Alcohol sclerotherapy for successful treatment of focal adenomyosis: a case report.

Adenomyosis is characterized by the presence of ectopic endometrial tissue within the myometrium. Treatment options range from use of non-steroidal anti-inflammatory drugs and hormonal suppression for symptomatic relief, to endometrial ablation or even hysterectomy. We report a case of successful ultrasound-guided aspiration of focal adenomyosis with intracavitary alcohol instillation in a patient with a recurrent intramural uterine lesion. This is the first report of the treatment of sclerotherapy by alcohol instillation, which may be considered as a reasonable alternative modality in treating rare cases of symptomatic adenomyosis. Published by John Wiley & Sons, Ltd.

Prenatal manifestation of superior mesenteric artery syndrome.

Intestinal obstruction is not a rarity in the newborn. Its etiology is diverse. Superior mesenteric artery syndrome (SMAS) is a phenomenon in which the duodenum is obstructed by the SMA. This causes bowel obstruction accompanied by duodenal dilatation. It has previously been described in adults and children but rarely in infants. We report for the first time on an intrauterine manifestation of SMAS.

A possible genetic factor in the pathogenesis of ovarian dermoid cysts.

This study was undertaken in order to evaluate a possible genetic influence on the pathogenesis of ovarian dermoid cysts. We have performed a case-control study comparing the prevalence of a history of dermoid cysts in first-degree relatives of women with dermoid cysts and among first-degree relatives of women without dermoid cysts. The study group included 285 women with an established diagnosis of ovarian dermoid cysts. The control group included 378 women with sonographically normal ovaries. To assess the relationship between a first-degree family history of dermoid cysts and the diagnosis of ovarian dermoid cysts, a multivariate stepwise logistic regression model was applied. In 28 families of the study group (9.8%), a dermoid cyst was found in at least 1 first-degree relative as compared with only eight families (2%) among the controls (adjusted odds ratio -5.60; 95% CI 2.24-14.2). The data suggest a genetic predisposition towards dermoid cysts which merits further exploration.

The contribution of transvaginal ultrasound in the diagnosis of acute appendicitis: an observational study.

OBJECTIVE: To assess the contribution of transvaginal and transabdominal sonography in the diagnosis of acute appendicitis. METHODS: The study group included female patients in whom acute appendicitis was diagnosed preoperatively by ultrasound and confirmed by histology. Each patient was examined by transabdominal (TAS) and transvaginal (TVS) sonography. The contribution of both approaches to the diagnosis of acute appendicitis was assessed. RESULTS: Acute appendicitis was diagnosed sonographically in 38 women. In all of them the diagnosis was confirmed histologically. All patients had both TAS and TVS. In 16 (42%) patients the inflamed appendix was detected by both approaches, in 13 (34%) only by the transabdominal route and in nine (24%) only transvaginally. Thus, TAS detected only 76% of the cases and TVS added 24%. CONCLUSION: The use of TVS in conjunction with TAS seems to improve the detection rate of acute appendicitis.

The bright edge of the endometrial polyp.

OBJECTIVE: To evaluate the accuracy of sonographic detection of endometrial polyps using a new ultrasound marker denoted 'the bright edge of the polyp'. METHODS: The ultrasound scans of the uterus were examined for the presence of the bright edge in two groups of women. The first, a retrospective group, included 40 women in whom both a histological diagnosis of endometrial polyps and sonographic scans were available for evaluation. The second, a prospective group, included 80 women scheduled for operative hysteroscopy because of endometrial irregularities detected by sonography. In this group the hysteroscopical and histological results of the removed endometrial tissue were correlated with the sonographic diagnosis. RESULTS: In the retrospective group, the bright edge marker, indicative of the presence of a polyp, was detected in 30 out of 40 scans available for evaluation. In the prospective group this marker was detected in 60 women out of 80. Endometrial polyps were confirmed in 56 of these 60 women. In three cases a submucosal myoma was found and in one case the histology showed simple cystic hyperplasia. Two polyps were found in 20 cases where the bright edge had not been detected. This marker has a sensitivity of 96%, specificity of 82%, positive predictive value of 93%, and negative predictive value of 90% in this group at high risk for endometrial abnormalities. CONCLUSION: The bright edge of the polyp is an accurate sonographic marker for the detection of endometrial polyps in women with endometrial irregularities demonstrated on ultrasound.

Conservative management of ovarian cystic teratoma during pregnancy and labor.

OBJECTIVE: Our goal was to evaluate the adequacy of conservative management during pregnancy and labor in women with an ultrasonographically diagnosed ovarian cystic teratoma. STUDY DESIGN: Forty-nine women with ultrasonographically diagnosed ovarian cystic teratoma <6 cm were followed for detection of possible complications through pregnancy and labor. Serial ultrasonographic examinations before pregnancy, during pregnancy, and after delivery were performed to detect changes in the size of the cystic teratoma. RESULTS: In a group of 49 women with dermoid cysts (mean age, 30 years), 68 pregnancies resulted. Of the 68 pregnancies, 4 ended in miscarriages, 1 was electively terminated, and in the remaining 63 pregnancies, a total of 64 healthy infants were delivered. Five patients needed treatment with assisted reproductive techniques. Fifty-five pregnancies ended in normal vaginal deliveries and 8 were delivered by cesarean (cesarean delivery rate of 16%). None of the classical complications attributed to dermoid cysts such as torsion, dystocia, or rupture occurred in the study group. In a follow-up of 56 dermoid cysts throughout pregnancy, cyst size remained unchanged. CONCLUSIONS: Ovarian dermoid cysts <6 cm are not expected to grow during pregnancy or to cause complications in pregnancy and labor.

Aspiration of simple pelvic cysts during pregnancy.

Traditional management of persistent ovarian cysts in pregnancy is explorative laparotomy at 16-20 weeks of gestation and resection of the tumor. Scheduling surgery to this time of pregnancy is accepted in order to prevent abortions that are common whenever surgery is done in the first trimester, without delaying treatment of ovarian tumors which harbor a malignant potential. In the following article we report of 10 cases where simple ovarian cysts diagnosed during pregnancy were successfully treated by sonographically guided cyst aspiration. This new approach is justified with no fear of missing a malignant ovarian tumor due to strict ultrasonic characteristics of benign cysts that include unilocular simple appearing cyst with no solid echogenic parts, septations or papillary structures. For 5 of the 10 women undergoing aspiration, this constituted the definitive treatment, while the remaining 5 were later operated. We conclude that aspiration of simple cysts during pregnancy is safe, may save surgical intervention and in some cases this will be the definitive treatment.

Diagnosis of abdominal tuberculosis by transabdominal ultrasound-guided needle biopsy.

Laparotomy and laparoscopy have been used for biopsy of pelvic masses in the differential diagnosis between abdominal tuberculosis and ovarian cancer. We suggest the use of transabdominal needle biopsy under ultrasound guidance in such cases. Two women developed abdominal distention, one of whom had been receiving medical treatment for known tuberculosis. In both cases, ultrasonography showed a pelvic mass and ascites associated with high levels of CA 125. A transabdominal ultrasonographically-guided biopsy of the masses with a trucut needle established their tuberculous origin. The transabdominal sonographic needle biopsy is a reliable diagnostic procedure in the differential diagnosis between abdominal tuberculosis and ovarian malignancy. This minimally invasive procedure saves the patient with tuberculosis from unnecessary laparotomy.

Chorionic villus sampling in multiple pregnancies.

OBJECTIVE: To evaluate the accuracy and risk of chorionic villus sampling (CVS) for prenatal diagnosis in multiple pregnancies. METHOD: Twenty-eight chorionic villus samplings were carried out in a group of women with twin pregnancies. A transabdominal route was chosen in 24 samplings and the rest (four samplings) were carried out in a transcervical route. In the group of women with triple pregnancies, 14 tests were performed in a transabdominal route and one in a transcervical route. RESULTS: No sampling failure occurred. One laboratory failure occurred in a triplet pregnancy, and one abnormal karyotype (47,xy+18) was found in the group of 28 twin fetuses. The rest of the fetuses in this group had normal karyotypes. Of the five triplets, two chromosomal abnormalities were diagnosed: a mosaic 46,xy/47,xxy was found in both cases. One fetus was affected by fragile -x syndrome. Selective reduction of the affected fetuses was carried out. There was no spontaneous fetal loss. Fetuses which were found to have normal prenatal tests were also found to be normal when born. CONCLUSION: In this relatively small series of CVS in twins and triplets, the procedure has been proven to be safe and reliable for prenatal diagnosis.

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas.

OBJECTIVE: To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas. METHODS: Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy. RESULTS: Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery. CONCLUSION: The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.

Successful treatment of advanced interstitial pregnancy with methotrexate and hysteroscopy. A case report.

BACKGROUND: Data concerning medical treatment of interstitial ectopic pregnancies are scarce. These pregnancies are characterized by late and serious clinical manifestations. We report a case of advanced interstitial pregnancy treated successfully by combining methotrexate (MTX) and hysteroscopy. CASE: A routine ultrasonic evaluation of a 10-week pregnancy revealed a right interstitial gestational sac 58 mm in diameter and containing an embryo with a crownrump length of 29 mm and embryonic heartbeats. Serum beta-human chorionic gonadatropin (hCG) level was 97,950 mIU/mL. The patient was treated with a systemic MTX/leucovorin regimen. At the end of the one-week course, no embryonic cardiac activity was detected, and a decrease in beta-hCG levels commenced. Persistent trophoblastic tissue, manifested by a low (26 mIU/mL) beta-hCG level in plateau, was successfully removed by way of hysteroscopy. CONCLUSION: Early detection of interstitial pregnancy may facilitate conservative medical treatment.

Sonographic characteristics of various types of intrauterine contraceptive devices.

OBJECTIVE: We sought to demonstrate the usefulness of ultrasonography for the in utero identification of different types of intrauterine contraceptive devices. METHODS: We used sonography to differentiate among types of intrauterine contraceptive devices. RESULTS: Each type of intrauterine contraceptive device had typical sonographic characteristics, in most cases, best demonstrated in the axial plane. Photographs of each type are shown and their sonographic appearance is discussed. CONCLUSION: Sonographic identification of intrauterine contraceptive devices is accurate and specific. Sonography may serve as a useful method for determining the time to change the device and to identify those types that are more prone to complications.

Unsuspected uterine leiomyosarcoma discovered during treatment with a gonadotropin-releasing hormone analogue: a case report and literature review.

We report a case of a 37-year-old woman who had received five courses of gonadotropin-releasing hormone (GnRH) agonist (Decapeptyl) for presumed uterine leiomyomata associated with episodes of uterine bleeding. Submucous myoma (histologically proven) was partially removed on the first visit. After a period of significant reduction in the tumor size and cessation of uterine bleeding, the symptoms recurred along with rapid re-growth of the uterus. Total abdominal hysterectomy was performed and the pathologic evaluation revealed leiomyosarcoma with a high mitotic rate. This case and the literature review emphasize the problems encountered with the early diagnosis of uterine leiomyosarcoma during GnRH agonist therapy.

The growth pattern of ovarian dermoid cysts: a prospective study in premenopausal and postmenopausal women.

OBJECTIVE: To evaluate prospectively the evolution of ovarian dermoid cysts and the safety of nonsurgical management in premenopausal women. DESIGN: A prospective study. SETTING: Tertiary hospital-based ultrasonographic unit. PATIENT(S): Between 1985 and 1994, 72 premenopausal and 14 postmenopausal women had ovarian dermoid cysts < 6 cm in diameter diagnosed by ultrasound and were followed up at Kaplan Medical Center in Israel. INTERVENTION(S): Ultrasound examination was scheduled at 3 and 9 months after the initial diagnosis and then annually. Every cyst was measured in three planes. The growth rate of the cysts was calculated from the data gathered. MAIN OUTCOME MEASURE(S): Prospective evaluation of the evolution of dermoid cysts and the safety of nonsurgical management in premenopausal women by an ultrasonographic follow-up. RESULT(S): For the premenopausal and postmenopausal women, the mean age (+/-SD) at diagnosis was 32.3 +/- 8.2 and 61.1 +/- 6.9 years, the mean duration of follow-up was 34.5 +/- 21.6 and 35.3 +/- 26.8 months, the mean cyst size at diagnosis was 3.7 +/- 1.2 and 4.1 +/- 1.5 cm, and the calculated mean growth rate was 1.77 +/- 3.86 and -1.59 +/- 2.48 mm/y, respectively. The difference in the mean growth rate of the cysts between the two groups was statistically significant. The mean growth rate was significantly different from zero in the premenopausal group but not in the postmenopausal group. Twenty-eight women were delivered of 35 healthy infants without complications attributable to the dermoid cysts. The cysts were removed surgically in 24 of the 86 women (27.9%), and benign cystic teratomas were confirmed by histologic examination in all cases. CONCLUSION(S): Premenopausal women with ovarian dermoid cysts of < 6 cm in diameter can be safely managed expectantly, especially if pregnancy is desired. The mean growth rate of dermoid cysts in premenopausal women is 1.8 mm/y.

Significant inhibition of spontaneous IgA secretion by selective peripheral-type benzodiazepine receptor ligands.

The in vitro effect of benzodiazepine (BZ) receptor ligands on the secretion of immunoglobulin isotypes IgM, IgG, and IgA by human peripheral blood mononuclear cells (PBMCs) was examined. It was found that the specific peripheral-type BZ receptor (PBR) ligands (Ro5-4864 and PK 11195) inhibit the spontaneous secretion of IgA by human PBMCs in a dose-dependent manner, in the micromolar range. The decreased secretion of IgG and IgM induced by these ligands did not reach significant levels. The mixed BZ ligands (diazepam and flunitrazepam) had no consistent or significant effect on the production of the three immunoglobulin isotypes tested in the current study. The central-type ligand (clonazepam) did not affect IgM, IgG, or IgA secretion. The significant inhibitory effect of PBR ligands was confined to the spontaneous secretion of IgA by human PBMCs, and no such effect was detected in cells stimulated by pokeweed mitogen to produce immunoglobulins. It seems that PBR ligands are capable of suppressing spontaneous IgA secretion, but fail to affect the augmented production induced by mitogen.

Doppler flow characteristics of dermoid cysts: unique appearance of struma ovarii.

The purpose of our study was to evaluate the Doppler flow characteristics of ovarian dermoid cysts. In 70 women (mean age, 38.7 +/- 14.6 years), 78 ovarian lesions with mean diameter of 48.9 +/- 28.4 mm and preoperative sonographic diagnosis of dermoid cyst of the ovary were evaluated prospectively by Doppler flow sonography; these cysts were eventually removed surgically. The findings were compared to the postoperative histologic results. In 74 lesions (eight cases were bilateral), when blood flow patterns were detected (detection rate of 24.3%) they were obtained only from the ovarian tissue surrounding the dermoid cavity, with a mean resistive index of 0.6 +/- 0.1 (range, 0.4 to 0.76). In four cases, which were proved postoperatively to be struma ovarii, blood flow was detected not only from the cyst capsule but also from the centrally positioned solid area (dermoid tissue), with a mean RI of 0.565 +/- 0.08 (range, 0.509 to 0.667). Dermoid cysts of the ovary are devoid of blood flow, with flow detection rate being only 24.3% from the cyst capsule. When apparently vascularized solid tissue is detected in the central part of a sonographically suspected benign cystic teratoma, struma ovary is highly suspected.

Peripheral-type benzodiazepine receptor ligands modulate human natural killer cell activity.

Following our earlier work, we evaluated the in vitro effect of ligands active at the peripheral-type benzodiazepine receptors on human natural killer cell activity. Peripheral blood mononuclear cells were incubated with benzodiazepine receptor ligands. After 4 h we observed a nonspecific inhibition of natural killer cell activity induced by both peripheral (Ro5-4864 and PK 11195) and central (clonazepam) benzodiazepine receptor ligands; after 24 h, the suppressive activity was specific to peripheral and mixed (diazepam) ligands, and the central-type ligand had no effect. This significant, specific suppression of NK cell activity was completely reversed by the addition of human recombinant interleukin-2 or human leukocyte interferon. Our research provides additional information on the immunomodulatory effects of peripheral-type benzodiazepine ligands. Further studies are needed to clarify the underlying mechanism of natural killer cell inhibition and to determine the clinical implications of these findings.