At the time I was starting this blog two patients with similar fibroids came to see me. Both were severely anemic, and one was hemorrhaging and in shock.
Before any procedure was done I received both patients’ permission to share their stories. At the time of the initial writing one had treatment 6 weeks ago and one 3 weeks ago. Neither of their experiences to date are necessarily typical, but I am following through on my commitment to share their stories.
Comment: (Updated 6-17-2010)
Yesterday was a difficult day. We did surgery on my first patient (who had the embolization) and found a high-grade sarcoma (cancer) which had spread throughout the abdomen. I talked to her about deleting her story, but she was comfortable with leaving it in. Uterine sarcoma is very uncommon, being seen in fewer than 1 in 500 rapidly growing fibroids. The risk of cancer is much lower for fibroids that are not rapidly growing. Benign fibroids have never been shown to undergo malignant change.
Could this have been diagnosed earlier, and if so would it have made a difference? Probably not. There is a single study in which a blood test coupled with a special MRI done with IV contrast rapidly infused differentiated between sarcoma and fibroids. To my knowledge this has not been confirmed by other studies, and by the time the tumor can be diagnosed there is a high probability that it would have already spread.
It is easy to overreact and be overly aggressive in removing fibroids because of the fear of cancer, which is in fact rare. We would be doing hundreds of unnecessary surgeries to find a single sarcoma. Yes, had she chosen myomectomy or hysterectomy, we would have diagnosed her sarcoma two months earlier, but it is unlikely that the outcome would be different. I was tempted to remove this story for fear that it would frighten women into surgery that is not needed. But I promised to tell the story as it is. Please understand that this is very unusual, and most women do well when embolization is done in appropriate situations. — Paul Indman, M.D
First Visit
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| A 48 year old woman (who prefers her name not be used) came in hemorrhaging and in shock. Her hemoglobin was 4.6. (Normal 12-13). She does not desire to maintain fertility. |
Jan, a 41 year old woman with heavy periods, came for her first visit, and was not actively bleeding. She was short of breath and weak, but not in shock. Her hemoglobin was 5.0. Jan would like to have another baby.
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Findings at first visit:
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| Uterus the size of a 16 week pregnancy. MRI shows 9 cm. fibroid, mostly intramural but indenting the cavity |
Uterus the size of a 18 week pregnancy. MRI shows 11.5 x 10 cm. fibroid, mostly intramural but indenting the cavity |
Initial treatment:
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| Hospitalized, transfused 4 units of blood. Bleeding stopped with medications. Started on medication and iron to build up blood, and high doses of progesterone |
Started on high dose birth control pills to prevent further bleeding. Given medication and iron to build up blood. Was able to continue her usual work as an engineer until surgery. |
Decision making: All options, including UFE (embolization), myomectomy, and hysterectomy were discussed.
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Since fertility was not an issue, she felt that embolization would be the least invasive treatment.
Advantages: avoids an incision.
Disadvantages: Average decrease in volume of 50%, is only a 20% decrease in diameter. Submucous fibroids may shed tissue and may cause a heavy discharge for prolonged period of time. |
As Jan wants to have another baby, she chose to have the fibroid removed. Given the size and location, I felt an abdominal myomectomy would allow the best repair of the uterus. |
Treatment:
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| Embolization (UFE or UAE).
A catheter is inserted into an artery to inject inject particles which will plug the arteries feeding the fibroid.
Below is from her actual embolization done by an interventional radiologist, and shows the catheter in the right side. The blood vessels appear black.
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Jan’s Abdominal Myomectomy: Large uterus fills pelvis to above belly button.
Fibroid (above) being removed from uterus (below)
Fibroid measures 15cm. (6 inches). Two smaller fibroids were also removed.
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2 weeks after procedure:
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| Low grade fever, chills, vaginal bleeding |
Read Jan’s letter written 5 days after her myomectomy.
Seen early for post-op check because she wants to return to work. She is off of her pain medicine, and can return to her work.
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4 weeks after procedure:
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Bleeding a pad every 3-4 hours. Uterus is now size of 20 week pregnancy, and is tender.
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At time of this writing it is not yet 4 weeks since Jan’s myomectomy. I’ll post her progress.
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6 weeks after procedure:
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Uterus has increased to size of 22 week pregnancy and is tender. MRI and CT scan ordered. Results: large mass with large abdominal lymph nodes suggesting malignancy.
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Findings at surgery: sarcoma (an aggressive cancer). See above comment!
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Four month check-up after Jan’s abdominal myomectomy |
Comment: (Updated 6-17-2010)
Yesterday was a difficult day. We did surgery on my first patient (who had the embolization) and found a high-grade sarcoma (cancer) which had spread throughout the abdomen. I talked to her about deleting her story, but she was comfortable with leaving it in. Uterine sarcoma is very uncommon, being seen in fewer than 1 in 500 rapidly growing fibroids. The risk of cancer is much lower for fibroids that are not rapidly growing. Benign fibroids have never been shown to undergo malignant change.
Could this have been diagnosed earlier, and if so would it have made a difference? Probably not. There is a single study in which a blood test coupled with a special MRI done with IV contrast rapidly infused differentiated between sarcoma and fibroids. To my knowledge this has not been confirmed by other studies, and by the time the tumor can be diagnosed there is a high probability that it would have already spread.
It is easy to overreact and be overly aggressive in removing fibroids because of the fear of cancer, which is in fact rare. We would be doing hundreds of unnecessary surgeries to find a single sarcoma. Yes, had she chosen myomectomy or hysterectomy, we would have diagnosed her sarcoma two months earlier, but it is unlikely that the outcome would be different. I was tempted to remove this story for fear that it would frighten women into surgery that is not needed. But I promised to tell the story as it is. Please understand that this is very unusual, and most women do well when embolization is done in appropriate situations. — Paul Indman, M.D.
