Color Doppler evaluation of blood flow changes in leiomyomas after uterine artery ligation.

OBJECTIVE: To detect possible changes in main blood vessels within leiomyomas after uterine artery ligation using color Doppler sonography. METHOD: Blood flow in main leiomyoma blood vessels was measured before and after the procedure in 14 women who also had abnormal uterine bleeding, pelvic pain or pressure, and/or anemia. RESULTS: Of the 14 patients, 13 reported complete disappearance of preoperative pain or pressure and 1 reported significant relief. Within 1 week to 4 months after uterine artery ligation, major blood flow within leiomyomas had significantly decreased in all patients. Eight months after the procedure, 1 of the women became pregnant. CONCLUSION: Laparoscopic uterine artery ligation via a lateral retroperitoneal technique is a safe and effective treatment for leiomyomas. Color Doppler sonography verified the ability of the procedure to diminish blood flow within leiomyomas in all patients.     

The hemodynamic effect of GnRH agonist therapy on uterine leiomyoma vascularity

The objective of this study was to correlate, during 12 weeks of therapy with gonadotropin releasing hormone agonist (GnRH-a), the chronological effect and the hemodynamic changes on the uterine artery and the leiomyometrial supplying vessels. Twenty-three premenopausal women with clinically diagnosed uterine leiomyomas received 3.75 mg of leuprolide acetate intramuscularly every 4 weeks for 12 weeks. Pretreatment values of serum estradiol, uterine and leiomyoma volumes and blood flow characteristics of the main uterine artery and leiomyoma supplying vessels – resistance index (RI), pulsatility index (PI) and peak-systolic velocity, obtained by transvaginal color Doppler sonography – were compared with treatment values at 4, 8 and 12 weeks of leuprolide acetate therapy.

The first event in the chronological response to the GnRH-a therapy was a statistically significant increase in RI and PI values for major leiomyoma vessels, observed at the end of the 4th week (p < 0.05), which increased significantly after 8 and 12 weeks (p < 0.01 and p < 0.001, respectively). These findings were in direct correlation with a significant decrease of estradiol levels after 4, 8 and 12 weeks (p < 0.05, p < 0.001 and p < 0.001, respectively). The significant decrease of blood flow in the leiomyometrial vessels was followed by a significant decrease of the main uterine artery blood flow after 8 weeks and uterine and leiomyoma volumes by 42% and 55%, respectively, after 12 weeks of GnRH-a therapy.

We concluded that a significant increase in leiomyometrial vessels RI and PI values, which was found 4 weeks after the first dose of GnRH-a, but without major leiomyoma volume decrease, emphasizes that the first significant effect of GnRH therapy in the process of uterine and leiomyoma volume shrinkage is the reduction of leiomyometrial rather than uterine blood flow. This effect is followed by a considerable reduction of utenrine vasculariry and a significant decrease of uterine and leiomyoma volumes. If a decrease of blood loss during myomectomy is the main aim of GnRH-a therapy, we believe that 8 weeks would be an appropriate therapy duration.     

T-cadherin expression in uterine leiomyoma

Objective

T-cadherin is a tumor-suppressor with low expression in many malignant tumors, but with high expression in endothelial cells and so on. In this study we investigated whether T-cadherin was expressed and if together with bFGF play a role in the occurrence and development of uterine leiomyoma.

Method

Uterine leiomyoma, the adjacent normal myometrium, control normal myometrium without uterine leiomyoma and vascular features of myoma were collected. Immunohistochemistry, western blot and relative quantitative real time PCR were used to evaluate bFGF and T-cadherin on the three specimens. Data were statistically analysed.

Results

T-cadherin was observed on the leiomyoma cellular layers but not in the endochylema, extracellular matrix and leiomyoma vascular endothelial cell, bFGF in the leiomyoma endochylema but not observed in the extracellular matrix and leiomyoma vascular endothelial cell. The protein and mRNA expression of bFGF and T-cadherin in uterine leiomyoma were significantly with higher expression than that in adjacent normal myometrium and control normal myometrium. In addition, T-cadherin correlated well with bFGF. There was relationship between T-cadherin and color Doppler flow imaging (CDFI).

Conclusion

bFGF and T-cadherin have high expressions in uterine leiomyoma, and T-cadherin is associated with CDFI, indicating that a cross talk between bFGF and T-cadherin plays an important role in the occurrence and development of uterine leiomyoma or even malignant tumors.     

Prospective Evaluation of the Incidence of Uterine Vascular Malformations Developing After Abortion or Delivery

Study ObjectiveTo describe the incidence of uterine vascular malformations (UVMs) including uterine arteriovenous malformations (AVMs) in patients after abortion or delivery and in outpatients.DesignProspective study (Canadian Task Force classification II-3).SettingFukushima Red Cross Hospital.PatientsSix patients with a UVM including 1 with an AVM.InterventionsClinical screening of patients using transvaginal color Doppler ultrasonography between April 2010 and March 2012.Measurements and Main ResultsThe incidence of UVM developing after abortion or delivery or in outpatients was prospectively evaluated using transvaginal color Doppler ultrasonography. From 959 patients, we identified 6 (0.63%) with UVMs, including 1 (0.10%) with a uterine AVM. Specifically, we detected UVMs in 4 of 77 patients (5.2%) after abortion, 1 of 458 patients (0.22%) after delivery, and 1 of 424 outpatients (0.24%). Four patients after abortion and 1 after delivery reported mild symptoms, which were treated conservatively; however, the outpatient had a severe uterine AVM, which was confirmed via 3-dimensional computed tomography angiography.ConclusionThe incidence of UVMs was relatively higher, in particular in the patients after abortion, and was significantly higher than that in postpartum or outpatient groups. Therefore, it is important to consider the possibility of UVMs in any patient with episodes of unexplained uterine bleeding and to perform follow-up analysis using color Doppler ultrasonography. Such an approach will facilitate accurate diagnosis and lead to appropriate clinical management to prevent unnecessary dangerous repeat curettage, which might induce profuse uterine bleeding.     

The accuracy of transvaginal ultrasound and uterine artery Doppler in the prediction of adenomyosis

ObjectiveTo measure the accuracy of the ultrasonographic features in predicting adenomyosis and to determine if there is a role for uterine artery Doppler in adenomyosis prediction.Study designA prospective comparative study.SettingCairo University hospital.Materials and methodsThree hundred and fifty-two women who were scheduled for hysterectomy for various indications underwent preoperative transvaginal ultrasound scan (TVS) and uterine artery Doppler velocimetry in an attempt to diagnose adenomyosis. All the results were then correlated with histopathological results after hysterectomy.ResultsForty-eight participants were ultrasonographically diagnosed as having adenomyosis from which 37 patients were histologically confirmed. Both groups were comparable in age, but adenomyosis tend to occur in multiparas. We found that subendometrial linear striations, myometrial cysts’ number and poor endometrial delineation were significantly associated with adenomyosis. Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of TVS for diagnosing adenomyosis were: 75.68%, 90.79%, 49.12%, 96.95% and 89.20%, respectively. Heterogenous myometrial echotexture was the most common ultrasonographic feature in adenomyotic cases. Neither uterine artery resistance index nor pulsatility index showed significant association with adenomyosis.ConclusionTVS is a potentially valuable tool in predicting adenomyosis especially when subendometrial linear echogenic striations, myometrial cysts, and poor endometrial delineations were found. However, uterine artery Doppler has no diagnostic values.     

A Reduction in Intraovarian Arterial Blood Flow Resistance After Ovulation is Necessary to Achieve Pregnancy in Natural Cycle

Purpose: Color Doppler imaging permits the accurate localization of vessels and high-frequency pulsed Doppler ultrasonography has improved the resolution of flow velocity waveforms. In this study, intraovarian arterial blood flow before and after follicle rupture in the natural cycle was examined using transvaginal color flow Doppler imaging and changes in intraovarian arterial resistance in relation to the outcome of infertility treatment was analyzed.Methods: In a prospective study, 227 spontaneous cycles in 118 infertile patients who were undergoing infertility treatment at the division of Reproductive Medicine in our center were recruited in this study. The impedance to flow in intraovarian vessels was measured by means of transvaginal color flow Doppler imaging during the periovulatory period in the natural cycle of all patients. The pulsatility index (PI) of intraovarian arterial blood flow and pregnancy rate was evaluated.Results: On the basis of PI values before and after follicular rupture, 227 cycles were classified into severely decreased (113 cycles) and not-severely decreased groups (114 cycles). The pregnancy rate per cycle in the severely decreased group was 18.6% (21/113), significantly higher than that in the not-severely decreased group (7/114; 6.1%, p = 0.004). The miscarriage rate was similar in the two groups.Conclusions: A reduction in intraovarian blood vessel resistance is necessary to achieve pregnancy in a natural cycle.     

Clinical characteristics indicating adenomyosis at the time of hysterectomy: a retrospective study in 291 patients

Purpose

To better characterize adenomyosis as a disease entity.

Methods

We retrospectively reviewed the medical records of women undergoing hysterectomy with a histologic diagnosis of adenomyosis, adenomyosis and leiomyomas, and leiomyomas alone.

Results

The study included 291 women: 38 with adenomyosis alone, 56 with adenomyosis and leiomyomas, and 197 with leiomyomas alone. In univariate analysis, women with adenomyosis were younger (p?=?0.018) and had lower uterine weights (p?p?=?0.008). In multinomial logistic regression analysis, a lower uterine weight (OR 0.99, CI 95% 0.99–1.0), pelvic pain (OR 4.8, CI 95% 1.5–15.2), a history of smoking (OR 2.6, CI 95% 1.1–6.5) and at least one delivery (OR 4.3, CI 95% 1.5–12.3) were associated with a greater likelihood of having adenomyosis but not leiomyomas alone.

Conclusions

Women undergoing hysterectomy with adenomyosis alone have different clinical characteristics from women with adenomyosis and leiomyomas and from those with only leiomyomas.     

Accuracy of sonographic criteria for diagnosis of adenomyosis in perimenopausal women with menorrhagia

ObjectiveTo determine the accuracy of transvaginal ultrasound in the diagnosis of uterine adenomyosis in women with menorrhagia.DesignProspective observational clinical trial.SettingKasr El-Aini Hospital, Cairo University.Participants and interventionsFifty perimenopausal women with menorrhagia were divided into two groups: those who have received hormonal therapy for menorrhagia (21 cases) and those who received nothing. Transvaginal sonography was done for all cases and correlation with histopathological assessment done after hysterectomy.ResultsTransvaginal US had a sensitivity of 83%, a specificity of 86%, and a positive and negative predictive value of 66% and 94%, respectively. The diagnosis of adenomyosis uteri of the 10 patients with true-positive findings at US, the myometrium demonstrated heterogeneous and hypoechoic areas with or without the presence of cysts in 10 (100%) patients, hypoechoic areas with cysts in 5 (50%) patients, linear striation and globular uterus in 5 (50%). Eleven out of 12 (91%) cases of adenomyosis had an enlarged uterus.ConclusionAdenomyosis of the uterus can be accurately diagnosed with transvaginal US with use of specific sonographic criteria. It is safe, available and cheap modality of diagnosis.     

Diagnostic criteria for uterine smooth muscle tumors: leiomyoma variants associated with malignant behavior

OBJECTIVE: To determine the prognostic accuracy of current diagnostic criteria for uterine smooth muscle tumors. STUDY DESIGN: Cases of uterine leiomyosarcoma (LMS) treated from 1976 to 1999 were analyzed retrospectively. Uterine LMS specimens were reevaluated using current criteria by a pathologist specializing in gynecologic diseases. Kaplan-Meier survival curves were evaluated. RESULTS: Specimens were available from 67 patients diagnosed with uterine LMS. On rereview, only 47 specimens were thought to represent uterine LMS. The 20 other patients were deemed to have leiomyomas or leiomyoma variants, including 13 cellular leiomyomas, 5 atypical leiomyomas and 2 leiomyomas. Median survival for patients with uterine LMS was 2.1 years. (Ninety-seven percent of disease-specific deaths occurred within 6 years after the diagnosis.) With leiomyoma variants, median survival was > 25 years. Among these 18 women were 3 disease-specific deaths (all > 6 years after diagnosis). CONCLUSION: Diagnostic criteria for uterine smooth muscle tumors require continued refinement. A small but significant number of patients diagnosed with leiomyoma variants will die of the disease. In contrast to the aggressive behavior of uterine LMS, disease-specific deaths attributed to leiomyoma variants occurred later. With this potential for delayed recurrence, these patients warrant close clinical surveillance.     

Epithelioid vascular leiomyoma of the uterus mimicking glomangiomyoma

Case report: An unusual case of epithelioid vascular leiomyoma mimicking glomangiomyoma arising in the uterine corpus of a 55-year-old Japanese woman is presented. The surgically resected uterine mass, measuring 4.0 × 3.5 cm², demonstrated a dark red well-circumscribed tumor. Histologically, the rounded epithelioid cells around the dilated vessels showed gradual transition to spindled smooth muscle cells. Immunohistochemistry was positive for smooth muscle actin, but negative for collagen IV. Conclusion: The experience in this case emphasizes that glomangiomyoma-like feature is interesting and might indeed be a new histological variant of uterine leiomyomas.     

Extra-uterine pelvic leiomyoma: diagnosis and practical management

Objectives

To analyze the possibilities of setting up a therapy for extra-uterine pelvic leiomyomas.

Methods

Three cases of leiomyomas of the broad ligament, of the round ligament and of the ovary, and literature review.

Results

Little is known about physiopathology of extra-uterine leiomyoma. The diagnosis of extra-uterine leiomyoma is based on histopathological analysis, using standard histology, and immunohistochemistry with anti-desmin and anti smooth muscle actin antibodies. The main differential diagnoses are fibroma, fibrothecoma, ovarian fibrosarcoma, and gastrointestinal stromal tumors. To define criteria of malignancy, we use Bell's classification without being sure that the uterine and extra-uterine models are comparable. So there is a risk of ignoring a low grade leiomyosarcoma. Providing therapy depends on the clinicopathologic features: the so called "parasitic leiomyoma", a tumor developed at the expense of local smooth muscle cells, metastasis of a benign metastasizing leiomyoma or leiomyomatosis peritonealis disseminata.

Conclusion

The extra-uterine leiomyoma has no precise nosologic status and no specific criteria of benignity; thus no precise evolution can be predicted. We must be extremely careful, and the issue of the monitoring and long-term therapy of patients must come up.     

Color Doppler ultrasonography in the differentiation of uterine sarcomas from uterine leiomyomas

OBJECTIVE: The aim of this study was to investigate uterine vascularity in cases of uterine leiomyomas and uterine sarcomas, as well as to determine the efficiency of uterine blood flow analysis in differentiating between them. MATERIALS AND METHODS: Transvaginal color and pulsed Doppler findings obtained from 117 patients with histologically proven uterine leiomyoma and 12 with uterine sarcoma were retrospectively assessed. RESULTS: The mean intratumoral resistance index (RI) and pulsatility index (PI) were significantly lower and the intratumoral peak systolic velocity (PSV) was significantly higher in patients with sarcomas than in patients with uterine leiomyomas. Marked reduction of RI and PI and increased PSV could be found in 14 of the leiomyoma cases which showed large size and/or necrotic, degenerative and inflammatory changes. When a cut-off value of 0.5 for the RI was considered, the detection rate for uterine sarcoma was 67% and the false-positive rate was 11.8%. CONCLUSION: These results suggest that the intratumoral RI detected by color and pulsed Doppler ultrasonography in themselves could be poor for the preoperative differential diagnosis of uterine sarcoma.     

Transvaginal Doppler-Guided Uterine Artery Occlusion for the Treatment of Symptomatic Fibroids: Summary Results From Two Pilot Studies

ObjectiveTo evaluate the feasibility, safety, and short-term efficacy of bilateral uterine artery occlusion, using a transvaginal Doppler-guided vascular clamp as a minimally invasive therapy for symptomatic uterine leiomyomas.MethodsWe conducted two prospective, non-randomized, phase I pilot studies (Canadian Task Force Classification II-2) at a university-affiliated teaching hospital. Between June 2004 and May 2005, 30 premenopausal women with symptomatic uterine leiomyomas underwent bilateral uterine artery occlusion using a transvaginal Doppler-guided vascular clamp. Bilateral uterine artery occlusion was performed for 5.8 ± 1.4 hours in the first 17 patients (Group 1) and from 6 to 9 hours (mean 7.05 ± 1.0 hours) in the latter 13 patients (Group 2). Outcome measures included dominant fibroid volume (cm³), uterine volume (cm³), and improvement of menorrhagia at one, three, and six months.ResultsBilateral occlusion of the uterine arteries was achieved in all 30 patients. In Group 1, the Ruta Menorrhagia Severity Scores decreased from baseline by 16%, 22% and 39% at one, three, and six months respectively. The dominant fibroid (DF) and uterine volumes decreased by 24% and 16% respectively at six months. In Group 2, the Ruta scores changed from baseline by + 3%, –24%, and –42% at one, three, and six months respectively. The DF and uterine volumes decreased by 29% and 16%, respectively at six months.ConclusionFollowing bilateral uterine artery occlusion using a transvaginal Doppler clamp, the dominant fibroid volume decreased by an average of 24%, uterine volume decreased by12%, and menorrhagia symptoms were reduced by up to 42%. Uterine artery occlusion may provide the gynaecologist with an alternative to uterine artery embolization (UAE). The system is simple, easy to apply, and short-term efficacy may be equivalent to UAE.     

Comparison of Transvaginal Color Doppler Imaging and Color Doppler Energy for Assessment of Intraovarian Blood Flow

Objective: To investigate any systematic differences in the analysis of blood flow velocity waveforms derived by color Doppler imaging and color Doppler energy examination of corpora lutea and adnexal tumors, to test whether the accuracy for diagnosing ovarian malignancy differs between end points derived by color Doppler imaging and color Doppler energy, and to compare the reproducibility of flow velocity waveform analysis obtained by both methods.Methods: Fifty-six asymptomatic women with presumed corpora lutea and 67 women with known adnexal masses were included in the study. They all were examined using transvaginal sonography with color Doppler imaging and color Doppler energy. Pulsed Doppler sonography was used to obtain flow velocity waveforms to determine the pulsatility index (PI), resistance index (RI), peak systolic velocity, and time-averaged maximum velocity. The tumors were classified retrospectively according to histologic criteria.Results: There were 52 women with benign, three with borderline, and 12 with malignant ovarian tumors. Repeated-measures analysis of variance revealed no systematic differences in the values of all four measurements performed under color Doppler imaging and color Doppler energy for all cases of corpora lutea and adnexal tumors (PI: P = .153, RI: P = .197, peak systolic velocity: P = .355, time-averaged maximum velocity: P = .159). All cases of borderline and malignant tumors had detectable pulsatile blood flow with color Doppler imaging and color Doppler energy. Forty-two (80.8%) of the benign tumors had flow detectable with color Doppler imaging, compared with 40 (76.9%) with color Doppler energy (P = .480). Analysis of receiver operating characteristic curves showed a marginal but nonsignificant improvement in diagnostic performance with color Doppler energy compared with color Doppler imaging for all four measurements (PI: P = .182, RI: P = .178, peak systolic velocity: P = .254, time-averaged maximum velocity: P = .238). The intraclass correlation coefficients for all four measurements were superior with color Doppler imaging compared with color Doppler energy.Conclusion: Flow velocity waveform analysis and diagnostic accuracy for ovarian malignancy are not significantly different between color Doppler imaging and color Doppler energy. Examinations with color Doppler imaging appear to be more reproducible than those with color Doppler energy.     

Adenomyosis within a uterine septum in a patient with secondary infertility

Abstract

Background: Adenomyosis is a benign infiltration of endometrial stroma and glands into the myometrium. Until the advent and advancement of imaging techniques such as transvaginal ultrasound scan (TVUS) and magnetic resonance imaging (MRI), the diagnosis of adenomyosis could only be made with confidence using histology following hysterectomy.

Case: The patient is a 37-year-old woman, with a long history of secondary infertility. A hysterosalpingogram (HSG) and a pelvic MRI showed two separate uterine cavities. The patient underwent laparoscopy and hysteroscopy revealing a bicornuate appearance of the uterus and a uterine septum. Resection of the septum showed adenomyosis on histologic examination.

Comment: Adenomyosis of uterine septum should be considered if MRI shows features of adenomyosis elsewhere in the uterus with thickened junctional zone. Further research is needed to investigate this association with the pathogenesis of adenomyosis.     

Aldosterone stimulates the proliferation of uterine leiomyoma cells

Objective.?Although uterine leiomyomas are the most common gynaecological benign tumour and greatly affect reproductive health and well being, the pathophysiology and epidemiology of uterine leiomyomas are not well known. Elevated blood pressure has an independent, positive association with risk for clinically detected uterine leiomyomas. Aldosterone is a key biological peptide in the renin-angiotensin-aldosterone system that regulates blood pressure. In this study, we investigated the siginificant stimulatory effect of aldosterone on leiomyoma cells proliferation.

Study design.?This study investigated the potential role of aldosterone in the proliferation of ELT-3 leiomyoma cells.

Results.?Aldosterone-induced ELT-3 leiomyoma cell proliferation and the expression of mineralocorticoid receptor (MR) were confirmed. Pre-incubating the cells with the MR blockers spironolactone or eplerenone effectively repressed aldosterone-induced and angiotensin II (Ang II)-induced cell proliferation. Treatment of aldosterone increased the levels of Ang II type-1 receptor mRNA.

Conclusion.?These experimental findings in?vitro show the presence of complex regulation of Ang II and aldosterone induced leiomyoma cell proliferation.     

Three dimensional sonography and 3D power angiography in differentiation of adnexal tumors

BACKGROUND: Three-dimensional sonography is a novel diagnostic method proposed to be an additional non-invasive tool in the assessment of ovarian tumors. OBJECTIVE: To study diagnostic potential of 3D sonography and power Doppler angiography in the preoperative differentiation of adnexal masses. MATERIAL AND METHODS: One hundred twenty-eight women with tumors thought to be of adnexal origin were examined preoperatively. Following morphological (papillae, septae, tumor size and volume) and color Doppler (PI, RI, Vmax and TAMX) assessment, 3D ultrasound of adnexal tumors according to Kurjak et al. (2000) was performed. Various scanners were used and included: ATL 5000 HDI (Phillips, USA) and Combison 530 and Voluson 730 (Kretztechnik, Austria) machines. Following variables were studied: inner wall structure, presence of papillae, thickening > 3 mm of septa as well as vascular branching pattern, number and localization of small blood vessels and the presence of vascular anastomoses. RESULTS: Twenty-one tumors were malignant (3 FIGO stage I) and 101 masses were benign. Power Doppler combined with 3D sonography predicted malignancy with a sensitivity of 92.6% (25 of 27 patients). Commonly used morphological and Doppler criteria produced lower sensitivity, the values being in range of 45% to 87.5%. Negative predictive value of 97.2% was the highest for 3D sonography (> 7 points in Kurjak's scale). CONCLUSIONS: Selective use of 3D ultrasound and power Doppler angiography could be used to better characterize adnexal tumors. Detailed 3D sonography may help to identify women who, if needed, may have less invasive surgical procedure such as laparoscopy or be referred to gynecological oncologist.     

阴道超声对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值

目的探讨阴道超声及血清CA125测定对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值。方法对卵巢子宫内膜异位囊肿及子宫腺肌病患者631例进行回顾性分析，术前均经阴道超声检查，部分患者进行了血清CA125测定。结果阴道超声检查卵巢子宫内膜异位囊肿符合率98．7％；子宫腺肌病符合率91．7％；卵巢子宫内膜异位囊肿合并子宫腺肌病符合率95．1％。血清CA125检查卵巢子宫内膜异位囊肿，阳性率39．4％；子宫腺肌病阳性率52．2％；卵巢子宫内膜异位囊肿合并子宫腺肌病阳性率59．2％。结论阴道超声可做为较准确诊断卵巢子宫内膜异位囊肿及子宫腺肌病的首选方法。阴道超声下囊肿穿刺是治疗卵巢子宫内膜异位囊肿的简便、有效的方法之一。血清CA125测定可做为卵巢子宫内膜异位囊肿及子宫腺肌病的协助诊断方法，应进一步完善对照组的研究。