One week stenting after pediatric laparoscopic pyeloplasty; is it enough?

INTRODUCTION: The use of ureteric stents for urinary diversion after pediatric dismembered pyeloplasty and its duration remain debatable. Classically, an indwelling Double J ureteric stent has to be left for 4-6 weeks. However, such a duration is not free of stent-related complications, in addition to the need to remove it under general anesthesia in the pediatric age group. OBJECTIVES: This study aims to evaluate the outcome of short-term stenting after laparoscopic pyeloplasty in pediatric sector. METHODS: A prospective randomized study of 37 children (less than 16 years-old) with pelvi-ureteric junction obstruction (PUJO) were managed by laparoscopic pyeloplasty by the same surgeon in the period between April 2015 and September 2017. In group A (18 patients), the DJ was removed after 4 weeks under general anesthesia, while in group B (19 patients), the DJ was fixed to the urethral catheter by a stitch, and it was removed with the urethral catheter after one week in the outpatient office. All patients were followed regularly for symptomatic improvement. Urine culture and sensitivity was done 1 month postoperatively. Abdominal ultrasound was done at 3, 6, 12 months and annually thereafter, while renal isotope scanning was done after 6 months. RESULTS: There were no significant differences between both groups regarding operative duration, postoperative leakage, hospital stay, early postoperative complications. Both groups improved after pyeloplasty with no significant differences regarding symptoms, follow-up ultrasound, and renal scanning. The incidence of irritative symptoms and need for anticholinergics after catheter removal as well as urinary tract infection after 1 month were significantly higher in group A (P-value: 0.004 and 0.029, respectively) (Table). DISCUSSION: To the authors knowledge, this is the first prospective controlled randomized study comparing short-term stenting with the classic 4 weeks stenting after laparoscopic pyeloplasty in the pediatric age group. In addition, the used technique of stenting not only allows stent removal on outpatient basis without anesthesia but also benefits from the pre-operative retrograde study so as not to miss any associated pathology in the ureter. CONCLUSION: Short-term ureteric stenting after laparoscopic pyeloplasty in pediatric age group is safe and not inferior to the standard 4-week stenting. It also avoids the stent-related complications.

Use of holmium laser for urethral strictures in pediatrics: A prospective study.

INTRODUCTION: The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions. OBJECTIVE: To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures. PATIENTS AND METHODS: From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation. RESULTS: The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six. DISCUSSION: One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study. CONCLUSION: HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.

The Added Value of Volume-of-Interest C-Arm CT Imaging during Endovascular Treatment of Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Successful endovascular treatment of intracranial aneurysms requires understanding the exact relationship of implanted devices to the aneurysm, parent artery, and other branch vessels during the treatment. Intraprocedural C-arm CT imaging has been shown to provide such information. However, its repeated use is limited due to increasing radiation exposure to the patient. The goal of this study was to evaluate a new volume-of-interest C-arm CT imaging technique, which would provide device-specific information through multiple 3D acquisitions of only the region of interest, thus reducing cumulative radiation exposure to the patient. MATERIALS AND METHODS: VOI C-arm CT images were obtained in 28 patients undergoing endovascular treatment of intracranial aneurysms. VOI images were acquired with the x-ray source collimated around the deployed device, both horizontally and vertically. The images were reconstructed by using a novel prototype robust reconstruction algorithm to minimize truncation artifacts from double collimation. The reconstruction accuracy of VOI C-arm CT images was assessed quantitatively by comparing them with the full-head noncollimated images. RESULTS: Quantitative analysis showed that the quality of VOI C-arm CT images is comparable with that of the standard Feldkamp, Davis, and Kress reconstruction of noncollimated C-arm CT images (correlation coefficient = 0.96 and structural similarity index = 0.92). Furthermore, 91.5% reduction in dose-area product was achieved with VOI imaging compared with the full-head acquisition. CONCLUSIONS: VOI imaging allows multiple 3D C-arm CT acquisitions and provides information related to device expansion, parent wall apposition, and neck coverage during the procedure, with very low additional radiation exposure to the patient.

Endovascular Recanalization in Acute Ischemic Stroke Using the Solitaire FR Revascularization Device with Adjunctive C-Arm CT Imaging.

In this clinical report, we examined a single-center experience by using the Solitaire FR Revascularization Device in the treatment of acute ischemic stroke in which there was poor initial visualization of the occluded arterial branches by using biplanar cerebral angiography. In all cases, adjunctive C-arm CT was used during the deployment of the thrombectomy device to gain additional information regarding device placement and expansion. Outcome measures included the extent of reperfusion, posttreatment changes in NIHSS scores, posttreatment TICI scores, cerebral hemorrhage, and survival. Clot removal with successful arterial recanalization was achieved in 15/18 cases (83.3%) with TICI scores of 2b/3 in all patients who had initial recanalization. The NIHSS score improved, on average, from 19 pretreatment to 11 posttreatment, and 72% of patients survived. In cases of acute stroke in which there is little information available regarding the positioning and deployment of a retrievable stent during mechanical thrombectomy, the use of C-arm CT may provide more information about device placement across an area of thrombus.

Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus. A case report and review of literature.

Pulsatile tinnitus is a rare yet potentially disabling symptom that can have either vascular or nonvascular etiologies. A recently described vascular cause is an aneurysm of dural venous sinuses. To our knowledge, eight of such cases have been published, five of which were treated surgically and three by endovascular approach. We describe one additional case treated successfully by endovascular coiling and review the current data on this subject.

The relationship between bcl-2 oncogene expression and clinicopathological criteria in various stages of cervical neoplasia in Egyptian women.

PURPOSE: To assess the degree of bcl-2 expression in the various stages of cervical neoplasia in a sample population of Egyptian women and relate the findings to clinicopathological criteria of invasive cervical cancer. METHODS: Bcl-2 protein expression was assessed by immuno-histochemistry in 40 patients with cervical neoplasia (intraepithelial and invasive) in comparison to 20 patients with benign changes. Patients with invasive disease were followed up 2 years later and the outcome was correlated to the bcl-2 status at the time of diagnosis. RESULTS: Bcl-2 expression increased from 20% in normal cervical tissue to 42.9% in cervical intraepithelial neoplasia grade II then dropped to 33% in invasive disease. Bcl-2 was not expressed (0%) in patients with advanced disease stage and grade nor in patients with lympho-vascular space invasion. CONCLUSION: Bcl-2 expression is reduced along the spectrum from benign towards invasive disease of the cervix. The maximum expression found in CIN II may suggest increased potential of progression to CIN III.

Management of major blunt pediatric renal trauma: single-center experience.

OBJECTIVE: To review the impact of major pediatric renal trauma and its management on long-term function and morphology of the injured kidney. METHODS: Thirty-six blunt trauma patients (20 males, 16 females) presented in 2004-2007 (age range 2 days to 14 years; mean 6.2 years). Thirty-seven renal units were included: 13 grade III, 14 grade IV, and 10 grade V injuries. Follow up was for 3-38 (mean 14) months. Patients were managed non-operatively unless vitally unstable. The most common causes of trauma were motor vehicle accidents and falls. Fourteen patients had associated non-renal injuries. Four patients had pre-existing renal problems. RESULTS: The surgical intervention group (13 patients, 36%) included 9/10 grade V and 4/14 grade IV renal injuries. Surgical repair of lacerations was performed in seven cases, partial nephrectomy in four cases and nephrectomy in two cases. Follow up showed no significant change in renal function, and none developed hypertension. The non-operative group (24 patients, 63.2%) included all grade III injuries, 10 grade IV injuries, and one grade V injury. There was an excellent outcome for 18/24 patients (75%) with kidney preservation, no complications from urinary extravasation and hematoma resolution. The remaining patients had lower polar infarction (1), renal atrophy (1), persistent subcapsular collection (2), recurrent hematuria requiring angioembolization (1), and there was one death related to central nervous system injury. CONCLUSION: The outcome of our management of pediatric major renal trauma was favorable overall. Longer follow up is needed with regard to renal function and development of hypertension.

Outcome of complete primary bladder exstrophy repair: single-center experience.

OBJECTIVE: Reconstruction of bladder exstrophy remains a challenge. We evaluated our experience with complete primary repair in classic bladder exstrophy. METHODS: A retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. Fifty-one patients (21 females and 30 males) with classic bladder exstrophy were included. Age of presentation ranged from 24h to 14 months. Mean follow up was 3 years (1 month-7 years). Patients were evaluated for continence, upper tract dilatation and cosmetic result. RESULTS: Eight patients (15.6%) had failed closures and six (11.7%) had fistulae. Evaluation of continence excluded 16 patients not followed up at our center. Thirty-seven percent were continent on clean intermittent catheterization after the age of 5 years. Patients became dry only after augmentation cystoplasty. Upper tract changes were mild during our study with all patients having normal serum creatinine. CONCLUSION: Patients may require more than one procedure for reconstruction. In our series, augmentation was required to achieve acceptable dryness. Early promising results with dry intervals in young patients did not translate to continence in older patients.

Embolization of Cerebral Aneurysms with Spherically Shaped Detachable Microcoils (MicruSphere Microcoil System). A Single Centre Experience.

SUMMARY: We present our initial experience of concentric-filling technique using MicruSphere 3D coils (Micrus Endovascular, San Jose, CA) in the treatment of intracranial aneurysms. 149 intracranial saccular aneurysms in 142 consecutive patients (mean age 56.6-/+12.7, ruptured in 54 (36.2%)) were treated with the concentric-filling technique. The mean aneurysm volume was 169.0-/+363.0 mm(3). Neck remodeling technique was used in 120 (80.5%). Procedure-related problems were recorded. Initial embolization results were evaluated, and the coil packing density was calculated. Clinical and angiographic follow-ups were performed after six months. Any changes in embolization status were classified as 'improved', 'unchanged', or 'worse'. The overall packing density was 40.1% (range 10.5-90.9%). The permanent morbidity and mortality rates were 4.0% and 1.3%, respectively. The initial Raymond and Roy classification results were class 1 in 37 aneurysms (24.8%), class 2 in 50 (33.6%), and class 3 in 62 (41.6%). On the mean follow-up examination of 8.2 months in 103 patients (72.5%), there were one transient ischemic attack, one minor stroke, and one instance of rebleeding. Angiographic follow-up in 101 aneurysms (67.8%) showed the change in embolization status as 'improved' in 42 aneurysms (41.6%), 'unchanged' in 42 (41.6%), and 'worse' in 17 (recanalisation rate, 16.8%). The concentric-filling technique using Micrusphere 3D coils was effective in achieving high packing density which in turn resulted in stable embolization in the majority of the aneurysms. Longer follow-up is warranted to determine the durability of these results.

Wall shear stress on ruptured and unruptured intracranial aneurysms at the internal carotid artery.

BACKGROUND AND PURPOSE: Hemodynamics is often recognized as one of the major factors in aneurysm rupture. Flow impingement, greater pressure, and abnormal wall shear stress are all indications for aneurysm rupture. Characterizing wall shear stress for intracranial aneurysms at similar anatomic locations may help in understanding its role. MATERIALS AND METHODS: Twenty-six intracranial aneurysms at the paraclinoid and superclinoid segments of the internal carotid artery from 25 patients between July 2006 and July 2007 were studied retrospectively. Among them, 8 aneurysms were ruptured and 18 were unruptured. Computational fluid dynamics was used to determine the wall shear distribution. Morphologic and hemodynamic variables was analyzed by using the Mann-Whitney rank sum test. RESULTS: Wall shear stress was qualitatively the same throughout the cardiac cycle; thus, only wall shear stress at the end of diastole was compared. Both ruptured and unruptured aneurysms have similar maximal wall shear stress (26 versus 23 N/m(2)), and mean wall shear stress is shown to be a function of the aneurysm area. Ruptured aneurysms also have a greater portion of aneurysm under low wall shear stress (27% versus 11% for unruptured aneurysms, P = .03). CONCLUSION: For intracranial aneurysms at the internal carotid artery, an area of low wall shear is associated with aneurysm rupture.

Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience.

BACKGROUND AND PURPOSE: Growing evidence of the relationship between poor antiplatelet response and occurrence of clinical events elicited the need of monitoring the response which has not been part of our daily practice. We present our initial experience with a new point-of-care antiplatelet-function test (VerifyNow assay) in neurointerventional procedures. MATERIALS AND METHODS: Among the 106 consecutive patients from July 2006 to April 2007, ninety-eight met the inclusion criteria. Our preferred antiplatelet regimen was aspirin (325 mg daily) and clopidogrel (300 mg of loading dose followed by 75 mg daily) starting 5-10 days before the procedure. The test results were reported as aspirin-reaction unit (ARU) for aspirin and P2Y(12) reaction units (PRU), baseline (BASE), and percentage inhibition for the P2Y(12) assay and were summarized as mean +/- SD of the values. We analyzed the effects of several factors of poor clopidogrel response (<40% inhibition). The occurrence of thrombotic events was recorded. RESULTS: The mean ARU of aspirin assays was 438.3 +/- 47.9 (range, 350-632), and the response was poor in 2 patients (2.1%). For clopidogrel, the mean of the BASE, PRU, and percentage inhibition was 356.8 +/- 56.3 (range, 234-495), 198.9 +/- 104.4 (range, 8-401), and 45.2 +/- 27.1% (range, 0-98), respectively. Forty-two patients (42.9%) showed poor response. Multivariate analysis showed greater body weight (81.9 Kg +/- 19.1 kg versus 69.9 +/- 15 kg) in the poor-response group. All 3 cases of intraprocedural thrombosis (3.1%) were observed only in the poor-response group. CONCLUSION: We observed a high frequency of poor clopidogrel responses in the neurointerventional setting. Routine monitoring of the drug response would be helpful for the early identification of poor antiplatelet responders so that we may modify the regimen and/or treatment plan.

Intimal Thickening after Placement of a Neuroform Stent. Its Incidence and Relation to Angiographic Follow-up Results of Aneurysm Embolization.

SUMMARY: Little attention has been given to the intimal thickening of the parent artery associated with the use of Neuroform stent. The purposes of this study were are to analyze quantifyanalyze the incidence of the parent artery intimal thickening the incidence and pattern of luminal changes, to to see somedetermine possible predictors of the phenomenonof the intimal thickening, to to evaluate the its effectthe phenomenonrestenosis on the aneurysm treatment results. We reviewed the initial and six-month followup angiographic images in 32 intracranial aneurysm patients treated with Neuroform stent and coilsin wide-necked aneurysm treatment. The initial embolization results were evaluated by the Raymond and Roy classification. The angiographic changes from immediate post-embolization to the six-month follow-up were classified as 'improved', 'unchanged' and 'worse'. The occurrencerates of parent artery intimal thickening was observed. Any perceivable change in the stented segment of the parent artery was considered as 'intimal thickening' and any change of >/=50% as 'significant thickening'. Fisher exact tests and logistic regression analysis were applied to determine the relation between the occurrence of the intimal thickening and several variables. The incidence of the intimal thickening was 18.8% (6/32) and of significant thickening, 3.1% (1/32). The change in angiographic occlusion of the aneurysm was 'improved' in 40.6% (13/32), 'unchanged' in 37.5% (12/32), and 'worse' in 21.9% (7/32). Among the variables, patient's age (>/=55) and follow-up angiographic results ('improved') correlated with the occurrence of the intimal thickening. Of notable finding was all six cases with intimal thickening of the parent artery were associated with 'improved' in their followup angiographic result. Neuroform-associated intimal thickening usually occurs in younger patients and is frequently associated with improved angiographic result of the aneurysm embolization on follow-up.

Tubeless percutaneous nephrolithotomy in children.

OBJECTIVE: To assess the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) as an alternative to extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis in children. MATERIALS AND METHODS: In 2003-2005 we operated on 20 cases that met the inclusion criteria. Extensive follow-up tests were performed in all patients; stone clearance was defined as the absence of residual fragments on plain abdominal X-ray and renal ultrasound. Pain-scale ruler (0-10) was used to evaluate pain postoperatively. Comparison was made with a group of 10 patients with very similar criteria operated upon with PCN tube. RESULTS: Mean follow-up period was 9 months (3-18 months) and mean age 7.5 years (4-15 years). Mean operative time was 115 min (45-180) with no significant bleeding intra- or postoperatively. Conversion to open surgery was necessary in one case. There were no major perioperative complications. In the tubeless group the pain score was 3-6 (mean 4.6), there was no need for IV analgesia, and median hospital stay was 1.7 days (1-4 days); urine leakage occurred in one patient. In the group with PCN tube the pain score was 5-8 (mean 5.5), IV analgesia was mandatory in four patients, and median hospital stay was 2.8 days (3-4 days); urine leakage occurred in five patients and a small residual stone was detected in one child. CONCLUSION: Tubeless PCNL in children has the advantages of being less painful, less troublesome and shortening the hospital stay of the child. The decision to use this procedure is best made intraoperatively and depends on the experience of the surgeon.

Preferential survival of acute lymphoblastic leukemia cells at 33 degrees C is associated with up-regulation of bcl-2.

An important feature of childhood acute lymphoblastic leukemia (ALL) is the risk of testicular relapse in affected males, which may occur months or years after induction of remission. However, little is known about the factors that regulate leukemic cell survival and resistance to chemotherapy in the testis. In the present study, incubating ALL cell lines and primary cells from ALL patients at 33 degrees C resulted in increased survival, resistance to chemotherapeutic agents and upregulation of bcl-2. Acute myeloid leukemia cell lines incubated at 33 degrees C also showed increased survival and resistance to chemotherapeutic agents, but did not demonstrate upregulation of bcl-2. This may be important in determining survival of ALL cells at lower temperatures in the testis.

Transvenous occlusion of a dural cavernous sinus fistula using a new expandable hydrogel-platinum coil (hydrocoil(r)).

SUMMARY: Hydrogel-coated platinum coils (Hydrocoils(R)) are currently under clinical investigation for their efficacy to improve anatomic results of endovascular occlusion of cerebral aneurysms. A case is presented in which this new expandable coil type was added to bare platinum coils in order to accelerate the transvenous occlusion of a dural cavernous sinus fistula (DCSF). A 53-year-old woman presenting with mild left-sided eye redness and diplopia due to a DCSF (type D) underwent transvenous occlusion using bare platinum coils (Trufill(R)) and hydrogel coated coils (Hydrocoil(R)). After successful catherization of the cavernous sinus, bare platinum coils were densely packed and eventually combined with Hydrocoils(R) which resulted in immediate and complete occlusion of the fistula. No technical or clinical complication occurred. The new expansile hydrogel-coated platinum coil (Hydrocoil(R)) can be successfully combined with bare platinum coils to accelerate transvenous occlusion of an AV-shunting lesion. Controlled volume expansion after deployment of this device offers potential benefits for occlusion of dural arteriovenous fistulas in other locations or for parent vessel occlusions in the treatment of giant or large complex aneurysms.

The patterns of expression of an apoptosis-related CK18 neoepitope, the bcl-2 proto-oncogene, and the Ki67 proliferation marker in normal, hyperplastic, and malignant endometrium.

Expression of a neoepitope on cytokeratin 18, recognized by the monoclonal antibody M30, is an early indicator of apoptosis in epithelial cells. The aim of this study was to determine the equilibrium between apoptosis (M30), anti-apoptosis (bcl-2), and proliferation (Ki-67) in different endometrial conditions. Paraffin-embedded samples (n = 107), representing proliferative endometrium (18), secretory endometrium (19), postmenopausal endometrium (15), disordered proliferative endometrium (6), simple hyperplasia (12), complex hyperplasia (8), and endometrial adenocarcinoma (29), were evaluated immunohistochemically. The indirect streptavidin-biotin-horseradish peroxidase technique, with 3-amino-9-ethylcarbazole as the chromogen, was used to visualize the reactions. Proliferative endometrium showed high bcl-2 and Ki-67 expression levels with no M30. In the secretory phase, the balance was tipped in favor of M30 with a decrease of bcl-2 and Ki-67. Postmenopausal endometrium revealed high Ki-67 and bcl-2 expression levels and no M30. In complex hyperplasia, M30, bcl-2, and Ki-67 showed increased expression. In endometrial carcinoma, an increasing reactivity for M30 and Ki-67 was seen as the grade progressed. bcl-2 reacted weakly and only in grade 1 cancer. Immunohistochemistry facilitates the study of the expression of proteins related to cyclic endometrial activity. Interruption of these cyclic events is associated with specific disturbances in the expression patterns of these proteins.

Apoptosis, bcl-2 expression, and proliferation in benign and malignant endometrial epithelium: An approach using multiparameter flow cytometry.

OBJECTIVE: Disturbances in the regulation of cell proliferation and differentiation play an important role in the formation of neoplastic lesions. Consequently, abnormalities in apoptosis regulation may contribute to this process. Expression of a neoepitope on cytokeratin 18, unmasked by an early caspase cleavage event and recognized by the novel monoclonal antibody M30, is an indicator of early epithelial cell apoptosis. The purpose of this study was to evaluate the quantitative relation among apoptosis (M30), cell persistence (bcl-2), and proliferation (S-phase fraction; SPF) in malignant and benign endometrium. METHODS: Using multiparameter DNA flow cytometry on 54 formalin-fixed paraffin-embedded samples from benign (proliferative, secretory, inactive, and hyperplastic endometrium) and malignant (grades 1-3 endometrial adenocarcinoma) endometrial tissue, bcl-2 expression and M30 reactivity were assessed together with the SPF in the cytokeratin-positive epithelial cells. RESULTS: Benign cyclic endometrium showed a relatively high bcl-2 expression and low M30 reactivity in the proliferative phase whereas in the secretory phase this relation was inverse. In endometrial hyperplasia the expression of bcl-2 was increased compared to that in secretory and postmenopausal endometrium, but still below the level of proliferative samples. The expression of M30 also increased compared to normal proliferative endometrium but did not reach the level of endometrium in the secretory phase of the menstrual cycle. In cancer the expression of bcl-2 decreased with the progression of differentiation grade. For M30 expression this relation was inverse. Overall there was a significant increase of M30 reactivity in cancerous compared to hyperplasia and normal cyclic endometrium. CONCLUSION: Transition of endometrial epithelium from hyperplasia to cancer seems to involve both increased apoptosis and decreased bcl-2 expression. Flow cytometric evaluation of M30 and bcl-2 expression levels, with the SPF, in currettage specimens from postmenopausal patients complaining of bleeding provides a quantitative assessment of endometrial apoptosis, anti-apoptosis, and proliferation. Further studies are needed to determine the relationship among these three processes as indicators of the biological behavior of gynecological tumors.