Clinical and imaging features of carcinosarcoma of the uterus and cervix

Aim The purpose of our study was to analyze the clinical and imaging features of uterine carcinosarcoma (UCS) and cervical carcinosarcoma (CCS), and to explore the diagnostic and staging accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) examinations. Methods 41 patients including 37 with UCS and 4 with CCS from July 2011 to September 2020 were enrolled in the study. Of the 37 UCS cases, 7 had CT images, 27 had MRI images, and 3 had both CT and MRI images. The Clinical data, CT or MRI imaging findings were analyzed. Diagnosis and staging accuracy of CT and MRI images were also analyzed. Results Carcinosarcoma usually occurs in postmenopausal women (40/41), with the typical clinical symptom being vaginal bleeding (33/41). The CA125 degree was significantly different between the two invasion depth groups (p = 0.011). Most uterine carcinosarcomas showed unclear boundaries, uneven density, low or equal signal on T1WI, high or mixed signal on T2WI, uneven high signal on diffusion-weighted image (DWI), and mild enhancement. The diagnostic accuracies of CT and MRI for carcinosarcoma were 0% and 3.33%, respectively. The diagnostic accuracy for malignant tumors on CT and MRI was 50% and 83.33%, respectively. Conclusions Carcinosarcoma lesions presented with huge mass filling in the cavity, and some presented with small polypoid lesions or endometrial thickening. Evaluation of lymph node metastasis is a significant challenge for imaging staging.

False Endometrial Thickening in Postmenopausal Patients Using Anticoagulants or Antiplatelets Agents

Objective There is no report that anticoagulant or antiplatelet use may lead to abnormal endometrial sonographic findings. This retrospective study reports our first results associated with endometrial sampling in asymptomatic postmenopausal women using anticoagulants or antiplatelet. Materials methods A total of 268 postmenopausal patients who applied to our gynecology outpatient clinic for any reasons except postmenopausal bleeding were included in the study. Patients were divided into three groups according to using drug status: first healty control group [HCG], second anticoagulants agents group [ACG], and third antiplatelet agents group [APG]. The effects of anticoagulant and antiplatelet agents on endometrial thickness were compared with histopathological findings. Results The mean endometrial thickness was significantly greater in group ACG [5.2 mm] and APG [4.1 m] than in group HCG [3.3 mm]. No significant differences were found in the mean endometrial thickness between groups HCG and APG. However, it is noteworthy that the average endomeric thickness in the ACG group is more than the other two groups and this is statistically significant [p < 0.05]. Conclusion If the thickness of the endometrium was > 4 mm. endometrial sampling may be recommended in in asymptomatic postmenopausal women using anticoagulants or antiplatelet agents.

High grade endometrial stromal sarcoma: a clinician dilemma

Uterine sarcomas are relatively rare tumors of mesodermal origin. ESS occurs primarily in perimenopausal women in 4th and 5th decade of their life; about one third occurs in postmenopausal women. Here in we describe a case of 44 years old patient presented with one month history of foul smelling discharge per vagina and a pelvic mass. Ultrasound and MRI gave possibility of a large anterior wall and fundal fibroid with degeneration versus neoplastic endometrial thickening. The patient underwent exploratory laparotomy with total abdominal hysterectomy with bilateral salpingoophorectomy with pelvic lymphadenectomy. Histopathology showed tumor cells with round to oval nuclei with high mitotic activity, blood vessel proliferation between the tumor cells and extensive lymphovascular invasion. The pathological diagnosis was HG-ESS stage IB. The patient was referred to radiotherapy department for adjuvant therapy. HG-ESS is a rare clinical entity and considered as important differential diagnosis.

Accuracy of Transvaginal Ultrasound in the Diagnosis of Intrauterine Lesions

Objective To evaluate the accuracy of transvaginal ultrasound in the diagnosis of intrauterine lesions, using hysteroscopy as the gold standard. Methods This was a prospective observational study with 307 patients. All patients underwent hysteroscopy after a previous transvaginal ultrasound to compare the results. The hysteroscopy was performed by experienced examiners, and transvaginal ultrasounds were performed in various public and private services, which is reflective of routine healthcare practices in obstetrics and gynecology. The sensitivity, specificity, and accuracy of the transvaginal ultrasound were calculated using hysteroscopy as the gold standard. The level of agreement between the two exams was calculated using the Kappa test. Results The mean age was 56.55 ± 12.3 years. For endometrial polyps, we observed a sensitivity of 39.8%, specificity of 72.7%, accuracy of 52.8%, and Kappa index of 0.11 (p = 0.025). For fibroids, the sensitivity was 46.7%, specificity was 95.0%, accuracy was 87.9%, and Kappa index was 0.46 (p < 0.001). For endometrial thickening, the sensitivity was 68.7%, specificity was 41.7%, accuracy was 47.6%, and Kappa index was 0.06 (p = 0.126). For endometrial atrophy, we found a sensitivity of 6.7%, specificity of 99.3%, accuracy of 90.2%, and Kappa index of 0.10 (p = 0.006). For the other findings, the sensitivity was 15.6%, specificity was 99.6%, accuracy was 87.3%, and Kappa index was 0.23 (P < 0.001). Conclusion Our study demonstrated a low level of accuracy of transvaginal ultrasound for the diagnosis of endometrial lesions, when performed by a non-experienced professional. Thus, it is important to consider the use of hysteroscopy to avoid unnecessary and inappropriate treatments.

Poor Endometrial Proliferation after Clomiphene is Associated with Altered Estrogen Action

Context Suboptimal endometrial thickening is associated with lower pregnancy rates and occurs in some infertile women treated with clomiphene. Objective To examine cellular and molecular differences in the endometrium of women with suboptimal versus optimal endometrial thickening following clomiphene. Design Translational prospective cohort study from 2018-2020. Setting University-affiliated clinic. Patients or Participants Reproductive age women with unexplained infertility treated with 100mg of clomiphene cycle days 3-7 who developed optimal (≥8mm; n=6, controls) or suboptimal (&lt;6mm; n=7, subjects) endometrial thickness. Interventions Pre-ovulatory blood and endometrial sampling. Main outcome measures Endometrial tissue architecture, abundance and location of specific proteins, RNA expression, ERαbinding. Results The endometrium of suboptimal subjects compared to optimal controls was characterized by a reduced volume of glandular epithelium (16% vs 24%, P=0.01), decreased immunostaining of markers of proliferation (PCNA, ki67) and angiogenesis (PECAM-1), increased immunostaining of pan-leukocyte marker CD45 and ERβ, but decreased ERαimmunostaining (all P&lt;0.05). RNAS-seq identified 398 differentially expressed genes between groups. Pathway analysis of differentially expressed genes indicated reduced proliferation (Z-score= -2.2, P&lt;0.01), decreased angiogenesis (Z-score= -2.87, P&lt;0.001), increased inflammation (Z-score= +2.2, P&lt;0.01), and ERβactivation (Z-score= +1.6, P&lt;0.001) in suboptimal subjects. ChIP-seq identified 6 genes bound by ERα that were differentially expressed between groups (P&lt;0.01), some of which may play a role in implantation. Conclusions Women with suboptimal endometrial thickness after clomiphene exhibit aberrant estrogen receptor expression patterns, architectural changes and altered gene and protein expression suggesting reduced proliferation and angiogenesis in the setting of increased inflammation.

Ovarian thecoma: A very unusual cause of postmenopausal bleeding

We describe a 67-year-old woman with postmenopausal bleeding having ceased estrogen plus progestogen therapy nine months before. Transvaginal ultrasonography showed endometrial thickening with normal ovarian appearance. Hormonal studies revealed high estradiol and inhibin B levels but normal androgens and adrenal hormones. Magnetic resonance image demonstrated a 13-mm left ovarian tumour. Hysterectomy and bilateral salpingo-oophorectomy were performed, and the pathological study revealed an 8 mm ovarian thecoma. This case illustrates a very unusual cause of postmenopausal bleeding. We suggest a study protocol and discuss the differential diagnosis of this case.

False Endometrial Thickening in Postmenopausal Patients Using Anticoagulants or Antiplatelets Agents

Objective There is no report that anticoagulant or antiplatelet use may lead to abnormal endometrial sonographic findings. This retrospective study reports our first results associated with endometrial sampling in asymptomatic postmenopausal women using anticoagulants or antiplatelet. Materials methods A total of 268 postmenopausal patients who applied to our gynecology outpatient clinic for any reasons except postmenopausal bleeding were included in the study. Patients were divided into three groups according to using drug status: first healty control group (HCG), second anticoagulants agents group (ACG), and third antiplatelet agents group (APG). The effects of anticoagulant and antiplatelet agents on endometrial thickness were compared with histopathological findings. Results The mean endometrial thickness was significantly greater in group ACG (5.2 mm) and APG (4.1 m) than in group HCG (3.3 mm). No significant differences were found in the mean endometrial thickness between groups HCG and APG. However, it is noteworthy that the average endomeric thickness in the ACG group is more than the other two groups and this is statistically significant (p < 0.05). Conclusion If the thickness of the endometrium was > 4 mm. endometrial sampling may be recommended in in asymptomatic postmenopausal women using anticoagulants or antiplatelet agents. Key words: Anticoagulants, antiplatelets, biopsy, endometrial thickness, menopause, ultrasonography

Recurrent Postmenopausal Bleeding: Just Endometrial Disease or Ovarian Sex Cord Stromal Tumor? A Case Report and Literature Review

Background: Postmenopausal bleeding (PMB) is a common gynecologic complaint among elderly women, and endometrial hyperplasia is a common cause of this bleeding. Ovarian fibromas are the most common ovarian sex cord stromal tumors (SCST). They arise from non-functioning stroma, rarely show estrogenic activity, and stimulate endometrial hyperplasia, leading to abnormal vaginal bleeding. Case presentation: We report herein the case of a 64-year-old Chinese woman who presented with recurrent PMB. A sex-hormone test revealed her estrogen level was significantly higher than normal, and other causes of hyperestrogenism had been excluded. In the past 7 years, the patient had undergone four curettage-and-hysteroscopy procedures due to recurrent PMB and endometrial hyperplasia. Finally, the culprit behind the rise in estrogen – an ovarian cellular fibroma with estrogenic activity – was found in the fifth operation.Conclusions: Ovarian cellular fibromas occur insidiously, and some may have endocrine functions. For postmenopausal patients with recurrent PMB and endometrial thickening indicated by ultrasonography, it is recommended they undergo sex-hormone testing while waiting for results regarding the pathology of the endometrium. If the estrogen level remains elevated, even if the imaging does not indicate an ovarian tumor, the clinician should consider the possibility of an ovarian SCST and follow the patient closely. Once the tumor is found, no matter the size, it should be removed as soon as possible to avoid endometrial lesions caused by long-term estrogen stimulation. More studies are needed to confirm whether preventive total hysterectomy with bilateral salpingo-oophorectomy should be recommended for postmenopausal women with recurrent bleeding whose estrogen levels are higher than normal, even when the auxiliary examination does not indicate ovarian mass. It is possible this could avoid the physical and psychological burden caused by repeated curettage.