CELLULAR CHANGES FOLLOWING UTERINE ARTERY EMBOLIZATION FOR THE TREATMENT OF ADENOMYOSIS

Dear Editor We present a case of the uterine artery embolization (UAE) for the treatment of adenomyosis and discuss cellular changes after UAE that may occur as a result of this treatment. UAE for the treatment of symptomatic uterine ®broids was ®rst reported in the French literature in 1991 by Revina et al. Since then, UAE has been used with increasing frequency as a non-surgical treatment for a variety of clinical conditions, including those of leiomyoma, adenomyosis and persistent haematoma. Although many reports on radiological features of UAE for ®broid diseases have been previously documented, we could ®nd no description of the cellular changes seen after UAE in the English language literature based on vaginal cytology after embolization for the treatment of adenomyosis. A 44-year-old women complaining of severe dysmenorrhea and menorrhagia consulted our radiology department concerning ®broids. A diagnosis of uterine submucosal ®broids was made at an outside hospital and hysterectomy was recommended or the use of gonadotrophin releasing hormone analogues. However, the patient refused both treatments. A pelvic magnetic resonance image (MRI) obtained at our hospital revealed a submucosal mass 3 cm in diameter in which there was a round haemorrhagic cyst 1.5 cm in diameter, suggestive of an adenomyotic cyst, together with two small ®broids in the submucosal and intramural regions. The patient was thought to be a candidate for UAE and underwent the procedure successfully. Post-procedural cramping continued for 16 h, but was temporary. The patient had a yellowish-to-white vaginal discharge the next day. An MRI obtained 7 days after UAE showed a submucosal mass containing an adenomyotic cyst as well as an unenhanced thickened junctional zone, suggestive of infarction. The same MRI demonstrated that two ®broids resulted in 100% infarction. The patient was discharged 7 days after UAE. An MRI obtained 4 months after UAE demonstrated that the infarcted adenomyosis had decreased markedly in volume compared with 1 week after UAE, and the submucosal mass containing the adenomyotic cyst had disappeared completely. The same MRI showed that the submucosal and intramural ®broids had decreased in size. The uterine volume reduction was 38%. At the time writing, the patient was well, 16 months after embolization treatment. One day after the embolization, smears were taken from the vaginal discharge, spray ®xed and then stained with the Papanicolaou method. These smears were abundantly cellular and had many loosely cohesive, tall columnar cells with a respiratory epithelium or endocervical cell appearance, lying in an in ̄ammatory background (Figure 1). Necrotic debris was scanty, and endometrial cells in typical densely packed three-dimensional clusters were infrequent. The tall columnar cells had larger and more eccentric nuclei than the usual endometrial cells. The cytoplasm of these cells revealed ®ne granularity with some cilia (Figure 2). They were thought to originate from the endometrium. Typical clusters of endometrial glandular cells as seen in endometrial samples were observed infrequently. This cytological pattern was presumed to indicate massive exfoliation of endometrial glandular cells due to ischemic changes induced by UAE. In the late 1970s, use of transarterial embolization for the successful treatment of obstetric and gynaecological disease associated with haemorrhage was added as presurgical prophylaxis. Embolization of the uterine arteries to improve clinical symptoms and reduce ®broid size has been described and has several advantages. Overall, embolization Cytopathology 2001, 12, 270±277