Dr. Khilnani is an Interventional Radiologist at Cornell Vascular and an Associate Professor at the Weill Medical College of Cornell University. He has been with Cornell since finishing his training at Columbia in 1992. His clinical interests are in the minimally invasive treatment of uterine fibroid tumors and lower extremity varicose veins. He currently performs all of the uterine fibroid embolizations at the New York Presbyterian Hospital-Weill Cornell Center and will be directing the clinical and research efforts of this institution in treating fibroids with MR Guided Focused Ultrasound.
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Fibroids1: What is an Interventional Radiologist?
Dr. Khilnani: Interventional Radiologists are physicians who perform image guided minimally-invasive procedures that can treat diseases which previously required more invasive surgery. Generally, the procedures performed by Interventional Radiologists are as effective as more invasive surgery and are generally safer and associated with significantly shorter recovery periods. Interventional Radiologists train in Board Certified Programs for five years in radiology and then do another one to two years of training in Interventional Radiology; the purpose of this is to learn how to use the sophisticated image-guided techniques to treat many different kinds of diseases.
Fibroids1: How did you choose the field of Interventional Radiology?
Dr. Khilnani: I entered the field as a kind of metamorphous rather than as an early passion. My father was an academic radiologist and, while I was interested in medicine and radiology, I was very much a gadget-type person. I studied bioengineering at Princeton and was considering a career in engineering allied to the medical sector. Somewhere late in college, I realized that I wanted to become a physician. I went to medical school and, perhaps influenced by my father, I became interested in Radiology.
I found radiology appealing in terms of the its cutting edge technology, the intellectual component of understanding of mechanisms and manifestations of disease, and the detective role that Radiologists play in helping to solve patient diagnostic problems. However, early in my Residency, I recognized that I really missed patient contact. I had selected radiology over a surgical sub-specialty and I wondered if I had made the right choice. But, then along came interventional radiology. IR gave me the opportunity to combine many of my interests and skills. I enjoyed being involved in the diagnosis of disease, and then being able to use patient care skills and modern tools to treat these diseases. IR morphed into a nice specialty for me.
Fibroids1: What are some typical symptoms that you see with women suffering from fibroids?
Dr. Khilnani: Typical symptoms seen with fibroid patients are heavy menstrual bleeding, pelvic pain and pressure, bloating, frequency of urination, and constipation.
Fibroids1: What are the traditional treatments for fibroids?
Dr. Khilnani: For a long time, the only treatments for fibroids were hysterectomy, or myomectomy, which many Gynecologists feel uncomfortable performing. Medical therapy for fibroids has been relatively unsuccessful with the exception of several drugs, which chemically place patients into menopause. Drugs of that nature, which would include Lupron, essentially create a hormonal environment that stops the cyclical estrogen and progesterone stimulation of fibroid growth so they stop growing and they then shrink—a scenario that happens in menopause.
These drugs work well in terms of reducing the fibroid size and controlling their symptoms; however, they do so at the expense of rapidly developing menopausal symptoms that most patients don’t find tolerable. Several new drugs are being looked at which may have similar efficacy to Lupron but with less of the side effects. However, there is currently no data to substantiate this. Several minimally- invasive treatments have been developed that allow women to preserve their uterus, treat their fibroid symptoms, and get them back on their feet in shorter length of time than if they had had surgery. Fibroid embolization and focused ultrasound treatment are two of these options.
Fibroids1: Fibroids must be a sensitive topic for some of your patients. How do you approach discussing it with them?
Dr. Khilnani: Yes, it is a sensitive topic. Many women, understandably, are concerned about how they will feel after the treatment that is usually first proposed to them, which is a hysterectomy. I think it’s important for all physicians to be sensitive to this issue and to give patients a fair assessment of what other options are available to them. I have come across many patients in their mid to late thirties/forties who haven’t had children. Although they may not want to have children, they like to keep the option available to them. They are reluctant to pursue treatment for significant fibroid related symptoms since the only option presented to them is hysterectomy. I think that fibroid embolization certainly is an option that allows these women to feel more comfortable proceeding with some form treatment to enhance their quality of life.
Fibroids1: How is the uterine fibroid embolization procedure done?
Dr. Khilnani: Fibroid embolization is a procedure where an Interventional Radiologist (IR) inserts a very small tube called a catheter into the artery—usually at the top of the thigh. Using intermittent x-ray guidance, we move this tube, about the size of a linguini, through the arteries until it’s positioned within the artery that feeds the uterus. At that point small, tiny little plastic beads are injected through the tube—these are about half a millimeter in size---and they block off the blood supply to the fibroids. When deprived of blood, like any other tissue, the fibroids die and shrink into a scar. As they shrink, the symptoms associated with the fibroid get better.
Fibroids1: Who would be an ideal candidate for uterine fibroid embolization?
Dr. Khilnani: Many women with fibroids who have symptoms are ideal candidates for embolization. Certainly the best candidates are those with the worst symptoms. It turns out that those with the worst symptoms—especially heavy bleeding—are often the ones who have the most spectacular response. The best way to determine if one is a candidate for uterine fibroid embolization is to have a consultation with an Interventional Radiologist. A great way to find one is to use the physician search function on the Fibroids1 website.
Fibroids1: How does this differ from the focused ultrasound treatment?
Dr. Khilnani: The principle of focused ultrasound therapy is different. Focused Ultrasound, or FUS, is a procedure that has been available for many years; however, only recently has it been made practical by using an MRI to pinpoint its effectiveness. During FUS treatment for fibroids, sound waves are focused on fibroid tumors creating heat within the fibroids which destroys the tumors.
This happens in the same way that light from the sun can be focused with a magnifying lens to burn a leaf. FUS is completely non-invasive except for an I.V., which is inserted to administer some sedation during the treatment. During the FUS, the patient lies on her stomach within an MRI scanner for somewhere around two hours. The MRI equipment is utilized to first locate the fibroid and then to direct the ultrasound energy on the tumors within the uterus to cause them to be destroyed. To contrast the two procedures: Fibroid embolization usually involves a one night hospital stay and about eight to ten day recovery period. Focused Ultrasound takes about two hours with no hospital stay and a 1-2 day recovery time.
Fibroids1: Who would be a good candidate for focused ultrasound therapy for fibroid treatment?
Dr. Khilnani: Not all patients are candidates for FUS. We are finding that certain types of fibroids are more amenable to focused ultrasound than others based on characteristics seen on the MRI. We recognize the limitations as to the amount of fibroid tissue that can be treated. Generally, with the amount of time that is practical to keep a patient within the MRI scanner, we are limited to treating a fibroid within the seven to eight centimeter range; however, someone with several fibroids or fibroids that are larger may not be a candidate for FUS. However, many of the patients who are not candidates for FUS can still be considered candidates for fibroid embolization.
Fibroids1: Are there any other drawbacks to the procedure?
Dr. Khilnani: Although FUS is approved by the FDA for the treatment of fibroids, in my mind, this technology is still somewhat investigational. In the follow-up data collected to date, we know that fibroid tissue destroyed at the time of procedure remains destroyed several months after the procedure. We also know through a short term follow-up that patients treated with FUS had equivalent symptomatic improvement to similar patients treated with hysterectomy with fewer complications.
What we are still waiting to demonstrate is whether these fibroid tumors will shrink and what the long term fibroid and symptomatic recurrence rate is, if there is one. In our institution, I am going to be one of the physician’s involved in our research trial using the next-generation FUS equipment coupled with a higher resolution MRI scanner. I am looking forward to seeing what this particular technology has to offer.
One of the problems with any focal fibroid treatment (focal treatment means removing or destroying fibroids one at a time) such as such as myomectomy or FUS is that we leave a lot of smaller fibroids or parts of fibroids untreated. It is likely that the recurrence rate for these types of procedures will be higher. One of the advantages of fibroid embolization is that it is a global therapy and treats all of the fibroids in the uterus.
In over 90% of fibroid embolization cases, all the fibroid tissue is completely destroyed and even in those cases where it isn’t, there is often only a minimal amount of the fibroid tissue that is left alive. In the future, I think that fibroid embolization will continue to have an important role in treating fibroid patients; the focused ultrasound will also have a role but it may be somewhat limited.
Fibroids1: What role does the pill play with fibroids? Some researchers say it contributes to fibroids.
Dr. Khilnani: The pill itself is an interesting story. It is a common belief of many woman that the pill, also know as an oral contraceptive, will increase the rate of fibroid growth. I think the important thing for women to realize is that over years, the pill has been improved. Almost all of the oral contraceptives being offered nowadays have a much smaller stimulatory effect on the fibroid growth. The pill can help control dysfunctional bleeding that is often found in women with fibroids. It is appropriate in many cases for gynecologists to prescribe oral contraceptives to control the symptoms associated with fibroids. I think patients who have fibroids and are considering oral contraceptives should discuss this with their gynecologist.
Fibroids1: The Center for Uterine Fibroids is currently enrolling families in the "Finding Genes for Fibroids" study. Do you think they will find that fibroids are genetic?
Dr. Khilnani: We know that one of the more important causes of fibroids is genetic. What we don’t understand is the actual inheritance patterns and where the encoded hereditary material is within the human genome. You certainly see families with multiple fibroid patients, and you can also recognize that certain ethnic groups are prone to developing fibroids. I think what is left to be resolved is what those inheritance patterns are and whether anything can be done to modulate the expressions of these risks.
Fibroids1: Do you think there are any environmental factors at play?
Dr. Khilnani: Investigators have looked very carefully at environmental risk factors for fibroids and several associations have been made. However, none of that data is incredibly strong. One thing that many of my patients ask about is the potential stimulatory effect of red meat on the growth of their fibroids. I know that this association has been promoted by some investigators, but my sense is that avoiding red meat solely to prevent fibroid growth probably doesn’t make a huge difference.
Fibroids1: How important is it then for the patient to be informed and educated about her kind of fibroids?
Dr. Khilnani: Patient education benefits not only the patient but the also the physician. The more a patient knows about fibroids and her treatment options, the more comfortable she will be with her treatment decisions. Certain types of fibroids have specific characteristics that lend themselves to certain types of treatments. As a result, I am fairly liberal about utilizing an MRI to help me advise patients about their options. For example, a patient with a single fibroid may be a good candidate for a laparoscopic or hysteroscopic fibroid removal/FUS, as opposed to a patient with innumerable fibroids, who may do better with either an embolization or hysterectomy.
Fibroids1: Do you have any other recommendations for women living with fibroids?
Dr. Khilnani: I think it’s important for women to recognize that there are more treatment options than just hysterectomy, and that most women can find something that will appeal to them and work reasonably well. Women with fibroids who have no symptoms should recognize that they will rarely need any treatment; in most cases, it is reasonable to wait until the fibroids affect the quality of one’s life before seeking treatment. Even though many of the minimally-invasive therapies are safer than surgery, all procedures have a finite rate of complication.
It is best to avoid all risks if the symptoms are not demanding treatment. All procedures that leave the uterus in place have the potential for fibroid recurrence, and the longer you can hold off on the first fibroid treatment, the less likely you are going to need multiple treatment within the course of your reproductive life. I think many women recognize that the Internet is a great resource to keep abreast of the medical research developments; fibroid embolization became so successful because of the initiative of women to identify what other treatments were available and what would be best for them. Women should continue to be their best advocates.
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