Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix

OBJECTIVE

The objective of this study was to describe the sonographic characteristics of squamous cell cancer (SCC) and adenocarcinoma (AC) of the cervix using transvaginal ultrasound.

METHODS

Women with early stage cervical cancer undergoing transvaginal ultrasound examination before surgery were prospectively included. The sonographic characteristics were assessed with regard to tumor morphology, vascularization, size, extension and location. Histological assessment of tumor subtype, size, growth pattern, extension and location was performed. Both sonographic and histological assessments were carried out according to a standardized protocol.

RESULTS

Fifty-five women were recruited. Ten were excluded because no tumor was seen on ultrasound examination and five were excluded because radical surgery was aborted as a result of positive lymph nodes, detected using the sentinel node technique. Among the remaining 40 women, 20 had AC and 20 had SCC. At pathological examination, 34 women had tumors confined to the cervix, three had parametrial invasion and three had vaginal invasion. Hypoechogenicity was associated with SCC in 73% (11/15) of the women, while isoechogenicity indicated AC in 68% (13/19) of the women (P = 0.03). Mixed echogenicity (n = 4) showed a non-significant association with larger tumor volume (P = 0.23). Hyperechogenicity was found in two women, both of whom had the less malignant villoglandular AC. Color Doppler signals were found in all cases of AC and in 90% (18/20) of cases of SCC, compared with most normal cervical tissue in which virtually no detectable vascularization was found.

CONCLUSION

We found that the sonographic appearance of SCC and AC differs. This knowledge should be useful in the clinical evaluation of cervical tumors.

Course of Cation Absorption by Plant Tissue

The absorption of rubidium by excised barley roots from solutions containing calcium was a strictly linear function of time for 1 hour and was temperature-sensitive throughout; there was no evidence of an initial nonmetabolic exchange phase of uptake. The rubidium absorbed reached concentrations many times the external concentration without any slackening of the rate of absorption-evidence for a high degree of irreversibility of the overall absorption process. This is discussed in terms of the "enzyme-kinetic" model of ion transport by carriers.

Salt toleration by plants: enhancement with calcium

Bean plants subjected to a sodium chloride concentratioz about onetenth that of seawater for 1 week suffered no damage if the calcium concentration of the nutrient solution was 1 millimole per liter or higher, but at lower calcium concentrations damage was severe and apparently due to a massive breakthrough of sodium into the leaves.

Transport of Sodium in Plant Tissue

Two mechanisms are implicated in the absorption of alkali cations by barley roots. Mechanism 1 has a high affinity for potassium, but its affinity for sodium is so low that, in the presence of even a low concentration of potassium (1 mM), sodium absorption by this mechanism is all but abolished. Mechanism 2 has a much lower affinity for alkali cations and is not highly selective; it transports sodium as well as potassium.

Saline culture of crops: a genetic approach

Increasing salinity of soil and water threatens agriculture in arid and semiarid regions. By itself, the traditional engineering approach to the problem is no longer adequate. Genetic science offers the possibility of developing salt-tolerant crops, which, in conjunction with environmental manipulation, could improve agricultural production in saline regions and extend agriculture to previously unsuited regions.

Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group

The IETA (International Endometrial Tumor Analysis group) statement is a consensus statement on terms, definitions and measurements that may be used to describe the sonographic features of the endometrium and uterine cavity on gray-scale sonography, color flow imaging and sonohysterography. The relationship between the ultrasound features described and the presence or absence of pathology is not known. However, the IETA terms and definitions may form the basis for prospective studies to predict the risk of different endometrial pathologies based on their ultrasound appearance.

Does an active sun exposure habit lower the risk of venous thrombotic events? A D-lightful hypothesis

BACKGROUND

Venous and arterial thrombotic complications exhibit a seasonal variation, with risk peaking in winter and dropping to a nadir in summer. We sought a possible correlation between sun exposure habits and venous thromboembolism (VTE) events.

METHODS

This was a cohort study comprising 40,000 women (1000 per year of age from 25 to 64 years) who were drawn from the southern Swedish population registry for 1990 and followed for a mean of 11 years. Seventy-four per cent answered an inquiry at the inception of the study (n=29,518), and provided detailed information on their sun exposure habits. Cox regression analysis was used with the presence of VTE as a dependent variable and selected demographics as independent variables. The main outcome was the relationship between VTE and sun exposure habits.

RESULTS

Swedish women who sunbathed during the summer, on winter vacations, or when abroad, or used a tanning bed, were at 30% lower risk of VTE than those who did not. Risk estimates did not change substantially after adjustment for demographic variables. The risk of VTE increased by 50% in winter as compared to the other seasons; the lowest risk was found in the summer.

CONCLUSIONS

Women with more active sun exposure habits were at a significantly lower risk of VTE. We speculate that greater ultraviolet B light exposure improves a person's vitamin D status, which in turn enhances anticoagulant properties and enhances the cytokine profile.

Gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and vascularity as assessed by color Doppler for discrimination between benign and malignant endometrium in women with postmenopausal bleeding

OBJECTIVE

To determine if gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and endometrial vascular morphology as assessed by color Doppler ultrasonography can discriminate between benign and malignant endometrium in women with postmenopausal bleeding.

METHODS

In a prospective study 95 consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm as measured by transvaginal ultrasound were included. Gray-scale and color Doppler ultrasound examination of the endometrium was performed. The ultrasound examiner characterized the morphology of the endometrium before and during saline infusion and assessed the endometrial vascular tree using a predetermined classification protocol without suggesting a diagnosis. A histopathological diagnosis was obtained by operative hysteroscopy, dilatation and curettage or hysterectomy.

RESULTS

There were no statistically significant differences in ultrasound findings between benign and malignant endometria of uterine cavities without fluid. Heterogeneous echogenicity, irregular surface, and both heterogeneous echogenicity and irregular surface of a focal lesion (or of the endometrium in the absence of focal lesions) in a uterine cavity filled with fluid (spontaneous or infused) were significantly more common in malignant than in benign endometrium. The sensitivity, false positive rate, positive and negative likelihood ratios of these findings were as follows: heterogeneous echogenicity, 80%, 29%, 2.74, 0.28, P = 0.003; irregular surface, 89%, 33%, 2.70, 0.17, P = 0.002; and both, 78%, 12%, 6.59, 0.25, P < 0.001. Two or more vessels were found in 67% (8/12) of the malignant endometria vs. 51% (40/79) of the benign endometria (non-significant difference). Vascular branching tended to be more common in malignant endometria (10/11; 91%) than in benign endometria (39/61; 64%), P = 0.09.

CONCLUSION

Heterogeneous echogenicity and an irregular surface of a focal lesion or of the endometrium in a fluid-filled uterine cavity are useful ultrasound criteria for predicting endometrial malignancy. Assessment of vascular morphology using color Doppler ultrasound is of limited--if any--value for discrimination between benign and malignant endometrium.

Frequency and type of adnexal lesions in autopsy material from postmenopausal women: ultrasound study with histological correlation

OBJECTIVE

To determine the prevalence and histology of adnexal cysts in autopsy material from postmenopausal women.

METHODS

The study included 104 adnexa from 52 consecutive women with a mean age of 79 (range, 64-96) years, who underwent autopsy and died from causes other than gynecological cancer or intraperitoneal cancer of extragenital origin. The adnexa were removed, put in sterile saline in separate plastic containers and examined sonographically using an 8-MHz transvaginal transducer. Each lesion detected at ultrasound examination was measured with calipers on the frozen ultrasound image and was classified according to its ultrasound morphology. The adnexa were then put in 4% formaldehyde solution and sent for histological examination.

RESULTS

At ultrasound examination, 56% (29/52) of the women had adnexal lesions, cysts being detected in 54% (28/52) and solid lesions in 12% (6/52). At least one adnexal cyst with a largest diameter of 2-10 mm, > 10 mm, > 20 mm, > 30 mm and > 40 mm, respectively, was found in 33% (17/52), 21% (11/52), 12% (6/52), 8% (4/52) and 4% (2/52) of the women. The largest lesion measured 65 mm in diameter. At ultrasound examination we found 36 intra-ovarian cysts (26 inclusion cysts, three cystically degenerated corpora albicantia, five simple cysts, one serous cystadenoma and one 3-mm cyst not confirmed by the pathologist), 19 extra-ovarian cysts (all simple cysts according to the pathologist), five solid intra-ovarian lesions (two fibromas, one cystadenofibroma, one Brenner tumor and one case of dystrophic calcification), and one solid extra-ovarian lesion (fibroma). In addition, the pathologist detected one 20-mm solid corpus albicans, eight extra-ovarian simple cysts of 1-8 mm, and 77 intra-ovarian inclusion cysts of 1-4 mm.

CONCLUSION

Small (< or = 50 mm) benign adnexal cysts and small benign solid tumors are so common in postmenopausal women that their presence may be regarded as normal. Our results support conservative management of adnexal lesions with benign ultrasound morphology incidentally detected at ultrasound examination in postmenopausal women.

Intraobserver and interobserver reproducibility of ultrasound measurements of endometrial thickness in postmenopausal women

OBJECTIVES

To determine intraobserver and interobserver reproducibility of ultrasound measurements of endometrial thickness in postmenopausal women.

DESIGN

Forty-eight postmenopausal women underwent transvaginal ultrasound examination by two examiners. Each observer took three replicate measurements of the endometrium in each woman. Intraobserver repeatability was expressed as the difference between the highest and lowest measurement values obtained by one observer, the repeatability coefficient, and the intraclass correlation coefficient. Interobserver reproducibility was expressed as the difference between the mean of the three measurements of each observer, limits of agreement, and interclass correlation coefficient. The repeatability coefficient and the limits of agreement define the range within which 95% of the differences between two measurements are likely to fall. Data were analyzed for all women, as well as separately for women with endometrium < or = 6 mm and > 6 mm. The agreement between observers in classifying women as having endometrium < or = 4.4 mm or > or= 4.5 mm was determined by calculating Cohen's kappa.

RESULTS

In women with endometrium <or = 6 mm the intraclass correlation coefficient was 0.95 for Observer 1 and 0.88 for Observer 2, the median difference between the highest and lowest values being 0.4 mm (range, 0-1.4) for Observer 1 and 0.7 mm (range, 0.1-2.2) for Observer 2, and the repeatability coefficient was 0.8 mm and 1.4 mm, respectively. The corresponding figures for women with endometrium > 6 mm were 0.99 and 0.99, 0.7 mm (0-2.9) and 1.0 mm (0.2-3.4), and 1.7 mm and 1.9 mm. In women with endometrium < or = 6 mm the interclass correlation coefficient was 0.77, and the mean interobserver difference was 0.2 mm +/- 1.8 mm (2 standard deviations), when calculations were based on the mean of three measurements per observer (+/- 1.9 mm when calculations were based on only one measurement per observer). The corresponding figures for women with endometrium > 6 mm were 0.98, 0.2 mm +/- 3.1 mm (+/- 3.2 mm). The agreement between observers in classifying women as having an endometrium < or = 4.4 mm or > or = 4.5 mm was very good (kappa 0.81).

CONCLUSIONS

The reproducibility of endometrial measurements seems to be clinically acceptable and to allow reliable discrimination between postmenopausal women with endometrium < or = 4.4 mm and > or = 4.5 mm. In clinical practice, it is enough to take one endometrial measurement when performing transvaginal ultrasound examination.

An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding

OBJECTIVE

To determine if power Doppler ultrasound examination of the endometrium can contribute to a correct diagnosis of endometrial malignancy in women with postmenopausal bleeding and endometrium > or = 5 mm.

METHODS

Eighty-three women with postmenopausal bleeding and endometrium > or = 5 mm underwent gray-scale and power Doppler ultrasound examination using predetermined, standardized settings. Suspicion of endometrial malignancy at gray-scale ultrasound examination (endometrial morphology) was noted, and the color content of the endometrium at power Doppler examination was estimated subjectively (endometrial color score). Computer analysis of the most vascularized area of the endometrium was done off-line in a standardized manner. Stepwise multivariate logistic regression analysis was carried out to determine which subjective and objective ultrasound and power Doppler variables satisfied the criteria to be included in a model to calculate the probability of endometrial malignancy.

RESULTS

Endometrial thickness, vascularity index (vascularized area/endometrial area), and use of hormone replacement therapy (HRT) satisfied the criteria to be included in the model used to calculate the 'objective probability of endometrial malignancy'. Endometrial morphology, endometrial color score and HRT use satisfied the criteria to be included in the model to calculate the 'subjective probability of malignancy'. Endometrial thickness > or = 10.5 mm had a sensitivity with regard to endometrial cancer of 0.88 and a specificity of 0.61. At a fixed sensitivity of 0.88, the specificity of the 'objective probability of malignancy' (0.81) was superior to all other ultrasound and power Doppler variables (P = 0.001-0.02). The 'objective probability of malignancy' detected more malignancies at endometrium 5-15 mm than endometrial morphology (5/7 vs. 1/7, i.e. 0.71 vs. 0.14; P = 0.125) with a similar specificity (49/57 vs. 51/57, i.e. 0.86 vs. 0.89).

CONCLUSION

Power Doppler ultrasound can contribute to a correct diagnosis of endometrial malignancy, especially if the endometrium measures 5-15 mm. The use of regression models including power Doppler results to estimate the risk of endometrial cancer deserves further development.

Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding

OBJECTIVE

To determine the prevalence of focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > or = 5 mm and the extent to which such lesions can be correctly diagnosed by D&C.

METHODS

In a prospective study, 105 women with postmenopausal bleeding and endometrium > or = 5 mm at transvaginal ultrasound examination underwent diagnostic hysteroscopy, D&C and hysteroscopic resection of any focally growing lesion still left in the uterine cavity after D&C. Twenty-four women also underwent hysterectomy. If the histological diagnosis differed between specimens from the same patient, the most relevant diagnosis was considered the final one.

RESULTS

Eighty percent (84/105) of the women had pathology in the uterine cavity, and 98% (82/84) of the pathological lesions manifested a focal growth pattern at hysteroscopy. In 87% of the women with focal lesions in the uterine cavity, the whole or parts of the lesion remained in situ after D&C. D&C missed 58% (25/43) of polyps, 50% (5/10) of hyperplasias, 60% (3/5) of complex atypical hyperplasias, and 11% (2/19) of endometrial cancers. The agreement between the D&C diagnosis and the final diagnosis was excellent (94%) in women without focally growing lesions at hysteroscopy.

CONCLUSION

If there are focal lesions in the uterine cavity, hysteroscopy with endometrial resection is superior to D&C for obtaining a representative endometrial sample in women with postmenopausal bleeding and endometrium > or = 5 mm.

Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding

OBJECTIVE

To determine the prevalence of focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > or = 5 mm and the extent to which such lesions can be correctly diagnosed by D&C.

METHODS

In a prospective study, 105 women with postmenopausal bleeding and endometrium > or = 5 mm at transvaginal ultrasound examination underwent diagnostic hysteroscopy, D&C and hysteroscopic resection of any focally growing lesion still left in the uterine cavity after D&C. Twenty-four women also underwent hysterectomy. If the histological diagnosis differed between specimens from the same patient, the most relevant diagnosis was considered the final one.

RESULTS

Eighty percent (84/105) of the women had pathology in the uterine cavity, and 98% (82/84) of the pathological lesions manifested a focal growth pattern at hysteroscopy. In 87% of the women with focal lesions in the uterine cavity, the whole or parts of the lesion remained in situ after D&C. D&C missed 58% (25/43) of polyps, 50% (5/10) of hyperplasias, 60% (3/5) of complex atypical hyperplasias, and 11% (2/19) of endometrial cancers. The agreement between the D&C diagnosis and the final diagnosis was excellent (94%) in women without focally growing lesions at hysteroscopy.

CONCLUSION

If there are focal lesions in the uterine cavity, hysteroscopy with endometrial resection is superior to D&C for obtaining a representative endometrial sample in women with postmenopausal bleeding and endometrium > or = 5 mm.

Rebleeding and endometrial growth in women with postmenopausal bleeding and endometrial thickness < 5 mm managed by dilatation and curettage or ultrasound follow-up: a randomized controlled study

OBJECTIVE

To compare the frequency of rebleeding and endometrial growth during a 12-month follow-up period between women with postmenopausal bleeding and an endometrial thickness < 5 mm managed by dilatation and curettage, and those managed by ultrasound follow-up.

DESIGN

Consecutive women with postmenopausal bleeding and an endometrial thickness < 5 mm were randomized to ultrasound follow-up after 3, 6, and 12 months (n = 48) or to primary dilatation and curettage with ultrasound follow-up at 12 months (n = 49). At all follow-up examinations, the endometrial thickness was measured and the women were asked about rebleeding. The endometrium was sampled at the 12-month examination, if sampling had not been performed previously because of rebleeding or endometrial growth.

RESULTS

Rebleeding was reported by 33% (16/48) of the women in the ultrasound group and by 21% (10/48) of those in the dilatation and curettage group (P = 0.17). Endometrial growth to >or= 5 mm was found in 21% (10/48) of the women in the ultrasound group and in 10% (5/48) of those in the dilatation and curettage group (P = 0.16). No endometrial pathology was found in women with isolated rebleeding. Endometrial pathology during follow-up was found more often in women with endometrial growth than in those without (33% vs. 4%; P = 0.008).

CONCLUSION

Rebleeding and endometrial growth are common during a follow-up period of 12 months in women with postmenopausal bleeding and an endometrial thickness < 5 mm, irrespective of whether or not dilatation and curettage is primarily carried out. If these women are managed by ultrasound follow-up, endometrial sampling should be performed if the endometrium grows, but not necessarily in the case of rebleeding without endometrial growth.

Charles Bonnet syndrome in glaucoma patients with low vision

PURPOSE

To characterize the nature and frequency of Charles Bonnet syndrome in glaucoma patients with low vision.

PATIENTS AND METHODS

All patients attending the glaucoma clinic during a period of 10 months who had visual acuity of 20/80 or less in both eyes were included in this study. Each patient was questioned about the occurrence of visual hallucinations. Those who responded positively had a thorough interview relating to the characteristics of the hallucinations. Medical history and social history were taken, followed by a complete ocular examination.

RESULTS

Eighty-nine patients met the inclusion criteria. Eleven patients (12.3%), eight men and three women, admitted to having experienced visual hallucinations. Except for one case, the patients did not disclose this experience previously. Eight patients had one repeatable hallucination, and three patients experienced more than one sight. The visions were usually sharp, and the figures were occasionally incomplete. Most hallucinations were chromatic. Frequency of hallucinations varied between daily and weekly, and duration was mostly a few minutes. In addition to glaucoma, nine of the eleven patients had other ocular findings that could have contributed to the reduction of vision.

CONCLUSION

Visual hallucinations are not rare in glaucoma patients with low vision. Patients tend to conceal their experience of visual hallucinations, but a discussion of these phenomena with the patient and assurance of their harmless nature will reduce his or her anxiety and concerns.

Comparison of Endorette and dilatation and curettage for sampling of the endometrium in women with postmenopausal bleeding

MAIN QUESTION: To compare the diagnostic properties of Endorette and D&C in women with postmenopausal bleeding, to relate the properties to endometrial thickness as measured by ultrasound, and to assess the women's experiences of the two methods.

METHODS

In a prospective study, 133 consecutive women with postmenopausal bleeding were examined with transvaginal ultrasound. After measuring the endometrial thickness, Endorette sampling was performed without anesthesia. Dilatation and curettage (D&C) was carried out under general anesthesia within six weeks. After completion of each sampling procedure the women filled in a questionnaire regarding their experience of the sampling.

RESULTS

Endorette sampling failed in 16% (21/133) of the women. More than half (56%) of the women experienced moderate or strong pain during Endorette sampling, and the doctor underestimated the pain in 62% of the women. Endorette failed to diagnose two of seven (29%) endometrial cancers found at D&C. In one of these two cases, the examiner suspected that the Endorette device had not reached the uterine fundus. In women with endometrium < 7 mm, Endorette and D&C showed similar results with regard to obtaining a sufficient endometrial sample and to distinguishing normal endometrium, benign pathological endometrium and malignancy. In women with endometrium > or =7 mm, Endorette yielded insufficient samples significantly more often than D&C (23% vs 6%, p=0.02; the McNemar test) and missed all polyps and most (77%) hyperplasias diagnosed by D&C.

CONCLUSION

Endorette and D&C have similar diagnostic properties in women with postmenopausal bleeding and endometrium < 7 mm. D&C is superior to Endorette in women with endometrium > or =7 mm.

Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm

OBJECTIVES

To determine the ability of transvaginal ultrasound, with or without saline infusion, to detect focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > 5 mm, and to determine the accuracy of conventional ultrasound, saline contrast sonohysterography and diagnostic hysteroscopy under general anesthesia to diagnose endometrial polyps, submucous myomas and uterine malignancy.

DESIGN

In a prospective study, 105 women with postmenopausal bleeding and endometrium > 5 mm underwent conventional ultrasound examination and saline contrast sonohysterography. Diagnostic and operative hysteroscopy under general anesthesia was then performed. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy.

RESULTS

There was almost perfect agreement (96%) between saline contrast sonohysterography and hysteroscopy in the diagnosis of focally growing lesions. Saline contrast sonohysterography and hysteroscopy both had a sensitivity of approximately 80% with regard to diagnosing endometrial polyps (false-positive rates of 24% and 6%, respectively), whereas conventional ultrasound missed half of the polyps (sensitivity, 49%; false-positive rate, 19%). Hysteroscopy was superior to both saline contrast sonohysterography and conventional ultrasound with regard to discriminating between benign and malignant lesions (sensitivity, 84%, 44%, and 60%; false-positive rate, 15%, 6% and 10%, respectively). The risk of malignancy was increased seven-fold (odds ratio, 7.3; 95% confidence interval, 1.9-27.8) in women with distension difficulties at saline contrast sonohysterography, and two thirds of the women with a poorly distensible uterine cavity had a malignant diagnosis.

CONCLUSION

Saline contrast sonohysterography is as good as hysteroscopy at detecting focally growing lesions in the uterine cavity in women with postmenopausal bleeding. However, neither hysteroscopy nor saline contrast sonohysterography can reliably discriminate between benign and malignant focal lesions. Distension difficulties at saline contrast sonohysterography should raise a suspicion of malignancy.

A role of PDGFRalpha in basal cell carcinoma proliferation

Activation of the hedgehog pathway, through the loss of patched (PTC) or the activation of smoothened (SMO), occurs frequently in basal cell carcinoma (BCC), the most common human cancer. However, the molecular basis of this neoplastic effect is not understood. The downstream molecule Gli1 is known to mediate the biological effect of the pathway and is itself up-regulated in all BCCs. Gli1 can drive the production of BCCs in the mouse when overexpressed in the epidermis. Here we show that Gli1 can activate platelet-derived growth factor receptor alpha (PDGFRalpha) in C3H10T(1/2) cells. Functional up-regulation of PDGFRalpha by Gli1 is accompanied by activation of the ras-ERK pathway, a pathway associated with cell proliferation. The relevance of this mechanism in vivo is supported by a high level expression of PDGFRalpha in BCCs of mice and humans. In the murine BCC cell line ASZ001, in which both copies of the PTC gene are inactivated, DNA synthesis and cell proliferation can be slowed by re-expression of PTC, which down-regulates PDGFRalpha expression, or by downstream inhibition of PDGFRalpha with neutralizing antibodies. Therefore, we conclude that increased expression of PDGFRalpha may be an important mechanism by which mutations in the hedgehog pathway cause BCCs.