Abstract GS3-05: Prospective optimization of estrogen receptor degradation yields ER ligands with variable capacities for ER transcriptional suppression

ER+ breast cancers can depend on ER signaling throughout disease progression, including after acquired resistance to existing endocrine agents, providing a rationale for further optimization and development of ER-targeting agents. Fulvestrant is unique amongst currently approved ER ligand therapeutics due to classification as a full ER antagonist, which is thought to be achieved through degradation of ER protein. However, the full clinical potential of fulvestrant is believed to be limited by poor bioavailability, spurring attempts to generate ligands capable of driving ER degradation but with improved drug-like properties.

Here, we evaluate three ER ligand clinical candidates that recently emerged from prospective optimization of ER degradation – GDC-0810, AZD9496 and GDC-0927 - and show that they display distinct mechanistic features. GDC-0810 and AZD9496 are more limited in their ER degradation capacity relative to GDC-0927 and fulvestrant, display evidence of weak transcriptional activation of ER in breast cancer cells (i.e. partial agonist activity), and do not achieve the same degree of in vitro anti-proliferative activity as GDC-0927 and fulvestrant. In the HCI-013 (ER.Y537S) and HCI-011 (ER.WT) ER+ patient-derived xenograft models, GDC-0927 drives greater transcriptional suppression of ER, and greater anti-tumor activity relative to GDC-0810.

We found that despite their full antagonist phenotype, GDC-0927 and fulvestrant promote association of ER with DNA, including at canonical ERE motifs, prior to ER degradation. Interestingly however, integration of ER ChIP-Seq and ATAC-Seq data revealed that ER complexed with fulvestrant or GDC-0927 fails to increase chromatin accessibility at DNA binding sites, in contrast to partial agonists which result in increased chromatin accessibility at ER binding sites. Thus, although ER contacts DNA when engaged with fulvestrant and GDC-0927, it is functionally inert. To further explore mechanistic features that might account for the differential activity of full antagonists and partial agonists that occurs prior to ER degradation, we used cell-based florescence recovery after photobleaching (FRAP) to measure the kinetics of ER diffusion within the nucleus. We demonstrate that while ER is generally highly mobile, including after engagement with GDC-0810 and AZD9496, GDC-0927 and fulvestrant immobilize intra-nuclear ER. A site saturating mutagenesis screen revealed a series of novel ER mutations that prevent ER immobilization by fulvestrant and GDC-0927. This class of “always mobile” ER variants promotes an antagonist-to-agonist transcriptional switch for fulvestrant and GDC-0927, and simultaneously prevents ER degradation by these molecules, implying that ER immobilization is a key functional determinant of robust transcriptional suppression.

We thus propose that ER degradation is not a driver of full ER antagonism, but rather a downstream consequence of ER immobilization, occurring after a suppressive phenotype has been established at chromatin. We additionally argue that evaluating the transcriptional output of candidate ER therapeutics, both pre-clinically and clinically, will be critical for the identification of ER ligands with best-in-class potential.

Citation Format: Metcalfe C, Zhou W, Guan J, Daemen A, Hafner M, Blake RA, Ingalla E, Young A, Oeh J, De Bruyn T, Ubhayakar S, Chen I, Giltnane JM, Li J, Wang X, Sampath D, Hager JH, Friedman LS. Prospective optimization of estrogen receptor degradation yields ER ligands with variable capacities for ER transcriptional suppression [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS3-05.

Abstract P5-11-01: Phamacodynamic and circulating tumor DNA evaluation in a phase I study of GDC-0927, a selective estrogen receptor antagonist/ degrader (SERD)

Background: Modulation of estrogen activity and/or synthesis is the mainstay therapeutic strategy in the treatment of ER positive breast cancer. However, despite the effectiveness of available endocrine therapies, many patients ultimately relapse or develop resistance to these agents via estrogen-dependent and estrogen-independent mechanisms, including mutations in ESR1 affecting the ER ligand binding domain that drive ER-dependent transcription and proliferation in the absence of estrogen. Based on preclinical and clinical data, SERDs are expected be effective in patients harboring ESR1 mutations. Biomarker analysis was performed on plasma and tumor samples from the Phase I study of GDC-0927 in metastatic breast cancer (Dickler et al, SABCS 2017) with the goal of evaluating activity in both ESR1 mutant and wildtype tumors, and to assess ER pathway modulation.

Methods: Hotspot mutations in ESR1, PIK3CA, and AKT1 were analyzed in baseline, on-treatment and end of treatment plasma derived circulating tumor DNA (ctDNA) using the BEAMing assay in patients treated at multiple dose levels of GDC-0927. A subset of samples was analyzed with Foundation Medicine's next generation sequencing ctDNA assay (FACT), which covers genomic alterations in 62 commonly altered genes. Paired pre- and on-treatment biopsies were collected to assess ER pathway modulation. ER, PR, and Ki67 protein levels were analyzed by immunohistochemistry. Gene expression analysis was performed using Illumina's RNA Access library preparation kit followed by paired-end (2x50b, 50M reads) sequencing on the HiSeq.

Results: Baseline and on-treatment plasma samples were available for 40 patients. ESR1 and PIK3CA mutations were observed in 52% and 33% of patient baseline samples, respectively (BEAMing method). Mutant allele frequencies (MAF) generally declined in the first on-treatment samples collected for both ESR1 (16 out of 21 samples) and PIK3CA (7 out of 12 samples). The majority of the reductions were greater than 95% relative to baseline. Increases in ESR1 MAFs were observed in later time-points and were not associated with any particular ESR1 mutation. There were six instances for which an ESR1 mutation was detected in an on-treatment sample that was not detected in the baseline sample, three at L536P and one each at D538G, L536H, and S463P, and four out of six with MAFs close to the limit of detection. The FACT assay also detected alterations in CDH1, NF1, PTEN, and TP53 in baseline samples. The relationship between MAF changes and clinical benefit to GDC-0927 will be presented. A predefined, experimentally-derived set of ER target genes were evaluated in pre- and on-treatment tumor biopsy pairs from six patients. Four of the six patients showed evidence of suppression in ER pathway activity, one patient treated at the 1000 mg dose level and three at the 1400 mg dose. The degree of pathway suppression was associated with pre-treatment pathway levels and decreases of ER and Ki67 protein levels.

Conclusions: We report here evidence of consistent reduction of ESR1 and PIK3CA ctDNA in patients treated with GDC-0927. ER pathway suppression was observed at both the transcript and protein level confirming pharmacodynamic activity of the SERD.

Citation Format: Spoerke JM, Daemen A, Chang C-W, Giltnane J, Metcalfe C, Dickler MN, Bardia A, Perez Fidalgo JA, Mayer IA, Boni V, Winer EP, Hamilton EP, Bellet M, Urruticoechea A, Gonzalez Martin A, Cortes J, Martin M, Gates M, Cheeti S, Fredrickson J, Wang X, Friedman LS, Liu L, Li R, Chan IT, Mueller L, Milan S, Lauchle J, Humke EW, Lackner MR. Phamacodynamic and circulating tumor DNA evaluation in a phase I study of GDC-0927, a selective estrogen receptor antagonist/ degrader (SERD) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-11-01.

Abstract P5-04-26: Identification of preclinical mechanisms driving acquired resistance to endocrine therapy in estrogen-receptor positive (ER+) breast cancer cells

Estrogen Receptor positive (ER+) breast cancer accounts for the majority of breast cancer cases and standard of care for these tumors is treatment with endocrine therapy, including the blockade of estrogen production (i.e. aromatase inhibitors; AIs) as well as the use of antagonists of ER function, i.e. selective estrogen receptor modulators (SERMs, i.e. tamoxifen) and selective estrogen receptor degraders (SERDs, i.e. fulvestrant). Despite the initial dependency of ER+ breast tumors on estrogen and ER for their survival and proliferation, treatment in the metastatic setting invariably leads to therapeutic resistance. While mechanisms of resistance to AIs include mutations in the estrogen receptor gene ESR1, less is known about mechanisms of resistance to SERMs and SERDs, thus it is essential to further investigate the latter, in order to successfully treat relapsed patients. To pre-clinically model cell-autonomous acquired resistance to these agents, we used T47D, an ER+ and p53- estrogen-responsive cell line treated with increasing concentrations of the SERM/SERD hybrid (SSH) ER-targeting agent GDC-0810 over the period of several months during which individual clones with acquired resistance to GDC-0810 were selected. GDC-0810-resistant clones were cross-resistant to other endocrine agents, including SERMs (tamoxifen) and SERDs (fulvestrant), consistent with general loss of dependency on ER. Surprisingly, the cells also lost sensitivity to palbociclib, the latter likely linked to their loss of one copy of the retinoblastoma (Rb) tumor suppressor gene. Comprehensive genetic and phenotypic characterization of the resistant clones relative to the parental cells revealed multiple mutations and deletions in DNA repair and cell cycle genes, and associated defects in DNA repair and cell cycle checkpoints. Cell cycle, proteomic, and mRNA expression analysis of parental versus resistant clones at baseline and upon DNA damage, identified a distinct cell cycle profile in the GDC-0810-resistant clones, characterized by accumulation of cells in the mitotic phase. A broad chemical screen identified pharmacologic inhibitors of cell cycle regulators and chemotherapeutic drug classes that preferentially target the ER-independent, GDC-0810 resistant clones compared to the parental cells. Our work provides novel insights into mechanisms and biomarkers of acquired resistant to estrogen therapies in ER+ breast cancer and reveals the acquisition of actionable dependencies that may potentially be exploited in resistant tumors. Furthermore, our studies provide rationale for testing specific chemotherapy regimens upon endocrine resistance accompanied by cell cycle and DNA repair checkpoint dysfunction in ER+ breast cancer.

Citation Format: Ong C, Daemen A, Merrick K, O'Brien T, Friedman L, Hatzivassiliou G. Identification of preclinical mechanisms driving acquired resistance to endocrine therapy in estrogen-receptor positive (ER+) breast cancer cells [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-26.

Abstract P4-21-21: Her2 is not a cancer subtype but rather a driver found in all intrinsic subtypes and highly enriched in molecular apocrine tumors

Her2-enriched (Her2E) breast tumors defined by molecular profiling are discrepant from Her2-amplified tumors defined by clinical assessment – over half of all Her2-amplified tumors are not Her2E, while one-third of Her2E tumors are not Her2-amplified. We explored this discordance using genomic profiles of 4,000 breast tumors. We find clear support that Her2 amplification is a discrete cancer driver event and not a subtype, with little genomic impact other than in expression of genes on the amplicon. Many Her2-amplified tumors clearly belong to the basal, luminal A, or luminal B subtypes.

After accounting for the Her2 amplicon, most tumors classified as Her2E appear to be molecular apocrine, expressing high levels of androgen receptor and low to moderate levels of ER. The high rate of Her2 amplification in this group (63%) suggests that additional growth drivers are required for molecular apocrine tumors.

Her2 amplification is also a driver across subtypes of several non-breast tumor types. Her2 is amplified in 2% of 5,400 non-breast tumors, spanning 23 tumor types. The Her2 region in non-breast cancers shows a similar range of amplification and breadth of the amplicon, and a comparable rate of overexpression of genes within the amplicon for most Her2A tumors.

These discoveries reveal therapeutic opportunities for combining anti-Her2 therapy with endocrine or anti-androgen agents for breast cancer, and for expanding anti-Her2 therapy to other tumor types.

Citation Format: Daemen A, Manning G. Her2 is not a cancer subtype but rather a driver found in all intrinsic subtypes and highly enriched in molecular apocrine tumors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-21.

Abstract P4-06-05: Treatment of ESR1 mutant and PIK3CA mutant patient-derived breast cancer xenograft models reveals differential anti-tumor responses to estrogen receptor degraders and PI3K inhibitors in vivo

The phosphoinositide 3-kinase (PI3K) pathway is a key driver of hormone receptor (HR)–positive breast cancer growth and survival. It is estimated that 40-45% of HR+ breast cancers harbor oncogenic mutations in the PIK3CA gene, which encodes the p110α isoform of PI3K. Taselisib (GDC-0032) is a mutant-selective PI3K inhibitor that demonstrates enhanced potency in PIK3CA mutant breast cancer cells and is being developed as a treatment for metastatic breast cancer that targets PIK3CA-mutant, HR-positive, HER2-negative patients. Activating mutations in the ESR1 gene were recently described in metastatic breast cancer. These mutations confer hormone independent growth and may be associated with resistance to aromatase inhibitors. Drugs that selectively bind and antagonize the Estrogen Receptor alpha (ERα) protein and target it for degradation, such as fulvestrant, are referred to as selective estrogen receptor degraders (SERDs). Preclinical activity of the orally bioavailable SERD, GDC-0810, has not been well characterized in ESR1 mutant PDX models. Therefore, our aim was to evaluate the efficacy and pharmacodynamic responses to agents that target ERα and PI3K as monotherapies and in combination, in ESR1 and PIK3CA mutant HR+ breast cancer patient-derived xenograft (PDX) models. We hypothesized that mutational status of ESR1 and PIK3CA may predict the responsiveness of HR+ PDX models to SERDs and PI3K inhibitors in vivo. Characterization of seven PDX models included authentication of hormone receptor status by immunohistochemistry (IHC) and determination of ESR1 and PIK3CA genotype and allele frequency by exome sequencing. For a subset of models that utilize estrogen for growth, mice were supplemented with 17β-estradiol, and cells or tumor fragments were implanted into the fat pad of intact female NOD-SCID or NOD-SCID-IL2Rgamma null mice and treated with fulvestrant, GDC-0810, or taselisib. Both fulvestrant and GDC-0810 were efficacious in ESR1 wild type (WT) and mutant PDX models but to variable degrees ranging from tumor stasis to growth delay, with GDC-0810 resulting in superior single agent activity at relevant clinical exposure in the WHIM20 and WHIM43 ESR1 mutant models. PIK3CA mutations (E542K, E545K, M1004V, and H1047R) were confirmed in six PDX models and PI3K pathway activation verified by strong pS6RP IHC staining. Taselisib induced tumor growth inhibition and tumor regressions in models harboring PIK3CA mutations, and models with no detectable expression of WT p110α were the most sensitive. In the WHIM43 (ESR1 D538G, PIK3CA M1004V), HCI-011 (ESR1 WT, PIK3CA E545K) and HCI-013 (ESR1 Y537S, PIK3CA H1047R) PDX models, combining fulvestrant and taselisib treatment further enhanced tumor growth inhibition with respect to either treatment alone. Our studies demonstrate the diverse anti-tumor responses of HR+ PDX models to SERDs and the PI3K inhibitor taselisib in the context of clinically relevant ESR1 and PIK3CA mutations. Pharmacological and genomic characterization of additional PDX models may aid in strengthening associations between genotype, drug sensitivity and predictive biomarkers of response.

Citation Format: Young A, Crocker L, Cheng E, Lacap J, Hamilton P, Oeh J, Ingalla E, Arrazate A, Hager J, Nannini M, Friedman L, Daemen A, Giltnane J, Sampath D. Treatment of ESR1 mutant and PIK3CA mutant patient-derived breast cancer xenograft models reveals differential anti-tumor responses to estrogen receptor degraders and PI3K inhibitors in vivo [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-06-05.

Abstract PD3-04: PAK-1 amplified breast cancer cell lines are preferentially sensitive to PAK inhibition with G-5555

The small GTP-binding proteins Rac1 and Cdc42 stimulate activity of the serine/threonine kinase p21-activated kinase-1 (PAK-1) to drive growth factor signaling networks and Ras-driven tumorigenesis. Genomic amplification and over-expression of PAK1 are prevalent in luminal breast cancer and correlate with poor clinical outcome. Here we use a novel and selective small molecule inhibitor, G-5555, of the group I PAKs (PAK1, 2, and 3) to evaluate the importance of PAK1 in promoting growth of PAK1 amplified breast cancer cells. Cell lines with amplification of PAK1 were found to be more sensitive to PAK1 inhibition than non-amplified cell lines. Additionally, reverse phase protein array (RPPA) was used to assess the effects of PAK1 inhibition on a wide range of signaling pathways in both amplified and non-amplified cell lines. Reduced levels of phosphorylation of MEK S298 was observed in all cell lines exposed to G-5555 irrespective of amplification status, consistent with PAK1 inhibition in these cell lines. However, modulation of this downstream PAK1 substrate did not correlate with inhibition of cell proliferation or induction of cell death. Cell lines that showed inhibition of proliferation in response to G-5555 also showed enhanced levels of cell death along with apoptosis. Moreover, G-5555 reduced tumor growth in the PAK1 amplified MDA-MB-175 xenograft tumor model. Finally, we compared the in vitro activity of G-5555 with palbociclib, a recently approved inhibitor of the cyclin-dependent kinases CDK4 and CDK6, in PAK1 amplified luminal breast cancer cell lines. Our data supports PAK1 as an attractive target in PAK1 amplified cells and tumors and suggests that inhibiting PAK1 rather than CDK4/6 in this context may be a more attractive therapeutic strategy.

Citation Format: Ong CC, Blackwood E, Jakubiak D, Daemen A, Ramaswamy S, Heise C, Schmidt M, Sanders L, Wilson TR, Huw L, Ndubaku C, Rudolph J, Hoeflich KP, Friedman L, O'Brien T. PAK-1 amplified breast cancer cell lines are preferentially sensitive to PAK inhibition with G-5555. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD3-04.

Changes in Cesarean section scar dimensions during pregnancy: a prospective longitudinal study

OBJECTIVES

To describe changes in Cesarean section (CS) scars longitudinally throughout pregnancy, and to relate initial scar measurements, demographic variables and obstetric variables to subsequent changes in scar features and to final pregnancy outcome.

METHODS

In this prospective observational study we used transvaginal sonography (TVS) to examine the CS scar of 320 consecutive pregnant women at 11-13, 19-21 and 32-34 weeks' gestation. For scars visible on TVS, the hypoechoic part was measured in three dimensions and the residual myometrial thickness (RMT) was also measured. Analyses were carried out using one-way repeated measures ANOVA and mixed modeling. The incidence of subsequent scar rupture was recorded.

RESULTS

The CS scar was visible in 284/320 cases (89%). Concerning length and depth of the hypoechoic part of the scar and RMT, the larger the initial scar measurement, the larger the decrease observed during pregnancy. For the hypoechoic part of the scar, the width increased on average by 1.8 mm per trimester, while the depth and length decreased by 1.8 and 1.9 mm, respectively (false discovery rate P < 0.0001). Mean RMT in the first trimester was 5.2 mm and on average decreased by 1.1 mm per trimester. Two cases (0.62%) of uterine scar rupture were confirmed following a trial of vaginal delivery; these had a mean RMT of 0.5 mm at second scan and an average decrease of 2.6 mm over the course of pregnancy.

CONCLUSION

This study establishes reference data and confirms that the dimensions of CS scars change throughout pregnancy. Scar rupture was associated with a smaller RMT and greater decrease in RMT during pregnancy. There is the potential to test absolute values and observed changes in CS scar measurements as predictors of uterine scar rupture and outcome in trials of vaginal birth after Cesarean section.

Impact of ovulation and implantation timing on first-trimester crown-rump length and gestational age

OBJECTIVE

To determine the impact of ovulation and implantation timing on first-trimester crown-rump length (CRL) and the derived gestational age (GA).

METHOD

One hundred and forty-three women who were trying to conceive were recruited prospectively. The timing of ovulation and implantation and the ovulation to implantation (O-I) interval were established in 101 pregnancies using home urinary tests for luteinizing hormone and human chorionic gonadotropin. In 71 ongoing pregnancies, GA determined by measurement of fetal CRL at 10-14 weeks' gestation was compared with GA based on ovulation and implantation day. First-trimester growth was determined by serial ultrasound scans at 6-7, 8-9 and 10-14 weeks.

RESULTS

The median ovulation and implantation days were 16 and 27, respectively, with an O-I interval of 11 days. GA estimated from CRL at 10-14 weeks was on average 1.3 days greater than that derived from ovulation timing. CRL Z-score was inversely related to O-I interval (ρ= -0.431, P=0.0009). There was no significant relationship between CRL growth rate and the difference between observed CRL and expected CRL based on GA from last menstrual period (ρ=0.224, P=0.08).

CONCLUSIONS

Early implantation leads to a larger CRL and late implantation to a smaller CRL at 10-14 weeks, independent of CRL growth rate. Implantation timing is a major determinant of fetal size at 10-14 weeks and largely explains the variation in estimates of GA in the first trimester derived from embryonic or fetal CRL.

Visibility and measurement of cesarean section scars in pregnancy: a reproducibility study

OBJECTIVES

To evaluate the visibility of cesarean section (CS) scars by transvaginal sonography (TVS) in pregnant women, to apply a standardized approach for measuring CS scars and to test its reproducibility throughout the course of pregnancy.

METHODS

In this observational cohort study, 320 consecutive pregnant women with a previous cesarean delivery were examined to assess scar visibility by two independent examiners. TVS was carried out at 11-13, 19-21 and 34-36 weeks' gestation. A scar was defined as visible when an area of hypoechogenicity representing myometrial discontinuity at the anterior wall of the lower uterine segment was identified. In a subset of patients (n = 111), visible scars were measured by two independent examiners in three dimensions: scar width, depth and length as well as the residual myometrial thickness (RMT). Descriptive analysis was used to assess scar visibility, and the intraclass correlation coefficient (ICC) was calculated to show the strength of absolute agreement between two examiners for scar measurements. For RMT, a cut-off of 2.4 mm was used and measurement agreement was assessed using Cohen's kappa coefficient.

RESULTS

The scar was visible in 284/320 cases (88.8%). Visible scars were significantly associated with anteverted uteri (P < 0.0001). Both examiners had 100% agreement on scar visibility at 12 and 20 weeks' gestation, while agreement was 96% at 34 weeks. The intra- and interobserver agreements for scar measurements were generally good (ICC 0.86 and 0.89, respectively). The kappa coefficient for the RMT was 0.27 in the first trimester, compared with 0.51 and 0.72 in the second and third trimesters, respectively.

CONCLUSION

CS scars remain visible in the majority of women throughout pregnancy. They can be reproducibly measured in three dimensions when assessed by TVS in all trimesters of pregnancy. The agreement between two observers for CS scar measurement can be considered good for the first trimester, compared with relatively moderate agreement for the second and third trimesters.

Does the presence of a cesarean section scar influence the site of placental implantation and subsequent migration in future pregnancies: a prospective case-control study

OBJECTIVES

To describe placental location in the first trimester of pregnancy and subsequent placental migration in women with and without a history of previous cesarean delivery.

METHODS

In this prospective case-control study, placental location was defined according to five anatomical sites in relation to the endometrial cavity. Placental localization was carried out by transabdominal ultrasound between 11 and 14 weeks' gestation. We recruited 738 women who had undergone one or more previous cesarean sections (CS) and 1856 patients without previous cesarean delivery. Comparative analysis was performed of placental location between the two groups, and to assess placental migration of those classified as being low lying at 20 and 32 weeks' gestation.

RESULTS

There were significant differences in placental location between the two groups. In the CS group there were significantly more posterior and fewer fundal placentae than in the control group (47.2 vs 31.5% and 4.7 vs 15.5%, respectively). The number of previous cesarean deliveries did not have a significant effect on placental location. There was no significant difference in the incidence of anterior low-lying placenta between groups (1.5 vs 0.9%). Placental migration of the low-lying subtypes was similar in both groups (62 vs 64%).

CONCLUSION

The presence of CS scars in the uterus are associated with an increase in the number of posterior placentae and a reduced number that implant in the fundus of the cavity. Migration of a low-lying placenta is independent of the presence of a CS scar in the uterus.

Do pocket-sized ultrasound machines have the potential to be used as a tool to triage patients in obstetrics and gynecology?

OBJECTIVES

To evaluate the performance and potential impact on patient management of a pocket-sized ultrasound machine (PUM) in comparison to high-specification ultrasound machines (HSUM).

METHODS

This was an observational cohort study with 204 unselected patients in three categories: 1) women with pain and bleeding in early pregnancy (101 patients); 2) women presenting for routine obstetric ultrasound assessment (53 patients); 3) women with possible gynecological pathology (50 patients). Scans were carried out transabdominally using a PUM. A second operator repeated the examination transvaginally and/or transabdominally, depending on the clinical indication, using an HSUM. The operators were blind to each other's findings.

RESULTS

In the early pregnancy group, there was good to very good agreement between the PUM and HSUM for identifying the presence or absence of an embryo, gestational sac, fetal heart motion, pregnancy location and final diagnostic outcome (kappa coefficients, 0.844, 0.843, 0.729, 0.785 and 0.812, respectively; P < 0.0001). In the obstetric ultrasound group there was good to very good agreement for fetal presentation, placental location and placental position (kappa coefficients, 0.924, 0.924 and 0.647, respectively; P < 0.0001). In the gynecological pathology group, there was very good agreement for final diagnosis and type of ovarian mass (low risk or complex) (kappa coefficients, 0.846 and 0.930, respectively; P < 0.0001). For the measured continuous variables, there was close agreement for crown-rump length, mean sac diameter, femur length and mean diameter of an ovarian mass, but not for endometrial thickness. Neither patient demographics (age, body mass index, ethnicity) nor operator experience and familiarity with a PUM had an impact on agreement between the two machines. If a PUM had been the only equipment available for an initial assessment, only two cases would have led to a suboptimal patient management plan.

CONCLUSION

The findings and final diagnosis in the three study groups were similar for both a PUM used transabdominally and an HSUM used transvaginally and/or transabdominally.

Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study

OBJECTIVES

There is significant variation in cut-off values for mean gestational sac diameter (MSD) and embryo crown-rump length (CRL) used to define miscarriage, values suggested in the literature ranging from 13 to 25 mm for MSD and from 3 to 8 mm for CRL. We aimed to define the false-positive rate (FPR) for the diagnosis of miscarriage associated with different CRL and MSD measurements with or without a yolk sac in a large study population of patients attending early pregnancy clinics. We also aimed to define cut-off values for CRL and MSD that, on the basis of a single measurement, can definitively diagnose a miscarriage and so exclude possible inadvertent termination of pregnancy.

METHODS

This was an observational cross-sectional study. Data were collected prospectively according to a predefined protocol. Intrauterine pregnancy of uncertain viability (IPUV) was defined as an empty gestational sac or sac with a yolk sac but no embryo seen with MSD < 20 or < 30 mm or an embryo with an absent heartbeat and CRL < 6 mm or < 8 mm. We recruited to the study 1060 consecutive women with IPUV. The endpoint was presence or absence of a viable pregnancy at the time of first-trimester screening ultrasonography between 11 and 14 weeks. The sensitivity, specificity, positive and negative predictive values were calculated for potential cut-off values to define miscarriage from MSD 8 to 30 mm with or without a yolk sac and from CRL 3 to 8 mm.

RESULTS

Of the 1060 women with a diagnosis of IPUV, 473 remained viable and 587 were non-viable by the time of the 11-14-week scan. In the absence of both embryo and yolk sac, the FPR for miscarriage was 4.4% when an MSD cut-off of 16 mm was used and 0.5% for a cut-off of 20 mm. There were no false-positive test results for miscarriage when a cut-off of MSD ≥ 21 mm was used. If a yolk sac was present but an embryo was not, the FPR for miscarriage was 2.6% for an MSD cut-off of 16 mm and 0.4% for a cut-off of 20 mm, with no false-positive results when a cut-off of MSD ≥ 21 mm was used. When an embryo was visible with an absent heartbeat, using a CRL cut-off of 4 mm the FPR for miscarriage was 8.3%, and for a CRL cut-off of 5 mm it was also 8.3%. There were no false-positive results using a CRL cut-off of ≥ 5.3 mm.

CONCLUSIONS

These data show that some current definitions used to diagnose miscarriage are potentially unsafe. Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancies. An MSD cut-off of > 25 mm and a CRL cut-off of > 7 mm could be introduced to minimize the risk of a false-positive diagnosis of miscarriage.

Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study

OBJECTIVES

We studied changes in mean gestational sac diameter (MSD) and embryonic crown-rump length (CRL) in intrauterine pregnancies of uncertain viability (IPUVs). We aimed to establish cut-off values for MSD and CRL growth that could be definitively associated with either viability or miscarriage, and to establish the relationship between growth in MSD and appearance of embryonic structures in the gestational sac.

METHODS

One thousand and sixty consecutive IPUVs were recruited prospectively from four London University hospitals: 462 with no yolk sac or embryo, 419 with a yolk sac but no embryo, and 179 with an embryo but no heartbeat visible. IPUV was defined as an empty gestational sac with or without a yolk sac but no embryo seen with MSD < 20 or < 30 mm (depending on center) or an embryo with no heartbeat and CRL < 6 mm or < 8 mm (depending on center). Scans were repeated 7-14 days later. The endpoint was viability at first-trimester screening ultrasonography between 11 and 14 weeks. Change in MSD and CRL between the first and second scans of each pregnancy was compared with respect to viability and appearance of embryonic structures using the two-sample t-test.

RESULTS

The study included 359 pregnancies in which a gestational sac with or without embryo was identified at the follow-up scan 7-14 days later. Of these, 192 were viable and 167 non-viable at the 11-14-week scan. MSD growth was significantly higher in viable than non-viable pregnancies (mean 1.003 vs. 0.503 mm/day; P < 0.001, 95% CI of difference 0.403-0.596). A difference in CRL growth was found between the two groups (mean 0.673 vs. 0.148 mm/day; P < 0.001, 95% CI of difference 0.345-0.703). MSD growth of 0.6 mm/day was associated with a specificity for diagnosing miscarriage of 90.1%, a sensitivity of 61.7% and 19 false-positive test results. A cut-off of CRL growth rate of 0.2 mm/day gave a sensitivity of 76.3% and there were no false-positive test results for miscarriage. On repeat scan the failure of either a yolk sac or embryo to be visualized was always associated with miscarriage.

CONCLUSION

There is an overlap in MSD growth rates between viable and non-viable IPUV. No cut-off exists for MSD growth below which a viable pregnancy could be safely excluded. A cut-off value for CRL growth of 0.2 mm/day was always associated with miscarriage. These data suggest that criteria to diagnose miscarriage based on growth in MSD and CRL are potentially unsafe. However, finding an empty gestational sac on two scans more than 7 days apart is highly likely to indicate miscarriage, irrespective of growth.

Umbilical artery pulsatility index and fetal abdominal circumference in isolated gastroschisis

OBJECTIVES

To investigate changes in abdominal circumference (AC) and umbilical artery pulsatility index (UA-PI) with gestation in fetuses with isolated gastroschisis, and to determine whether a relationship exists between UA-PI and fetal AC.

METHODS

Data from 58 pregnancies with isolated gastroschisis diagnosed at between 24 and 36 weeks' gestation were included in the study. Z-scores were calculated with respect to expected UA-PI values in normal pregnancies after log-transformation. AC-Z-scores were calculated with respect to expected size in normal pregnancies according to a standard chart. Functional linear discriminant analysis (FLDA) was applied to generate 50(th), 5(th) and 95(th) percentile curves for changes in both AC and UA-PI with gestational age in fetuses with gastroschisis. These curves were compared with the standard curves, as were the means. UA-PI was also plotted against AC. For this relationship, a robust Spearman correlation coefficient was obtained with FLDA.

RESULTS

In fetuses with gastroschisis, there was a highly significant negative correlation between UA-PI and AC, normalized for gestation using Z-scores (median correlation coefficient, - 0.289; median P = 0.000023). Moreover, compared with standard curves AC was lower and UA-PI higher in the gestational-age range studied. Both the AC and UA-PI curves showed a significantly different rate of change with gestation compared with the normal ranges. The mean values for fetuses with gastroschisis compared with the standard AC and UA-PI range curves were significantly different for AC throughout gestation, and for UA-PI from 32 weeks' gestation.

CONCLUSIONS

In fetal gastroschisis, it is well known that AC tends to be smaller, though UA-PI has not been reported to be abnormal in any consistent way. There is a clear relationship between the fetus's AC for gestation and UA-PI, which is not the case for normally grown fetuses. The data suggest that the growth restriction seen in gastroschisis may be explained by hypoxia, and not simply by the classical explanation of extra-abdominal displacement of the abdominal viscera.

Effect of cancer prevalence on the use of risk-assessment cut-off levels and the performance of mathematical models to distinguish malignant from benign adnexal masses

OBJECTIVE

Two logistic regression models have been developed for the characterization of adnexal masses. The goal of this prospective analysis was to see whether these models perform differently according to the prevalence of malignancy and whether the cut-off levels of risk assessment for malignancy by the models require modification in different centers.

METHODS

Centers were categorized into those with a prevalence of malignancy below 15%, between 15 and 30% and above 30%. The areas under the receiver-operating characteristics curves (AUC) were compared using bootstrapping. The optimal cut-off level of risk assessment for malignancy was chosen per center, corresponding to the highest sensitivity level possible while still keeping a good specificity.

RESULTS

Both models performed better in centers with a lower prevalence of malignant cases. The AUCs of the two models for centers with fewer than 15% malignant cases were 0.97 and 0.95, those of centers with 15-30% malignancy were 0.95 and 0.93 and those of centers with more than 30% malignant cases were 0.94 and 0.92. This decrease in performance was due mainly to the decrease in specificity from over 90 to around 76%. In the centers with a higher percentage of malignant cases, a sensitivity of at least 90% with a good specificity could not be obtained by choosing a different cut-off level.

CONCLUSIONS

Overall the models performed well in all centers. The performance of the logistic regression models worsened with increasing prevalence of malignancy, due to a case mix with more borderline and complex benign masses seen in those centers. Because the cut-off of 0.10 is optimal for all three types of center, it seems reasonable to use this cut-off for both models in all centers.

Improving the preoperative classification of adnexal masses as benign or malignant by second-stage tests

OBJECTIVE

The aim of this study was to establish when a second-stage diagnostic test may be of value in cases where a primary diagnostic test has given an uncertain diagnosis of the benign or malignant nature of an adnexal mass.

METHODS

The diagnostic performance with regard to discrimination between benign and malignant adnexal masses for mathematical models including ultrasound variables and for subjective evaluation of ultrasound findings by an experienced ultrasound examiner was expressed as area under the receiver-operating characteristics curve (AUC), sensitivity and specificity. These were calculated for the total study population of 1938 patients with an adnexal mass as well as for subpopulations defined by the certainty with which the diagnosis of benignity or malignancy was made. The effect of applying a second-stage test to the tumors where risk estimation was uncertain was determined.

RESULTS

The best mathematical model (LR1) had an AUC of 0.95, sensitivity of 92% and specificity of 84% when applied to all tumors. When model LR1 was applied to the 10% of tumors in which the calculated risk fell closest to the risk cut-off of the model, the AUC was 0.59, sensitivity 90% and specificity 21%. A strategy where subjective evaluation was used to classify these 10% of tumors for which LR1 performed poorly and where LR1 was used in the other 90% of tumors resulted in a sensitivity of 91% and specificity of 90%. Applying subjective evaluation to all tumors yielded an AUC of 0.95, sensitivity of 90% and specificity of 93%. Sensitivity was 81% and specificity 47% for those patients where the ultrasound examiner was uncertain about the diagnosis (n = 115; 5.9%). No mathematical model performed better than did subjective evaluation among the 115 tumors where the ultrasound examiner was uncertain.

CONCLUSION

When model LR1 is used as a primary test for discriminating between benign and malignant adnexal masses, the use of subjective evaluation of ultrasound findings by an experienced examiner as a second-stage test in the 10% of cases for which the model yields a risk of malignancy closest to its risk cut-off will improve specificity without substantially decreasing sensitivity. However, none of the models tested proved suitable as a second-stage test in tumors where subjective evaluation yielded an uncertain result.

The relationship between first trimester fetal growth, pregnancy-associated plasma protein A levels and birthweight

OBJECTIVE

We sought to define the relationship between first trimester fetal growth, pregnancy-associated plasma protein A (PAPP-A) levels and birthweight.

METHODS

Two-hundred and one women with repeat first trimester crown-rump length (CRL) measurements were included. In 194, the first trimester PAPP-A value was known and in 169 there was complete data including birthweight. Fetal growth curves were derived using functional linear discriminant analysis (FLDA) and growth compared between those with < 10th percentile, 10th to 90th and > 90th percentile PAPP-A multiple of median (MoM) levels and birthweight percentiles.

RESULTS

Median maternal age was 35 years, gestation at PAPP-A sampling and of first scan was 11 weeks. Median delivery gestation was 40 weeks and birthweight 3425 g. There was no association between first trimester fetal CRL growth and either PAPP-A MoM percentile or birthweight percentile. There was a significant positive correlation between PAPP-A MoM and birthweight percentile (p = 0.0004).

CONCLUSIONS

First trimester fetal growth rate is not related to birthweight percentile or first trimester PAPP-A levels. Irrespective of gestation, a low PAPP-A is associated with delivery of a smaller baby, and a high PAPP-A with a larger baby.

Prediction of lymph node involvement in breast cancer from primary tumor tissue using gene expression profiling and miRNAs

The aim of this study was to investigate whether lymph node involvement in breast cancer is influenced by gene or miRNA expression of the primary tumor. For this purpose, we selected a very homogeneous patient population to minimize heterogeneity in other tumor and patient characteristics. First, we compared gene expression profiles of primary tumor tissue from a group of 96 breast cancer patients balanced for lymph node involvement using Affymetrix Human U133 Plus 2.0 microarray chip. A model was built by weighted Least-Squares Support Vector Machines and validated on an internal and external dataset. Next, miRNA profiling was performed on a subset of 82 tumors using Human MiRNA-microarray chips (Illumina). Finally, for each miRNA the number of significant inverse correlated targets was determined and compared with 1000 sets of randomly chosen targets. A model based on 241 genes was built (AUC 0.66). The AUC for the internal dataset was 0.646 and 0. 651 for the external datasets. The model includes multiple kinases, apoptosis-related, and zinc ion-binding genes. Integration of the microarray and miRNA data reveals ten miRNAs suppressing lymph node invasion and one miRNA promoting lymph node invasion. Our results provide evidence that measurable differences in gene and miRNA expression exist between node negative and node positive patients and thus that lymph node involvement is not a genetically random process. Moreover, our data suggest a general deregulation of the miRNA machinery that is potentially responsible for lymph node invasion.

New crown-rump length curve based on over 3500 pregnancies

OBJECTIVES

The Robinson and Hadlock crown-rump length (CRL) curves are commonly used to estimate gestational age (GA) based on the CRL of an embryo or fetus. However, the Robinson curve was derived from a small population using transabdominal sonography and the Hadlock curve was generated using early transvaginal ultrasound equipment. The aim of this study was to use transvaginal and transabdominal ultrasound to study a large population of early pregnancies to assess embryonic or fetal size, and so create a new normal CRL curve from 5.5 weeks' gestation. We compared this with the Robinson and Hadlock CRL curves.

METHODS

A retrospective database study of CRL in first-trimester embryos was conducted in a fetal medicine referral center with a predominantly Caucasian population. Linear mixed-effects analysis was performed to determine the relationship between CRL and GA. After internal validation of this curve, the CRL was compared with the expected CRL at a given GA according to both the Robinson and Hadlock models based on the paired t-test. Bland-Altman plots were constructed to compare the CRL measurements obtained in our study population with those predicted according to GA by both the Robinson and Hadlock curves.

RESULTS

In total 3710 normal singleton pregnancies with a known last menstrual period were included in the study, corresponding to 4387 scans. Our data differed significantly from both the Robinson and the Hadlock curves (paired t-test, P < 0.0001). A mixed-effects model for CRL as a function of GA was developed on 70% of the data and internally validated with z-scores on the remaining 30%. The new curve extended from 5.5 to 14 weeks' gestation. Compared to our CRL curve, the Robinson curve gave a 4-day underestimation of GA at 6 weeks with a difference in CRL of 3.7 mm and a 1-day overestimation from 11 to 14 weeks with a difference in CRL of 0.9-1 mm. A comparison between our curve and the Hadlock curve showed a difference in CRL of 2.7 mm at 6 weeks, equivalent to an underestimation of 3 days, and a difference in CRL of 4.8 mm at 14 weeks, equivalent to an overestimation of 2 days. At 9 weeks all three curves were similar.

CONCLUSION

The new CRL curve suggests differences in the range of CRL measurements compared with the Robinson and Hadlock curves. These differences are most significant at the beginning and the end of the first trimester, and may lead to more accurate estimations of GA.

Gel infusion sonography in the evaluation of the uterine cavity

OBJECTIVES

To compare gel infusion sonohysterography (GIS) with saline contrast sonohysterography (SCSH) with regard to technical feasibility and procedure-related pain experienced by patients.

METHODS

This prospective observational cohort study included 551 consecutive patients with abnormal bleeding: SCSH was attempted in the first 402 women and GIS was attempted in the following 149. All procedures were performed by the same examiner, in the same clinical setting, using a 2-mm diameter catheter. After contrast sonohysterography, most patients underwent office hysteroscopy (n = 502) and endometrial sampling (n = 323). The women were asked to rate the pain experienced during each procedure using a 100-mm visual analog scale (VAS). Patients' characteristics, ultrasound findings, histological diagnosis, technical failures and procedure-related pain were compared between the two procedures.

RESULTS

The mean +/- SD VAS score for contrast sonography, subsequent hysteroscopy and endometrial biopsy were 22.9 +/- 21.7, 38.8 +/- 26.6 and 50.0 +/- 26.3, respectively, in the SCSH subgroup vs. 16.5 +/- 21.5, 27.6 +/- 28 and 33.6 +/- 30.3, respectively, in the GIS subgroup (P = 0.0051, P = 0.0005 and P = 0.0003, respectively). The technical failure rate was 5% in the SCSH subgroup vs. 2% in the GIS subgroup (P = 0.1522).

CONCLUSIONS

GIS and SCSH showed similar technical feasibility. The procedure-related pain reported by patients during contrast sonohysterography, as well as during subsequent hysteroscopy and endometrial sampling, was less in the GIS group.

Ultrasound methods to distinguish between malignant and benign adnexal masses in the hands of examiners with different levels of experience

OBJECTIVES

To determine the effect of an ultrasound training course on the performance of pattern recognition when used by less experienced examiners and to compare the performance of pattern recognition, a logistic regression model and a scoring system to estimate the risk of malignancy between examiners with different levels of experience.

METHODS

Using ultrasound images of selected adnexal masses, two trainees classified the masses as benign or malignant by using pattern recognition both before and after they had attended a theoretical gynecological ultrasound course. They also classified the masses by using a logistic regression model and a scoring system, but only after they had attended the course. The performance of these three methods when they were used by the trainees was then compared with that when they were used by experts.

RESULTS

One hundred and sixty-five adnexal masses were included, of which 42% were malignant (21% invasive tumors and 21% borderline tumors). The area under the receiver-operating characteristics curve of pattern recognition when used by the trainees was similar before and after they had attended the course. Training decreased sensitivity (84% vs. 70% for Trainee 1, P = 0.004; 70% vs. 61% for Trainee 2, P = 0.058) and increased specificity (77% vs. 92% for Trainee 1, P = 0.001; 89% vs. 95% for Trainee 2, P = 0.058). The performance of pattern recognition was poorer in the hands of the trainees than in the hands of the experts. The sensitivities of the logistic regression model were 70% and 54% for the trainees vs. 83% for an expert (P = 0.020 and < 0.001, respectively) and the specificities were 84% and 94% vs. 89% (P = 0.25 and 0.59, respectively). The sensitivities of the scoring system were 59% and 54% for the trainees vs. 75% for the expert (P = 0.002 and < 0.001, respectively), and the specificities were 90% and 93% vs. 85% (P = 0.103 and 0.008, respectively).

CONCLUSION

Theoretical ultrasound teaching did not seem to improve the performance of pattern recognition in the hands of trainees. A logistic regression model and a scoring system to classify adnexal masses as benign or malignant perform less well when they were used by inexperienced examiners than when used by an expert. Before using a model or a scoring system, experience and/or proper training are likely to be of paramount importance if diagnostic performance is to be optimized.

Building decision trees for diagnosing intracavitary uterine pathology

OBJECTIVES

To build decision trees to predict intrauterine disease, based on a clinical data set, and using mathematical software.

METHODS

Diagnostic algorithms were built and validated using the data of 402 consecutive patients who underwent grey scale ultrasound, followed by colour Doppler, saline infusion sonography (SIS), office hysteroscopy and endometrial-- sampling. The "final diagnosis" was classified as "abnormal" in case of endometrial polyps, hyperplasia or malignancy or intracavitary myoma. "Pre-test parameters" included patient's age, weight, length, parity, menopausal status, bleeding symptoms and cervical cytology; "post-test parameters" included ultrasound-, color Doppler-, SIS-, hysteroscopy- findings and histology results after endometrial sampling. Decision Tree #1 was built using both "pre-test" and "post-test" parameters; Tree #2 was only based on "post-test" parameters; Tree #3 was designed without using the hysteroscopy variables. The Waikato Environment for Knowledge Analysis (Weka) software was used for the development of decision trees.

RESULTS

All trees started with an imaging technique: hysteroscopy or SIS. The diagnostic accuracy was 88.3%, 88.3% and 84.0% for Tree #1, #2 and #3 respectively, the sensitivity and specificity was 95.5% and 82%, 97.7% and 80.0, 93.2 and 76.0%, respectively.

CONCLUSION

The method used in this study enables the comparison between different decision trees containing multiple tests.

Real-time ultrasound vs. evaluation of static images in the preoperative assessment of adnexal masses

OBJECTIVE

To determine if the prediction of the malignancy of an adnexal mass using pattern recognition, i.e. subjective evaluation of gray-scale and Doppler ultrasound findings, is as accurate when based on static images as it is when based on a real-time ultrasound examination.

METHODS

The static images of 166 non-consecutive patients with 'difficult' adnexal masses, who all underwent surgery and for whom a histopathological diagnosis was available, were evaluated by three experts in gynecological ultrasound ('image experts'). All ultrasound examinations had been performed and the static images saved by a fourth expert sonologist ('real-time' sonologist). All four sonologists classified the adnexal masses as benign or malignant based on their subjective impression and stated with what degree of confidence their diagnosis was made. The diagnostic performance of the real-time sonologist was compared with that of each of the three image experts and with that of the 'consensus opinion' of the image experts (i.e. the diagnosis suggested by at least two of the latter).

RESULTS

The real-time sonologist correctly predicted the diagnosis with an accuracy of 89% (148/166) vs. 85% (141/166) for the consensus opinion of static images (P = 0.0707). Equivalent values for sensitivity and specificity were 80% (56/70) vs. 83% (58/70) (P = 0.4142) and 96% (92/96) vs. 86% (83/96) (P = 0.0027), respectively.

CONCLUSIONS

The preoperative diagnosis of an adnexal mass made on the basis of a real-time ultrasound examination is more precise than a diagnosis made on the basis of saved static ultrasound images. Evaluation of static images is associated with lower diagnostic specificity.

Functional linear discriminant analysis: a new longitudinal approach to the assessment of embryonic growth

BACKGROUND

Functional linear discriminant analysis (FLDA) is a new growth assessment technique using serial measurements to discriminate between normal and abnormal fetal growth. We used FLDA to assess and compare growth in live pregnancies destined to miscarry with those remaining viable.

METHODS

This was a prospective cohort study of women with ultrasound scans on at least two separate occasions showing live pregnancies. Serial crown-rump length (CRL), mean gestational sac diameter and mean yolk sac diameter measurements were recorded. The ability of FLDA to predict subsequent miscarriage was compared with that of a single CRL measurement.

RESULTS

Of 521 included pregnancies, 493 (94.6%) remained viable at 14 weeks and 28 (5.4%) miscarried. The CRL growth rate was significantly lower in those that miscarried (one-sample t-test, P = 2.638E-22). The sensitivity of FLDA in predicting miscarriage from serial CRL measurements was 60.7% and specificity was 93.1% [positive predictive value (PPV) 33.3%, negative predictive value (NPV) 97.7%]. This was significantly better for predicting miscarriage than a single CRL observation of more than 2SD below that expected (sensitivity 53.6%, specificity 72.2%, PPV 9.9%, NPV 96.5%).

CONCLUSIONS

FLDA discriminates between normal and abnormal growth to predict miscarriage with high specificity. FLDA predicts miscarriage better than a single observation of a small CRL.

Pain experienced during transvaginal ultrasound, saline contrast sonohysterography, hysteroscopy and office sampling: a comparative study

OBJECTIVE

To evaluate and compare the pain experienced by women during transvaginal ultrasound, saline contrast sonohysterography (SCSH), diagnostic hysteroscopy and office sampling.

METHODS

This was a descriptive study of 402 consecutive patients presenting at a 'one-stop' Bleeding Clinic between October 2004 and November 2006. Thirty-nine percent of the patients were postmenopausal. The patients underwent the following examinations transvaginally: first ultrasound with color Doppler, second SCSH, third diagnostic hysteroscopy and fourth endometrial biopsy. After completion of the examinations the patients were asked to complete a questionnaire including a visual analog scale (VAS) about their subjective appreciation of all four examinations. Two-hundred and ninety-three (72%) patients returned the questionnaire.

RESULTS

The median (range) VAS scores for transvaginal ultrasound, SCSH, diagnostic hysteroscopy and endometrial sampling were 1.0 (0-8.1), 2.2 (0-10), 2.7 (0-10) and 5.1 (0-10), respectively (P < 0.0001). The patients' answers to the other questions about the pain experienced, including comparison with other minor procedures such as venous blood sampling, were all concordant with the VAS scores.

CONCLUSIONS

Transvaginal ultrasound was the procedure best accepted, followed by SCSH, hysteroscopy and endometrial sampling. These results suggest that patients would prefer SCSH over hysteroscopy as an initial diagnostic approach in the evaluation of abnormal uterine bleeding.