Atsuko Shiota

Does three‐dimensional power Doppler ultrasound improve the diagnostic accuracy for the prediction of adnexal malignancy?

Objective:  The aim of the present study was to investigate the diagnostic accuracy of three‐dimensional power Doppler ultrasound (3DPD) in the differentiation between benign and malignant adnexal masses and evaluate 3DPD for assessing malignancy in comparison with two‐dimensional transvaginal gray‐scale sonography (2DTVS), magnetic resonance imaging (MRI) and positron emission tomography (PET).

Positron emission tomography with the glucose analog [18F]-fluoro-2-deoxy-D-glucose for evaluating pelvic lymph node metastasis in uterine corpus cancer: Comparison with CT and MRI findings

Objective:  The aims of this study were to investigate the ability of positron emission tomography (PET) with the glucose analog [18F]‐fluoro‐2‐deoxy‐D‐glucose (FDG) to detect pelvic lymph node metastasis of uterine corpus cancer and to perform a retrospective comparison with computed tomography (CT) and magnetic resonance imaging (MRI) findings.

Nuchal Translucency Thickness and Fetal Cardiac Flow Velocity in Normal Fetuses at 11–13 Weeks of Gestation

Objective: To investigate the relationship between nuchal translucency thickness and cardiac flow velocity in normal fetuses at 11–13 weeks of gestation. Subjects and Methods: Eighteen normal pregnancies were prospectively studied with transvaginal sonography and pulsed and color Doppler ultrasound. Flow velocities at the fetal atrioventricular valves (mitral and tricuspid valve) and outflow tract levels (ascending aorta and pulmonary artery), and at the descending aorta were recorded. Nuchal translucency thickness was also measured. Results: Mitral peak velocity during early diastolic filling correlated with gestational age. Mitral peak velocities during early diastolic filling and atrial contraction, tricuspid peak velocity during early diastolic filling, ascending aorta peak velocity, and pulmonary artery peak velocity correlated well with nuchal translucency thickness. There was an inverse correlation between umbilical artery pulsatility index and gestational age. Conclusions: These results suggest that the increase of nuchal translucency thickness in normal fetuses at 11–13 weeks of gestation may be the consequence of changes in fetal cardiac functions.

Three-dimensional power Doppler sonographic features of uterine vascular malformation.

Pelvic arteriovenous malformations (AVMs) are uncommon lesions of frequently unknown cause. Congenital AVMs are considered to be undifferentiated vascular structures resulting from arrest of embryonic development at various stages1,2. Acquired AVMs are usually caused by neoplasms, trophoblastic disease or trauma, and procedures such as curettage and uterine surgery have been implicated3–5. These malformations are characterized by their slow growth with a period of latency before becoming symptomatic. They may produce local or systemic effects, including vaginal bleeding, abdominal pain, urinary symptoms, and high-output congestive heart failure. Many methods have been used to diagnose pelvic AVMs. Angiography, which is the gold standard for diagnosis, has the advantage of demonstrating the feeding arteries and draining veins of the AVM6. However, angiography is an invasive procedure, and should be reserved for cases in which surgical intervention or therapeutic embolization of the lesion is planned such as those with persistent and severe uterine hemorrhage7–9. Recently, color and power Doppler sonography has provided a valuable, non-invasive method for the definitive diagnosis of AVM10,11. We present our initial experience with applying three-dimensional sonography in the diagnosis of uterine vascular malformation. A 27-year-old Japanese woman, gravida 3 para 2, was referred to our outpatient department because of persistent high serum β-human chorionic gonadotropin (β-hCG) levels. Gray-scale sonography (GE Voluson 730 Expert, Yokogawa, Tokyo, Japan) revealed an ill-defined mildly echogenic lesion with multiple small hypoechoic spaces on the right side of the uterus. Twodimensional color and power Doppler flow imaging showed a hypervascular lesion with turbulent flow, with a peak velocity of 80.3 cm/s and low pulsatility index of 0.445. The clinical diagnosis of invasive mole was made, and five courses of chemotherapy with Etoposide were administered. After 3 courses of chemotherapy, the serum β-hCG levels normalized. Six months after chemotherapy, three-dimensional power Doppler sonography clearly showed an aneurysm-like structure typical of uterine vascular malformation including its feeding vessels and drainage within the right mesosalpinx (Figure 1). The diagnosis of uterine vascular malformation was confirmed by magnetic resonance angiography. The patient had no manifestation of clinical symptoms. The aneurysm-like structure of the uterine vascular malformation was still evident 17 months after the initial examination. The typical color Doppler sonographic pattern of an AVM is ‘chaotic’ flow characterized by a turbulent flow velocity waveform. The ‘chaotic’ or turbulent flow results from the area being filled with numerous individual velocity vectors randomly occurring in all directions. The diagnosis of AVM might be made from these findings on color Doppler ultrasound but confirmation of the diagnosis is usually achieved by angiography12. There has been only one report on the three-dimensional power Doppler sonographic diagnosis of AVM of the mesosalpinx12. In our case, the aneurysm-like structure of the uterine vascular malformation with its feeding vessels and drainage within the right mesosalpinx was shown beautifully by means of three-dimensional power Doppler sonography. Moreover, it could be observed from any angle, which enables a much easier and quicker understanding of the spatial relationships of the vessels involved12. As surgical manipulation for uterine or pelvic AVM may sometimes result in hemorrhage or even death, conservative management by means of serial observations, may be preferable8,12. Timmerman et al.10 reported that conservative management is possible in more than two-thirds of patients presenting with uterine vascular malformation diagnosed by color Doppler sonography, and that peak systolic velocity values appear to be useful in distinguishing lowfrom highrisk patients. Peak systolic velocities of ≥ 83 cm/s were associated with higher probabilities of further treatment such as embolization whereas no vascular malformation with a peak systolic velocity value

Adrenomedullin concentrations in early 2nd-trimester amniotic fluid: Relation to preterm delivery and fetal growth at birth

Objective: The purpose of this study was to evaluate whether adrenomedullin concentrations in the early 2nd-trimester amniotic fluid predict preterm delivery or fetal growth at birth. Methods: The adrenomedullin concentrations in early 2nd-trimester amniotic fluid were measured in 70 pregnancies with term delivery and in 3 pregnancies with preterm delivery. Total and free adrenomedullin concentrations were measured from early 2nd-trimester amniotic fluid samples using an immunoradiometric assay. Results: The amniotic fluid total adrenomedullin concentrations in women with preterm delivery were significantly higher (129.7 ± 19.6 fmol/ml) than those in women with term delivery (92.5 ± 28.2 fmol/ml; p < 0.05). There were no significant differences for amniotic fluid free adrenomedullin concentrations and free/total adrenomedullin ratios between the two groups. Total or free adrenomedullin concentrations in the early 2nd-trimester amniotic fluid showed an inverse correlation both with birth weight (r = 0.27, p < 0.05, and r = 0.21, p < 0.05) and height (r = 0.30, p < 0.05, and r = 0.28, p < 0.05). There were no correlations between placental weight and total or free adrenomedullin concentrations in the early 2nd-trimester amniotic fluid. Conclusions: These results suggest that adrenomedullin concentrations in the early 2nd-trimester amniotic fluid might be related to further in utero fetal growth and that high levels of adrenomedullin in the early 2nd-trimester amniotic fluid may be involved in the occurrence of preterm delivery.

Reciprocal Effects of Tamoxifen on Hormonal Cytology in Postmenopausal Women

OBJECTIVE To evaluate the estrogenic effect of tamoxifen (TAM) therapy in postmenopausal women. STUDY DESIGN The subjects were 26 postmenopausal women. The maturation index (MI), maturation value (MV) and karyopyknotic index (KPI) were evaluated based on hormonal cytology. Endometrial cytologic examinations and transvaginal ultrasonography were also performed. RESULTS Of the 26 patients, 16 had low estrogenic activity from the viewpoint of hormonal cytology before TAM administration. During administration, their mean MV rose significantly, from 25.8 +/- 17.7 to 68.8 +/- 13.2, (mean +/- SD) and their mean KPI rose from 9.0 +/- 8.3 to 47.1 +/- 23.1. In contrast, among the 10 patients with high estrogenic activity, mean MV and KPI decreased from 62.9 +/- 8.4 and 27.2 +/- 16.9 to 58.4 +/- 7.7 and 17.7 +/- 16.1, respectively, with TAM administration. Mean endometrial thickness increased more significantly with TAM administration in the low estrogenic activity group than in the high estrogenic activity group. CONCLUSION TAM had a reciprocal effect; no additional estrogenic effect was seen in patients with high estrogenic activity. Conversely, an estrogenic effect was seen in those with low estrogenic activity. An individualized gynecologic evaluation based on hormonal cytology is useful in selecting patients who will be more susceptible to TAM-induced endometrial abnormality.

Ultrasound for evaluation of adnexal malignancy: From 2D to 3D ultrasound

Conventional two‐dimensional (2D) ultrasound has been widely used for the evaluation of adnexal malignancy in gynecologic fields. This 2D ultrasound evaluation includes a morphological assessment, color/power and pulsed Doppler sonographic assessment, scoring system, and contrast agent assessment of adnexal masses. The introduction of three‐dimensional (3D) ultrasound would facilitate the novel assessment of adnexal masses. With the recent advance in 3D power Doppler (3DPD) ultrasound as well as quantitative 3DPD histogram analysis, quantitative and qualitative assessments of the vascularization and blood flow of adnexal masses have become feasible. These novel techniques may assist in the evaluation of adnexal malignancy, and offer potential advantages relative to conventional 2D sonographic assessments. 3D ultrasound may be an important modality in future gynecologic oncology research and in the evaluation of adnexal malignancy in clinical practice, although some limitations regarding the assessment of adnexal malignancy employing 3D ultrasound remain unresolved.

Three-Dimensional Sonographic Features of Nuchal Edema

Objective: To describe the three-dimensional (3D) sonographic features of nuchal edema in the early second trimester of pregnancy. Methods: From 16 to 22 weeks of gestation 5 cases with nuchal edema were studied using transabdominal 3D sonography. Results: Nuchal edema could be easily imaged with both two-dimensional and 3D sonography; however, visualization of the continuity and curvature of structures was more easily accomplished with 3D sonography. Before 20 weeks of gestation, the skin has a transparent structure, so the bony structures are clearly identified. 3D sonography allowed visualization of nuchal edema in all three dimensions at the same time, providing an improved overview and a more clearly defined demonstration of the adjusted anatomical planes. Conclusion: These results suggest that 3D sonography provides a novel means of visualizing nuchal edema in utero.

Three-dimensional sonographic features of a fetus with Wolf-Hirschhorn syndrome

We present a case of fetal Wolf-Hirschhorn syndrome diagnosed by conventional two-dimensional and three-dimensional ultrasonography. Conventional two-dimensional ultrasonography revealed a diaphragmatic hernia, nuchal edema, and suspected hypospadias. Three-dimensional ultrasonography clearly showed a flattening of the face, a high forehead, a broad nasal bridge continuing to the forehead, exophthalmos, and micrognathia (resembling the appearance of a Greek warrior helmet), but conventional two-dimensional ultrasonography did not depict these findings. Prenatal chromosomal analysis confirmed the diagnosis of Wolf-Hirschhorn syndrome [46XY, del(4)(p15.2)]. Here we demonstrate how three-dimensional ultrasonography provided a novel visual depiction of the facial dysmorphism, which helped substantially in prenatal counseling.

Mixed mesodermal tumor of the ovary: Immunohistochemical study with histogenetic consideration

The clinical, histological and immunohistochemical features of three cases of ovarian mixed mesodermal tumor (MMT) were examined. The epithelial component was serous papillary cystadenocarclnoma in case 1 and 3, and endometrioid adenocarcinoma in case 2. In case 1, undifferentiated adenocarcinoma was also seen. The mesenchymal component was fibrosarcomatous and chondrosarcomatous in case 1 and 2. In case 3, only fibrosarcomatous area was seen. No endometriosis was observed. Immunohistochemically, the epithelial component showed positivity for epithelial membrane antigen in all three cases. S‐100 protein was positive in two cases with chondrosarcomatous differentiation. The fibrosarcomatous area showed positivity for vimentin in all three cases. However desmin, myosin and myoglobin were negative. The antibodies thought to be epithelial or mesenchymal markers unexpectedly reacted positively in some cells; for example, EMA was positive in fibrosarcomatous and chondrosarcomatous cells. Therefore, it was speculated that because the undifferentiated tumor cells had a biphasic character, MMT might originate from immature multipotential cells of surface epithelium and subcapsular connective tissue of the ovary.