Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology.

OBJECTIVE: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. METHODS: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. RESULTS: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. CONCLUSIONS: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Developing a robust and efficient pathway for the referral and investigation of women with post-menopausal bleeding using a cut-off of < or =4 mm for normal thickness.

The majority of women with post-menopausal bleeding (PMB) do not have endometrial cancer, and transvaginal ultrasound (TVUS) is accepted as the screening tool of choice to identify those at highest risk of malignancy. A new referral pathway was instigated in 2000, with patients only being referred to a gynaecologist following an abnormal TVUS result. An initial audit revealed a low positive predictive value for TVUS and a low incidence of detected malignancy. The cut-off value for a normal endometrium was increased from 3 mm to 4 mm in line with published data. This re7hyphen;audit evaluated the effectiveness of implemented changes and identified other areas for improvement. Of the 277 women referred during the study period, 193 had an abnormal or unseen endometrium and were subsequently seen by a gynaecologist. For patients without a histological diagnosis, clinical notes were reviewed and the hospital cancer database scrutinized for all endometrial cancers. Despite a 15.4% increase in referrals, only an additional 2.9% were assessed by gynaecologists. 14 cases of malignancy were identified with a mean endometrial thickness (ET) of 15.7 mm. Failed endometrial sampling was more prevalent with a minimally thickened endometrium. 80 patients with abnormal TVUS had no recorded histological diagnosis. Increasing the ET cut-off value has reduced unnecessary investigations in women at low risk of malignancy. No woman discharged back to her GP has been diagnosed with an endometrial malignancy within 1 year of initial referral. An algorithm has been proposed to further improve the investigation of women with PMB following an abnormal TVUS.

Annual surveillance by CA125 and transvaginal ultrasound for ovarian cancer in both high-risk and population risk women is ineffective.

OBJECTIVE: To assess the efficacy of annual CA125 and transvaginal ultrasound (TVU) scan as surveillance for ovarian cancer. DESIGN: Retrospective audit. SETTING: NHS Trust. POPULATION: Three hundred and forty-one asymptomatic women enrolled for ovarian cancer screening: 179 were in a high-risk group (>10% lifetime risk of developing ovarian cancer), 77 in a moderate risk group (4-10% lifetime risk of developing ovarian cancer) and 71 in a near population risk group (<4% lifetime risk). METHODS: Retrospective audit of case records, laboratory CA125 results, radiology reports, histology records and local cancer registry data. MAIN OUTCOME MEASURES: Ovarian cancers occurring in study population. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVU, and CA125 as a screening tool for ovarian cancer. RESULTS: Four ovarian cancers and one endometrial cancer occurred. One ovarian cancer was detected at surveillance, three occurred in women who presented symptomatically between screenings. Thirty women underwent exploratory surgery because of abnormal findings at surveillance. Two women had cancer (PPV = 6.7%); one had ovarian cancer and the other endometrial cancer. Twenty-eight women (93.3%) had no malignancy. Sensitivity, specificity, PPV and NPV for TVU in the whole cohort were 33.3, 85.8, 0.6 and 99.8%, respectively. For high-risk individuals, the figures for TVU were 33.3, 84.5, 1.1 and 99.6, respectively. Combining both modalities for the whole cohort, the sensitivity, specificity, PPV and NPV were 66.7, 82.9, 1.5 and 99.8% and 50.0, 82.8, 1.3 and 99.7%, respectively, for the high-risk group alone. CONCLUSIONS: Ovarian screening by annual TVU and CA125 is inefficient at detecting early-stage ovarian cancers.

Accuracy of transvaginal ultrasound in diagnosing endometrial pathology in women with post-menopausal bleeding on tamoxifen.

The incidence of endometrial pathology is increased in women with tamoxifen-induced post-menopausal bleeding (PMB). The aim of this study was to determine the accuracy of transvaginal ultrasound (TVS) in diagnosing endometrial pathology in symptomatic women taking tamoxifen, using endometrial thickness measurements (5 mm and 10 mm cut-offs) and morphological changes within the uterine cavity to define abnormality. The sensitivity of TVS was 97% (95% confidence interval (CI) 83% to 100%) and the specificity 35% (95% CI 17% to 56%) at a 5 mm threshold. The corresponding likelihood ratios for a positive test were 1.47 (95% CI 1.16-2.10) and a negative test were 0.09 (95% CI 0.02-0.53). The use of a higher 10 mm threshold, characterization of endometrial morphology or combining endometrial thickness and morphology did not improve overall accuracy. TVS measurement of endometrial thickness using a 5 mm cut-off is highly accurate in excluding endometrial disease in symptomatic women taking tamoxifen and may negate the need for further diagnostic testing in women unless symptoms recur. A positive TVS result is of little value, so further testing is mandatory in order to detect benign and malignant endometrial disease associated with tamoxifen and PMB.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary.

BACKGROUND: Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain. CASE: A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery. CONCLUSION: The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.

Long term safety of fluoroscopically guided selective salpingography and tubal catheterization.

BACKGROUND: The irradiation of the ovaries of reproductive age women during fluoroscopically guided selective salpingography and tubal catheterization has raised concern about the safety of the procedure. In addition to the risk of cancer induction, which exists with the irradiation of all tissues, with the gonads, the induction of hereditary disorders is possible. The objective of this study was to estimate these risks and present them in a clinically meaningful way. METHODS: Retrospective analysis was undertaken of 366 consecutive cases of selective salpingography and tubal catheterization performed at the Birmingham Women's Hospital, UK. The radiation doses of different types of procedure were compared with the background annual radiation dose. The risks of cancer and genetic disorders induction were calculated using conversion coefficients published by the International Commission on Radiological Protection. RESULTS: The radiation dose women were exposed to during selective salpingography and tubal catheterization under fluoroscopic guidance was a fraction of the background annual radiation dose. The excess lifetime risks of cancer and hereditary disorders were in the order of four to 13 and two to six per million procedures respectively. CONCLUSIONS: The long term risks of selective salpingography and tubal catheterization under fluoroscopic guidance are low.

Fetal magnetic resonance imaging in prenatal diagnosis of central nervous system abnormalities: 3-year experience.

OBJECTIVE: To evaluate the comparative merits of ultrasound and fetal magnetic resonance imaging (MRI) in the correct antenatal diagnosis of suspected central nervous system abnormalities. METHODS: A retrospective review of 27 consecutive pregnancies referred for fetal MRI for suspected central nervous system abnormalities between July 1998 and July 2001. Women were referred for the MRI examination when further anatomical and/or pathological clarification of the ultrasound scan findings was needed. Antenatal ultrasound scan and MRI were reviewed in relation to the findings on postpartum investigations. RESULTS: Data were complete for 26 pregnancies. The median gestational age at the time of the ultrasound examination was 26 weeks (95% CI 24 weeks 2 days to 28 weeks 1 day). The median gestational age at the time of magnetic resonance imaging was 27 weeks' gestation (95% Cl 26 weeks 1 day to 29 weeks 2 days). Eight fetuses had associated skeletal, renal and/or cardiac abnormalities previously noted on ultrasound examination. MRI confirmed the ultrasound diagnosis in 15/26 cases (58%). It changed the diagnosis to the correct one in 7/26 (27%) and misdiagnosed four cases (15%). Three of the four cases that were misdiagnosed on MRI occurred in the first 18 months of our 36-month experience. CONCLUSION: Ultrasound remains the primary imaging modality for prenatal diagnosis. Fetal MRI appears to be a useful adjunct to ultrasound to confirm or exclude certain abnormalities; this will consequently help in the counselling of parents and assist in planning further management. However, like any imaging technique, the sensitivity and specificity of the test are likely to improve with experience.

Enlarged fetal bladders: aetiology, management and outcome.

Ultrasound routinely identifies the fetal bladder from 10 weeks of gestation. Understanding the normal embryology of the fetal bladder forms the basis of understanding the mechanisms for pathology. Early onset megacystis <12 mm (maximum diameter) frequently regresses spontaneously however when associated with other structural abnormalities 40% are chromosomally abnormal. Survival in this group is rare and the underlying histopathology is of urethral fibrostenosis. Second and third trimester megacystic indicates a heterogenous group where a precise antenatal diagnosis may be impossible. A distended thick wall bladder associated with a dilated posterior urethra and oligohydramnios is pathonemonic of posterior urethral valves; without this combination of ultrasound signs the underlying pathology is less certain. Prediction of other aetiologies for the megacystis is less accurate but includes primary reflux, cloacal plate, urethral duplication and megacystic microcolon in the differential diagnosis. Robust published data is currently unavailable to define appropriate management for individual cases of megacystis. Therefore current best practice for antenatal management will be discussed.

Obstetric ultrasound: What the radiologist needs to know.

Obstetric ultrasound forms an integral part of modern obstetric care. This includes the use of ultrasound for screening as well as in diagnostic and therapeutic roles. Radiologists involved in this field must have the appropriate training and expertise to match the type of investigation or screening procedure to be undertaken. There should be an explicit understanding of this training and expertise both for the referring obstetrician and expectant mother. All radiologists involved in the care of women should have a thorough understanding of the normal and abnormal appearances of the first trimester as early pregnancy disorders present to the generalist; however, a smaller number of radiologists are involved in anomaly screening and management of growth disorders and still fewer in tertiary referral work. Obstetric medical practice is increasingly litigious and the aims of screening ultrasound and the limitations (false-negative and false-positive rates) should be explicit not only to the referring clinician but also to the expectant parents prior to screening. The diagnostic accuracy of ultrasound should be known in order that the expectant mother can give informed consent.

Prenatal diagnosis of mosaicism for partial trisomy 8: a case report including fetal pathology.

A case of prenatally diagnosed partial trisomy 8 is described. The 'syndrome' is associated with skeletal and cardiac anomalies, as well as hepatic calcification. Differing proportions of 47,XY, +der(8) and 46 XY were present in the different fetal tissues sampled. The highest proportion of 47,XY,+der(8) cells was found in the placenta.

The 4 year outcome following the demonstration of bilateral renal pelvic dilatation on pre-natal renal ultrasound.

There is little in the literature regarding long-term prognosis in cases of fetal pyelectasis and calyceal dilatation. The aim of this study was to correlate antenatal ultrasound findings with outcome in a large group of children, most of whom had routine antenatal mid-trimester scans. 75 babies with bilateral pyelectasis and calyceal dilatation in the pre-natal period and complete radiological and clinical data were identified over a 3 year period. Pre-natal ultrasound was correlated with results of post-natal investigation and the frequency of post-natal surgery was established. Follow-up was documented to discharge or to at least 4 years of age. Prognosis was related to the degree of pelvic dilatation, but neonatal morbidity was much more likely to be associated with pre-natal calyceal dilatation and/or hydroureter. 68% (51 of 75) of babies had insignificant abnormalities on post-natal investigation, defined as either transient fetal pyelectasis and calyceal dilatation, extrarenal pelves, or transient neonatal pyelectasis and calyceal dilatation. Five babies died in the neonatal period, all classified as either moderate or severe disease. Of the surviving 70 cases (93.3%), 27% had renal anomalies that required treatment by prophylactic antibiotics or surgery. The remaining babies were conservatively managed and followed as outpatients. One child required transplantation and a further two had a severe degree of chronic renal failure by the age of 4 years. These data will be of value in prospective counselling.

Patient dosimetry in hysterosalpingography: a comparative study.

Ovarian doses for 45 women undergoing hysterosalpingography (HSG) at our institution were calculated. Lithium borate thermoluminescent dosemeters were used to measure entrance surface doses in standard positions. The study compares the estimated dose received by 21 patients undergoing the procedure using an analogue fluoroscopic unit and standard film-screen radiography with that received by 24 patients who were imaged using a digital screening system with a C-arm. Our results show significant dose reduction is obtainable for patients undergoing HSG when a digital system is employed.

Bladder visualisation as a prognostic sign in oligohydramnios-polyhydramnios sequence in twin pregnancies treated using therapeutic amniocentesis.

Oligohydramnios-polyhydramnios sequence in twin pregnancies may be managed by aggressive amniocentesis and is described in nine consecutive cases. In four of the nine pregnancies both twins survived, one pair died in the neonatal period, and the other four pairs all suffered intrauterine death. The median number of amnioreductions performed was five (range 2-7). In this series the reaccumulation of urine in the bladder of the 'stuck twin' was a predictive prognostic marker of survival in both twins, with a sensitivity and specificity of 100%.

Structural chromosome anomalies in congenital diaphragmatic hernia.

In order to determine the outcome and associated chromosomal and structural anomalies in fetuses diagnosed in utero as having a congenital diaphragmatic hernia, we reviewed 48 consecutive cases referred to our regional Fetal Diagnostic Unit between 1988 and 1995. All babies were delivered in units with appropriate neonatal resuscitation facilities. Thirteen babies [34 per cent of those tested, confidence interval (CI) 19-49 per cent] had karyotypic abnormalities. Three had trisomies but the other nine had more complex karyotypic abnormalities including translocations, deletions, and marker chromosomes. Twenty-one fetuses (44 per cent, CI 30-58 per cent) had additional ultrasound abnormalities which affected the heart in ten cases (21 per cent). Overall, 13 babies survived (27 per cent, CI 14-40 per cent). In babies with normal chromosomes and no additional structural abnormalities the survival rate was 50 per cent (CI 25-75 per cent). Poor outcome was not predicted by early gestation at diagnosis, the hernial contents, or the presence of polyhydramnios. We conclude that parents should be counselled about prognosis with information derived from series of prenatally diagnosed diaphragmatic hernias. The investigations offered should include a detailed ultrasound examination, particularly of the heart, and karyotyping by fetal blood sampling.

Fetal echogenic gut: a marker of intrauterine gut ischaemia?

The pathophysiological significance of fetal echogenic gut (FEG) is unknown. Our aim was prospectively to evaluate FEG in infants with intrauterine growth retardation (IUGR) and absent umbilical artery end diastolic flow velocities. Over a 15 month period, nine infants with FEG met these criteria. Nine infants who, on antenatal assessment, had demonstrated IURG and absent umbilical artery end diastolic flow velocities, but no evidence of FEG, were selected as case-controls. Gastrointestinal function was then prospectively evaluated in both groups after delivery. All liveborn infants received nasogastric feeds of breast milk by 8 days of age. All in the FEG group developed marked abdominal distension, large, bile stained, nasogastric aspirates, and constipation requiring rectal washouts. This led to a discontinuation of enteral feeds on one or more occasions. Two patients in the FEG group required water soluble contrast enemas in order to relieve intestinal obstruction. In the control group, 3/9 patients had abdominal distension, but no rectal washouts were given and enteral feeds were not interrupted. The median (range) time to tolerate full enteral feeds was 15 (7-32) days in the FEG group, compared with 4 (1-8) days in the control group. In the FEG group 5/6 patients required parenteral nutrition for 5-27 days. In the control group one patient required parenteral nutrition over a period of four days only. No child had necrotising enterocolitis or cystic fibrosis. When FEG is observed in the fetus with IUGR, problems with enteral feeding should be anticipated.

Patients' perception of the hysterosalpingogram: the initial stages of the audit cycle.

A prospective study of 98 consecutive hysterosalpingogram examinations was undertaken to evaluate patients' understanding of the examination, to assess their anxiety levels and to identify any factors where improvements might alleviate this anxiety. This was achieved by employing three simple questionnaires, two being completed by the patient (before and after the examination), the third being completed by the radiologist who recorded clinical and technical details. In this study the majority of patients knew why the examination was being performed, although only 50% had received an explanation of the technique prior to their arrival in the department. Anxiety levels associated with the examination were high. The importance of a sympathetic approach by the radiologist prior to the examination was highlighted, and it was found that time delays contributed to the anxiety level.

The role of hysterosalpingography in modern gynaecological practice.

A retrospective review of hysterosalpingography (HSG) in a major gynaecological centre was carried out. 324 patients attended (95%) for HSG out of 341 patients referred for this investigation. 189 examinations (58.3%) were abnormal. The requests and radiological findings were reviewed and the results compared with laparoscopy. HSG remains an integral part of gynaecological investigation and its value has not diminished in modern practice.