Vascular and Interventional RadiologyE2621. Cryoablation of Abdominal Wall Endometriosis: A Minimally Invasive Treatment
Dibble E, D'Amico K, Bandera C, Littrup P. Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI
Address correspondence to E. Dibble (firstname.lastname@example.org)
Objective: Abdominal wall endometriosis (AWE) is ectopic endometrial tissue in the abdominal wall that may be seeded during surgery and is often painful. The goal of this study is to present the novel application of cryoablation, which has successfully treated malignant and nonmalignant soft tissue lesions, as a definitive treatment for AWE.
Materials and Methods: Institutional review board–approved, retrospective review of patient charts was performed of three patients with prior cesarean sections and known or suspected AWE who opted for cryoablation. Patient 1 was a 43-year-old woman with chronic narcotic-requiring pain from AWE within the left rectus muscle. Patient 2 was a 37-year-old woman with chronic narcotic-requiring pain from a mass in the subcutaneous fat suspicious for AWE. Patient 3 was a 40-year-old woman with chronic ibuprofen-requiring pain at the site of a subcutaneous mass abutting the left rectus muscle suspicious for AWE. We used combined ultrasound and CT guidance with hydrodissection and probe elevation to protect adjacent sensitive structures. Cryoprobe density was ~1/cm tumor diameter. Local 1% lidocaine and IV midazolam and fentanyl were used. For patient 1, three cryoprobes were placed in the mass and lifted anteriorly to elevate from bowel, which hydrodissection displaced. A 10-minute freeze, 5-minute thaw, and 6-minute refreeze were performed. For patient 2, biopsy was performed, then two cryoprobes were placed into the mass and lifted anteriorly to elevate from underlying muscle. Hydrodissection displaced muscle and skin. A 5-minute freeze, 5-minute thaw, and 6-minute refreeze were performed. For patient 3, after biopsy was performed three cryoprobes were placed into the mass. Hydrodissection displaced muscle. An 8-minute freeze, 6-minute thaw, and 5-minute freeze were performed. Postablation CTs confirmed ice coverage of masses and lack of progression into adjacent structures. Follow-up calls and clinic visits or both documented pain levels and evaluated for complications.
Results: Patient 1 had 8/10 pain preprocedure, 8/10 pain 1–3 days postprocedure, 5/10 pain 1 week postprocedure, and 3–4/10 pain 3 weeks postprocedure requiring acetaminophen but no narcotics. A CT at 3-week assessment performed for abdominal pain showed expected postablation changes. Six weeks postablation, she reported intermittent 2/10 pain requiring no narcotics. Biopsy confirmed AWE in patient 2. She had 5–6/10 pain preprocedure, 8–9/10 pain 1–3 days postprocedure, and 1–2/10 pain 8 days postprocedure requiring intermittent ibuprofen but no narcotics. One month postprocedure, she required no analgesics. Follow-up MRI showed no residual endometrioma. Biopsy confirmed AWE in patient 3. Preprocedure pain was 2–3/10 at baseline but 9/10 during menstrual cycles. Follow-up MRI 2 months postprocedure showed no residual endometrioma. At 3 months postprocedure, she required no analgesics and reported 0/10 pain including during two menstrual cycles.
Conclusion: Three patients with debilitating pain were successfully treated and stopped narcotic or heavy analgesic use after this minimally invasive outpatient procedure. To our knowledge, this is the first application of cryoablation to treat AWE.