A Case Report of a Left Atrial Mass: The Importance of a Detailed Physical Exam

Cardiac myxomas are rare clinical findings. They are frequently found in the left atrium and more commonly affect women. Clinical presentation can vary widely and symptoms can be vague and non-specific. We present a case of a 67-year-old woman presenting with 3 weeks of progressive heart failure symptoms that failed to respond to oral diuretic therapy. On physical exam, she was found to have a diastolic murmur, rumble and an early diastolic plop. Transthoracic echocardiogram revealed a 5.6 cm × 2.5 cm × 4.3 cm left atrial mass attached to the mitral valve causing left atrial outflow obstruction. The patient subsequently underwent surgical resection of the mass with resolution of symptoms immediately thereafter. Lack of recognition of this pathologic process as a cause of heart failure symptoms and lack of a quality physical exam can lead to a delay in diagnosis and treatment.

Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation

BACKGROUND

Iatrogenic parasitic myomas (PMs), caused by intra-corporeal power morcellation during laparoscopy is gradually increasing. However, the pathogenesis and medical treatment of PMs remain largely unelucidated.

METHODS

Laparoscopically-induced PM xenografted mouse model was conducted by xenografting human uterine myoma fragments into the abdominal cavity of SCID mice and hormonal manipulation was performed using this mouse model to demonstrate the role of oestrogen in the development of implanted PMs. Immunohistochemistry of oestrogen receptor α (ERα), progesterone receptor (PR), vimentin, vascular endothelial growth factor (VEGF), microvessel density (MVD) and Ki-67 index was performed and compared.

RESULTS

In the patient with PMs, ERα, PR, angiogenesis and proliferative property expression were upregulated in PM lesions compared to uterine myomas. In the laparoscopically-induced PM mouse model, implanted myomas had more steroid receptor expressions, angiogenesis and proliferative property compared with pre-xenografted or non-implanted myoma. Depletion of oestrogen in the ovariectomized (OVX) mice decreased laparoscopically-induced PM implantations. In comparison, the implantations of PMs were increased with additional E2 supplement. Hormonal manipulation in the PM mouse model, including AI, GnRHa and SERM groups, were compared and AI significantly decreased the implantations, steroid receptor, angiogenesis, cell density, and proliferative index of PMs compared with control group. Furthermore, GnRHa significantly decreased VEGF and MVD expressions compared with control group.

CONCLUSIONS

These data highlight the crucial role of oestrogen in the development of laparoscopically-induced PMs and suggest that hormone manipulation may be a potential therapeutic agent.

TRIAL REGISTRATION

This protocol was approved by the Human and Animal Institutional Review Board of Taipei Veterans General Hospital ( VGHIRB No 2014-10-002C on Nov. 17^th, 2014; IACUC 2014-119 on Aug. 22^nd, 2014).

Incarceration of gravid uterus by growing subserosal myoma: case report

Incarceration of gravid uterus is a rare condition, occurring in one in 3,000 to 10,000 pregnancies during second trimester. Incarceration of uterus can cause several complications, such as uterine rupture, labor dystocia, and uncontrollable postpartum hemorrhage. Early diagnosis is important to prevent these complications, but there are no standard treatments of incarceration of gravid uterus. The authors present a case report of incarceration of gravid uterus caused by growing subserosal myoma, which was treated with myomectomy during second trimester.

[Urinary retention secoundary to cervical myoma large items]

OBJECTIVES

To describe the clinical-diagnostic importance of cystic appearance of a cervical myoma large elements result produced secondary

METHOD

We described a case of a 40-year-old with abdominal discomfort producing difficulty walking, dyspareunia, urinary retention seven months of evolution. The USG diagnosis was a cystic mass consistent with a right ovarian cyst. The surgical abdominal total hysterectomy is performed.

RESULTS

Histopathological study of approximately 1 3x6 cm uterus with myoma fund of approximately 4 cm and myoma level cervical posterior surface of 15x12 cm.

[Atypical localization of myomas during surgery: report of two cases including one in an emergency context]

Les fibromyomes sont des tumeurs bénignes de localisation utérine courante. Elles sont fréquentes chez la femme noire, le diagnostique est échographique et anatomo-histologique. La localisation extra utérine est rare et de physio-pathogénie mal connue. Cette localisation pose des problèmes de diagnostique. Nous rapportons deux cas cliniques de fibromes localisés sur le segment sigmoïdien de l'intestin et sur la paroi interne du muscle transverse de l'abdomen d'une part chez une patiente âgée de 41 ans et d'autre part en région épigastrique, chez une patiente de 47 ans. Toutes les patientes ont été opérées respectivement l'une de myomes utérins pour infertilité et l'autre de laparotomie en urgence pour syndrome sub-occlusif au cinquante huitième jour post hystérectomie. Ces observations doivent inciter les cliniciens ou les radiologistes à réaliser un bilan étendu à la recherche de localisation extra-utérine avant une myomectomie ou hystérectomie car un myome peut en cacher un autre en dehors de l'utérus.

Typical and atypical clinical presentation of uterine myomas

Myoma is the most common benign neoplasm that can occur in the female reproductive system, most frequently seen in women in their 50s. Although the majority of myomas are asymptomatic, some patients have symptoms and/or signs of varying degrees. Typical myoma-related symptoms or signs include: (1) menstrual disturbances like menorrhagia, dysmenorrhea and intermenstrual bleeding, (2) pelvic pain unrelated to menstruation, (3) compression symptoms, similar to a sensation of bloatedness, urinary frequency and constipation, (4) subfertility status such as recurrent abortion, preterm labor, dystocia with an increased incidence of Cesarean section, and postpartum hemorrhage, and (5) cosmetic problems due to increased abdominal girth However, there are undoubtedly some clinical presentations secondary to uterine myomas are not so specific, such as: (1) uncommon compression-related symptoms, (2) cardiac symptom and atypical symptoms secondary to vascular involvement or dissemination, (3) abdominal symptoms mimicking pelvic carcinomatosis, (4) dyspnea, (5) pruritus, (6) hiccup or internal bleeding, and (7) vaginal protruding mass or uterine inversion. Familiarization with these symptoms and awareness of other unusual or atypical presentations of uterine myomas will remind clinical practitioners of their significance, and of the necessity of follow-up examinations and individualized management to fit the needs and childbirth desires of the patients.

[A survey of heart tumors: clinical and echocardiographic approach]

Heart tumors can be primary in origin, can develop from direct extension of a neighboring tumor or they can be the manifestation of metastasis of a distant tumor. Myxomas are the most frequently encountered primary benign cardiac tumors. Primary malignant tumors of the heart are rare, and they are mostly sarcomatous in structure. Secondary heart tumors constitute a wide spectrum, nevertheless they most frequently originate from lung cancer, breast cancer and hematological malignancies. Heart tumors may involve myocardium, endocardium, epicardium, pericardium, or any combination of the aforementioned layers. On the other hand, the usual site for metastasis to the heart is the pericardium. These tumors do not have a well- established classification. Clinical findings are usually non-specific and transient in nature and frequently present late in the disease process. Transthoracic and transesophageal echocardiography are the most widely used diagnostic modalities. Magnetic resonance imaging and computerized tomography may be helpful for selected cases. Surgery is the principal therapeutic option in benign tumors and when recurrences are not taken into account, they have favorable prognoses. Since surgical resection is usually incomplete in malignant tumors, therapy must be individualized for each patient; even with adjuvant chemotherapy, postoperative survival is usually short. Metastases to the heart are usually approached symptomatically except for exceptional cases.

Uterine myomas: management

OBJECTIVE

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

DESIGN

Literature review of 198 articles pertaining to uterine myomas.

RESULT(S)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

CONCLUSION(S)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

A new enucleation method for cervical myoma via laparoscopy

Laparoscopic myomectomy was performed on five women suffering from hypermenorrhea. A new method was used which enucleated the cervical myoma from postcervical medial incision. The wound was sutured in 2 layers intracorporeally. Clipping of the uterine artery and injection of diluted vasopressin were performed to decrease bleeding during laparoscopy. This is a minimally invasive and safe procedure.

Treatment patterns for women with new episodes of uterine myomas in an insured population in the US

INTRODUCTION

Uterine myomas are the most common benign tumors in reproductive-aged women and a leading reason for gynecologist visits and hysterectomies in the United States. This study examines the treatment patterns of insured women with new episodes of uterine myomas.

MATERIALS AND METHODS

We used administrative claims from a proprietary research database to evaluate services (inpatient, outpatient, and prescription claims) incurred from January 1, 2001 to December 31, 2003. We identified women with CPT or ICD-9-CM codes suggestive of myoma and described treatment patterns for all women with a new episode of myoma and those with abnormal bleeding.

RESULTS

The primary study group included 35 329 women with new episodes of care and at least three months of data before and after their index date for myoma. Most women (82.9%) had no code for diagnostic testing in the three months before or after the first myoma marker. Of 14 434 women with one year of follow-up, 26.1% had surgery and 24.7% were treated pharmacologically (oral contraceptives, progestins, or gonadotropin-releasing hormone agonists). Over half (55.1%) of women were untreated, including 45% of those with an ICD-9 code that indicated abnormal bleeding.

CONCLUSIONS

Women with new myoma episodes rarely had codes for confirmatory diagnostic tests. Many women with myomas go untreated for at least a year. This is true even for those with evidence of abnormal bleeding. Myoma care may be improved through the introduction of new, safe, and effective therapies.

Endometrial stromal sarcoma mimicking submucosal myoma protruding to the vagina: MRI findings

A 46-year-old woman complained of persistent abnormal vaginal bleeding over ten days. Her intrauterine device had been removed two years before. Soon after, she suffered from menorrhagia and metrorrhagia. An incidental finding of severe anemia was also noted. In this admission, our initial T2-weighted magnetic resonance imaging (MRI) revealed a well-demarcated mass predominantly in the uterine cavity. The mass was depicted by an isointense signal relative to the myometrium on T1-weighted images, high signal intensity on T2-weighted images, and slightly heterogeneous enhancement on post-contrast images. The patient refused surgery. After two years, follow-up MRI showed a pedunculated mass protruding into the upper third of the vagina with a stalk connecting to the posterior wall of the uterine cavity, simulating submucosal myoma. Histological diagnosis was compatible with low-grade endometrial stromal sarcoma.

Magnetic resonance imaging of intramuscular myxoma with histological comparison and a review of the literature

OBJECTIVE

To evaluate the magnetic resonance (MR) features of intramuscular myxoma (IM) compared with its pathological findings.

DESIGN

Two radiologists retrospectively reviewed records and imaging studies of patients with histologically proven IM. Two radiologists also analyzed by consensus all the MR studies (pre- and post-contrast T1-weighted and T2-weighted sequences) and a pathologist reviewed the available histological material.

PATIENTS

Seventeen patients with 18 histologically proven IM were reviewed. Histological samples of 11 of these 18 tumors were available for pathological analysis.

RESULTS

There were 14 women and three men, with a mean age of 58.9 years. IM involved predominantly the thigh (n=10). MR imaging showed well-circumscribed intramuscular masses, hypointense on T1-weighted and hyperintense on T2-weighted images. Eleven masses were homogeneous and seven slightly heterogeneous due to fibrous septa. Enhanced MR imaging demonstrated three different patterns: peripheral enhancement (n=1), peripheral and patchy internal enhancement (n=7) or peripheral and linear internal enhancement (n=4). Intratumoral cysts were detected in four masses. MR imaging showed the presence of a pseudocapsule (n=12), fat around the lesion (n=16) and peritumoral edema (n=16). Histologically, all the tumors were hypocellular, hypovascular and myxoid. Peripheral areas of collagenous fibers formed a partial capsule and IM often merged into surrounding muscular fibers. More cellular tumors and those with scanty myxoid stroma tended to show a more prominent internal enhancement.

CONCLUSION

IM shows several recognizable MR features which suggest its diagnosis.

Selecting distending medium for out-patient hysteroscopy. Does it really matter?

BACKGROUND

The aim of this prospective randomized study was to evaluate the role of carbon dioxide (CO2) and normal saline for diagnostic accuracy in out-patient hysteroscopy.

METHODS

Women admitted to our Department in order to undergo total abdominal hysterectomy also underwent diagnostic hysteroscopy, 12-24 h prior to surgery. The selection of distending medium was made after randomization. Two groups of patients were formed, group A (CO2; n=39) and group B (normal saline; n=35). More than half of the women in the study population were post-menopausal. Post-hysteroscopy, all women were asked to rank any symptom that they felt during the procedure on a 4-point scale (0=none; 1=mild; 2=severe; 3=inability to perform hysteroscopy). The hysteroscopic diagnosis was compared with the macroscopic findings and the histological examination of the surgical specimen after hysterectomy.

RESULTS

The percentage who completed hysteroscopy was 89.74% within group A and 97.14% within group B. Most patients of both groups felt some pain of mild intensity. The diagnostic accuracy of hysteroscopy was similar for both media when major pathology [large polyps (group A 91.7%; group B 92.7%), myomas (group A 81.25%; group B 92.7%) and/or hyperplasia (group A 87.5%; group B 90.2%)] of the endometrial cavity was detected. In contrast, in cases of minor pathology (small polyps, mucosal elevations, crypts, hypervascularization), hysteroscopy with saline presented with significantly higher diagnostic accuracy (85.4%) compared with hysteroscopy with CO2 (64.6%).

CONCLUSIONS

In out-patient hysteroscopy, CO2 and normal saline were comparable with regard to patient discomfort and for the detection of major pathology of the endometrial cavity. Normal saline seems to be the most appropriate medium for the detection of minor pathology of the endometrial cavity.

A stepwise transcervical resection of a large uterine myoma after vaginal delivery

CASE REPORT

This study reported a stepwise (4-times) transcervical resection (TCR) performed on a patient with a large uterine myoma. The patient (36 years old) was at 6 weeks of pregnancy when at the first medical examination a uterine myoma, as large as the head of newborn infant, was discovered. After the delivery, myomectomy was performed by way of conserving the uterine. Since the myoma nodule was large, TCR was performed several times to completely resect it.

CONCLUSION

TCR has been indicated only for small submucosal myoma; however, this study shows that TCR utilizing a stepwise technique can also be indicated for larger myoma.

[Ovarian fibroma--a case report]

The ovarian fibroma is a rare benign tumor growing from the connective tissue of the ovarian cortex. The authors introduce a case with primary sterility and fibroma ovarii dextra. They discuss the etiology and diagnostic methods for this kind of tumor formation as well as the predictivity of the ultrasound examination.

[Submucosal isthmicocervical myoma--problems of diagnosis, labor and puerperium]

A case of submucosal isthmicocervical myoma, 85 mm in diameter, diagnosed for first time during CS. The neonate is with atrophy of left m. sternocleidomastoideus and facial asymmetry due to impression in the left temporoparietal region, without neurological impairment. Multiple ultrasound examinations were done but the fibroids vas not diagnosed. During one examination we presume that the fibroid was mistaken for the head because the BPD was in great discrepancy with other ultrasound parameters of the fetus. During the operation OICC was not found that is why the dilatation was made through the vagina. A myomectomy was not made during the operation. Because of the pressure and the deformation of the cervical canal from the myoma a drain was inserted through the canal to facilitate the evacuation of the lochia. The post operative period passed without any complications, the drainage was taken off on the 7th post operative day and the patient was discharged on the 8th day.

[Diagnostic hysteroscopy after D&C in women with perimenopausal bleeding]

OBJECTIVES

Comparative estimation of D&C and hysteroscopy as a method of receiving material to histological estimation in perimenopausal women.

MATERIALS AND METHODS

In 74 women (age 46-70) during the last year before this study, D&C was performed. There were neither material nor pathologic changes in hystological estimation. Now we made hysteroscopy and again took the material to histological research.

RESULTS

29 endometrial polyps, 14 submucosus myomas, 2 endometrial hyperplasias and 2 endometrial cancers were detected.

CONCLUSIONS

1. Hysteroscopy with direct biopsy has superiority over curettage in detecting all types of intrauterine pathology, in particular focal changes. 2. Hysteroscopy should determine a method of choice for women with recurrent bleedings from the uterus, which pathological changes were not detected with curettage.

Carney's syndrome: complex myxomas. Report of four cases and review of the literature

Cardiac myxomas are rare tumors. They usually appear as a sporadic isolated condition in the left atrium of middle-aged women with no other coincidental pathology. Carney and others have described in young people a special complex group of cardiac myxomas associated to a distinctive complex pathology, giving identity to the "Syndrome Myxoma" or "Carney's Syndrome". Four additional cases of this syndrome, treated from 1977 to 1999 at the Hospital Clínico de la Universidad de Chile are presented here with a comprehensive review of the literature, accumulating 100 cases. The main features of our cases include the presence of malignant non cardiac tumors, a familial trend, follow-up of 23 years and an iterative recurrence in the elder case. To date all patients are tumor free. Reviewing the literature, patients with Carney's Syndrome were younger, with a mean age of 26 years and female predominance (62%). Cardiac myxomas affected the four chambers of the heart: 64% the left atrium; 44% the right atrium; 14% the left ventricle and 12% the right ventricle. They were multiple tumors in 41% and involved more than one chamber in 31%, being synchronous or metachronous. There was a marked familial trend (52%), a high incidence of recurrence (20%), with more than one occurring in half the cases. Extra-cardiac involvement consisted of: 68% pigmented skin lesions, 40% cutaneous myxomas, 37% adrenal cortical disease, 27% myxoid mammary fibroadenoma and 34% male patients with testes tumors. A low percentage had pituitary adenoma, melanotic schwannomas and thyroid disease. The diagnosis is made when two or more of these criteria are present. In agreement with these findings the four chambers of the heart should be examined at surgery for atypical myxoma locations, right atriotomy and combined superior-transseptal approach improve exposure of the cavities, careful screening of the first degree family members should be conducted, and closed short and long term follow up controls are important. Complex myxoma appears as a multi-systemic disorder, occasionally having an ominous prognosis and malignant potentiality, and is still undergoing investigation for better understanding and identification.

[Endometriosis as an unexpected finding during laparoscopy on sterile women]

OBJECTIVES

Assessment of the laparoscopy as endoscope method at diagnosing as unsuspected finding at sterile women.

MATERIALS AND METHODS

Studying is retrospective and includes 20 years period of time (1976-1996). We have examined the documentation of 912 patients on whom performed laparoscopy. 678 from them have been primary and 234 have been with secondary sterility.

RESULTS

We have established the following findings: cases only with endometriosis--164 patients; endometriosis and polycystic disease of the ovaries--11 patients; endometriosis and tubal sterility--42 patients; endometriosis and pelvic inflammatory disease (PID)--56 patients; endometriosis and uterus myomatosus--6 patients.

DISCUSSION

Diagnosis of endometriosis by laparoscopy effectively helps in the further treatment of sterile women.

[Panoramic hysteroscopy in prophylaxis of precancerous lesions and endometrial carcinoma]

OBJECTIVES

The purpose of the study was to check the conformity of diagnosis based on macroscopic hysteroscopy image with the respective pathology report.

MATERIALS AND METHODS

Study population consisted of 160 patients aged 45-86 years, with abnormal uterine bleeding or abnormal ultrasonographic image of endometrium. In all cases pelvic sonography and hysteroscopy were performed.

RESULTS

Abnormal findings were detected hysteroscopically in 123 cases out of 160 hysteroscopies performed. Hysteroscopic diagnosis was confirmed by pathological examination in 100 cases (81.3%). The conformity of hysteroscopic image with the pathology report varied in different lesions, amounting to 90.9% in cases of submucosus myomas, 86.9% in endometrial polyps, 25.0% in endometrial hyperplasia and 71.42% in cases of endometrial carcinoma.

CONCLUSIONS

1. Hysteroscopic features are in high agreement with pathology report with reference to endometrial cancer, endometrial polyps and submucosus myomas. 2. Hysteroscopy does not seem to be a satisfactory tool for the differentiation between endometrial hyperplasia and endometrial carcinoma.

Acute uterine inversion due to a growing submucous myoma in an elderly woman: case report

A case of acute non-puerperal uterine inversion due to a growing submucous myoma in elderly woman is presented. This is rare and the diagnosis is often difficult.

Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy

OBJECTIVE

To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity.

DESIGN

Independent double-blind study.

SETTING

University medical hospital.

PATIENT(S)

One hundred six consecutive premenopausal women who underwent hysterectomy for benign diseases.

INTERVENTION(S)

Results of MRI, TVS, HSE, and hysteroscopy were compared with the results of histopathologic examination at hysterectomy (the gold standard).

RESULT(S)

The overall sensitivity was MRI 0.76, TVS 0.69, HSE 0.83, and hysteroscopy 0.84. The specificity was MRI 0.92, TVS 0.83, HSE 0.90, and hysteroscopy 0.88 (MRI, HSE, hysteroscopy vs. TVS <0.05). Polyps were missed in 9 of 12 cases at MRI, 7 at TVS, 4 at HSE, and 2 at hysteroscopy (MRI vs. hysteroscopy, and TVS vs. hysteroscopy <0.05). The sensitivity for identification of submucous myomas was MRI 1.0, TVS 0.83, HSE 0.90, and hysteroscopy 0.82; the specificity was MRI 0.91, TVS 0.90, HSE 0.89, and hysteroscopy 0.87 (MRI vs. TVS, and MRI vs. hysteroscopy). Magnetic resonance imaging was significantly more precise than TVS, HSE, and hysteroscopy in determining submucous myoma in-growth (2-way ANOVA <0.05).

CONCLUSION(S)

For exclusion of abnormalities in the uterine cavity, MRI, HSE, and hysteroscopy were equally effective and slightly superior to TVS. Magnetic resonance imaging and TVS missed endometrial abnormalities such as polyps, but MRI and HSE were most accurate for the evaluation of submucous myomas, and MRI was superior in evaluation of exact submucous myoma in-growth.

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE

To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review, cross-reference of published data, and review of selected meeting abstracts.

RESULT(S)

Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas.

CONCLUSION(S)

Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding

OBJECTIVE

Abnormal perimenopausal bleeding is common and accounts for much medical and surgical intervention. This study was undertaken to evaluate an ultrasonography-based triage paradigm for perimenopausal patients with abnormal uterine bleeding.

STUDY DESIGN

Four hundred thirty-three perimenopausal patients with abnormal uterine bleeding (either metrorrhagia, menorrhagia, or both) were evaluated. In lieu of undergoing a sampling procedure they were brought back on days 4 to 6 of the subsequent bleeding cycle, when the endometrium was expected to be its thinnest. If a distinct endometrial echo < or = 5 mm (double layer) was imaged by endovaginal ultrasonography, dysfunctional uterine bleeding was diagnosed. If a thickened endometrial echo > 5 mm or no endometrial echo was reliably visualized, a saline infusion sonohysterography was performed. If saline infusion sonohysterography revealed a symmetric single-layer endometrial thickness < 3 mm, dysfunctional uterine bleeding was diagnosed. If focal lesions were noted (polyps, submucous myomas, focal thickening), the patient was scheduled for curettage with hysteroscopy. If the endometrium was globally thickened, nondirected office biopsy was performed.

RESULTS

A total of 341 patients (79%) had ultrasonographic evidence of no anatomic abnormality, and dysfunctional uterine bleeding requiring no further studies was diagnosed. Fifty-eight patients (13%) had focal polypold masses, all of which were removed hysteroscopically and confirmed pathologically. Twenty-two patients (5%) had submucous myomas; 10 patients (23%) had globally thickened endometrium on saline infusion sonohysterography, and then nondirected office sampling revealed hyperplasia in 5 and proliferation in 5. Two patients had technically inadequate saline infusion sonohysterography, and thus we proceeded to hysteroscopy with curettage.

CONCLUSION

Nondirected office biopsy alone without imaging would have potentially missed the diagnosis of focal lesions such as polyps, submucous myomas, and focal hyperplasia in up to 80 patients (18%). Our clinical algorithm for perimenopausal patients with abnormal uterine bleeding used unenhanced endovaginal ultrasonography followed by saline infusion sonohysterography for selected patients. This approach allowed for no endometrial sampling, nondirected sampling, or directed sampling depending on whether the ultrasonography-based triage revealed no anatomic abnormalities, globally thickened endometrial tissue, or focal abnormalities, respectively.

[Therapy and follow-up of superficial bladder cancer in in patients less than 30 years of age]

Transitional cell carcinoma of the bladder is relatively uncommon in patients under 30 years old. We treated 11 patients with superficial bladder carcinoma under 30 years of age. In 10 cases gross haematuria was the most common presenting symptom. The pathological reports of the patients revealed grade I, stage Ta transitional cell carcinoma in seven patients, grade I, stage T1 tumour in two patients and bladder myoma and inverted papilloma in two patients each. Four of nine patients with superficial bladder carcinoma stayed free of disease for 1-10 years after initial transurethral resection (TUR). Four patients suffered multiple tumour recurrences 1-4 months after initial TUR, with progressive disease in three cases. One patient was lost to follow-up after primary operation. In the two patients with benign bladder tumours, no recurrences were observed within 12 and 48 months. Owing to the high rates of recurrence (44%) and tumour progression (33%) all patients under 30 years of age should be treated as aggressively as necessary on the basis of the grade and stage of the tumour, in the same way older patients.

The coexistence of stromomyoma and uterine tumor resembling ovarian sex-cord tumors. Report of a case and immunohistochemical study

The case of a 40-year-old female with a uterine tumor resembling an ovarian sex-cord tumor, located within another neoplastic nodule having the histopathological features of a stromomyoma is reported. Light microscopic examination of the uterine sex-cord-like tumor revealed a highly cellular tumor tissue with no specific differentiation, consisting of solid nests and anastomosing cords and a few pseudo-tubular structures. The vacuolated cytoplasm of the lipid-rich cells proved vimentin-positive, but desmin- and keratin-negative. The coexistence of the two variants of endometrial stromal tumor was interpreted as arising from endometrial stroma or multipotential uterine mesenchyme that showed a diverse differentiation toward ovarian sex-cord stroma and uterine smooth muscle with interspersed stromal cell clusters.

CT and MRI of uterine lipoleiomyoma

Uterine lipoleiomyomas are rare tumors containing variable amounts of fat. Diganostic considerations usually include ovarian fatty tumors and benign and malignant degeneration in ordinary leiomyomas. A case in which a preoperative diagnosis was made using computed tomography (CT) and magnetic resonance imaging (MRI) is presented. The fatty nature of the lesion was demonstrated with CT and standard spin echo MRI and further supported using inversion recovery MRI. MRI also clearly depicted the intrauterine location of the tumor.

Diagnostic and therapeutic hysteroscopy in the management of abnormal uterine bleeding

Three hundred seventy cases of abnormal uterine bleeding that occurred from January 1985 to June 1989 were studied. Diagnostic and operative hysteroscopy was performed as an outpatient procedure. Included in the study were all patients with dysfunctional uterine bleeding that did not respond to progestogens for three months, patients with severe menometrorrhagia and those with postmenopausal bleeding. Patients with pregnancy-associated bleeding, obvious uterine enlargement, polycystic ovary disease and abnormal cervical smears were excluded. The ages of the patients ranged from 22 to 82 years. The uterine cavity was found to be normal in 33.51%. Polyps were found in 21.53% of cases, submucous myomata in 11.35%, endometrial hyperplasia in 22.97%, endometrial atrophy in 1.62%, synechiae in 5.67% and adenocarcinoma in 1.35%. Targeted biopsies, excision of polyps, removal of myomata (with scissors and resectoscope) and curettage were performed as necessary.

Clinical evaluations of the tumor marker sialyl SSEA-1 antigen for clinical gynecological disease

Sialyl SSEA-1 antigen (SLX) is a highly specific tumor marker composed of sugar chain antigens that have Lewis X at their terminals and bind to sialic acid. This antigen is rarely detected in normal tissues, and is present in adenocarcinoma and fetal tissues. We studied the clinical usefulness of SLX in gynecological patients and obtained the following results. (1) The antigen was frequently positive in patients with ovarian cancer with a mean of 89.5 +/- 48.3 U/ml (72.8%, 8/11) and in those with endometriosis with a mean of 39.8 +/- 10.3 U/ml (75.0%, 6/8). (2) Among the gynecological malignancies, the percent positivity was low in those with cervical cancer (20.0%, 5/25), endometrial cancer (33.3%, 1/3), and cancer of the fallopian tube (33.3%, 1/3). (3) The antigen was negative in 20 with myoma uteri, 20 normal pregnant women, and 9 nonpregnant healthy women during the follicular, luteal, or menstrual phase. It was negative in 8 of 9 patients with benign ovarian cyst. False negative results were rare. (4) The SLX level was higher in the ascites than in the serum in patients with ovarian cancer and in those with benign ovarian tumors. (5) The serum SLX in patients with ovarian cancer, which was positive before tumor resection, became negative 2 weeks postoperatively. These results suggest that SLX is a tumor marker with a high specificity to adenocarcinoma of the reproductive organs.

Myomectomy during pregnancy: uncommon case report

A case of myomectomy during pregnancy is presented. Generally myomectomy is contraindicated during this period. On the 14th week of pregnancy our patient presented with progressive lower abdominal pain and a tender mass of nearly 12 centimeter diameter in the pouch of Douglas. Therefore an exploratory laparotomy was performed to exclude torsion of an adnexal mass or pedunculated subserous myoma. A dorsal degenerating myoma with short thick pedicle (4 cm diameter) was found. It was compressed between the promontory of the sacrum and the uterus. Myomectomy was performed and pregnancy progressed without complications.

[Ultrasonic study of the soft tissues of the hand. II. Tumors and pseudotumors of soft tissues. Preliminary results apropos of 12 surgically treated cases]

Thirty patients underwent a sonographic examination of the hand because of nodular masses. In 12 out of these, the surgical removal exhibited 5 benign tumors (2 giant cell tumors, 1 angioma, 1 lipoma, 1 myoma), 5 pseudo-tumors (1 granulomatous tenosynovitis, 1 nodular tendinitis, 2 sebaceous cysts, 1 synovial cyst) and 2 congenital abnormalities of the lumbrical muscles. Except the lipoma and the nodular tendinitis, all the masses were hypoechoic or anechoic. The major interest of sonography in such a disease is a precise localization of the mass and the description of its connections with the surrounding anatomical structures.

[Prostatic pathology imaged by magnetic resonance. 58 cases]

Forty-eight patients with prostatic disease (benign prostatic hyperplasia (B.P.H.), carcinoma, cysts, myoma and prostatitis) and 10 normal volunteers underwent magnetic resonance imaging (M.R.I.) of the prostate. The prostatic parenchyma was best evaluated by a T2-weighted spin-echo pulse sequence. The prostate in patients with B.P.H. often had a homogeneous or more rarely a nodular appearance on T2-weighted images. In most cases, a peripheral dark rim is observed. All prostate in patients with carcinoma had an heterogeneous appearance on T2-weighted images. While most of the prostatic carcinomas appeared hypo-intense relative to adjacent prostatic parenchyma, some of the neoplasms had a high or mixed-high and low signal. The myoma showed a low-signal nodule like carcinoma. The cyst appears as a liquid tumor. The prostatitis had an homogeneous bright signal. With the used methodology, MRI can differentiate prostatic diseases in many cases. Nevertheless the technique has to be optimized to improve its accuracy.

[Myoid tumors of the stomach. Diagnostic contribution of ultrasound and x-ray computed tomography. Apropos of a case]

The authors report a new case of myoid tumour of the stomach, a chance discovery in an asymptomatic patient. The diagnosis of a heterogeneous tumour of gastric origin was made possible by echography and tomodensitometry. The myoid nature of the tumour was confirmed histologically. With the recognition of this new case the literature on the subject was reviewed. The features special to these tumours are studied with emphasis on the usefulness of echography and tomodensitometry in diagnosis, also the therapeutic approach to be adopted with regard to these tumours.

[Evaluation of the value of ultrasound in the diagnosis of gynecologic tumors]

The value of ultrasound (US) is analysed by means of ROC-curves (receiver operating curves) taking into consideration both the sensitivity and specificity of the method, as well as the prevalence of particular tumours in the examined group. US diagnosis is compared with clinical and surgical findings. The authors have found that the degree of reliability achieved by either the clinical or the US method of diagnosing myomas is almost the same. In the diagnosis of benign cysts and carcinomas, however, US has more advantages.

[A contribution to the diagnosis of renal hamartoma (angiography, sonography, computerised tomography) (author's transl)]

In two cases of renal hamartoma, the examination methods of angiography, sonography and computerised tomography are introduced. Angiography yields the correct preoperative diagnosis. In one of the two cases under discussion, computerised tomography supported the angiographic finding or supplied sufficient proof in itself. In both cases, sonography yielded information on the diagnosis of the space-occupying process only.