- Email: [email protected]
INTRAUTERINE ULTRASONOGRAPHY AND ENDOMETRIAL CANCER
842
region of the UK between 1982 and 1986 (the latest dates for which figures are available) is lower than that for England and Wales overall: 15 per 100 000 population compared with 31per 100 000 for the rest of the country, although the incidence is increasing (S. Polakoff, personal communication). Other factors that may have maintained the hospital free of infection are its rural setting, the small number of admissions to the hospital, and the fact that young children are no longer admitted to such institutions in the UK. Others have found a similar low prevalence of potential infectivity for hepatitis B in rural hospitals for the mentally handicapped.3,4It is not unlikely that we have a population vulnerable to infection but protected because of isolation. Our point is that there seems little present to urge wholesale immunisation of all staff in the of a future possible potential risk. The situation described by Dr French and his colleagues is different from ours and we support their policy of immunisation given their local circumstances. Accepting that the purpose of immunisation is to protect individuals against a perceived risk, and that within an institution this could be for both patients and their attendants, we do not disagree with the use of hepatitis B vaccine, where this is indicated on epidemiological grounds. Screening new entrants would be more cost-effective than wholesale immunisation of patients and staff and this approach could be considered for other long-stay institutions in which hepatitis B carriers have not been found. With respect to Down syndrome patients we agree with Dr Green’s point that their increased susceptibility and greater likelihood of longterm carriage for hepatitis B would be an indication for routine early immunisation, and preferably before admission to an institution. reason at
hospital because
Prudhoe Hospital, Prudhoe, Northumberland NE42 5NT
S. P. TYRER
Newcastle General Hospital
A. A. CODD
Clinical Pharmacology Department, University of Newcastle upon Tyne
R. G. THOMSON M. D. RAWLINS
Department of Medicine, University of Newcastle upon Tyne
P. F. W.
JAMES
1. Tevaluoto-Aarnio M. Epidemiology of hepatitis B antigenaemia in an institution for the mentally retarded. Scand J Infect Dis 1974; 6: 309-13. 2. Polakoff S. Incidence and prevalence rates in the UK. In: Short R, Jones G, eds Hepatitis B in the UK. London: Mark Allen, 1986. 4-7. 3. McGregor MA, Cowie VA, Wassef E, Veasey D, Munro J. Hepatitis B in a hospital for the mentally subnormal in South Wales. J Ment Def Res 1988, 32: 75-77. 4. McLaughlin MV. The prevalence of hepatitis B in a large residential population of female mentally handicapped persons. Eighth World Congress of the International Association for the Scientific Study of Mental Deficiency, Dublin, Trinity College, 1988 (abstr).
INTRAUTERINE ULTRASONOGRAPHY AND ENDOMETRIAL CANCER
SIR,-Dr Cruickshank and colleagues (Feb 25, p 445) report experience with vaginal endosonography in endometrial cancer. We have been estimating myometrial invasion of endometrial cancer, using an intrauterine probe (Aloka ASU-58 pistol-type scanner [75 MHz] in combination with Aloka SSD 520). The pistol-type scanner has a rotating probe, 7 mm in diameter and 284 mm long, with 90° and 120° visual angles. This equipment is convenient to use in association with dilatation and curettage. Immediately after dilatation to Hegar 8 the probe is inserted into the uterine cavity up the fundus. While the probe is withdrawn images are recorded on videotape. Since invading endometrial cancer is expressed by lower echogenicity on intrauterine sonographic images’ this procedure discloses the depth of any such malignancy present. Representative images from one such case are shown in the figure. The extent of invasion was confirmed histopathologically. We have used this procedure in seven patients with histopathologically proven endometrial cancer (table). Endosonography via the transvaginal or the intrauterine route to to
a
evaluate invasion of cancer into the uterine corpus seems to be a valuable and simple procedure, especially in differentiating between stages I and II.2 Preoperative evaluation of myometrial invasion by
Intrauterine ultrasound scans preoperatively on patient with stage I endometrial cancer (FIGO grade 3). Probe in top of uterine cavity ,top scan middle of cavity (centre), and isthmus region (bottomi Diffuse outline of cancer (in contrast to more echogenic borders of leiomyomas) is seen deeply and massively invading upper parts of uterus; invasion in lower uterus 1’-) more focal and less deep. 13 = bladder, M= myometrium, S = utrine serosa, C = cancer.
843 DEGREE OF MYOMETRIAL INVASION
applied regularly until the stump separates and signifies hope for a long life.2 Some cord-care regimens are unhygienic, such as the application of a piece of stone wrapped in wet cloth.3 Other practices have
favourable effect. The cord was seared with heat in China the Ming dynasty (Sheila Kitzinger, personal communication) and until recently a candle flame was used to sear the cord in Guateniala.4 This was reported to be the reason for the low incidence of neonatal tetanus in some areas of Guatemala. Neonatal tetanus remains a serious threat in developing countries. However, attempts to change local customs of cord care may be ineffective, especially when the infant is cared for by family members in the home, despite extensive educational programmes. Adequate immunisation of mothers may be more fool-proof and could emphasise the need for immunisation of the whole family a
during
the use of intrauterine ultrasound scanning may help to plan more selective therapy. The specificity and sensitivity of the method are now being evaluated. Department of Obstetrics and Gynaecology, University Hospital, S-581 85 Linkoping, Sweden
P. ROSENBERG O. M. HAKANSSON
against tetanus. Department of Paediatrics, Zuiderziekenhuis, 3075 EA Rotterdam, Netherlands
ANNE MARIE OUDESLUYS-MURPHY
Oudesluys-Murphy AM, Eilers GAM, de Groot CJ. The time of separation of the umbilical cord. Eur J Pediatr 1987; 146: 387-89. 2. MacCormack CP Health, fertility and birth in Moyamba district, Sierra Leone. In: MacCormack CP, ed. Ethnography of fertility and birth. London: Academic Press, 1.
1. Engelmeier K-H, Hecker R, Hotzinger H, Thiel H Automatische Kontursuche und Segmentierung von sonographischen Transversalschnittbildern des Uterus hinsichtlich einer optimiertern individuellen Isodosengestaltung bei Korpuskarzinomen. Strahlentherapie 1985; 161: 275-80. 2 Bemaschenk G Die endosconographische Diagnostik bei Uterusmalignomen. Ultraschall 1987; 8: 160-65.
VAGINAL ULTRASOUND
SiR,—Dr Cruickshank and colleagues (Feb 25, p 445) describe the use of vaginal endosonography in the preoperative assessment of patients with endometrial cancer. In the five cases presented ultrasound and histological findings correlated reasonably well. These findings may warrant thorough evaluation on a large group of patients so that sensitivities can be computed. However, Cruickshank et al suggest that there is a clear clinical advantage in having this information before surgery, in that selective therapy could be expected to improve the results of treatment. This statement cannot be justified because there are no data supporting the use of more radical surgery in high-risk cases. It seems unlikely that a more radical, but still local, procedure would enhance survival in a condition where death frequently results from distant relapse. It would also seem untenable to suggest that morbidity might be limited by preoperative assessment, allowing for more conservative approaches, when most gynaecologists (including, it seems, Cruickshank and colleagues) adopt total abdominal hysterectomy with bilateral salpingoophorectomy as their routine approach to endometrial cancer. The related fields of tumour imaging and tumour markers continue to produce novel and more sensitive approaches to cancer assessment. Improved survival and diminished morbidity depend upon such assessments being able accurately to direct effective therapies. Until the efficacy of treatments are proven, assessment strategies are unlikely to make any positive clinical impact. Maternity Department, Dudley Road Hospital, Birmingham B18 7QH
1982. 115
fertility aspects of Yoruba medical practice affecting In: MacCormack CP, ed. Ethnography of fertility and birth. London: Academic Press, 1982. 161. 4 Cosminsky S. Knowledge and body concepts of Guatemalan midwives. In: Kay MA, ed. Anthropology of human birth. Philadelphia: FA Davis Company, 1982: 233 3. Maclean U Folk medicine and women.
DETECTION OF BONE MARROW LESIONS
SiR,—Dr Reske and colleagues (Feb 11, p 299) describe radioimmunoimaging of bone marrow involvement in breast cancer and malignant lymphoma. They state that marrow lesions presented as focal defects in antibody uptake. Only selected lesions so detected were confirmed by computed tomography (CT) or histological examination. Hajek et aP found localised or spotty bone marrow alterations with the characteristics of fat in 60% of 158 magnetic resonance images (MRI) of the spine. This prevalence for focal fatty infiltration of haematopoietic vertebral bone marrow was reproduced in a study of healthy volunteers with MRI in our department (an example is shown in the figure). The diagnostic sensitivity for detection of bone marrow lesions is high for CT and even higher for MRP,2 but specificity remains moderated Thus the
DAVID LUESLEY
UMBILICAL CORD CARE AND NEONATAL TETANUS
SIR,-Dr Traverso and colleagues (March 4, p 486) report that repeated application of ghee to the umbilical cord in rural Pakistan increased the risk of neonatal tetanus. The higher frequency of neonatal tetanus with onset after the age of one week (but not before) in boys is interesting. A possible reason could be later cord separation in boys. We found’ that the sex of the infant was one factor which influenced the time of separation: the cord separated slightly later in boys. The later the cord stump separates the longer the umbilicus is a possible portal of entry for microorganisms,
including Clostridium tetani. In many countries the care of the umbilical cord is surrounded by deep-rooted customs and rituals. An example of this is the use of the "never die leaf" (Brophyllus pinnatum) in Sierra Leone. This is
Tl
weighted MRI of spine (SE 500/517) in normal healthy volunteer.
Arrows show high signal intesity which resembles focal fatty replacement of haematopoietic bone marrow.
region of the UK between 1982 and 1986 (the latest dates for which figures are available) is lower than that for England and Wales overall: 15 per 100 000 population compared with 31per 100 000 for the rest of the country, although the incidence is increasing (S. Polakoff, personal communication). Other factors that may have maintained the hospital free of infection are its rural setting, the small number of admissions to the hospital, and the fact that young children are no longer admitted to such institutions in the UK. Others have found a similar low prevalence of potential infectivity for hepatitis B in rural hospitals for the mentally handicapped.3,4It is not unlikely that we have a population vulnerable to infection but protected because of isolation. Our point is that there seems little present to urge wholesale immunisation of all staff in the of a future possible potential risk. The situation described by Dr French and his colleagues is different from ours and we support their policy of immunisation given their local circumstances. Accepting that the purpose of immunisation is to protect individuals against a perceived risk, and that within an institution this could be for both patients and their attendants, we do not disagree with the use of hepatitis B vaccine, where this is indicated on epidemiological grounds. Screening new entrants would be more cost-effective than wholesale immunisation of patients and staff and this approach could be considered for other long-stay institutions in which hepatitis B carriers have not been found. With respect to Down syndrome patients we agree with Dr Green’s point that their increased susceptibility and greater likelihood of longterm carriage for hepatitis B would be an indication for routine early immunisation, and preferably before admission to an institution. reason at
hospital because
Prudhoe Hospital, Prudhoe, Northumberland NE42 5NT
S. P. TYRER
Newcastle General Hospital
A. A. CODD
Clinical Pharmacology Department, University of Newcastle upon Tyne
R. G. THOMSON M. D. RAWLINS
Department of Medicine, University of Newcastle upon Tyne
P. F. W.
JAMES
1. Tevaluoto-Aarnio M. Epidemiology of hepatitis B antigenaemia in an institution for the mentally retarded. Scand J Infect Dis 1974; 6: 309-13. 2. Polakoff S. Incidence and prevalence rates in the UK. In: Short R, Jones G, eds Hepatitis B in the UK. London: Mark Allen, 1986. 4-7. 3. McGregor MA, Cowie VA, Wassef E, Veasey D, Munro J. Hepatitis B in a hospital for the mentally subnormal in South Wales. J Ment Def Res 1988, 32: 75-77. 4. McLaughlin MV. The prevalence of hepatitis B in a large residential population of female mentally handicapped persons. Eighth World Congress of the International Association for the Scientific Study of Mental Deficiency, Dublin, Trinity College, 1988 (abstr).
INTRAUTERINE ULTRASONOGRAPHY AND ENDOMETRIAL CANCER
SIR,-Dr Cruickshank and colleagues (Feb 25, p 445) report experience with vaginal endosonography in endometrial cancer. We have been estimating myometrial invasion of endometrial cancer, using an intrauterine probe (Aloka ASU-58 pistol-type scanner [75 MHz] in combination with Aloka SSD 520). The pistol-type scanner has a rotating probe, 7 mm in diameter and 284 mm long, with 90° and 120° visual angles. This equipment is convenient to use in association with dilatation and curettage. Immediately after dilatation to Hegar 8 the probe is inserted into the uterine cavity up the fundus. While the probe is withdrawn images are recorded on videotape. Since invading endometrial cancer is expressed by lower echogenicity on intrauterine sonographic images’ this procedure discloses the depth of any such malignancy present. Representative images from one such case are shown in the figure. The extent of invasion was confirmed histopathologically. We have used this procedure in seven patients with histopathologically proven endometrial cancer (table). Endosonography via the transvaginal or the intrauterine route to to
a
evaluate invasion of cancer into the uterine corpus seems to be a valuable and simple procedure, especially in differentiating between stages I and II.2 Preoperative evaluation of myometrial invasion by
Intrauterine ultrasound scans preoperatively on patient with stage I endometrial cancer (FIGO grade 3). Probe in top of uterine cavity ,top scan middle of cavity (centre), and isthmus region (bottomi Diffuse outline of cancer (in contrast to more echogenic borders of leiomyomas) is seen deeply and massively invading upper parts of uterus; invasion in lower uterus 1’-) more focal and less deep. 13 = bladder, M= myometrium, S = utrine serosa, C = cancer.
843 DEGREE OF MYOMETRIAL INVASION
applied regularly until the stump separates and signifies hope for a long life.2 Some cord-care regimens are unhygienic, such as the application of a piece of stone wrapped in wet cloth.3 Other practices have
favourable effect. The cord was seared with heat in China the Ming dynasty (Sheila Kitzinger, personal communication) and until recently a candle flame was used to sear the cord in Guateniala.4 This was reported to be the reason for the low incidence of neonatal tetanus in some areas of Guatemala. Neonatal tetanus remains a serious threat in developing countries. However, attempts to change local customs of cord care may be ineffective, especially when the infant is cared for by family members in the home, despite extensive educational programmes. Adequate immunisation of mothers may be more fool-proof and could emphasise the need for immunisation of the whole family a
during
the use of intrauterine ultrasound scanning may help to plan more selective therapy. The specificity and sensitivity of the method are now being evaluated. Department of Obstetrics and Gynaecology, University Hospital, S-581 85 Linkoping, Sweden
P. ROSENBERG O. M. HAKANSSON
against tetanus. Department of Paediatrics, Zuiderziekenhuis, 3075 EA Rotterdam, Netherlands
ANNE MARIE OUDESLUYS-MURPHY
Oudesluys-Murphy AM, Eilers GAM, de Groot CJ. The time of separation of the umbilical cord. Eur J Pediatr 1987; 146: 387-89. 2. MacCormack CP Health, fertility and birth in Moyamba district, Sierra Leone. In: MacCormack CP, ed. Ethnography of fertility and birth. London: Academic Press, 1.
1. Engelmeier K-H, Hecker R, Hotzinger H, Thiel H Automatische Kontursuche und Segmentierung von sonographischen Transversalschnittbildern des Uterus hinsichtlich einer optimiertern individuellen Isodosengestaltung bei Korpuskarzinomen. Strahlentherapie 1985; 161: 275-80. 2 Bemaschenk G Die endosconographische Diagnostik bei Uterusmalignomen. Ultraschall 1987; 8: 160-65.
VAGINAL ULTRASOUND
SiR,—Dr Cruickshank and colleagues (Feb 25, p 445) describe the use of vaginal endosonography in the preoperative assessment of patients with endometrial cancer. In the five cases presented ultrasound and histological findings correlated reasonably well. These findings may warrant thorough evaluation on a large group of patients so that sensitivities can be computed. However, Cruickshank et al suggest that there is a clear clinical advantage in having this information before surgery, in that selective therapy could be expected to improve the results of treatment. This statement cannot be justified because there are no data supporting the use of more radical surgery in high-risk cases. It seems unlikely that a more radical, but still local, procedure would enhance survival in a condition where death frequently results from distant relapse. It would also seem untenable to suggest that morbidity might be limited by preoperative assessment, allowing for more conservative approaches, when most gynaecologists (including, it seems, Cruickshank and colleagues) adopt total abdominal hysterectomy with bilateral salpingoophorectomy as their routine approach to endometrial cancer. The related fields of tumour imaging and tumour markers continue to produce novel and more sensitive approaches to cancer assessment. Improved survival and diminished morbidity depend upon such assessments being able accurately to direct effective therapies. Until the efficacy of treatments are proven, assessment strategies are unlikely to make any positive clinical impact. Maternity Department, Dudley Road Hospital, Birmingham B18 7QH
1982. 115
fertility aspects of Yoruba medical practice affecting In: MacCormack CP, ed. Ethnography of fertility and birth. London: Academic Press, 1982. 161. 4 Cosminsky S. Knowledge and body concepts of Guatemalan midwives. In: Kay MA, ed. Anthropology of human birth. Philadelphia: FA Davis Company, 1982: 233 3. Maclean U Folk medicine and women.
DETECTION OF BONE MARROW LESIONS
SiR,—Dr Reske and colleagues (Feb 11, p 299) describe radioimmunoimaging of bone marrow involvement in breast cancer and malignant lymphoma. They state that marrow lesions presented as focal defects in antibody uptake. Only selected lesions so detected were confirmed by computed tomography (CT) or histological examination. Hajek et aP found localised or spotty bone marrow alterations with the characteristics of fat in 60% of 158 magnetic resonance images (MRI) of the spine. This prevalence for focal fatty infiltration of haematopoietic vertebral bone marrow was reproduced in a study of healthy volunteers with MRI in our department (an example is shown in the figure). The diagnostic sensitivity for detection of bone marrow lesions is high for CT and even higher for MRP,2 but specificity remains moderated Thus the
DAVID LUESLEY
UMBILICAL CORD CARE AND NEONATAL TETANUS
SIR,-Dr Traverso and colleagues (March 4, p 486) report that repeated application of ghee to the umbilical cord in rural Pakistan increased the risk of neonatal tetanus. The higher frequency of neonatal tetanus with onset after the age of one week (but not before) in boys is interesting. A possible reason could be later cord separation in boys. We found’ that the sex of the infant was one factor which influenced the time of separation: the cord separated slightly later in boys. The later the cord stump separates the longer the umbilicus is a possible portal of entry for microorganisms,
including Clostridium tetani. In many countries the care of the umbilical cord is surrounded by deep-rooted customs and rituals. An example of this is the use of the "never die leaf" (Brophyllus pinnatum) in Sierra Leone. This is
Tl
weighted MRI of spine (SE 500/517) in normal healthy volunteer.
Arrows show high signal intesity which resembles focal fatty replacement of haematopoietic bone marrow.