Prediction of benign and malignant endometrial disease: hysterosonographic-pathologic correlation.

PURPOSE: To determine the transvaginal hysterosonographic appearances of benign and malignant endometrial disease. MATERIALS AND METHODS: From April 11, 1994, through August 1, 1996, a total of 88 women (age range, 25-81 years) underwent transvaginal hysterosonography and histopathologic evaluation of the endometrium after dilation and curettage or after hysterectomy. A benign appearance at transvaginal hysterosonography was defined as a thin endometrium, diffuse smooth endometrial thickening, or a smoothly marginated, homogeneously echogenic, pedunculated endoluminal mass. A suspicious appearance was defined as either irregular thickening of the endometrium or an inhomogeneous endoluminal mass. RESULTS: Of 88 women, 37 had a benign-appearing endometrium at transvaginal hysterosonography; at histologic examination, 16 had a proliferative endometrium, 12 had a secretory endometrium, six had polyps, two had an inactive endometrium, and one had carcinoma. Of the 51 women with suspicious endometrial appearances, eight had carcinoma, 24 had adenomatous polyps, five had hyperplasia, 11 had fibroids, and three had endometritis. For carcinoma, the sensitivity of transvaginal hysterosonography was 89%, specificity was 46%, positive predictive value was 16%, and negative predictive value was 97%. CONCLUSION: A thin endometrium or diffuse smooth endometrial thickening is predictive of benign endometrial histologic findings, but all women with endoluminal masses require further histologic evaluation to exclude malignant disease.

Urethral complications of urinary catheterization presenting as primary scrotal masses: sonographic diagnosis.

We report on 2 debilitated male patients who had penile urethral complications of transurethral catheter drainage. One patient had a urethral diverticulum, and the other had a Foley catheter misplaced through a urethral perforation. Both lesions mimicked primary intrascrotal masses on physical examination and were therefore evaluated by scrotal sonography. The correct diagnosis of each lesion required careful examination of the mass and its anatomic relationship to the adjacent urethra. Penile urethral complications of catheterization in debilitated patients must be included in the differential diagnosis of scrotal cystic masses. These cases also emphasize the necessity of a thorough sonographic examination that extends beyond the specific area of presumed clinical interest.

The role of transvaginal sonography and endometrial biopsy in the evaluation of peri- and postmenopausal bleeding.

OBJECTIVE: The number of women seeking medical attention for peri- and postmenopausal bleeding (PMB) has been increasing. Determining the cause of PMB is essential in planning appropriate therapy. In these women, transvaginal sonography (TVS) is a sensitive means for diagnosing the causes of such bleeding, yet endometrial biopsy (EMB) is still preferred as the first diagnostic test. We prospectively compared TVS with aspiration biopsies of the endometrium in the examination of women with PMB. SUBJECTS AND METHODS: Between mid April 1994 and December 1995, 329 consecutive perimenopausal women underwent EMB. Of these EMBs 302 had negative results. We prospectively obtained TVS in 259 of these 302 women within 1 month of EMB (range, 10 days to 2 months) when the results of biopsy were negative. Forty-three patients were lost to follow-up. In 59 women who had endometrial thickening greater than 5 mm, dilatation and curettage, hysteroscopy, or hysterectomy was performed. Ninety-four of the 130 women who were found at TVS to have fibromyomata or diffusely enlarged uteri underwent hysterectomy for pathologic confirmation. The remaining 36 women with fibromyomata or diffusely enlarged uteri had no pathologic confirmation of their TVS findings. Twenty-one of 64 women with endometria thinner than 5 mm underwent dilatation and curettage, and 43 of these women were lost to follow-up. RESULTS: In 259 patients who underwent TVS, 57 patients who had an endometrium thicker than 5 mm and an endoluminal mass on hysterosonography had false-negative results on aspiration biopsies. Of the 18 patients who had malignancies in this series, 12 had false-negative results on biopsies. In the 94 patients with an enlarged uterus and negative EMB results who underwent hysterectomy, we found 87 with fibroids, three with adenomyosis, and four with sarcomas. Of the 64 women with endometria thinner than 5 mm seen on TVS, 21 had negative results from dilatation and curettage. CONCLUSION: EMB alone is not sufficient for screening women for PMB. TVS appears to be more sensitive than is EMB for the detection of abnormalities, particularly those outside the endometrium. For these reasons, TVS should be the initial screening test when examining women with PMB.

Predicting poor neonatal outcome: a comparative study of noninvasive antenatal testing methods.

OBJECTIVE: The assessment of fetal well-being in the third trimester of pregnancy depends on many variables including fetal size, amniotic fluid volume, umbilical cord arterial Doppler waveforms, the nonstress test, and the biophysical profile, yet little has been written that directly compares these variables. In this study, we compared amniotic fluid indexes, umbilical cord arterial Doppler waveforms, nonstress tests, and biophysical profiles for predicting poor neonatal outcomes in fetuses who are small for gestational age (SGA). SUBJECTS AND METHODS: From April 11, 1994, through August 1, 1995, a cohort of 108 SGA fetuses was identified. Follow-up was available in 97 of these cases. Receiver operating characteristic curves were constructed for Doppler systolic:diastolic ratios and for amniotic fluid indexes. Student's t test and logistic regression analysis were used to compare umbilical cord arterial Doppler imaging, amniotic fluid indexes, the nonstress test, and the biophysical profile for predicting poor neonatal outcome. RESULTS: Of the 30 fetuses who had poor outcomes, five were emergency cesarean deliveries, three died, three had intracranial hemorrhages, one had a cerebral infarct, 12 had prolonged admission to the neonatal intensive care unit (NICU) (> 10 days), and six had NICU admissions at term. Of the variables we assessed, the sensitivities for predicting poor outcome were as follows: cord Doppler imaging, 64%; low amniotic fluid volume (oligohydramnios), 32%; biophysical profile, 18%; and nonstress test, 14%. Receiver operating characteristic curves showed that a systolic:diastolic ratio of 4.0 and an amniotic fluid index of 5 cm (independent of gestational age) were the most accurate cutoff values for predicting poor outcome. Logistic regression analysis showed that amniotic fluid indexes and umbilical cord arterial Doppler imaging were independent predictors of poor outcome and that the predictive value of the biophysical profile varied according to the amniotic fluid index. CONCLUSION: Doppler waveform abnormalities were the most accurate predictor of poor neonatal outcome in a cohort of SGA fetuses. Umbilical cord arterial Doppler waveform analysis should be included in the surveillance of SGA fetuses.

Endometrial color flow/image-directed Doppler imaging: negative predictive value for excluding ectopic pregnancy.

PURPOSE: Visualization of an intrauterine pregnancy with transvaginal ultrasound virtually excludes an ectopic pregnancy. However, findings that might lower patients' risk for ectopic pregnancy have not been extensively investigated. We prospectively performed transvaginal color flow/image-directed Doppler imaging of the endometrium to determine the predictive value of endometrial blood flow for excluding ectopic pregnancy. MATERIALS AND METHODS: From April 1994 to August 1995, 211 consecutive women underwent transvaginal ultrasound examination to exclude an ectopic pregnancy. Color flow/image-directed Doppler imaging of the endometrium was performed on each patient. Flow was considered to be present only if a Doppler signal could be obtained with the cursor located completely within the endometrium. All Doppler imaging parameters were optimized for each patient. Resistive indices were obtained if arterial signal was present, and receiver operator characteristic curves were constructed for RI and peak systolic velocity. Findings were correlated with surgical and pathology results. RESULTS: Of 211 total patients, there were 55 ectopic pregnancies (52 diagnosed for a sensitivity of 95%), 89 incomplete spontaneous abortions, 40 completed spontaneous abortions, and 27 intrauterine pregnancies. Of 55 ectopic pregnancies diagnosed with real time imaging, 9 had areas of endometrial blood flow (6 venous, 3 arterial), and 46 did not. Of the 156 patients that did not have an ectopic pregnancy, 107 had arterial blood flow within the endometrium, and 49 had no flow. Using only cases with arterial signal, the negative predictive value of endometrial blood flow for excluding an ectopic pregnancy was 97% (107/107 + 3). The optimal cutoff values (5% false-positive rate) for peak systolic velocity and refractive index (RI) were 15 cm/s and 0.55. CONCLUSIONS: Arterial blood flow within the endometrium lowers the risk for ectopic pregnancy even when other findings that might indicate a high risk are present. Venous flow within the endometrium does not exclude an ectopic pregnancy.

Renocolic fistulas: complementary roles of computed tomography and direct pyelography.

Three patients with renocolic fistulas are presented. Antegrade or retrograde pyelography showed the fistula in one patient but was unsuccessful in two others. CT demonstrated perinephric inflammation extending to the colon, complex air-fluid collections within the kidney, or extension of renal contrast into the colon. CT and direct pyelography complement each other for the diagnosis of renocolic fistulas.

The chorionic rim and low-impedance intrauterine arterial flow in the diagnosis of early intrauterine pregnancy: evaluation of efficacy.

OBJECTIVE: We undertook this study to evaluate whether sonographic imaging of an intrauterine chorionic rim or arterial flow can help diagnose an early intrauterine pregnancy. MATERIALS AND METHODS: One hundred sixty-nine women with early intrauterine pregnancies and 69 women with ectopic pregnancies underwent pelvic sonography. All sonograms were examined for a chorionic rim (an echogenic rim bordering an intrauterine fluid collection) or a double decidual sac. Of these 238 patients, 126 also underwent Doppler examination for endometrial arterial flow. RESULTS: The chorionic rim and double decidual sac had sensitivities for intrauterine pregnancy of 80% and 64%, respectively, and specificities of 97% and 100%, respectively. Intrauterine arterial flow with either peak systolic velocity greater than or equal to 15 cm/sec or resistive index less than or equal to 0.55 had a sensitivity of 70% and a specificity of 95%, Combining these two signs led to sensitivities and specificities of approximately 90%. Similar test performance was observed in patients having intrauterine pregnancies that lacked an embryo, yolk sac, or amniotic remnant. CONCLUSION: The chorionic rim and low-impedance endometrial arterial flow can indicate an intrauterine pregnancy even when the double decidual sac is not seen. These two signs are particularly useful for patients with intrauterine pregnancies that show no other sonographic findings.

Transvaginal hysterosonography: comparison with biopsy in the evaluation of postmenopausal bleeding.

Transvaginal sonography is a highly sensitive method for detecting endometrial thickening. In the postmenopausal woman such thickening is non-specific and can be due to hyperplasia, polyps, submucosal endoluminal fibroids, or carcinoma. In such cases, transvaginal sonography combined with transvaginal hysterosonography may assist in the workup of these endometrial processes. We compared the combination of transvaginal sonography and transvaginal hysterosonography to aspiration endometrial biopsy in the evaluation of women with postmenopausal bleeding. We prospectively performed transvaginal sonography in 148 women within 1 month (range, 10 days to 2 months) after having had an aspiration endometrial biopsy. Transvaginal hysterosonography was then performed in 81 of these women who had endometrial thickness greater than 5 mm. In these 81 patients, transvaginal hysterosonography confirmed 45 lesions: 23 pedunculated endometrial masses and 22 inhomogeneous sessile lesions. Women with positive transvaginal hysterosonography examinations then underwent hysteroscopy or hysterectomy, whereas women with negative examinations were followed conservatively. Forty-one of the 45 cases with endoluminal masses on transvaginal hysterosonography had false-negative aspiration biopsies. Of the five (11%) lesions that were malignant, three resulted in false-negative biopsies, one biopsy revealed hyperplasia, and only one biopsy was true positive. All 36 women with negative transvaginal hysterosonography examinations also had negative biopsy findings. We conclude that the combination of transvaginal sonography and transvaginal hysterosonography is more sensitive in the detection of endometrial pathologic lesions than is endometrial biopsy, and that transvaginal sonography or transvaginal hysterosonography should be included in the evaluation of women with postmenopausal bleeding.

Transvaginal hysterosonography in the evaluation of small endoluminal masses.

Transvaginal sonography is highly sensitive for detecting endometrial mass lesions, but it is nonspecific. Biopsies performed on patients with abnormal findings seen on TVS often are negative. We performed transvaginal hysterosonography prospectively on 48 consecutive patients with endometrial thickness demonstrated on TVS to be between 5 and 10 mm to assess whether this technique would be useful in the evaluation of such patients. TVHS is a simple, painless technique that is performed by placing a small catheter into the endometrial canal and infusing a small amount of saline solution under sonographic visualization. Of 48 suspected lesions, TVHS confirmed only 19 endoluminal masses: 11 fibroids and eight polyps. Polyps tended to be homogeneously echogenic and to have a pedunculated attachment to the uterine wall without interruption of the endometrial lining. Fibroids showed more heterogeneous echogenicity and had a more sessile attachment. Four patients in our series had false-negative biopsy results prior to having had endometrial mass lesions depicted on TVHS. TVHS may prevent unnecessary biopsies in those patients who appear to have abnormalities on TVS. By depicting the nature of the attachment of endoluminal masses to the uterine wall more clearly, TVHS also may help direct subsequent biopsy procedures.

Portal vein thrombosis: imaging findings.

Portal vein thrombosis (PVT) is usually a complication of pre-existing cirrhosis, abdominal malignancy (e.g., pancreatic or hepatocellular carcinoma), or abdominal inflammation (e.g., appendicitis, diverticulitis, pancreatitis). Less frequently, PVT can be associated with myeloproliferative or connective tissue disorders or inflammatory bowel disease [1]. PVT can cause or exacerbate portal hypertension; variceal bleeding or hypersplenism may then develop acutely or several years later. PVT also complicates portosystemic shunt surgery or hepatic transplantation. Unfortunately, the signs and symptoms of PVT can be subtle or nonspecific and can be overshadowed by the underlying illness. The radiologist may be the only physician to suggest the preoperative or premortem diagnosis of PVT. Familiarity with the imaging findings of PVT, therefore, is imperative.

Pitfalls in the transvaginal sonographic diagnosis of ectopic pregnancy.

Transvaginal sonograms (TVS) of 40 adequately documented ectopic pregnancies were reviewed retrospectively. Difficulties that interfered with the accurate demonstration of the adnexal mass of the ectopic pregnancy were identified in 21 of these studies (52.5%). In three cases (7.5%) the ectopic pregnancy was visualized in an erroneous location. In 11 cases (27.5%), the ectopic pregnancy was overshadowed by coexisting pathologic findings, misinterpreted as a bowel segment or poorly demarcated from the adjoining ovary. In seven cases (17.5%), the adnexal mass of an ectopic gestation was completely over-looked on initial TVS. TVS in the women suspected of having an ectopic pregnancy must be performed meticulously and with due consideration to the pitfalls described.

Complementary use of Doppler sonography and delayed right lateral scintigraphy for the diagnosis of choledochal cysts.

Both sonography and hepatobiliary scintigraphy can help to demonstrate a choledochal cyst. Our case further demonstrates that Doppler sonography and right lateral or oblique scintigraphic views can be used to differentiate more completely this entity from other infantile cholestatic syndromes. These additional maneuvers may be particularly advantageous in the affected infant under a year old in whom a confusing clinical picture may obscure the correct diagnosis.

Duplex sonography of the portal venous system: pitfalls and limitations.

Duplex pulsed-Doppler sonographic examinations of the portal venous systems of 14 patients were reviewed, and the results were compared with the findings of other examinations including endoscopy and angiography. The sonograms of virtually every patient in the sample showed at least one of four pitfalls. The "mirror-image" artifact, in which the Doppler signal contained simultaneous and symmetric elements on both sides of the zero baseline, was identified in 11 patients (79%). The "flip" artifact, in which the Doppler signal would either flip from one side of the zero baseline to the other or would indicate a direction of blood flow opposite to that normally expected, was seen in six patients (43%). In four patients (29%), a Doppler flow signal could not be obtained from small vessels that were identified on standard real-time images. In 10 patients (71%), important vascular channels including bleeding gastroesophageal varices were obscured by bowel gas, ascites, or the patient's body habitus. Duplex sonography may still provide useful information about portal venous hemodynamics. However, it remains a prodigious technical undertaking whose accuracy can be severely hampered by artifacts and inherent technical difficulties.

The fatty liver: pitfalls of the CT and angiographic evaluation of metastatic disease.

Five patients with known primary malignancy demonstrated fatty infiltration of the liver on routine computed tomography (CT) examination. Within the diffuse fatty infiltration were focal areas of relatively increased beam attenuation in four cases. These areas of increased beam attenuation are nonspecific as to etiology. Their differential diagnosis is discussed. Since the true extent of the neoplastic process may be underestimated by conventional CT and celiac angiography, superselective angiography, computed angiotomography, or biopsy is required to accurately assess the etiology and the extent of the disease.