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子宮動脈栓塞術(shù)(UAE)治療子宮肌瘤沒有禁區(qū)

 昵稱40699196 2017-02-28

Quality Improvement Guidelines for Uterine Artery Embolization: An Evolution in Patient Selection

Gary P. Siskin, MD

子宮動脈栓塞術(shù)的質(zhì)量改進指南:患者選擇的革命性進步

Gary P. Siskin, MD 靳 勇 譯

在過去的20年中,對子宮動脈栓塞術(shù)(UAE)批判的努力反而導(dǎo)致這個手術(shù)被廣泛接受作為一種治療癥狀性子宮肌瘤的有效手段。目前,質(zhì)疑相應(yīng)的轉(zhuǎn)向?qū)μ囟ㄈ巳?/span>UAE的治療上,包括子宮腺肌癥、帶蒂的子宮肌瘤和有懷孕預(yù)期的患者。這些問題其實在過去的醫(yī)學(xué)文獻中已經(jīng)有定論了,不幸的是,即使今天,由于偏見使然,她們的醫(yī)生仍然不讓病人接觸到UAE這一治療手段或甚至沒有把UAE列在患者可供選擇的治療方法之中。由Dariushnia等人(1)修訂后的《UAE質(zhì)量改進指南》特意強調(diào)UAE治療的這一領(lǐng)域,并用最近的研究結(jié)果支持對這部分患者治療方法推薦的改進(1)。

我們都明白,讓醫(yī)生改變舊有的觀念,學(xué)習(xí)和接受新的治療方法是非常困難的。通過Dariushnia等人提出的信息(1)應(yīng)該再次提醒我們:病例報告結(jié)論應(yīng)該首先得到承認(rèn),再采用更好設(shè)計的大宗病例研究支持或反駁這些初步結(jié)論。這就是UAE治療帶蒂的肌瘤或子宮腺肌癥患者的情況。最初給人的感覺,合并子宮腺肌病患者UAE治療失敗率非常高,但已經(jīng)完成的大宗病例分析發(fā)現(xiàn)并非如此(2)。同樣,早期病例報告提出了關(guān)于漿膜下帶蒂肌瘤UAE術(shù)后可能脫離子宮,需要手術(shù)取出的擔(dān)憂(3)。這在最近的研究中也同樣沒有得到證實,相反,帶蒂的漿膜下肌瘤患者已顯示出UAE術(shù)后癥狀改善、肌瘤體積減少和肌瘤壞死。子宮腺肌病患者或帶蒂的漿膜下肌瘤患者選擇UAE操作帶來的癥狀緩解率遠(yuǎn)遠(yuǎn)超過早期病例報告引起的擔(dān)憂,再拒絕承認(rèn)UAE的優(yōu)勢是不合適的。

同樣的,現(xiàn)在是思考想要保留生育功能的患者是否可以接受UAE的時候了。Mara等人的研究(4)得出這樣的結(jié)論:子宮肌瘤剔除術(shù)比UAE能夠更好的保留生殖功能,但是,必須承認(rèn)的是這個研究中子宮肌瘤切除術(shù)患者的一般情況本來就好于接受UAE的患者。雖然目前的數(shù)據(jù)不支持使用UAE作為所有未來有懷孕計劃患者的一線治療方案,但他們同時承認(rèn),早期關(guān)于UAE不利于妊娠的結(jié)論可能是言過其實了。因此,UAE應(yīng)該被視為不適合外科手術(shù)患者、之前曾做過子宮肌瘤剔除術(shù)的患者和不愿意接受子宮肌瘤剔除術(shù)患者的合理選擇,至少UAE必須包含在可供這些患者選擇的治療計劃中。

介入放射學(xué)質(zhì)量改進指南在設(shè)計上就是不斷更新的。它總是會及時跟進UAE治療的新技術(shù)、新材料的革新,以及以后可能發(fā)展出的更好的替代治療手段。學(xué)習(xí)患者治療手段推薦的更新、手術(shù)的預(yù)期成果率、和并發(fā)癥的發(fā)生率等的目前研究綜述文章,對于確保介入醫(yī)生為他們患者盡最大努力選擇合適的治療方案是非常必要的。我們這些經(jīng)常實施UAE的醫(yī)生知道指南中進一步強調(diào)了(1)帶蒂的漿膜下肌瘤患者、子宮腺肌癥患者、和希望保留生育能力的患者是可以接受UAE手術(shù)的。Dariushnia等人(1)應(yīng)將這些問題置于聚光燈下讓更多的人熟知。我們介入醫(yī)生只是這個治療中的一個環(huán)節(jié)。那些首診并為患者提供治療建議的醫(yī)生,還有那些醫(yī)保機構(gòu)負(fù)責(zé)人觀念必須要更新。現(xiàn)在是改變舊有觀念的時候了,特別是上述的那些患者都已經(jīng)知道了這方面知識的更新并期待它得以實施。

原文:

During the past 20 years, the efforts made tocritically evaluate uterine artery embolization (UAE) have resulted in thealmost universal acceptance of this procedure as an effective treatment optionfor patients with symptomatic leiomyomata. In time, questions have been raisedregarding the applicability of UAE to de?ned subsets of patients, includingthose with adenomyosis, pedunculated ?broids, or a desire for future fertility.These questions are the result of dated reports inthe medical literature that, unfortunately, even today, have caused thesepatients to be denied access to UAE or to not even have UAE included in adiscussion on potential treatment options with their physician. The revised QualityImprovement Guidelines for UAE by Dariushnia et al (1) highlight these areasand turn to recent research that supports a change in the management recommendationsthat can be made for these particular patients (1).

We can all appreciate that the initial impressions formedby physicians when learning about new, innovative procedures are dif?cult tochange. The information presentedby Dariushnia et al (1) should once again serve as a reminder that theconclusions of case reports and small case series should be acknowledged butheld in reserve until larger, better designed studies support or refute thoseinitial conclusions.This certainlyseems to be the case with UAE performed in patients with pedunculated ?broidsor adenomyosis. The initial sense that patients with adenomyosis are at asigni?cantly increased risk for treatment failure after UAE (2) has not beenborne out as larger studies and analyses have been performed.Similarly, anearly case report raised concerns about treating pedunculated subserosal?broids with UAE for fear that the ?broid may detach from the uterus andrequire surgery for removal (3). This too has not been validated in more recentstudies, and, instead, patients with pedunculated subserosal ?broids have been shownto experience symptomatic improvement, ?broid volume reduction, and ?broidinfarction after embolization.It is justinappropriate to deny patients with adenomyosis or pedunculated subserosal?broids the option to undergo a procedure associated with symptomaticimprovement rates that far exceed the initial impressions formed by early case reports.

Similarly,it is time for a change in thinking regarding UAE in patients who wish topreserve their fertility. The study by Mara et al (4) does conclude thatmyomectomy has superior reproductive outcomes compared with UAE, but, if UAE isto be compared with myomectomy in this setting, it must be acknowledged thatthere are short comings in that study and the historical studies that have elevatedmyomectomy to the de facto standard for these patients.Although the most current data do not support theuse of UAE as ?rst-line therapy for all patients with plans for futurepregnancy, they have demonstrated that early concerns regarding negativepregnancy outcomes in association with UAE were likely overstated. As a result, UAEshould be considered as a reasonable option for patients who are poorcandidates for surgical treatment, patients who have had a previous myomectomy,and patients who do not wish to undergo a myomectomy, and must be included inall treatment-planning discussions with these patients.

The Society of Interventional Radiology Quality ImprovementGuidelines are meant to be continuo- usly evolving by design. There will alwaysbe new insights into UAE with time as changes in technique, changes in materials,and further development of alternative treatment options occur. A criticalreview of the most current research with an eye on making updated recommendationsfor patient selection, anticipated success rates, and complication thresholdsis necessary to insure that interventional radiologists are doing the best theycan for their patients. Those of us performing UAE on a regular basis know thatthe literature highlighted in this document (1) is what can be expected inclinical practice for patients with adenomyosis and pedunculated subserosal?broids, as well as for patients who wish to preserve their fertility.Dariushnia etal (1) should be commended for bringing these issues into the spotlight. Weare, however, only part of this equation. Evolution of thought must also be expectedfrom those physicians who are initially assessing and advising patients ontreatment options, as well as from the entities responsible for the payment forthese services.It is time for this changeto occur, especially because the patients described here are aware of theevolution of knowledge in this area and are expecting it to occur.


REFERENCES(參考文獻)

1. Dariushnia SR, Nikolic B, Stokes LS, Spies JB, for the Society of

Interventional Radiology Standards of Practice Committee. Quality

improvement guidelines for uterine artery embolization for symptomatic

leiomyomata. J Vasc Interv Radiol 2014; 25:1737–1747.

2. Smith SJ, Sewall LE, Handelsman A. A clinical failure of uterine?broid

embolization due to adenomyosis. J Vasc Interv Radiol 1999; 10:

1171–1174.

3. Ravina JH, Aymar A, Cirau-Vigneron N, et al. Embolisation arterielle

particulaire: un nouveau traitement des haemorragies des leiomyomes

uterins. Press Med 1998; 27:299–303.

4. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm

clinical and ?rst reproductive results of a randomized, controlledtrial

comparing uterine ?broid embolization and myomectomy. Cardiovasc

Interv Radiol 2008; 31:73–85.


刊載于:J Vasc Interv Radiol 2014; 25:1748–1749

網(wǎng) 址:http://dx./10.1016/j.jvir.2014.09.001


譯者簡介:

靳勇 蘇州大學(xué)附屬第二醫(yī)院介入科 主任 主任醫(yī)師 醫(yī)學(xué)博士 碩士生導(dǎo)師 中國抗癌協(xié)會腫瘤介入治療委員會全國青年委員 中國抗癌協(xié)會肺癌微創(chuàng)綜合治療委員會全國委員 江蘇省抗癌協(xié)會腫瘤介入委員會常委、腫瘤微創(chuàng)治療委員會委員 蘇州市醫(yī)德醫(yī)風(fēng)標(biāo)兵 蘇州大學(xué)優(yōu)秀共產(chǎn)黨員 蘇州市衛(wèi)生系統(tǒng)優(yōu)秀共產(chǎn)黨員及青年文明標(biāo)兵 蘇大附二院“十佳”醫(yī)生

專業(yè)特長:

肝硬化消化道大出血的介入治療

肝癌、肺癌、肝血管瘤等良惡性實體腫瘤的介入微創(chuàng)治療

食道、胃腸道、呼吸道狹窄及膽道梗阻的介入微創(chuàng)支架治療

出血及血栓栓塞性疾病的介入微創(chuàng)治療

子宮肌瘤、肌腺癥、宮外孕等婦產(chǎn)科疾病介入微創(chuàng)治療

門診時間 周二上午 周四上午


蘇州大學(xué)附屬第二醫(yī)院介入科


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