural, involving the right side of the fundus of the uterus and the other one was a very small (diameter 2.5 cm; volume 5.73 cc) intracavitary submucosal fibroid (white arrow in Figure 5(a)).
PMC5434313_04
Case 4: example of a treatment with a low ablation rate (NPV = 57%); (a) screening axial T2-w scan; (b) sagittal T1-w with fat saturation acquired after intravenous injection of paramagnetic contrast medium acquired at the end of the treatment.
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fig6
The patient in case 4 had a screening MRI demonstrating a single fibroid (3.6 cm in size with volume of 15.19 cc; Figure 6(a)), involving the fundus of the uterus; patient in case 5 showed two fibroids, of which only the larger anterior one (diameter 4 cm; volume 21.45 cc; Figure 7(a)) was treatable because the smaller one was posterior and not fully accessible. Posttreatment images showed a nonperfused volume of 8.62 cc and NPV ratio of 57% (Figure 6(b)).
Case 5: example of a treatment with a very high ablation rate (NPV = 99%); (a) screening axial T2-w scan; (b) sagittal T1-w with fat saturation acquired after intravenous injection of paramagnetic contrast medium acquired at the end of the treatment.
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fig7
The patient in case 4 had a screening MRI demonstrating a single fibroid (3.6 cm in size with volume of 15.19 cc; Figure 6(a)), involving the fundus of the uterus; patient in case 5 showed two fibroids, of which only the larger anterior one (diameter 4 cm; volume 21.45 cc; Figure 7(a)) was treatable because the smaller one was posterior and not fully accessible. Posttreatment, a nonperfused volume of 21.30 cc and NPV ratio of 99% were achieved (Figure 7(b)).