Early onset of breast carcinoma in African American women with poor prognostic factors

The purpose of this study was to determine prognostic significance of age and race as independent variables and to see role of age at the onset of breast carcinoma. A retrospective study was conducted of African American and white women with breast cancer treated at SUNY-Health Science Center Brooklyn and Kings County Hospital Center from 1983 to 1993. The objective was to analyze the differences in patterns of disease onset, as related to age and prognostic factors. A total of 738 patients were analyzed for race-adjusted comparison of stage, grade, disease-free survival, and median survival. Age at the time of diagnosis was analyzed to conduct age-specific comparisons of African American (AA) and white patients. The multivariate analysis indicated that AA women develop breast cancer 10 years earlier than white women (p = 0.00001). Corrected by stage and grade, i.e., chi2 test for stage-by-stage and grade-by-grade analysis has revealed that the AA women present with higher stage (p = 0.009), increased number of positive nodes (p = 0.00007), and more estrogen receptor/ progesterone receptor-negative tumors (p = 0.005). Further studies are required to probe into the etiologic possibilities of this significant difference. The important contributing factors could be hormonal, genetic, environmental, and socioeconomic. Obesity and dietary factors also need to be evaluated. Further studies to explore genetic susceptibility by ploidy is recommended to explain this significant difference. We conclude that the onset of breast cancer among AA women occurs at a significantly younger age than in white women, and their prognostic factors are poorer.

Labour-associated expression of intercellular adhesion molecule-1 (ICAM-1) in placental endothelial cells indicates participation of immunological processes in parturition

Inflammatory cytokines induce or upregulate de novo expression of cell adhesion molecules on endothelial and epithelial cells. In order to demonstrate inflammatory reactions within placental tissues in association with normal term as well as non-infection-induced preterm labour, the expression of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) was examined by immunohistochemical methods in both trophoblastic villi (n=123) and umbilical cord (n=61). As a result, ICAM-1 immunoreactivity was exclusively localized in the endothelial cells of the fetal vascular system, while VCAM-1 and ELAM-1 were not detected. Whereas ICAM-1 was not expressed in early pregnancy (9-12 weeks of gestation), it could be weakly detected at the end of pregnancy in cases of elective caesarean delivery in the absence of labour, and was significantly more strongly expressed in cases of vaginal delivery after spontaneous onset of normal term labour. Significantly increased immunoreactivity of ICAM-1 within umbilical cord tissues was also found in association with uncontrollable preterm labour in the absence of intrauterine infection which was excluded after histological examination of fetal membranes, umbilical cord and chorionic plate. We conclude that ICAM-1 expression in the endothelium of the fetal vascular system is associated with the presence of labour and reflects participation of immune-inflammatory reactions in labour-promoting mechanisms.

Spontaneous labour at term is associated with fetal monocyte activation

The aetiology of both term and preterm labour remains incompletely understood. Maternal infectious diseases as well as intra-uterine infections were shown to be a well established cause of uncontrollable preterm delivery, indicating that inflammatory reactions, regulated by maternal immunecompetent cells, are implicated in labour-promoting mechanisms. To investigate the possibility that the activation of the fetal immune system may be involved in labour induction, we examined cytokine production patterns of different cord blood cell populations obtained from neonates after spontaneous onset of normal term labour and vaginal delivery (n = 25), vaginal delivery but induced term labour (n = 17), and preterm delivery because of uncontrollable labour (n = 27, 20 patients received corticoid treatment for fetal lung maturation), in comparison with cells obtained from neonates after elective term caesarean delivery in the absence of labour (n = 15). Our results demonstrate that spontaneous term labour, but not induced term labour, was associated with significantly increased IL-6 production by myelomonocytic cell populations. Preterm delivery due to uncontrollable labour with resistance to tocolysis was not associated with increased IL-6 production by fetal myelomonocytic cells. Two-colour flow cytometry combined with intracellular cytokine staining was used to identify fetal monocytes as sources of labour-associated IL-6 release at term. We did not find any activation of cord blood T cells in association with spontaneous term or uncontrollable preterm labour. Therefore, fetal T cell responses may not cause monocyte activation. Our results suggest that increased release of IL-6 from fetal monocytes is involved in mechanisms promoting normal term, but not preterm labour, and that mechanisms inducing term and preterm labour are completely different.

Cytokine release from placental endothelial cells, a process associated with preterm labour in the absence of intrauterine infection

There is currently a great deal of interest in the role that cytokines may play in the processes mediating preterm as well as normal term labour. In case of preterm delivery a cause-effect relationship between infection, uncontrollable preterm labour, and increased uterine cytokine concentrations is widely accepted, but there is considerable information that increased uterine cytokine release is also a condition in normal term labour and preterm labour not due to infection. Thereby, the exact cellular sources of cytokine production have not yet been identified. In the present study, the authors used immunohistochemical analysis to localize interleukin 1beta (IL-1beta) interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-alpha) immunoreactivity within trophoblastic villi and fetal membranes. In the absence of chorioamnionitis, uncontrollable preterm labour, and also normal term labour was associated with strong immunoreactivity for IL-1beta and IL-6 in the endothelial cells within trophoblastic villi. In contrast, preterm delivery accompanied by histologically confirmed chorioamnionitis, was not associated with increased expression of cytokine antigens within endothelial cells of the fetal vascular system, but strong cytokine activity was found in polymorphonuclear cells infiltrating the amniochorionic membranes. Therefore, the data suggest two well-defined subgroups among patients delivering preterm. Thereby, increased uterine cytokine concentrations may be realized in both groups, but the cellular sources of cytokine production may be different.

[Resting cartilage and the growth plate in dystrophic dysplasia: case report and clinicopathologic characteristics as compared to pseudodystrophic dysplasia and type II atelosteogenesis]

The authors describe the histopathology of the resting cartilage and the growth plate in a case of diastrophic dysplasia and review the differential diagnosis with pseudo-diastrophic dysplasia and atelosteogenesis type II.

[Significance of myoma-induced complications in pregnancy. A comparative analysis of pregnancy course with and without myoma involvement]

In the present study we analyzed the relation between complications in pregnancy--fetal growth retardation, premature rupture of membranes, preterm labour, abruptio placentae, mode of delivery, puerperium--and the size, number and location of myomas. A retrospective comparison was performed in 474 patients (94 pregnant women with myoma and 380 with a normal uterus as controls). The course of pregnancy, the mode of delivery and the puerperium were examined. The study showed that retroplacental submucous myomas increase the risk of fetal growth retardation (14% vs. 6.6%) and abruptio placentae (3.2% vs. 1.3%). The size of the myomas was not relevant. A caesarean section, especially for fetal malpresentation, was also more frequent in patients with submucous myoma (52.9% vs. 27.9%). There was no difference, however, in the postpartal course between the submucous myoma group and the controls, respectively. Subserous or intramural fibroids had no influence on the course of pregnancy, the mode of delivery or the postpartal period.

Estimation of probability of malignancy using a logistic model combining physical examination, ultrasound, serum CA 125, and serum CA 72-4 in postmenopausal women with a pelvic mass: an international multicenter study

BACKGROUND

To assess the differential diagnostic potential of physical examination, ultrasound, the serum CA 125 assay, and serum CA 72-4 assay, and the contribution of each parameter to a logistic model predicting the probability of malignancy in postmenopausal patients presenting with a pelvic mass.

PATIENTS AND METHODS

In a multicenter, prospective study a total of 155 patients were evaluated preoperatively using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 72-4 (cutoff level 3 U/ml) and CA 125 (cutoff level 35 U/ml).

RESULTS

Fifty-nine malignant (39%) and 92 benign (61%) pelvic tumors were found in addition to 4 borderline tumors (3%). Forty-three patients appeared to have ovarian carcinoma, FIGO Stage III or IV in 28 cases. Borderline tumors were excluded from the statistical calculations. The diagnostic accuracy of each single parameter, i.e., pelvic examination, ultrasound, and serum CA 125 and CA 72-4 in discriminating between benign and malignant pelvic masses gave highly similar results (81, 76, 78, and 81% respectively). Best sensitivity was found in pelvic examination (92%); best specificity was found in CA 72-4 (93%). Using logistic regression analysis the power of pelvic examination appeared to be the most relevant (adjusted odds ratio 12.1), followed by ultrasound (odds ratio 9.7), serum CA 125 (odds ratio 5.0), and serum CA 72-4 (odds ratio 4.9). Age appeared to be nonpredictive. The logistic model gives a correct prediction in 87% of all cases.

CONCLUSIONS

The addition of serum CA 72-4 to the combination of pelvic examination, ultrasound, and serum CA 125 leads to an improved discrimination between malignant and benign pelvic masses.

Case report: prenatal diagnosis of diastrophic dysplasia by ultrasound at 21 weeks of gestation in a mother with massive obesity

Routine prenatal ultrasound of a massively obese mother at 21 weeks of gestation revealed short-limb dwarfism in the fetus. The proportionate shortening of tubular bones of about 50 per cent of the normal length, the absence of thoracic dysplasia, and a normal head circumference narrowed the diagnosis down to a severe but non-lethal skeletal dysplasia. Ulnar deviation of the hands and talipes made diastrophic dysplasia the most likely differential diagnosis. At post-mortem clinical examination, the diagnosis of diastrophic dysplasia was clearly apparent due to highly specific 'hitch-hiker thumbs', similarly luxated big toes, facial dysmorphism, and a cleft palate. Retrospective re-evaluation of the prenatal ultrasound videos revealed the misplaced thumbs, which together with the ulnar deviation of the wrist and suspected talipes, led to the conclusion that the definitive diagnosis can be established prenatally, even in a mother with massive obesity.

[Increased AFP in maternal serum as an indication for invasive diagnosis]

The association of increased maternal serum alpha-fetoprotein levels (MS-AFP) with certain morphologic anomalies of the fetus is fully established. These anomalies are abdominal wall defects (e.g. omphalocele, gastroschisis, complete eventration), neural tube defects (anencephalus, spina bifida, encepalocele) and other malformations (e.g. coccygeal teratoma). The present study compares MS-AFP levels with amniotic fluid alpha-fetoprotein (AF-AFP) and acetylcholinesterase activity, the results of ultrasound, genetic and morphologic examination. Between April 1992 and November 1995 60 patients were referred to our clinic for further diagnosis after detection of elevated MS-AFP. After an ultrasound examination was carried out amniocentesis (AC) was performed in 54 cases, AC + placentesis (PC) in 3 patients and PC only in 3 cases with anhydramnion. Mean maternal age was 29 years (range 20-37 years). Punction was performed at a median of 19 + 1 weeks of gestation (15 + 2-23 + 2 weeks of gestation). MS-AFP, AF-AFP and acetylcholinesterase activity was measured. MS-AFP and AF-AFP were given as multiples of the median (MoM). Values < or = 1-2.0 MoM were considered normal. Elevated levels were defined to be greater than 2 MoM. In all cases the chromosomal finding was normal or norm variant. Sonographical anomalies were detected in 7 fetuses (3 cases with spina bifida, 1 case with omphalocele and 3 cases with abdominal wall defects in connection with other malformations). All sonographic diagnoses were confirmed post partum. The MS-AFP varied between 0.9-6.0 MoM. In 7 cases MS-AFP previously (referring center) evaluated as increased was found to be within normal range in our department. This cases included normal values were found in 30 cases and 25 findings were pathological. 2 out of 7 structurally abnormal fetuses had normal values, 5 of them had elevated MS-AFP. In the group of normal fetuses the highest MS-AFP we found was 6.6 MoM. In the AC-group the AF-AFP ranged between 0.7-8.7 MoM, it was within normal range in 50 and pathological in 8 cases. In the group of fetuses without structural anomalies the highest AF-AFP was 7.5 MoM. In the group of fetuses with structural anomalies the AF-AFP values were 1x normal and 3x pathological (> 3.5 MoM). Acetylcholinesterase activity in the amniotic fluid was negative in 51 cases, positive in 4 cases and faint positive in 2 cases. In all fetuses with structural anomalies in which an AC could be performed, acetylcholinesterase activity was positive. On the other hand we found only 1 of the structurally normal fetuses with positive acetylcholinesterase activity. Elevated MS-AFP and AF-AFP may be an indicator for morphological anomalies. Yet there were many positive results without any sonographical findings. The determination of a positive acetylcholinesterase activity in the amniotic fluid is more specific. All malformations have been detected by ultrasound examination before the results of the AF-AFP were available.

[3-dimensional ultrasound in clinical diagnosis of meniscus lesions]

AIM

To compare the significance of the two-dimensional and three-dimensional sonography in the diagnosis of meniscal tears under clinical conditions.

METHODS

Sixty menisci of knees with clinical symptoms (44 medial and 16 lateral menisci) were examined by an identical transducer in a two- and three-dimensional sonography technique. The findings were compared with the diagnosis made with subsequent arthroscopy.

RESULTS

In the diagnosis of meniscal lesions the two- and three-dimensional sonography reached a sensitivity of 92% and 100% and a specificity of 83% and 88%, respectively. The positive predictive value of these methods was 58% and 67%. The negative predictive value was 98% and 100%. Because of the good results with the two-dimensional sonography, there were no statistically significant differences between both methods. The three-dimensional sonography, however, proved to be superior, to the two-dimensional sonography in the analysis of subgroups (medial and lateral menisci, menisci with and without clinical symptoms). The negative predictive value of the three-dimensional sonography was 100% for all of these subgroups.

CONCLUSION

Although this study shows no significant difference in the results of two- and three-dimensional sonography, the analysis of subgroups displays a slightly improved significance for diagnosis of meniscal tears by three-dimensional sonography. The high negative predictive value shows that three-dimensional sonography, performed by an experienced examiner, may be useful to exclude meniscal tears. This result may help focus further cost-intensive or invasive examinations.

[3-dimensional sonography in the diagnosis of meniscal lesions. An experimental and clinical study]

There is no consensus regarding the clinical significance of conventional two-dimensional ultrasound in the diagnosis of meniscal tears of the knee. Three-dimensional ultrasound spatially reconstructs a transparent image of subsequent ultrasound scans. In an experimental study of 96 menisci, radial and oblique tears were detected more often by three-dimensional ultrasound. In a clinical study of 60 menisci the two- and three-dimensional ultrasound reached a sensitivity of 92% and 100%, a specificity of 83% and 88%, a positive predictive value of 58% and 67%, and a negative predictive value of 98% and 100%, respectively. Altogether, there was no statistically significant difference between both methods. The high negative predictive value, however, shows that the three-dimensional ultrasound may be a clinically relevant examination for special questions in the diagnostics of meniscal tears.

Chemotherapy is a safe and effective initial therapy for infected malignant breast and chest wall ulcers

BACKGROUND AND OBJECTIVES

Locally advanced breast cancers may form large, infected skin ulcers, which were traditionally treated with radiation therapy. Neoadjuvant chemotherapy is now standard treatment for locally advanced breast cancer.

METHODS

The response of 33 patients with ulcerated breast cancer to primary chemotherapy was retrospectively analyzed. Antibiotics were not used in primary treatment. Tumor and ulcer responses were evaluated independently.

RESULTS

Chemotherapy alone healed 18 of these ulcers. Neither responding nor refractory patients developed sepsis during this treatment.

CONCLUSIONS

Chemotherapy is safe and effective treatment for patients with infected malignant breast ulcers and does not cause systemic sepsis.

[Doppler score for evaluating perinatal risk]

Doppler sonography now has a definite place in the surveillance of risk pregnancies. Uniform clinical management is sometimes difficult especially in borderline cases. The following study demonstrates the possibility of standardizing and systematizing Doppler results using a score. In a collective of 253 pregnant women we performed Doppler examinations in the fetal aorta, umbilical artery, middle cerebral artery, internal carotid artery. The results were divided into 4 groups and correlated to the fetal outcome. There was a highly significant worsening in prognosis regarding duration of pregnancy, birth weight and rate of cesarean sections with increasing Doppler score. In the event of pathological and highly pathological scores, the average duration of pregnancy was 23 and 48 days shorter than normal. As a result, there was a highly significant reduction in the average birth weight compared to fetuses with normal Doppler scores: by 1060.7 g in the case of a pathological score and by 1633.5 g in the case of a highly pathological score. There was a highly significant correlation concerning the rate of cesarean sections and the indication "fetal distress". The average interval between diagnosis and birth was 6.3 days in the case of pathological Doppler findings and 2.3 days in the case of highly pathological findings. The difference was highly significant. In the case of highly pathological scores all fetuses were delivered after at least 5 days, compared with after at least more than 10 days in those with only pathological Doppler findings. This reflects the fact that there is none room for discretion in case of a highly pathological flow. In summary the Doppler score allows better estimation of fetal risk and can improve fetal prognosis by special monitoring and earlier obstetric intervention.

The sensitivity of new color systems in blood-flow diagnosis. The maximum entropy method and angio-color-comparative in vitro flow measurements to determine sensitivity

BACKGROUND

Two new blood-flow-diagnosis techniques have recently been developed as supplements to the established color techniques: the MEM (maximum entropy method) technique and color flow amplitude (power Doppler). These are capable of representing blood flow in distinctly more slowly flowing areas than is possible with the conventional Doppler technique.

METHODS

Both methods make use of the Doppler technique in part, yet analyze the reflected signal in a different manner, in so doing optimizing the relation between the noise and the signal. Measurements were obtained on two anatomic flow models to test the sensitivity of both techniques under slow flow conditions.

RESULTS

The slowest flow the MEM technique was capable of recording was 0.5 mm/s, albeit utilizing a 5-MHz transducer for the MEM technique and a 10-MHz transducer for the angio technique. One may thus assume that the MEM technique would be still more sensitive when utilizing a 10-MHz transducer. The advantage of the MEM technique is its real-time flow representation: The angio technique requires a few seconds of acquisition time. This could have serious consequences during clinical utilization. Doppler sonography was merely capable of detecting a minimum flow velocity of 15 mm/s. The angio technique is less dependent on the angle during flow representation than the MEM technique.

CONCLUSIONS

The distinctly higher sensitivity of these two new color techniques offers new possibilities in the clinical sector as far as the perfusion diagnosis of organs and tumors is concerned.

Sonographic blood flow measurements in malignant breast tumors. A potential new prognostic factor

BACKGROUND

The aim of this study was to find a possible relationship between the biological behavior of carcinomas of the breast and sonographically detectable blood flow after first studies showed a correlation between blood flow and prognostic factors.

METHOD

259 patients with ductal invasive breast cancer were examined using MEM (i.e., the Maximum Entropy Method), a new sonographic blood flow measurement technique capable of discerning considerably slower blood flow velocities than Doppler sonography. Due to the lack of objective methods for quantifying the blood flow, the findings were divided into three classes dependent upon the visual color information obtained. The blood flow was correlated with the size of the tumor, lymph node and receptor status, ploidy and S-phase fraction.

RESULTS

Most of the patients with small tumors, without lymph node metastases, with positive receptors, with a diploid genome, and with a low S-phase fraction belonged to the group with the lowest blood flow.

CONCLUSION

The close relationship between the established prognostic factors and the sonographic blood flow measurements using MEM might be indicative of a new preoperative prognostic factor; this must, however, be confirmed by larger studies.

Isolated fetal choroid plexus cysts: not an indication for genetic diagnosis?

Offering invasive prenatal cytogenetic testing in cases of isolated choroid plexus cysts is controversial. To give a contribution to this discussion we recorded prospectively the course of 41 fetuses with cysts of the choroid plexus diagnosed in 4,326 pregnancies sonographically scanned in our center between January 1994 and August 1995. The fetuses were all in the 13th to 24th week of gestation, with an average of 19.3 weeks. Only 1 of these fetuses (with large bilateral choroid plexus cysts) had further sonographically visible malformations (renal and cardiac anomalies, malposition of the hands). 34 fetuses had bilateral and 7 one-sided plexus cysts. 38 of the 41 patients decided on invasive diagnosis; karyotyping was successful in all these cases. The complete follow-up until 5 days after birth is known in 38 fetuses, including 3 without genetic diagnosis. A chromosomal aberration was detectable only in 1 fetus (trisomy 18, this fetus had the additional malformations described above), the other fetuses all displaying neither chromosomal nor morphological abnormalities. All fetuses, excluding 1 (the pregnancy was terminated due to trisomy 18) were re-examined before the 25th week of gestation, plexus cysts only still being visible in 3 fetuses. By the 30th week of gestation in these 3 fetuses the cysts had also disappeared. Furthermore, 20 pregnancies with confirmed trisomy 18 diagnosed between 1990 and 1996 were analyzed retrospectively. In 19 cases heart defects had been detected by prenatal ultrasound, cervical hygroma being less common (6 cases) and other malformations still rarer. Choroid plexus cysts had, however, been seen only in the 1 case described above. There was no case of isolated choroid plexus cysts in this group. From our data and current literature we conclude that isolated choroid plexus cysts are not an absolute indication for fetal karyotyping. In our opinion a detailed ultrasound assessment to seek for further malformations in a specialized center would be necessary if fetal choroid plexus cysts have been diagnosed, and only if additional fetal malformations are indeed detectable a fetal karyotype should be recommended.

Telencephalosynapsis (synencephaly) and rhombencephalosynapsis with posterior fossa ventriculocele ('Dandy-Walker cyst'): an unusual aberrant syngenetic complex

Agenesis of the cerebellar vermis (paleocerebellar agenesis) with fusion of the cerebellar hemispheres (rhombencephalosynapsis) is a rare malformation of the central nervous system (CNS). Its combination with synencephaly (telencephalosynapsis), telencephalic ventricular aplasia, aqueductal atresia and cystic fourth ventricle has not yet been described, as far as we know. Here, we report this combination in a 23-weeks' gestation male fetus who was aborted to a 24-year-old diabetic mother. In this fetus with cerebral and cerebellar hemispheric fusion, vermian agenesis was associated with a Dandy-Walker-like posterior fossa cyst, in spite of the fusion of the hypoplastic cerebellar hemispheres. The CNS malformations were further accompanied by dysmorphic facial stigmata such as unilateral atresia of the external ear, ocular hypertelorism and a broad nasal bridge. Preaxial polydactyly and contractures of the upper limbs were the only associated non-cranial abnormalities. Cytogenetic studies revealed a numerically and structurally normal male (46, XY). The malformation complex described in this fetus of a mother with antedating pregnancy diabetes appears to represent a previously undescribed aberrant syngenetic CNS phenotype, some basic teratogenetic aspects of which will be discussed in this paper.

[Diagnosis of blood flow in breast tumors with increased blood pressure. New possibility in tumor field diagnosis]

On the assumption that the architecture of blood vessels of malignant tumors, formed by neoangiogenesis, shows characteristics that are different from those of blood vessels of benign tumors or physiological findings, we have tried in the present study to investigate the behavior of these different vessels under increased blood pressure. Using a special stand, the same sonographic section could be stably maintained during an examination time of approx. 4 minutes. Using a new computer program, the color pixels of the employed Angio color technique were quantified and recorded as a function of the measured blood pressure. To increase blood pressure, the patient had to press a hand grip, which practically always caused a systolic blood pressure elevation of more than 15-20 mmHg. Seventy patients with sonographically detected breast tumors were examined; 54 (14 benign and 40 malignant tumors) could be included in the evaluation. We found four typical types of curves: Curve type 1 is associated with an instantaneous increase in blood flow with increased blood pressure, followed by a drop in the blood pressure, with a slow decrease in blood flow as the blood pressure drops (with 29 malignant and 3 benign tumors). Curve type 2 shows a continuous increase in blood flow-though somewhat delayed with respect to the rise in blood pressure-which is also observed when the blood pressure drops (exclusively benign tumors). In curve type 3, maximum blood flow is reached after the blood pressure maximum, and then the blood flow decreases (1 benign and 3 malignant tumors). Curve type 4 features decreased blood flow in spite of increased blood pressure (3 benign and 5 malignant tumors). The described quantification method, in combination with the stand, permits for the first time analysis of a tumor under increased blood pressure as to its blood flow behavior over time in an examination using a challenge test. Here one can find two distinctive curve types (types 1 and 2) that correlate mostly with malignant (type 1) or benign (type 2) breast tumors. Should this tendency be substantiated by additional large-scale studies, it would seem that a new ultrasonic possibility for differential diagnosis has been found.

[Hygroma colli (cervical neck edema) as an ultrasonographic parameter of fetal chromosome anomalies]

A two year retrospective study of 57 women with fetal hygroma colli between 2 and 15 mm was carried out at the University Women Hospital in Heidelberg. In this study maternal age, week of gestation, thickness of the nuchal oedema and the genetic results of amniocentesis were documented. Chromosomal abnormalities were found in 20 cases (35%), monosomy X in eleven, trisomy 21 in five and trisomy 18 in four. No connection between an individual syndrome and a particular week of gestation could be found. An increase of the thickness of the nuchal oedema showed a significant correlation to the incidence of aneuploidies. Chromosomal abnormalities were not observed in cases of less than 3 mm thickness (0/5). Between 3 and 4.9 mm one abnormal karyotype (4 mm) was found (1/18) whereas in the group of 5-6.9 mm approximately one third (6/15) of all fetuses showed chromosomal abnormalities. Aneuploid karyotypes were found in two thirds of cases (14/20) with a fetal nuchal translucency of 7 mm and more. Surprisingly, a correlation between maternal age and incidence of fetal chromosomal abnormality could be seen, but it was not significant. While a chromosomal aberration could be connected to age in 50% of mothers under the age of 25 and over 34, only a third of women aged 25-29 and only one fifth aged 30-34 showed chromosomal abnormalities in combination with hygroma colli. Our results confirm the recommendation of previous studies for extensive ultrasound examination during the first and second trimester in order to improve early detection of fetal chromosomal abnormalities particularly in women not normally covered by the age-related indication for amniocentesis.

[Telecommunication--a medium for improving prenatal diagnosis and gynecologic ultrasound diagnosis? Initial experiences]

To establish the requirements for real-time transfer of an ultrasound examination via telecommunication network the following tests were performed: The ultrasound data were transferred from the video out of an ultrasound system to a basis terminal of the German Telekom. Simultaneously, an external video camera filmed the positioning and movements of the ultrasound transducer, and the verbal comments were recorded. These informations were transmitted to Karlsruhe and London, where they were rerouted to the examination room in Heidelberg. Here the informations were received on a Telecom reception unit/terminal and compared directly with the initial signal. The quality was sufficient if the moving ultrasound images and the camera image of the transducer as well as the oral comment were transmitted over 2 parallel ISDN lines. The delay to a real-time transmission of the examination process is only in the range of milliseconds. If only one ISDN line is used, the image quality is unsatisfactory, three parallel lines do not bring significant improvement of image quality. Telemedicine seems a new possibility to bring the knowledge of specialized centers to the practicing gynaecologists thus avoiding unnecessary referrals. Still unanswered, however, are the problem of liability, data protection and costs.

[Cardiotocographic changes after umbilical cord puncture and umbilical cord transfusion]

In connection with umbilical cord punctures and transfusions the degree of pathology still tolerable after these procedures as well as the influence on subsequent obstetric management has to be discussed. In a prospective study we evaluated 98 cordocenteses with (n = 44) and without (n = 54) transfusion (25-37 week of gestation). 30-160 ml of blood were transfused. In all cases the umbilical vein was punctured at the point of insertion into the placenta (46x posterior and 52x anterior wall placenta). A CTG was performed prior and after the punction and was evaluated according to the Fischer score. After the procedure, the course of pregnancy was normal in all puncture patients and in 52 of 54 patients who also underwent a transfusion. Because of a pathological CTG due to a severely hydroptic fetus, a caesarean section had to be performed in one woman seven hours after umbilical cord transfusion. In another patient an emergency section was necessary immediately after the umbilical cord transfusion, due to persistent fetal bradycardia. In the puncture group mean Fischer score values decreased from 9.1 to 7.5, in the transfusion. In another patient an emergency section was necessary immediately after the umbilical cord transfusion, due to persistent fetal bradycardia. In the puncture group mean Fischer score values decreased from 9.1 to 7.5, in the transfusion group from 8.6 to 7.4. The results were more unfavorable when amplitude and occurrence of accelerations were considered, especially in the transfusion group. In one fifth of the puncture cases and one fourth of the transfusion patients the criterium of baseline crossings improved after the procedure. In summary, a pathological CTG is to be expected after umbilical cord punctures and transfusions, with however, only the necessity of surveillance. Only in cases of persistent fetal bradycardia an active obstetric management is indicated.

Treatment of the twin-twin transfusion syndrome: initial experience using laser-induced interstitial thermotherapy

This paper describes our initial experience with laser-induced interstitial thermotherapy (LITT) for the treatment of the twin-twin transfusion syndrome (TTTS). This procedure was utilized in four pregnancies-three monochorionic twin pregnancies and one triplet pregnancy (20-26 weeks of gestation)-with severe TTTS with fetal dropsy, polyhydramnion of the acceptor, and anhydramnion of the donor. In vitro examinations of placental tissue had shown that laser coagulation can be monitored by sonography, hence we used this method for the first time in these four pregnancies. Blood vessels connecting the two umbilical cords were determined prior to the treatment using a new ultrasound color technique which is highly sensitive and capable of representing slow blood flow velocities. A 1.2 mm thick puncture needle was then directed to the shunt under on-line ultrasound control. All patients had an anterior wall placenta. The laser fiber was inserted via this thin needle. A coagulation time of 2-3 min was necessary at 3 W. In the one twin pregnancy the intrauterine fetal death of the smaller child occurred 10 weeks after LITT, the other child survived and is healthy. A cesarian section was necessary in another twin pregnancy 1 week after LITT due to the intrauterine death of the smaller child. In the third twin pregnancy, the donor, who had already had distinct bradycardia prior to the treatment, died immediately after LITT. The intrauterine fetal death of the donor in the triplet pregnancy occurred 3 days after LITT once the volume of amniotic fluid had basically returned to normal. The tragic intrauterine death of the uninvolved child occurred 13 weeks later as a result of umbilical cord strangulation, the surviving child is healthy. All four pregnancies were severe and advanced cases of TTTS with a very poor prognosis, leaving us with no other alternative to the described method of treatment. The instruments we used are a lot thinner than those utilized for fetoscopic laser treatment to date. Furthermore, it is not necessary to penetrate the amniotic sac in patients with an anterior wall placenta; intraplacental vessels can be coagulated, and the laser energy required for LITT is also much lower. In our opinion these advantages justify the utilization of LITT under more promising conditions than those described above.

[Experimental study of meniscus lesions. Significance of 3-dimensional ultrasonography]

AIM

The clinical value of two-dimensional ultrasound in examining the menisci of the knee compared to other methods is controversial. We studied the utility diagnosed by three-dimensional sonography in evaluating meniscal tears.

METHOD

96 menisci with standardised artificial lesions were examined in a bath of Ringer solution. Two-dimensional ultrasound was compared to three-dimensional ultrasound, which creates three-dimensional reconstruction of sequential ultrasonographic images.

RESULTS

The three-dimensional ultrasound had a higher sensitivity of 88% vs 69% with a specificity of 83% vs 94% for the diagnosis of meniscal tears compared with the two-dimensional method. The sensitivity in imaging was 54% in each case for longitudinal tears, 63% vs 96% for horizontal tears, 67% vs 37% for oblique tears and 54% vs 0% for radial tears. The difference of these results, however, was not statistically significant. Radial tears were more frequently diagnosed by three-dimensional sonography.

CONCLUSION

In our model, sonographic diagnosis of meniscal tears was improved only partially by using three-dimensional ultrasound. Whether in vivo other factors alter the minimal differences between the two techniques is the subject of ongoing investigation.

[The clinical value of Doppler ultrasound in obstetrics]

Doppler sonography now has many indications in obstetrical diagnosis. Its wide and often uncritical application was the reason for our study group to confirm its importance. Moreover, we wanted to prove our own procedure. We made 950 Doppler examinations in a group of 449 pregnant women and correlated the results to the fetal outcome. Children with pathological Doppler findings showed a significantly lower birth weight of 599 g, a significantly lower duration of pregnancy of 6 days, a significantly higher rate of Caesarean sections and a significantly higher death rate compared to children with normal Doppler findings. Concerning Apgar- and pH-values there was not any significant difference between the two collectives. These results show that fetuses with pathological Doppler values or growth retardation can have the same prognosis as fetuses with normal Doppler findings if they are recognized and monitored at an early stage. The morbidity by acidosis can thus be reduced.

[Sensitivity of new color systems: "maximum entropy method" and angio-color. Comparative in vitro flow measurements]

AIM

The sensitivity of the two procedures for slow blood flow velocities in two flow phantoms examined and compared to conventional colour Doppler.

METHOD

In two phantoms with vessels between 0.3 and 6 mm diameter the slowest measurable blood flow with the different techniques was determined. The influence of various application angles was also studied.

RESULTS

The slowest blood flow velocity detected with the MEM technique was 0.6 mm/s and with the angio-technique 0.4 mm/s. Two different scan-heads were used; a 5 MHz probe for the MEM procedures and a 10 MHz probe for ultrasound angiography. Using a 10 MHz scan-head will most likely lead to increased sensitivity of MEM. Blood flow representation with the MEM technique is real-time, while several seconds of acquisition time are required for the angio-technique, which is a disadvantage during clinical use. Conventional Doppler was merely able to represent 15 mm/s blood flow. The angio-technique was less dependent on the application angle than the MEM procedure.

CONCLUSION

The definitely increased sensitivity of the two colour methods open up new areas in the diagnosis of organ and tumour perfusion.

[Laparoscopy in (apparently) benign ovarian tumors between benefit and catastrophy and the deceptive safety of laparoscopic lap sacs]

Endoscopic ovarian surgery is currently spreading tremendously, but also rather uncritically. The technical possibilities both of organ preserving and ablative endoscopic surgery are controversial, so that structuring of the indication for an endoscopic procedure as well as optimization of the endoscopic removal of ovarian tumor or adnexae is of utmost relevance. Therefore, a study was performed at the Department of Obstetrics and Gynaecology of the Heidelberg University with the following aims: Risk evaluation of operating into an ovarian malignancy at endoscopy for "presumably" benign cystic ovarian tumors in n = 100 cases in Heidelberg and literature survey Analysis of problems and complications during clinical application of laparoscopic lap sacs for removal of cystic adnexal tumors or adnexae (n = 50) Experimental examination of the risk of an endoscopic lap sacs to rupture during a procedure The risk of endoscopically operating into an ovarian cancer lies between 0.4 and 3% according to literature data. Despite maximal preoperative selection, mainly by ultrasound examination, in our group of 100 patients, in three women without preoperative signs of malignancy but with discreet intracystic structures in the ultrasound, an endoscopic adnexectomy with complete removal in a lap sac was performed, and though immediate section for microscopic examination was negative, final histology revealed one ovarian cancer la and 2 borderline tumors, same stage. In the time period analyzed, three further patients were referred to our center for secondary, delayed (median 3 months) staging after endoscopic procedures for presumed benign lesions. Clinical application of lap sacs proved the necessity of an intensive training. In 3 patients an intraperitoneal rupture of the sac occurred. Typical problems were volume discrepancies between sac respectively abdominal incision and tissue to be removed (28% of cases). The risk of rupture of the various lap sacs examined differed significantly (p < 0.05). Due to the complex pathological nature of cystic adnexal tumors, a 100% selection for the endoscopic approach is not feasible. Therefore, an endoscopic procedure should only be performed after optimal preoperative diagnosis and, in case of the slightest doubt, only if intraoperative microscopic examination is available, and the possibility to perform an immediate staging laparotomy. Sufficient information of the patient is relevant. Laparoscopic removal of tumor or adnexae should be performed in a lap sac. However, there is no absolute certainty of preventing spillage even with the lap sac, since not all endoscopic sacs available are of a sufficient quality.

How reliable are conventional and color-coded sonography of the breast in the differential diagnosis of breast cancer?

Sonographic examinations of the female mammary gland within the frameworks of the diagnosis of breast cancer playa fundamental role in the early detection of benign and, in particular, of malignant growths. Sonographic blood flow determinations can be used as an auxiliary noninvasive examination method. This is based on the fact that malignomas differ from benign tumors in that they display a pathological increase in vascular-ization. These changes of the circulatory conditions can be utilized in the diagnosis of the dignity of breast cancer.

Differential diagnosis of mammary tumors with vocal fremitus in sonography: preliminary report

During sonographic examinations using the new color Doppler technique, maximum-entropy method (MEM), it was discovered, by chance, that artefacts which are produced by vibrations of the thorax can be used to differentiate between malignant and benign breast lesions. These artefacts, in the form of small color pixels, can either be brought about by vocal fremitus known from internal medicine or by humming in a low tone. In the case of malignant tumors, the color pixels are visible in the middle of the sonographically portrayed tumor as well as in the surrounding tissue, whereas in benign tumors the artefacts are only found in the surrounding tissue and are quite clearly not present in the center of the tumor. On the preoperative day, 95 patients with 46 benign and 49 malignant lesions were examined using the method described above. In 91% the differential diagnosis was in accordance with the histological results. In seven cases a benign lesion was classified before the operation as malignant and in two cases malignancy was incorrectly diagnosed as benign. Our explanation of the phenomenon is based on the fact that most benign tumors exhibit a restricted growth and form a clear-cut boundary with the surrounding tissue, so the vibrations are not conducted into the tumor. In contrast, malignant lesions grow by infiltrating the surrounding tissue, allowing the vibrations to be conducted into the tumor, where they can be demonstrated as small color pixels.

[Initial experiences with laparoscopic intraoperative ultrasound]

Preoperative ultrasound as well as intraoperative laparoscopic diagnosis have both their limits, a fact that might be significant for laparoscopic surgical management. In particular, since in this surgical domain, where almost everything has become technically feasible, the operator must decide what is to the benefit of the patient. A possible solution could be laparoscopic ultrasound, i.e. ultrasound diagnosis per laparoscopy at the very site of the lesion. The advantages are evident. Due to the closeness to the organ to be examined, the frequency of the scan head can be extremely high, resulting in better resolution. Also, structures could be visualized by ultrasound which e.g., due to adhesions cannot be seen with the laparoscope. Moreover, ultrasound offers a view into the structures which can be seen only from the exterior with the laparoscope. To perform these examinations we used a specially designed scanhead (Toshiba): Instead of the optical system a crystal array was inserted into a conventional gastroscope. The result was a high resolution 7.5 MHz linear array at the distal end of a freely movable gastroscope. Colour doppler sonography is feasible with this scanhead. We examined 19 patients, 16 of them with ovarian tumours, and attempted visualization of the uterine myometrium/endometrium as well as of the liver. In six cases of ovarian tumours in which only cystic structures were found by preoperative transvaginal sonography, laparoscopic ultrasound additionally revealed solid inner structures. In 5 cases direct laparoscopic view of the ovarian lesions was impossible due to severe adhesions. They were, however, easily detected by intraoperative ultrasound.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laser in gynecology. Palliative laser treatment in genital and breast cancers]

Local, so-called incurable, recurrences of breast or genital cancers were as therapeutic challenge in the past. The authors undertook a pilot trial of laser treatment in 45 patients, as a palliative measure, in view of the serious psychological and physical problems experienced by these women constantly confronted by the presence of painful, visible and often ulcerated tumor lesions. CO2 and Nd:YAG lasers were used for tumor vaporisation and coagulation, the combined use of these two wavelengths providing the new study concept which emerged from this pilot trial.

Initial results of intraluminal ultrasound in gynecologic diagnosis

The interior of hollow organs can be examined using extremely small intraluminal ultrasound transducers inserted into catheters. We tested the practicality of this method and the range of indications for which it could be useful in gynecology by performing initial examinations of extirpated uteri and fallopian tubes. In vivo, we inserted an intraluminal unit with transducer diameters of 3.5F and 5F through the cervix into the fallopian tubes of 15 patients during hysteroscopy or laparoscopy. The catheter was inserted successfully into the tube in all 15 women, and in 9 all the way to the distal end. The tubal wall was identified precisely, and a functional diagnosis of tubal motility was established for the first time. However, it was impossible to differentiate between tubal epithelium and muscularis. Also, uterine endometrium cannot be evaluated accurately with the current level of technology. This technique will enable the first functional examination and diagnosis of the tubes and uterus, provided that further improvements can be made in the quality of the images.

[Possibilities and limits of a new color technique: ultrasound angiography--results of the "Heidelberg Round Table Discussion"]

Sonographic diagnostics has been essentially enlarged by blood flow measurements with the color Doppler technique. Nevertheless, the method has certain limitations, especially when employed to visualize extremely slow blood flow velocities, which occur e.g. in malignant tumors due to neovascularization. Recently, a new technique, the so-called angio-color procedure, has been presented, which is supposed to overcome the above-mentioned limitations. The way of coding the signal differs considerably from that in conventional color Doppler: The amplitude is color coded, not the frequency deviations. Results and first experiences with the new procedure in various domains were discussed at a 'Heidelberg Round Table' and are summarized in the present article. In the obstetrics/gynecology there are clear advantages in the representation of blood flow in the placenta. In eutrophic fetuses a blood flow over the entire placental breadth was detected, in dystrophic fetuses, however, only on the margins of the placenta. Conventional color Doppler could not visualize blood flow in the placenta at all. Blood flow assessment in the fetal organs also provided different results with the two procedures: the angio-color method showed color pixels even in the peripheral areas. In 8 malignant breast tumors the same observation was made, the angio-color procedure seemed to visualize more color pixels. In 4 of 6 benign lesions blood flow could be measured with the traditional color Doppler, but in 5 of 6 patients with the angio-color Doppler. This was also observed in ovarian tumors. Angio-color representation of renal transplants with normal function resulted in blood flow information reaching deep into the renal capsule, whereas in cases of renal transplants with impaired function a clearly reduced perfusion was visualized. These differences were not so evident with the conventional Doppler method. In lymph node diagnosis, too, marked differences between malignant and reactive lymph nodes could be visualized. In the diagnosis of arteriosclerotic plaques, blood flow in the residual lumen could also be detected more exactly with the angio-color technique. Color representation of liver tumors also showed a higher color signal density with ultrasound angiography. In summary, ultrasound angiography can provide additional information in the color representation of vessels with slow flow velocities. However, an obvious problem is the unability to quantify detected low blood flow. The new procedure will not replace but usefully complete the established sonographic techniques.

[Initial experiences with a new color technique: ultrasound angiography]

The sonographic diagnosis can be expanded by Color Doppler. Nevertheless something is missing, especially concerning the demonstration of the very slow velocities as it can be found in neovascularized malignant tumors. A recently developed new color technique--the Angio-Color of the Diasonics Corporation, Sonotron (other companies have prototypes of this color)--promises to improve the detection of very low flow velocities. Due to a method very different to the conventional Doppler technique the registered signal is coded in the color image of the blood flow: that means that the amplitude and not the frequency shift is coded in color. Therefore there is less noise in the color mode with the possibility of showing the lower flow in comparison to the conventional Doppler. In Gynaecology and Obstetrics the advantages in the demonstration of the placental blood flow were obvious. In eutrophic fetuses the blood flow could be registered over the whole breadth of placenta, while in dystrophic fetuses this was possible only at the margin of the placenta with some color pixels in the middle of the organ. The conventional Color Doppler was not able to show the flow in the placenta even in eutrophic fetuses. Also the flow in fetal organs produced different results using both methods. So the angio-technique showed more color pixels in the periphery. In 8 malignant breast tumors both methods were able to show blood flow, but the Angio-Color showed more color pixels as the conventional color did.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound diagnosis of fetal lung maturity]

The immaturity of the fetal lung and the resulting respiratory distress syndrome are the main problems of obstetrics. Over a long period of time the only possibility to recognize the maturity of fetal lungs certainly was the determination of the L/S-ratio by amniocentesis. Two years ago first results were presented to determine fetal lung maturity by sonography. We examined 428 patients between 29 and 40 completed weeks of gestation. By comparing the characteristics of frequency of fetal lung echoes to those from the fetal liver as a reference organ it becomes possible to standardize fetal lung changes with gestation. In one ultrasound section we depicted lung and liver as well. According the A-mode we registered frequencies of both. The registered frequencies were entered digitally into a computer to evaluate the mean, maximal and minimal frequencies. Afterwards quotients of the frequencies of fetal lung and liver were calculated. For all weeks of gestation, mean values and standard deviations were made. It has been shown, that the liver is an adequate reference organ since the reflection pattern between the different weeks of gestation does not change, however significant changes have been seen in the fetal lungs. Q-mean, the quotient of fetal lung and liver reflection can be calculated. A quotient of Q-mean < 1.10 suggests lung maturity, while values > 1.10 speak for immaturity. Ultrasound examinations with 55 expectant women were compared with the lung conditions after delivery. 30 examinations were correlated with the results of the L/S-Ratio by amniocentesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound blood flow measurement in malignant tumors is a possible new prognostic factor]

OBJECTIVE

The aim of the present study was to find a possible relationship between biological behavior of breast cancer and sonographically detectable blood flow.

METHODS

157 patients with ductal invasive breast cancer were examined by means of a new sonographic procedure, the MEM (Maximum Entropy Method), able to detect considerably lower blood flow velocities than doppler sonography. In the absence of objectifyable quantification methods, findings were allotted to 3 classes, depending on the visual color information obtained. Blood flow was correlated to tumor size, lymph node and receptor status, ploidy and S-phase-fraction.

RESULTS

Most patients with small tumors, no lymph node metatases, positive receptors, diploid genome and low S-phase found to have low blood flow.

CONCLUSION

This close relation between established prognostic factors and results of sonographic blood flow examination with the MEM might indicate a new preoperative prognostic factor, which, however, will have to be proven by larger studies.

[Diagnosis of the breast tumor entity with "vocal fremitus" in ultrasound diagnosis]

In the published study a totally new method for the diagnosis of malign and benign tumors of the female breast is presented. During sonographic examinations with the maximum entropy method we found out, purely by chance, that artifacts produced by vibrations of the thorax can be used to differentiate malignant from benign lesions. These artifacts in form of small colour pixels can be provoked by the vocal fremitus of the internal medicine or by humming a deep sound. In case of malignancy, the colour artifacts are visible inside of the tumor, in benign lesions, however, only in the surrounding tissue. On the preoperative day, 95 patients were examined with the method described above. In 91% of the cases the diagnosis of the dignity corresponded with the histological results. Seven times a benign lesion was classified as a malignant tumor and twice malignancy was not correctly diagnosed. Our explanation of these phenomena is the following: Benign lesions of the female breast show a displacing growth and a definable boundary. Thus the vibrations are damped and not conducted into the tumor. In contrast, malignant lesions grow invasively into the surrounding tissue. Consequently, the vibrations can be conducted into the center of the tumor by this dissemination.

[Hysteroscopic endometrium ablation to avoid hysterectomy in "high risk" patients]

Hysteroscopic endometrial ablation under maximal anaesthesiological surveillance was performed in 34 high-risk patients to avoid hysterectomy. It was a collective of patients with heavy thrombo-embolic or thrombotic disease, either under permanent anticoagulation due to residual disease or multiple endoprosthetic treatment, or with endogenous coagulopathy. In all these women, hysterectomy was either a relative or an absolute contraindication. In 22 patients, treatment resulted in complete amenorrhoea or at least hypomenorrhoea (without menometrorrhagia) respectively cyclic spotting. In 6 further patients, amenorrhoea was achieved after a repeat procedure. Endometrial ablation was thus successful in 28 of 34 cases. In these patients, hysterectomy with the risk of major or even lethal complications, could thus be avoided. Hysterectomy, however, had to be performed in 2 women with extensive adenomyosis uteri interna. Within two respectively three years after endometrial ablation, two other patients died from causes unrelated to the surgical intervention (cardiac infarction, cerebral haemorrhage). Follow-up ranged from 1 to 5 years. Hysteroscopic endometrial ablation proved an effective therapeutic option in this selected group of patients. Other indications require further study.

Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study

BACKGROUND

In a prospective study, the differential diagnostic potential of pelvic examination, ultrasound, and serum CA 125 assay in postmenopausal patients presenting with a pelvic mass was assessed.

METHODS

A total of 228 patients were evaluated preoperatively in an international, multicenter, prospective study using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 125 determination with a cut-off level of 35 U/ml.

RESULTS

Ninety-five malignant (41.7%) and 127 benign (55.7%) pelvic tumors were found in addition to 6 borderline ovarian tumors (2.6%) in the 228 patients. Seventy-two patients had ovarian carcinoma, 49 of whom were International Federation of Gynecology and Obstetrics Stage III or IV. Borderline tumors were excluded from the statistical calculations. The individual accuracy of pelvic examination, ultrasound, and serum CA 125 in discriminating between benign and malignant pelvic masses was approximately the same (76, 74, and 77%, respectively). Using logistic regression analysis, the power of pelvic examination appeared to be the most relevant factor (adjusted odds ratio, 9.2), followed by serum CA 125 (odds ratio, 5.6), and ultrasound (odds ratio, 4.9). Age appeared to be nonpredictive. No cancer was found in any patient in whom all three methods scored negative (n = 53; positive predictive value for malignancy = 0 and 95%; confidence interval, 0-7).

CONCLUSIONS

The combined use of pelvic examination, ultrasound, and serum CA 125 leads to improved discrimination between malignant and benign pelvic masses, because malignancy can be excluded when all three examination methods are negative. A change to a more patient-tailored surgical approach could be considered in those cases.

[The positive "vocal fremitus" in malignant breast tumors in color MEM ultrasound imaging--an exciting artifact in confirming the diagnosis?]

In the experimental phase of application of a new Non-Doppler technology (MEM system, Acoustic Imaging, Phoenix; Dornier Medizintechnik) we observed, that in patients, who spoke during colour imaging of a breast tumour, artifacts appeared in or around the lesion: the colour artifacts were seen regularly inside the tumour in cases of malignancies, and exactly surrounding benign tumours. Postoperative histological findings served as an objective criterion of classification/differentiation. To examine this phenomenon, we performed a study in 71 patients. These women with a sonographically detectable tumour (37 malignant, 34 benign) were examined on the day before surgery. We observed, that if patients uttered the number "99" with a relatively low voice or alternatively hummed a deep sound, the artifacts could be regularly visualized. In 66/71 patients (93%) status evaluation by artifact generation due to vocal fremitus examination was correct. In 3 patients the tumour was erroneously described as malignant, histology showing a proliferative mastopathy. In 2 cases the tumour was classified as benign, whereas histology revealed a malignancy, in both patients a large ductal-invasive carcinoma (> 3 cm). This phenomena could, however, not be reproduced with other colour techniques. A possible explanation is: Thoracic vibrations during speech can be registered by the MEM technique. These vibrations are not perpetuated into the benign lesion characterised by a displacing growth, due to which the vibrations are "barred off" at the borders of the tumour. Infiltrating growth typical of a malignancy causes transmission of these vibrations into the center of the tumour.(ABSTRACT TRUNCATED AT 250 WORDS)

[Incontinence operation by "Retzius-scopy"? An endoscopic modification of the Marshall-Marchetti-Krantz operation]

The operative treatment of stress incontinence with the Marshall-Marchetti-Krantz procedure has proved effective. A new, endoscopic modification of this procedure is presented here, based on the principle of vesico-urethral suspension with fibrin glueing. Open abdominal surgery is replaced by retziusscopy and a minimal invasive endoscopic intervention in the Retzius' cavity.

[The advantages of spatial, three-dimensional ultrasound imaging in clinical application]

Following the first three-dimensional (3D) ultrasound imaging of organs using 3D ringstructures, which we developed in 1986, the method had to be improved and refined because of sources of error resulting from the ring structure. The newly developed 3D method enades its application in clinical routine. By rotating the sectional plane around a horizontal axis using an especially constructed 3D probe, in 5 s 60 ultrasound sections of the examined tissue are registered. These 60 sections are calculated transparently and than compiled into a transparent spatially reconstructed image. In spite of the enormous information, the 3D picture is projected on the screen after a very short time. There is no loss in information. The spatially reconstructed body can be cut along any imaginable plane so that planes can be demonstrated which normally are inaccessible to conventional sonography. This new method presents possibilities which were formerly confined to CT and MRI. We tested this method mainly in prenatal and tumor diagnoses. It has been shown that the dignity of tumors can be differentiated in many cases already by means of the 3D-image. An indistinct image is characteristic for a malign tumor, and a sharply defined image represents a benign lesion. The diagnosis of fetal malformations can profit from this new method. Exact localizations and volume determinations are now sonographically possible. New diagnostic possibilities by means of ultrasound are forthcoming. But this needs further technical investigations. Both the presentation with a closed surface and the transparent presentation will have indications in the future. Our goal is a free applicability of the probe.

[Development of Doppler parameters in fetal and maternal blood vessels 10 days before to 10 days after the calculated due date]

Doppler sonography can help to assess a foetal risk situation prospectively. This procedure is therefore well suited for the screening of risk pregnancies in the 3rd trimenon. The role of Doppler ultrasound at delivery is still controversial, since, on the one hand, no data on the behaviour of Doppler parameters directly at the onset of delivery are available, and on the other hand the obstetric consequences from pathological findings are not clear. For this reason, we observed 45 normal pregnancies from the 10th day prior to the date of confinement till the 10th day post partum. In 20 patients we registered Doppler parameters from 4 days before until the onset of true labour. In all these cases, a reduction of the end-diastolic blood flow in the foetal aorta was found, which became evident by the increase of the resistance index to pathological values. Concomitant decrease of the resistance index in the foetal carotid artery was typical for a circulatory system. Since foetal outcome was normal in all newborn, this change in Doppler parameters directly at the beginning of labour must be considered as physiological. The findings suggest a physiological placental insufficiency. Since however, parameters in the uterine vessels did not show any changes, the insufficiency has its probable origin in the placenta. From these findings, one might speculate, that the supply deficiency is the labour inducing factor. No clinical consequence can thus result from pathological Doppler data found in patients directly prior and after delivery. Cardiotocographic screening is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound--future developments]

During the last years, rapid technical evolution has led to the development of transducers with extremely high resolution (generating two-dimensional (2D) sectional scans not mere spacial cuts), thus creating the preconditions for spacial 3D reconstruction from a series of 2D sectional scans. For the 3D technique a transducer is required that can register a multitude of sectional scans of the organ examined. This series can only be reconstructed according to the actual spacial situation by a computer. Transparent calculation of the individual section diaphanous scans results in a 3D image of the organ. The new method presents the advantage of less subjectivity, since the 3D image is not merely created in the mind of the examining specialist, but is reconstructed by the computer. Moreover, the computer image can be disassembled into the original and even sonographically unattainable section scans, thus furnishing additional information. Objective and exact volume calculations, localization and control of the progress of a disease becomes feasible. Further progress in gynecologic ultrasound has been achieved by technical improvement resulting in the applicability of intraluminal sonography for gynecologic indications as well. Due to newly developed microtransducers, the advantages of intraluminal ultrasound, used mainly in angiology up to the present, can now be used for the representation and functional diagnosis of the fallopian tube as well. Some technical problems have, however, yet to be solved. By utilizing a computer-aided evaluation system, ultrasound information, not realized by the human eye, can be represented.(ABSTRACT TRUNCATED AT 250 WORDS)

Poor survival of black patients in carcinoma of the endometrium

PURPOSE

To compare the prognostic factors and survivals of black and white patients with endometrial carcinoma.

METHODS AND MATERIALS

A retrospective study was undertaken of a total of 290 patients with endometrial carcinoma who were treated similarly at the Health Science Center at Brooklyn and Kings County Hospital Center from 1975 and 1990. One hundred and thirty-six of 290 (47.2%) were black and 135/290 (46.9%) were white. Well-known prognostic factors affecting endometrial carcinoma were studied in black and white group of patients. Their overall survival and comparison of survival in each prognostic group were also estimated using multi-variate analysis.

RESULTS

Fifty-four percent of white patients had Stage I disease, compared to 45.9% in black patients. In Stage II, 51.6% were white and 48.4% were black, and in Stage III, 88.89% were black and 11.1% were white patients (p = 0.034). Fifty six percent Grade 1 patients were white and 44% were black. In Grade 2, 53.3% were white and 46.7% were black and in Grade 3 disease, 70.5% were black and 29.5% were white (p = 0.008). Up to the inner third of myometrial invasion had occurred in 60.6% of white patients and 39.4% in black patients. The middle third of the myometrium was invaded in 60.7% of white patients, and 39.3% of black patients. Thirty-seven percent of outer third of myometrial invasion was found in white patients and 63% in black patients (p = 0.038). Seventy-two percent of positive lymph nodes were found in black patients and 28.0% in white patients (p = 0.01). Sixty-one percent of patients with positive peritoneal cytology were black as compared to 38.7% in white patients (p = 0.017). The overall ten-year corrected survival for white and black patients was 72% and 40%, respectively (p = 0.0003). Survivals comparisons, when stratified by race and each prognostic group, showed statistically significant overall survival differences in favor of white patients.

CONCLUSION

Black patients with endometrial carcinoma have poor survival. Low socio-economic status (SES) would not explain these findings. More research is required to determine the cause of poor survival in black patients with endometrial carcinoma.