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Table of Contents
CLINICAL IMAGE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 45-46

Magnetic resonance imaging-guided high-intensity focused ultrasound ablation for endometriosis of the abdominal wall


Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam

Date of Submission27-May-2019
Date of Decision20-Sep-2019
Date of Acceptance03-Oct-2019
Date of Web Publication23-Jan-2020

Correspondence Address:
Dr. Minh Duc Nguyen
Department of Radiology, Pham Ngoc Thach University of Medicine, 02 Duong Quang Trung, Ward 12, District 10, Ho Chi Minh City
Vietnam
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_47_19

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How to cite this article:
Nguyen MD. Magnetic resonance imaging-guided high-intensity focused ultrasound ablation for endometriosis of the abdominal wall. Gynecol Minim Invasive Ther 2020;9:45-6

How to cite this URL:
Nguyen MD. Magnetic resonance imaging-guided high-intensity focused ultrasound ablation for endometriosis of the abdominal wall. Gynecol Minim Invasive Ther [serial online] 2020 [cited 2020 Jul 9];9:45-6. Available from: http://www.e-gmit.com/text.asp?2020/9/1/45/276502



A 38-year-old patient with three children suffered from right-sided palpable nodules along with cyclic pain and swelling nodule in the low abdominal region during menstruation for 9 months. The Visual Analogue Scale (VAS) of the patient was 8 at clinical examination. In addition, she had a history of three times adopted cesarean section delivery. The patient was diagnosed with endometriosis of the rectus abdominis muscle via ultrasound-guided biopsy 1 month ago and indicated an open surgery to eradicate lesion completely. Nevertheless, the patient desired to experience a noninvasive therapy; she was admitted to our interventional radiology center for magnetic resonance imaging-guided high-intensity focused ultrasound (MRI-guided HIFU). MRI findings showed that she had a 180-mm old transversal scar [Figure 1]a. There was no evidence of uterine adenomyosis. Endometriosis lesion is located in the right rectus abdominis muscle with a diameter of 12 mm. The lesion was high intensity on T2-weighted image [Figure 1]b. Before the treatment, the patient was adopted bowel preparation and fasted for 12 h. Diazepam (5 mg) was utilized 30 min prior to treatment. Intravenous drip infusions of paracetamol (1000 mg) and fentanyl citrate (100 μg) in 500 ml normal saline were managed before initiating the ablation. During the ablation procedure, the patient was positioned in the prone. In addition, due to prior long abdominal scar, we exploited polyethylene foam scar patch to cover the scar to avoid sonicating through the scar [Figure 1]c. Furthermore, we utilized a 4-cm thick gel pad so as to increase the distance from the transducer to the lesion to reduce the patient's heating sensation. Vital signs including blood pressure, heart rate, respiration rate, and oxygen saturation were all consecutively assessed during the treatment. We used only three of 4-mm diameter treatment cells with a very low power of 60 W to sonicate centeredly and cautiously the lesion to avoid damage of adjacent tissues. Between each sonication, we prolonged the cooling time up to 5 min so that the temperature of the skin can recover to the baseline temperature, therefore decreasing the risk of fat and skin burn. The total duration treatment was about 20 min. At immediate posttreatment, T1-weighted image with contrast enhancement manifested that the lesion was fully ablated [Figure 1]d. There was no evidence of the surrounding fat burn or skin burn. The patient was discharged at the same day. At 1-month, 3-month, and 6-month follow-ups, the VAS of the patient was reduced to 6, 2, and 1, respectively. In addition, on T2-weighted image at 6-month follow-up, the volume and high signal intensity of lesion were lessened significantly in comparison with the baseline features [Figure 2]. There were no severe complications during the follow-up period.
Figure 1: (a) Coronal T2-weighted fast-field echo image shows a long transversal cesarean scar (white arrow). (b) Axial T2-weighted image shows a hyperintense endometriosis lesion inside the right rectus abdominis rectus muscle (white arrow). (c) Coronal T2-weighted fast-field echo image shows a transversal cesarean scar covered with scar path (white arrow). (d) Coronal T1-weighted with contrast enhancement image shows the fully ablated lesion after MRI-guided HIFU treatment (white arrow)

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Figure 2: Axial T2-weighted image shows an absence of hyperintense endometriosis lesion inside the right rectus abdominis rectus muscle (white arrow) along with a reduction of lesion size compared to axial T2-weighted image features prior to the treatment

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Endometriosis of the abdominal wall accounts for 0.1% of endometriosis patients, which is generally diagnosed postoperatively.[1] Until now, conventional and standard therapy to treat this disease is surgery.[2] Recently, the wish of patients who do not want to undergo a surgery or have a new scar urges the innovation and utilization of some other minimally invasive therapies such as HIFU under the guidance of MRI or ultrasound. HIFU treatment is successfully applied for the treatment of various gynecological diseases such as uterine leiomyoma and uterine adenomyosis. The sonication beam lifts the tissue's temperature efficaciously up to 65°C or more which induces coagulation necrosis of lesion.[3] In this study, our findings showed that the endometriosis of the rectus abdominis muscle is ablated flourishingly without adverse effects. The patient's VAS was improved significantly during the follow-up period. Our results are fully concordant with the previous studies.[4],[5],[6],[7] In terms of therapeutic outcome, there is no significant difference between the HIFU and surgical treatment for this disease.[2] There are some advantages of HIFU treatment for this disease including quick recovery, no blood loss, no exposure to anesthesia, and no formation of a new scar. Nonetheless, there are some disadvantages of this therapy such as high installed investment, high maintaining cost, and large consuming space.[8] Overall, the clinician should take into consideration that HIFU in some circumstances can be utilized as an alternatively noninvasive treatment for endometriosis of the abdominal wall.

Ethical approval

Pham Ngoc Thach University of Medicine Institutional Review Board has approved this project, IRB No. 6_CDHA obtained on 22th May in 2015.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sedhain N, Dangal G, Karki A, Pradhan HK, Shrestha R, Bhattachan K, et al. Caesarean scar endometriosis. J Nepal Health Res Counc 2018;15:292-4.  Back to cited text no. 1
    
2.
Zhu X, Chen L, Deng X, Xiao S, Ye M, Xue M. A comparison between high-intensity focused ultrasound and surgical treatment for the management of abdominal wall endometriosis. BJOG 2017;124 Suppl 3:53-8.  Back to cited text no. 2
    
3.
Duc NM, Huy HQ. Influences of screening magnetic resonance imaging parameters on high-intensity focused ultrasound outcome for adenomyosis. Rep Med Imaging 2018;11:9-14.  Back to cited text no. 3
    
4.
Duc NM, Huy HQ, Keserci B. Adverse events of focused ultrasound surgery for uterine fibroids and adenomyosis. Rep Med Imaging 2018;11:15-26.  Back to cited text no. 4
    
5.
Nguyen MD. Single-phase focused ultrasound surgery for 15-leiomyoma and huge leiomyoma patients. Gynecol Minim Invasive Ther 2018;7:178-80.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Luo S, Zhang C, Huang JP, Huang GH, He J. Ultrasound-guided high-intensity focused ultrasound treatment for abdominal wall endometriosis: A retrospective study. BJOG 2017;124 Suppl 3:59-63.  Back to cited text no. 6
    
7.
Wang Y, Wang W, Wang L, Wang J, Tang J. Ultrasound-guided high-intensity focused ultrasound treatment for abdominal wall endometriosis: Preliminary results. Eur J Radiol 2011;79:56-9.  Back to cited text no. 7
    
8.
Kim YS. Clinical application of high-intensity focused ultrasound ablation for uterine fibroids. Biomed Eng Lett 2017;7:99-105.  Back to cited text no. 8
    


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