Kaoru Funaki

Early Results of Magnetic Resonance–guided Focused Ultrasound Surgery of Adenomyosis: Analysis of 20 Cases

STUDY OBJECTIVE To evaluate the thermal ablative effects of magnetic resonance-(MR) guided focused ultrasound surgery (MRgFUS) on adenomyosis and to assess improvement in clinical parameters. DESIGN Twenty patients with adenomyosis were treated with MRgFUS. Extensive adenomyosis (6 cases) was treated with 2 applications. Uterine volume was evaluated by MR imaging before and immediately after MRgFUS. Ablation of adenomyosis and the architecture of nonperfused areas were evaluated immediately after MRgFUS. Improvement in patient symptoms was assessed through the symptom severity score questionnaire (Canadian Task Force classification II-3). SETTING Department of gynecology at a Japanese general hospital. PATIENTS Premenopausal women at least 18 years of age with symptomatic adenomyosis. INTERVENTIONS Thermal ablation by MRgFUS. MEASUREMENTS AND MAIN RESULTS We classified the nonperfused lesions on contrast-enhanced MR images immediately after MRgFUS into 3 types: lesions with round margins (type R), serrated margins (type S), and honeycomb architecture (type H). Type R was the most common (16/20 patients). Most adenomyosis lesions could be sufficiently ablated close to the serosal surface or to the endometrium by MRgFUS. The mean uterine volume 6 months after therapy was decreased by 12.7%. Symptom severity score improved significantly during 6 months of follow-up. No serious complications were observed. CONCLUSION These early results indicate the safe and effective ablation of adenomyosis tissue by MRgFUS. The procedure also resulted in the improvement in clinical symptoms during the 6 months of follow-up.

Subjective effect of magnetic resonance-guided focused ultrasound surgery for uterine fibroids.

Aim:  We treated 69 patients with symptomatic uterine fibroids using a magnetic resonance‐guided focused ultrasound surgery (MRgFUS) system. Our objective was to determine the clinical outcome of MRgFUS, focusing on symptom improvement, with emphasis on the time and extent of improvement.

Giant cystic leiomyoma of the uterus occupying the retroperitoneal space.

A 31-year-old nulliparous woman visited our hospital complaining of abdominal distension. Abdominal ultrasonography and computed tomography revealed a 40 × 40 × 30-cm, multilocular cystic mass extending from the upper abdomen to the pelvis. Magnetic resonance imaging (MRI) revealed a cystic tumor that was hypointense on T1-weighted images and was heterogeneously hyperintense on T2-weighted images. The final diagnosis was an 8 kg leiomyoma with cystic degeneration. Uterine leiomyomas are common benign tumors in females of reproductive age. However, subserosal leiomyomas with complete cystic degeneration of the retroperitoneal space are rare, and they are difficult to accurately diagnosis without pathological examination.

The Early Effects of MRgFUS in Treating Uterine Fibroids

MRgFUS (Magnetic Resonance‐guided Focused Ultrasound Surgery, ExAblate2000™, InSightec) system creates thermal coagulation regions inside the fibroids in treating symptomatic uterine fibroids. The authors have treated 89 fibroids on 58 patients for 16 months starting from June 2004. We classified the fibroids into 3 types in accordance with T2‐weighted MR images for evaluating the effect of treatment to the modality of fibroids. They are: type 1: very low intensity as skeletal muscle; type 2: low intensity compared with uterine muscle but high with skeletal muscle; type 3: high or equal intensity compared with uterine muscle. The volumes of fibroid and the treated region were evaluated from MR images. The treated volume was calculated from the non‐perfusion area of meglumine gadoterate immediately after the treatments. The results show that type 1 and type 2 fibroids are suitable application of MRgFUS. On the other hand, type 3 fibroid is difficult application of MRgFUS treatment, for the treated ratio wa...

Correlations between nonperfused ratio immediately after MRgFUS and color flow Doppler around uterine myomas

Objective: To examine the relationship between color flow Doppler indices and MRgFUS ablation effect. Materials and Methods: This study includes forty‐seven myoma patients who underwent magnetic resonance‐guided focused ultrasound surgery (MRgFUS). Single myoma was treated in 27 patients, and two or more myomas were treated at once in 20 patients. All patients were assessed color flow Doppler of peri‐myoma artery just before MRgFUS procedure. Peak velocity, pulsatility index (PI), resistant index (RI) were measured. Treated area ratio was defined as nonperfused ratio of each ablated myoma immediately after MRgFUS. The treated area ratio is considered as an assumed ablation area, and the relationship between color flow Doppler indices and treated area ratio were examined respectively. We have already reported that high‐intensity myomas (type‐3) on pretreatment T2‐weighted MR imaging are less effectively treated by MRgFUS than low‐ (type‐1) and intermediate‐ (type‐2) intensity myomas, therefore, as of today...

Invasive ductal breast carcinoma metastatic to uterus.

Invasive lobular carcinoma (ILC) is the most common type of breast cancer that metastasizes to the uterus, whereas uterine metastasis from invasive ductal carcinoma (IDC) is very rare [1,2]. Metastatic characteristics also differ according to the histologic subtype of the primary cancer. Specifically, ILC usually forms small and diffuse nodal metastatic nests, while IDC usually causes relatively large metastatic foci [3,4]. A 66-year-old asymptomatic woman presented to our gynecologic outpatient department for a periodic follow-up examination after breast IDC. She had undergone radical mastectomy 10-years previously for primary left breast cancer (stage 1, grade 3). Pelvic examination revealed uterine enlargement resembling multiple subserosal myomas. Transvaginal ultrasound revealed a multinodular tumor with a low-echoic lesion inside, suggesting focal necrosis (Fig. 1). The only laboratory abnormality was cancer antigen (CA) 15-3 (101.8 μ/mL) and CA125 (131.4 μ/mL). Cervical and endometrial cytology tests were negative for malignancy. T1-weighted magnetic resonance imaging (MRI) showed a homogeneous iso-signal intensity mass located on the ventral side of the uterus; T2-weighted MRI revealed a homogeneous high-signal intensity mass with a higher-intensity area that coincided with the lowechoic lesion. Diffusion-weighted MRI (DWI) revealed hyperintense signals at the anterior and posterior sides of the uterus, while positron emission tomography (PET) indicated bifocal accumulation in the same locations (Figs. 2 and 3). A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The tumor was located in the anterior wall of the uterus with vesicouterine extension where it infiltrated the myometrium and bladder wall. The omentum was strongly adhered to the tumor, but not in the context of widespread dissemination. Pathologic examinations, including hematoxylin–eosin staining and immunohistochemical staining for human epidermal growth factor receptor 2 (HER2/neu; + for primary and ± for uterine), estrogen receptor (both +), progesterone receptor (+ for primary and − for uterine), and cytokeratins 7 (both +) and 20 (both −) were performed. Except for the difference in the HER2/neu expression levels, the series of immunohistochemical staining studies revealed that the uterine and primary breast cancers shared the same ⁎ Corresponding author. Department of Gynecology, Shinsuma Hospital, Isonare-cho, Suma-ku, Kobe, Hyogo, 654-0047, Japan. Tel.: +81 78 735 0001; fax: +81 78 735 5685. E-mail address: funakikaoru@ybb.ne.jp (K. Funaki).

The Volume Reduction Ratio of Uterine Fibroid Treated With MRgFUS

Objective: The objective of this study is to determine the mid‐term effect of MRgFUS (Magnetic Resonance‐guided Focused Ultrasound Surgery) focusing on the volume reduction ratio and the perfused volume of uterine fibroid. Material and Methods: Forty‐three fibroids on 30 patients were examined, excluding the case treated with GnRHa (gonadotropin releasing hormone analogue) just before MRgFUS. The fibroid’s volume and the perfused volume were measured by MR images on the treatment day and then again 6 months later. The fibroids were classified into 3 types according to the signal intensity on T2‐weighted MR images; Type 1, low intensity as skeletal muscle; Type 2, intermediate intensity that is lower than myometrium but higher than skeletal muscle; Type 3, high intensity that is the same as or higher than myometrium. Result: The non‐perfused ratio immediately after MRgFUS was significantly lower in Type 3 fibroid as we had previously reported. The non‐perfused volume of Type 3 fibroid showed a tendency to ...

Adenomyosis with extensive glandular proliferation simulating infiltrating malignancy on magnetic resonance imaging.

We report a case of multicystic adenomyosis, which is an exceedingly rare benign tumor. The patient complained of an irregular menstrual cycle and abnormal genital bleeding that gradually increased in amount and frequency. The patient finally became severely anemic, and a hysterectomy was therefore performed. T2-weighted magnetic resonance imaging (MRI) indicated hyperplasia of the endometrium, with a myometrial lesion, where a high signal intensity multicystic mass was observed. The preoperative diagnosis was complicated by confusing MRI results. Postoperative macroscopic examination revealed a villous endometrium and a myometrium thickened with multiple small cysts containing serous transparent fluid. The final diagnosis, based on the hysterectomy specimen, was adenomyosis coexisting with simple endometrial hyperplasia. The MRI and positron emission tomography images are presented.

Symptomatic improvement in uterine myomas after MRgFUS: 4 year follow up

Objective: To assess the long‐term improvement in symptoms after magnetic resonance‐guided focused ultrasound surgery (MRgFUS) for uterine myomas. Methods: Japanese women with symptomatic myomas underwent MRgFUS using the ExAblate 2000 system. The symptom severity score (SSS) was examined before and after the treatment at 3, 6, 12, 24, and 48 months. Simultaneously, we asked the patients’ satisfaction level regarding the overall change of subjective symptoms: symptom free, improved a great deal, improved to some extent, no change, or worsened. The myoma volumes were measured at 6, 12, 24, 36 and 48 months after MRgFUS. Results: No severe adverse event occurred with any of the patients. The mean SSS value before treatment was 38.3±21.5 (n = 106), which diminished significantly during follow‐up for 3–48 months after treatment. Patients’ satisfaction level was favorable, although the response rate was low. Over 80% of the patients replied that their symptoms were improved to at least some extent, and over 50...