Morphological Effect On Endometrium Using Ultrasound Ablation For The Uterine Fibroids

ObjectiveBy retrospectively analyzing the relevant factors which caused theendometrial reaction for the HIFU ablation treatment of uterine fibroids(including vaginal bleeding or vaginal fluid) and sieving the factors whichcan cause the endometrial reaction. While using the reaction of endometrialcell in the near field of ultrasound, studying the morphological changes ofthe endometrium using ultrasound ablation in vitro and the morphologicalchanges of the endometrium in vivo, offering theoretical basis for theimpact upon the endometrium in the ultrasound ablation of uterine fibroidsHIFU ablation, and providing the basis for a reasonable choice ofindications to reduce the occurrence of endometrial injury.Methods1. Three hundred and eighty-one patients with single uterine fibroidsor multiple uterine only individual treated fibroids were screened.According to the presence or absence of vaginal fluid; patients weredivided into two groups. The screened contents include three aspects as follows: The first part includes age, symptoms, composite scores, thenumber of pregnancy,the number of births and the number of abortions,BMI; The second part includes the related indicators of the MRIexamination: such as the thickness of rectos abdominals, fat thickness,abdominal wall thickness, size of the uterus,fibroids size, the place of thefibroids, endometrial thickness, the fibroids classification and the distancefrom fibroids shallow surface to skin; The third part includes the relatedindicators of the HIFU treatment, such as treatment time, irradiation time,intensity of treatment, the total energy of the treatment, treatment volume,the distance from the focus to the endometrial, distance from fibroids edgeto endometrium, distance from ablation fibroid necrosis edge toendometrium. The MRI pieces were read by both radiologists andgynecologist. Add up and analyze each influential factor’s differencebetween the vaginal fluid liquid and no vaginal flow liquid, seeking forthe factor that causes vaginal fluid.2. Take the endometrium of the hysterectomy due to uterine fibroids.Primary endometrial cell was mixed culture. Endometrial cells were placedin specially sealed flasks by a density of1×10~~6, the sealed flasksequipped with endometrial cells were placed at distance from physic focalregion of5mm,10mm,15mm and20mm. Each group endometrial cellsrespectively irradiated2s,4s and6s three groups. Irradiated cells werecultured with MTT detect cell proliferation at24h,48h and72hrespectively.3. To take the endometrium of the hysterectomy patient of uterinefibroids, the removal of the uterus were immediately cryopreservation inice container and send to HIFU treatment laboratory for ultrasound ablationtreatment. Put the uterine fibroids into the special containers on the JC200treatment couch. The fibroids in the focal region remote, monitoring ultrasound can be screen fibroids and uterus. Uterine fibroids were ablatedwith200W energy. When ultrasound grayscale covered fibroids, the uterinefibroids ablation finished and immediately slit fibroids along thelongitudinal axis of the fibroids. Endometrium were immediately cut andplaced into10%formalin for HE, other endometrium placed into2%glutaraldehyde for electron microscopic examination.4. To select seven cases posterior wall of the uterus fibroids of HIFUablation due to uterine fibroids. Before HIFU ablation, menstrual score,basis of sex hormones and MRI check fibroids were applied. After HIFUablation fibroids two hours, patients underwent MRI review and understandfibroids necrotic area for no fever and no abdominal pain and prepared forhysteroscopy examination. After HIFU ablation uterine fibroids threemonths, menstrual score, basis of sex hormone, MRI check fibroids andhysteroscopy examination were applied again.Results1.381patients who underwent HIFU ablation,133patiets withvarying degrees of vaginal flow or blood,disappeared about1week,accounting for34.9%.Anterior fibroids248,of which45patients vaginalfliud,accounting for18.1%; Posterior wall of fibroids133,of which88patients with vaginal fluid,accounting for66.2%.General and the presenceof vaginal discharge correlation analysis,patient age,BMI,menstrual cycledays,the number of pregnancy,number of births and the incidence ofvaginal discharge,there was no significant correlayion(p>0.05),symptomscomposite score (UFS) and the occurrence of vaginal discharge has apositive correation (r=0.235, P=0.000); quality of life (QOL) score and theoccurrence of vaginal discharge has a negative correlation(r=-0.165, p=0.001).The correlation analysis of fibroids features with or without vaginaldischarge,including abdominal wall thickness, fibroids,fibroids surface to the abdominal wall skin distance and the occurrence of vaginaldischarge,there was no significant correlation(p>0.05);uterine volume andthe occurrence of vagial discharge has a positive correlation(r=0.164,p=0.001); endometrial thickness and the occurrence of vaginaldischarge has a negative correlation(r=-0.225,p=0.000);deep surface of theanterior wall of fibroids to the endometrial distance and occurrence ofvaginal discharge has a negative correlation (r=-0.445,p=0.000); theanterior fibroid ablation zone deep surface has a negative correlation toendometrial distance and the occurrence of vaginal discharge(r=-0.442,p=0.000)；occurrence of the distance of the shallow surface of theposterior wall of the fibroids to endometrial and vaginal discharge has anegative correlation (r=-0.622,p=0.000);the anterior fibroid ablation zoneshallow surface to the endometrium of the distance and occurrence ofvaginal diacharge has a negative correlation (r=-0.532,p=0.000).Ultrasound ablation parameters with or without vaginal dischargecorrelation analysis,the focus distance to the endometrium,dose intensity,duration of treatment,the treatment of the total energy and ablation volumeand the occurrence of vaginal discharge has no significant correlation(p>0.05); while the irradiation time and the occurrence of vaginal dischargefactors symptoms score(UFS), life quality score (QOL) uterinevolume,emdometrial thickness,the endometrial fibroids edge to thedistance of the ultrasonic irradiation time. Multiple Logistic regressionanalysis gradually removing the variable including QOL,uterinevolume,endometrial thickness and the ultrasonic irradiation time(p>0.05),fibroids edge to endometrial distance and UFS of significantvariable quantity.2. Primary endometrial cells after a mixed culture of epithelial cellscan be passed to3or5generations, but stromal cells can be repeatedly passed.Under microscope, epithelial cells arranged in a spiral-shaped cellwere polygonal or tadpole-shaped but stromal cells infusiform. The cellidentification keratin CK19positive in epithelial cells, vimentin positive instromal cells. In the near-field of HIFU, endometrial cells wasproliferation.The cell proliferation ability becomes weak when distancedecreases from focal field in physics. The endometrial cell proliferationenergy was increased at the same distance of20mm with the increaseirradiation time.The endometrial cell proliferation energy was decreasingat a distance of15mm,10mm, and15mm with irradiation time increasing.The proliferation strongest point were at10mm pairwise comparison(p<0.01).3. The visible layer of the endometrium were thin under the lightmicroscope. The endometrium, glands and myometrium were no obviousnecrotic tissue under low magnification. Endometrial cells and smoothmuscle cells all shows no necrosis. On the electron microscope The smoothmuscle cells arranged in bundles, abundant cytoplasm, nucleus partialdissolution of the nuclear membrane integrity, vascular endothelial cellswelling, cell cycle gap expansion,mitochondrial swelling, swelling of theGolgi apparatus, nuclear membrane gap broadening were bunk, film glandsmorphology contour glandular epithelial cells structural damage and fusion.Ultrasound ablation from uterine fibroids has little damage for uterine baselayer.4. Seven patients of HIFU ablation treatment uterine fibroids were notstatistically significant compare before HIFU hormone and menstrualscore with after three months hormone and menstrual score usingHIFU(p>0.05). Under hysteroscopy, endometrium show color pinkhemorrhage, congestive points scattered near fibroids. Endometrium werepart glands fractur, endometrial stromal edema and hemorrhage. After three months HIFU ablation, uterine fibroids were significantly reduced by MRIexamination fibroids again. Endometrium were pink and no adhesion.ConclusionsHIFU ablation is a non-invasive treatment. The treatment of theuterine fibroids causes vaginal fluid or flooding, which is one of thecomplications. Vaginal discharge factors including symptoms compositescore,the quality of life score,uterine volume,endometrial thickess,thefibroids edge to endometrial distance,ultrasonic irradiation time,multiplelogistic regression analysis,vaginal fluid factor successively removed,endometrium is closely related to the distance to the edge of the fibroids.The tissue and cells of sound channel are affected by near-field of HIFUwith physics focal field distance and irradiation time. The near-field ofHIFU mainly promote cell proliferation.With distance from the nearerphysics focal field, the proliferation energy is reduced.When theirradiation time is longer,the proliferation energy is weakened more. Usingultrasound ablation fibroids in vitro, endometrial coagulation necrosis isobvious,but myometrium only organelle edema, no coagulation necrosis,itis easier to heat endometrial damage. On HIFU ablation uterinefibroids,endometrium near fibroids scattered congestive point,the othersendometrium didn’t blood. After HIFU ablation fibroids, ovarianendocrine function and menstrual score are no longer affected. Under thenormal sex hormone,bleeding endometrium may repair again. Therefore,endometriums of HIFU ablation fibroids were safe under the currenttreatment modalities.