Diagnosis of abnormal uterine bleeding with imaging

The major role of ultrasound in the evaluation of abnormal uterine bleeding, other than that occurring during pregnancy, is in postmenopausal women. Because postmenopausal bleeding can be the presenting symptom of endometrial cancer, any woman with this symptom should be evaluated to diagnose or exclude carcinoma. Over the last two decades, the role of ultrasound in the evaluation of postmenopausal bleeding has changed markedly, from little or no role in 1990 to a major role today. In the intervening years, numerous studies have shown that ultrasound is at least as sensitive as endometrial biopsy for endometrial cancer and that ultrasound can reliably exclude cancer without the need for biopsy in some women with postmenopausal bleeding. In particular, numerous studies have shown that women with an endometrial thickness of 4 mm or less have an extremely low likelihood of endometrial cancer and thus do not need to undergo endometrial biopsy. Ultrasound can also help in the selection of an appropriate biopsy technique. In a woman with postmenopausal bleeding and a thick endometrium, a sonohysterogram can determine whether the endometrium is diffusely thick or has focal areas of thickening. With diffuse thickening, a blind endometrial biopsy is appropriate. When there are one or more focal areas of thickening, hysteroscopic biopsy is likely to be the better choice. We present two clinical algorithms, either of which is an acceptable approach to the use of ultrasound and/or endometrial biopsy in women with postmenopausal bleeding: the "ultrasound-first" approach and the "biopsy-first" approach.     

Expression of acidic fibroblast growth factor (aFGF) and fibroblast growth factor receptor 4 (FGFR4) in breast fibroadenomas

BACKGROUND/AIM: Fibroadenomas are benign tumours composed of both glandular and fibrous tissue. The mechanisms regulating the growth of these tumours and the relation between the stromal and epithelial cells are poorly understood. Acidic fibroblast growth factor (aFGF) is a well known fibroblast activator, which acts through four specific cell surface receptors, among which, fibroblast growth factor receptor 4 (FGFR4) is highly specific. The aim of this study was to evaluate the distribution of aFGF and FGFR4 in specific cell types of fibroadenomas to understand their possible role in the growth of these breast lesions. METHODS: Formalin fixed and paraffin wax embedded tissues from 15 fibroadenomas and peritumoral normal breasts were investigated for the expression of aFGF and FGFR4 using immunohistochemistry. The presence of aFGF mRNA was also investigated using in situ hybridisation. RESULTS: Immunoreactivity for aFGF and FGFR4 was seen in epithelial cells, but it was lacking in myoepithelial cells of both normal tissues and fibroadenomas. Strong FGFR4 immunoreactivity was found in stromal fibroblasts, which were also weakly positive for aFGF. aFGF mRNA was detected in epithelial cells and in some stromal fibroblasts. CONCLUSIONS: These results suggest a paracrine/autocrine modulation of epithelial and stromal cells of fibroadenomas through an aFGF-FGFR4 interaction. This interaction might regulate various cell functions and the growth of fibroadenomas.     

Mechanisms of abnormal uterine bleeding

Over the past 10 years there has been an upsurge of interest in the mechanisms underlying normal and disturbed menstrual bleeding. These studies have particularly focused on the mechanisms underlying the common problems of menorrhagia associated with ovulatory and anovulatory dysfunctional uterine bleeding (DUB) and of unpredictable breakthrough bleeding during hormonal contraceptive use. A wide range of abnormalities of endometrial morphology and function have been demonstrated, but it is still not clear how all the pieces of this complex jigsaw puzzle fit together. Ovulatory DUB is predominantly associated with decreased endometrial vasoconstriction and vascular haemostatic plug formation, leading to defective control of the volume of blood which is lost during menstruation. By contrast, breakthrough bleeding is associated with a wide range of molecular disturbances which appear to result in unpredictable vessel breakdown through disturbed endometrial angiogenesis, increased vascular fragility and loss of the integrity of the endothelial, epithelial and stromal supporting structures. Anovulatory DUB is very poorly understood, but may be associated with disturbed angiogenesis, fragile vessels and defective haemostatic processes. Little is known about the actual mechanisms of the common problem of abnormal bleeding associated with specific genital tract pathologies such as uterine myomata.     

Pathologic basis for abnormal uterine bleeding with organic uterine pathologies

Research is ongoing into the mechanisms of abnormal uterine bleeding, including bleeding from organic etiologies, where there is an intrinsic uterine lesion. Most of the current studies are focused on abnormalities of angiogenesis. By elucidating these mechanisms, targeted therapies can be developed. This article reviews the literature on pathologic mechanisms involved in bleeding from organic etiologies.     

Diagnosis of abnormal uterine bleeding with biopsy or hysteroscopy

Abnormal uterine bleeding in women is a common cause for gynecologic consultation. Physicians must maintain a low threshold for endometrial assessment in abnormal uterine bleeding. Accurately determining the etiology of the bleeding permits appropriate treatment, minimizes unnecessary delays in therapy, and prevents needless worry in women. There are few national consensus guidelines, best practice guidelines, or treatment algorithms that provide gynecologists with scrupulous data to make concise decisions for the utilization of technology such as endometrial biopsy, transvaginal ultrasound, saline infusion sonography, or hysteroscopy in the evaluation of menstrual aberrations. Using technology that has a high sensitivity to detect a disease allows a physician to make concise decisions for proceeding with minimally invasive procedures or reliance on medical therapies that will probably be effective.     

Clinical spectrum of fibroblast growth factor receptor mutations

During the last few years, it has been demonstrated that some syndromic craniosynostosis and short‐limb dwarfism syndromes, a heterogeneous group comprising of 11 distinct clinical entities, are caused by mutations in one of three fibroblast growth factor receptor genes (FGFR1, FGFR2, and FGFR3). The present review list all mutations described to date in these three genes and the phenotypes associated with them. In addition, the tentative phenotype‐genotype correlation is discussed, including the most suggested causative mechanisms for these conditions. Hum Mutat 14:115–125, 1999. © 1999 Wiley‐Liss, Inc.     

GST-人可溶性成纤维细胞生长因子受体1融合蛋白在酵母细胞中的表达及活性测定

目的：表达重组人可溶性成纤维细胞生长因子受体１（ｓｏｌｕｂｌｅ　ｆｉｂｒｏｂｌａｓｔ　ｇｒｏｗｔｈ　ｆａｃｔｏｒ　ｒｅｃｅｐｔｏｒ　１，ｓＦＧＦＲ１），研究其对成纤维细胞生长因子（ＦＧＦ）生物学活性的拮抗作用。方法：采用逆转录－ＰＣＲ（ＰＴ－ＰＣＲ）技术自人肺成纤维细胞获得ｓＦＧＦＲ１　ｃＤＮＡ，测序确证后，将其克隆人酵母细胞表达载体ｐＹＥＸ４Ｔ－１；重组质粒转化入酵母细胞（ＤＹ１５０）中进行诱导表达，表达产物经ＳＤＳ－ＰＡＧＥ及 Ｗｅｓｔｅｒｎ　ｂｌｏｔ鉴定。利用 ＮＩＨ３Ｔ３细胞增殖抑制实验检测重组人 ｓＦＧＦＲ１的生物学活性。结果：经 ＣｕＳＯ４诱导，酵母细胞表达出重组谷胱苷肽转移酶（ＧＳＴ）－ｓＦＧＦＲ１融合蛋白，此蛋白在凝胶上表现为 １条约 ６０ｋＤ的阳性区带，在 Ｗｅｓｔｅｒｎ ｂｌｏｔ实验中可被ＧＳＴ特异性抗体识别。重组ＧＳＴ－ｓＦＧＦＲ１融合蛋白的粗提物在体外能够桔抗ＦＧＦ介导的促ＮＩＨ３Ｔ３细胞增殖的活性。结论：重组ＧＳＴ－ｓＦＧＦＲ１融合蛋白在酵母表达系统中得到有效表达，并具有很好的生物活性。     

Role of hysteroscopy with endometrial biopsy to rule out endometrial cancer in postmenopausal women with abnormal uterine bleeding

OBJECTIVE: To compare the diagnostic accuracy of ultrasonographic endometrial thickness and outpatient hysteroscopy, to establish the most appropriate exam for the diagnosis of endometrial cancer in postmenopausal women with abnormal uterine bleeding (AUB). The secondary aim was to develop a multivariable approach considering clinical history as an added value for these diagnostic procedures. METHODS: This prospective study was conducted on 220 consecutive postmenopausal patients with AUB, who underwent ultrasonographic evaluation of endometrial thickness, outpatient hysteroscopy and endometrial biopsy. Evaluation of sensitivity, specificity, positive and negative predictive value was performed. Receiver operator characteristic curve (ROC) was calculated to assess the global performance of ultrasonographic measurement of endometrial thickness and diagnostic hysteroscopy as tests for detecting endometrial cancer and atrophy. RESULTS: Histological findings for <4 mm level revealed that atrophy was present in 48 (65%) and in 2 cases (2.7%) endometrial cancer was found; for > or = 4 mm values polyps and myomas were present in 86 (59%) and there were 11 (7.5%) endometrial cancer. Sensibility and specificity for trans-vaginal ultrasound, with a cut-off value > or = 4 mm, was 55.6% and 49.7% while positive predictive value was 83.3% and negative predictive value 98.1% (ROC curve 0.597). Hysteroscopy revealed sensitivity 100%, specificity 49.6%, positive predictive value 81.3% and negative predictive value 100% (ROC curve 0.993). CONCLUSIONS: In conclusion, endometrial thickness <4 mm can miss malignancies but trans-vaginal ultrasound remains the first line diagnostic procedure in postmenopausal women without AUB, because it is not invasive and has high sensitivity for detecting endometrial cancer and other endometrial disease; according to our experience, outpatient hysteroscopy with biopsy is mandatory in all postmenopausal women with AUB.     

Epidermal growth factor receptor in human uterine tissues

Epidermal growth factor receptor (EGFR) was studied in human endometrium and myometrium collected throughout the menstrual cycle (five follicular, five luteal specimens) by immunohistochemistry and quantitative ligand binding. EGFR was principally present on the cell surface of glandular epithelium of the endometrium. Staining was no different between the follicular and luteal phases. There was more EGFR binding in endometrium than myometrium by quantitative ligand binding in membrane preparations: endometrium, median = 92.5 fmol/mg protein (range 25.3-294) n = 10; myometrium, median = 43.0 fmol/mg protein (range 23.4-57) n = 10. There was no difference in the level of binding in the follicular and luteal phases.     

Expression of vascular endothelial growth factor and basic fibroblast growth factor in extramammary Paget disease

Extramammary Paget’s disease (EMPD) is a special type of cancers. The etiology of the disease is still unclear. We aimed to study the expression differences of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in EMPD tissues and corresponding adjacent normal tissues. The mRNA expression was detected by RT-PCR and the protein expression was explored by immunohistochemistry. Higher immunostaining signal scores of bFGF and VEGF in EMPD tissues had been found (z = -3.827, P < 0.001, z = -3.729, P < 0.001, respectively). In addition, the mRNA expression of bFGF and VEGF was higher in EMPD tissues, which had been validated by RT-PCR (t = 5.771, P < 0.001, t = 3.304, P = 0.004, respectively). The VEGF and bFGF might be the key signaling proteins in angiogenesis of EMPD. How to block the VEGF and bFGF in EMPD and to destroy the blood supply of the tumor cells becomes the focus of our future research.     

人成纤维细胞生长因子受体2的研究进展

人成纤维细胞生长因子受体2(fibroblast growth factor receptor 2,FGFR2)属于人类FGFR家族。FGFR2在骨骼发育、腺体发育、肢体形成、皮肤形成及多种器官的形成中发挥重要的作用。该文就FGFR2的结构、功能、所参与的细胞信号转导通路、相关疾病及其抑制剂的研发与应用作一综述。     

Association between Chlamydia trachomatis and abnormal uterine bleeding

PROBLEM: The purpose was to identify distinct inflammatory markers in endometrial tissues of women with abnormal uterine bleeding (AUB) and Chlamydia trachomatis infection. METHOD OF STUDY: Archived endometrial specimens from 92 randomly selected premenopausal women with AUB were examined for C. trachomatis using the species-specific monoclonal antibody against major outer membrane protein (MOMP) and for histopathology associated with inflammation. Statistical analyses included single and multiple logistic regression. Diagnostic accuracy was summarized using receiver operating characteristic (ROC) curves. RESULTS: Chlamydia trachomatis was detected in 44 (48%) of 92 AUB specimens. There were statistically significant correlations of positive MOMP with higher counts of plasma cells (P < 0.01), macrophages (P < 0.0001), and lymphocytic foci (P = 0.01). The ROC curve for macrophages was the strongest predictor (area under the curve = 0.82) for C. trachomatis. CONCLUSION: The prevalence of C. trachomatis in women with AUB is under-estimated. Macrophages appear to be a strong marker for the presence of C. trachomatis in the endometrium.     

Transforming growth factor-alpha, epidermal growth factor receptor, and PCNA immunoexpression in uterine leiomyosarcomas and leiomyomas in B6C3F1 mice.

The role of growth factors in the development of murine uterine mesenchymal tumors is unknown. In this study, immunohistochemical expression of transforming growth factor alpha (TGF-alpha) and its receptor epidermal growth factor (EGF-R) was assessed in spontaneous uterine leiomyomas and leiomyosarcomas in B6C3F1 mice. Cell proliferation, which has been induced by some growth factors, was evaluated by immunohistochemical detection of an endogenous marker of cell proliferation, proliferating cell nuclear antigen (PCNA). PCNA labeling indices were determined and compared to the intensity and distribution of TGF-alpha staining in sequential sections of control myometrium or tumor tissue. Results showed uterine leiomyosarcomas had positive cytoplasmic staining for TGF-alpha; however, all uterine leiomyomas evaluated were negative. Positive EGF-R staining was also observed in the uterine leiomyosarcomas, but not in the leiomyomas. EGF-R immunoexpression was detected primarily within the cytoplasm of the leiomyosarcoma cells, with occasional nuclear immunoreactivity. Immunohistochemical staining for PCNA was more intense and there were increased numbers of positively staining nuclei in the leiomyosarcomas compared to samples of control myometrium or leiomyomas. The mean labeling index for the uterine leiomyosarcomas (7.40%) was significantly (p < 0.01) higher than that of leiomyomas (0.29%) and control uterine myometrium (0.13%). We conclude, that TGF-alpha and its receptor, EGF-R, are expressed more intensely in uterine leiomyosarcomas, compared to leiomyomas in B6C3F1 mice. Immunoexpression of TGF-alpha may be an important biomarker of malignancy in uterine smooth muscle tumors in mice. Futhermore, TGF-alpha may play a critical role in increased proliferation of uterine smooth muscle tumor cells as suggested by increased immunolocalization of PCNA in rodent leiomyosarcomas expressing TGF-alpha, although other factors regulating cell replication can not be ruled out.     

Expression of basic fibroblast growth factor in normal human tissues

The distribution of basic fibroblast growth factor (bFGF) was studied immunohistochemically in fresh frozen sections of normal human tissues. Immunodetection was performed with a specific anti-bFGF mouse monoclonal antibody that was found to react with recombinant human bFGF in Western blot analysis, and to specifically neutralize the mitogenic activity of bFGF on bovine vascular endothelial cells. Expression of bFGF on normal human tissues was ubiquitously detected in the basement membranes of all size blood vessels, but was not found in epidermal or epithelial basement membranes of a variety of tissues tested. Intensity and patterns of localization in blood vessels was consistent in various tissues, but varied among different regions of the vascular bed. Whereas homogeneous and intense immunoreactivity were observed in large and intermediate size blood vessels, heterogeneity of expression was found in capillaries. The most intense immunoreactivity was observed in branching capillaries. Endothelial cell staining was heterogeneous and varied in different regions. Strong staining for bFGF was also found in cardiac muscle fibers, smooth muscle cells of mid-size blood vessels, the gut and the myometrium, in central nervous system neurons and cerebellar Purkinje cells, and on epithelial cells of the bronchi, colon, endometrium, and sweat gland ducts of the skin. The presence of bFGF in the extracellular compartment of a diverse variety of organs may play a role in angiogenesis. However, the function of bFGF in parenchymal cells remains to be determined.     

Expression of FGFRL1, a novel fibroblast growth factor receptor, during embryonic development

FGFRL1 is a novel member of the fibroblast growth factor receptor (FGFR) family. To investigate its expression during mammalian embryonic development, we have used the mouse system. Expression of Fgfrl1 is very low in mouse embryos of day 6 but steadily increases until birth. As demonstrated by in situ hybridization of 16-day-old embryos, the Fgfrl1 mRNA occurs in cartilaginous structures such as the primordia of bones and the permanent cartilage of the trachea, the ribs and the nose. In addition, some muscle types, including the muscles of the tongue and the diaphragm, express Fgfrl1 at relatively high level. In contrast, the heart and the skeletal muscles of the limbs, as well as many other organs (brain, lung, liver, kidney, gut) express Fgfrl1 only at basal level. It is conceivable that Fgfrl1 interacts with other Fgfrs, which are expressed in cartilage and muscle, to modulate FGF signaling.     

Genetically confirmed thanatophoric dysplasia with fibroblast growth factor receptor 3 mutation

Thanatophoric dysplasia (TD), the most common lethal skeletal dysplasia, is a de novo genetic disease caused by a mutation in the fibroblast growth factor receptor 3 (FGFR3) gene. “Thanatophoric” means “dead bearing” in Greek. Because FGFR3 is the main modulator of bone maturation, typical features of TD include short extremities, curved femur, clover-leaf skull, small narrow chest, and platyspondyly. TD can be classified into two subgroups according to the morphologic findings, with prominent curved femur suggesting type I TD (TD 1) and with marked clover-leaf skull and relatively straight long bones, favoring type II TD (TD 2). However, considering the genetic profiles, TD 1 and TD 2 could be confidently delineated. Here, we report five genotype-phenotype correlated autopsy cases of TD. Five cases had stigmata of TD on antenatal ultrasonography. Terminations were done at gestational age 16 to 28 weeks, after family consultation. In autopsy, all fetuses showed short limbs and clover-leaf skull. The microscopic examination of the bones showed disorganized growth plate, consistent with TD. However, some differences existed in gross and microscopic findings between cases. In genetic analyses, three cases revealed missense mutation of Y373C, while the remaining two cases had missense mutation of S371C and S249C each. They were hot spot mutations of TD 1. A correlation between genotype and phenotype was not apparent due to the limited number of the cases. Therefore, a molecular work up to identify the mutation of FGFR3 is indispensable for TD diagnosis in the era of precision medicine for genetic consultation and future targeted therapy.     

The pathogenesis of abnormal uterine bleeding in myopathic uteri

It has been suggested that impaired venous drainage and endometrial vascular ectasia (EMVE), secondary to increased intramural pressure, explains abnormal bleeding in fibroid uteri. Striking EMVE with extravasated red blood cells (ecchymosis) has also been seen in uteri with grossly obvious myometrial hyperplasia (MMH), suggesting that increased intramural pressure can cause EMVE in the absence of fibroids. EMVE with MMH may explain the century old association of clinically enlarged uteri with abnormal bleeding, and this same mechanism may be operative in myopathic uteri with grossly obvious adenomyosis.EMVE with associated thrombosis, ecchymosis, and/or stromal breakdown is commonly seen in random sections of hysterectomies for bleeding. EMVE may also be associated with endothelial hyperplasia, consistent with a reaction to endothelial injury due to impaired venous drainage. This further supports the theory that EMVE bleeds when thrombosis occurs, due to Virchow's Triad (stasis, endothelial injury, and hypercoagulability). EMVE may be “the lesion for which surgery was performed” in hysterectomies with otherwise unexplained bleeding.     

Comparison of transvaginal ultrasonography and saline infusion sonohysterography in evaluating the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding

OBJECTIVE: To compare the diagnostic accuracy of transvaginal ultrasonography (TVUS) and saline infusion sonohysterography (SIS) of the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding. DESIGN: In a prospective study, TVUS and concurrent SIS findings of 100 pre- and 33 postmenopausal women were recorded. The pathological diagnoses of the specimens, obtained by means of dilatation and curettage, hysteroscopy, and hysterectomy, were taken as reference and compared with the results of TVUS and SIS. RESULTS: When TVUS and SIS findings were compared with pathological results, the sensitivity and specificity of TVUS in diagnosing endometrial pathologies were 83% and 70.6%, respectively, whereas the sensitivity and specificity of SIS were 97.7% and 82.4%, respectively. The sensitivity and specificity of SIS in the diagnosis of endometrial polyps were 100% and 91.8%, respectively, and in the diagnosis of fibroids were 95% and 100%, respectively. CONCLUSION: SIS is more accurate than TVUS alone in the evaluation of the endometrial cavity in women with abnormal uterine bleeding.