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Uterine Leiomyomata: Pathogenesis and Management
http://www.100md.com 《新英格兰医药杂志》
     Uterine Leiomyomata falls short of its potential to enlighten clinicians about this rapidly evolving topic. Uterine leiomyomas may affect up to 70 to 80 percent of American women, but for much of the past century there was little need for a new book on this topic, since treatment options were limited to hysterectomy and abdominal myomectomy. Recent advances in the understanding of the pathophysiology, improved diagnostic measures, and new treatments of uterine myomas have highlighted the need for a comprehensive book on the subject.

    To be fair, there are several exceptional aspects of this book. The chapters are written by an international panel of experts. The book is logically broken down into four sections that address basic sciences, clinical diagnosis, treatment, and new developments. The section about new developments includes uterine-artery embolization, ablation by means of high-intensity focused ultrasound, and selective progesterone-receptor modulators. Some of the chapters are excellent. Chapter 21, "High-Intensity Focused Ultrasound," by Vaezy, Zderic, and Fujimoto, is one of the best discussions of this topic that I have seen and includes details about technologic development, studies in animals, clinical trials, and continued limitations of high-intensity focused ultrasound that preclude its widespread use. Other outstanding chapters include those on the medical treatment of uterine leiomyomata, on hysteroscopic management, and on asoprisnil (a selective progesterone-receptor modulator). The chapter on hysterectomy includes an excellent discussion of techniques of vaginal hysterectomy for large myomas but is somewhat biased toward the vaginal approach. I recommend these chapters as stand-alone reviews of their topics.

    (Figure)

    Photomicrograph of a Uterine Myoma.

    From the Wellcome Photo Library.

    Intensive editing could have rescued the book from redundancies, contradictions, and tedious discussions. As it is, the book consists of a series of isolated chapters written by different authors. Far too often, the chapters begin with similar descriptions of such generalities as the incidence of uterine leiomyomata, associated symptoms, and other information that has only peripheral relevance to the chapter. Redundancy is most prevalent in the section about basic sciences, since many chapters rehash information about growth factors, genetics, and hormonal mechanisms. For example, chapter 3, "Regulation of Smooth-Muscle Cell Proliferation in Leiomyomata" and chapter 4, "Gene Expression and Hormonal Response," both provide detailed and overlapping discussions about growth factors. Two chapters' worth of material is a lot to plod through to reach the conclusion that little is known.

    Presumably, the book is intended for clinicians, yet most clinicians will get lost in several of the discussions of basic science, not only because of the complexity but also because of the use of acronyms for hormones, genes, and growth factors that will be unfamiliar to most clinicians. As a result, reading some sections is like reading a foreign language. For example, "the steroid receptor coactivator (SRC) family is composed of three distinct, but structurally and functionally related members: SRC-1, also known as NCoA-1; SRC-2 (TIF2/GRIP1/NcoA-2); and SRC-3 (p/CIP/RAC3/ACTR/AIB1/TRAM-1)." The apparent assumption of the authors that the reader is familiar with molecular biology might tempt the clinician to skip the entire basic-sciences section.

    Many of the clinical chapters are overly brief reviews for a book devoted to a single topic. For example, the introductory chapter on epidemiology barely discusses the racial and age-related incidences of uterine fibroids. Fortunately, more epidemiologic details are buried in later sections of the book. The chapter on sonography eloquently describes advantages of Doppler and color-flow imaging, but the chapter on magnetic resonance imaging has more information about routine ultrasonography than does the chapter on ultrasound. The chapter on myomectomy is a superficial overview of abdominal and laparoscopic myomectomy that leaves the reader no better prepared to perform these complex procedures. A chapter on cost-effectiveness is mostly repetitive and concludes with the statement that "it is still difficult to draw firm conclusions" about cost-effective treatments. A chapter about a new technology — laparoscopic occlusion of uterine vessels — is 10 pages long, but only 2 pages are devoted to the technique. Finally, the chapter on uterine-artery embolization is well written, but at four pages, including figures, it is far too brief.

    Future editions of Uterine Leiomyomata will benefit greatly from more influential editing that provides a stylistic uniformity, deletes redundancies, expands deficient areas, and removes inconsistencies that are too common in this edition. At its best, this could be an essential reference book for all providers of health care for women. Unfortunately, the bright spots are too few to be able to recommend this edition.

    Bradley S. Hurst, M.D.

    Carolinas Medical Center

    Charlotte, NC 28232

    bhurst@carolinas.org(Edited by Ivo Brosens. 32)