Recent advances in hysterography

RECENT THOUS

0.

ADVANCES MENEES,

IN HYS,TEROGRAPHY

M.D., GRAND

AED

RAPIDS,

J.

DUAKE

MILLER,

M.L).,

MICH.

M

OST of the previous roentgen studies of the uterus have been made during the course of investigations for tubal patency. This has been done, for the greater part, with iodized oils which have yielded very satisfactory shadows, indicating the size, shape, and tonicity of the uterus. Sometimes intrauterine lesions were demonstrated. The method, therefore, was extended to the investigation of the uterus itself. However, on complete filling of the cavity with contrast material, the density of the medium was so great that small lesions were often obscured or the irregularities of contour obliterated by the pressure employed. Some technical difficulties were occasionally experienced in keeping the medium in the uterus while changing the patient’s position. Also, there were certain dangers attending its use when recent bleeding had occurred. Last year we reported the development of a contrast medium for the roentgen demonstration cf the relief of the endometrium. A thorium hydroxide solution has been used for this purpose. On contact with alkaline mucus the solution is converted to a gel which adheres to the surface, thus applying a radiopaque coating. is placed in stirrups. After soap We have used the following technic : The patient and water preparation, a bimanual examination is made to rule out pregnancy and active pelvic inilammatory disease. A large bivalve speculum is inserted, the cervix cleansed with alcohol, and the posterior lip grasped with a tenaculum. Two or three small graduated dilators are passed, dilating the cervix sufficiently to insure a free return of fluid around the cannula. About 20 CC. of the medium are slowly injected into the uterine cavity allowing the excess to run back into the vagina as injection proceeds. The cannula is then removed and the remaining material wiped from the vault with gauze. It is advantageous to leave the coagulum adhering to the portio. The speculum is removed leaving the tenaculum in place and the patient transferred to the radiologic table. One anteroposterior film is taken on the Potter-Bucky diaphragm and developed at once. A sufficient quantity of contrast material usually adheres to the endometrium to cast a satisfactory shadow on the film. Occasionally the shadow is too faint and the injection must bc repeated; or too dense, in which case expulsion of the excess can be promoted by allowing the patient to walk about for a few minutes. If the film is satisfactory, right and left oblique and posteroanterior exposures are made.

The roentgenograms const,itute a record of the surface markings of the endometrium and show a considerable amount of detail previously unobtainable. 590

MENEES-MILLER

Examination 1. The

contour

2. The surface latticed appearance the cycle progresses longitudinal 3. The distance. 4. The

:

591

HYSTEROQRAPHY

of a normal uterus in this manner shows: of the

uterine

cavity.

markings of the endometrium. These produce a mottled or finely when the examination is made shortly after menstruation. AS the markings become coarse and the endometrium is thrown into

folds. cervical canal. It is normally portio

frequently

The longitudinal smooth and regular shows

on the

folds may in outline.

extend

into

it for

a variable

plates.

Certain pitfalls have been encountered during the course of our work which may lead to errors in or interfere with the radiologic diagnosis. We have previously warned against the introduction of air. An air bubble can product a clear rounded shadow similar to a polyp. Atten-

Fig.

1.--A,

Hysterogram truding

showing into the

small fundus

polyp in the fundus. resembling a large

B, Small polyp.

flbroid

pro-

tion has also been called to the necessity of a free return of the excess fluid around the cannula in order to prevent, if possible, the passage of solution through the tubes. We have seen no serious effects from spill into the peritoneal cavity, but coufusin g shadows are produced by deposit of the material out,side of the uterus and tubes which make the plates unsatisfactory fcr diagnosis. Contrast material in the tubes does not usually int,crfere with the study. In one case with retrodisplaced uterus, it did cause confusing shadows. The material deposited in this manner remained in the tubes for three weeks. It was our impression that we had demonstrated a hydrosalpinx. Examination of the specimen removed at operation sbowed this to be a,n endometriosis of the tubes. The presence of opaque material in the gastrointestinal tract may prevent a satisfactory examination. One such case occurred in which the defect produced by the bulging of a fibroid into the uterine cavity, aLs

592

AMERICAN

JOURNAL

OF

OHS’IT’I’RICG

AND

GTNIZCOLOGY

well as an irregularity of the surface immediately below t,hat poillt, caused by an early carcinoma, were ohscurcd on all but one plate by t,he presence of a bismuth mixture in t,hc colon. Satisfacatory examination of the latter area is quite impossible ~11this acconnt.

d. Fig.

2.---A,

Hyperplasia. Kotf! regularity (adenocarcinotna).

4 Fig. 3.--A, Uterine fibroid. Examimtiun gram of same case six months following

IT. of uter;ne contour. Note irregulxrity of

B, Advanred shadow.

malignam,)

B. on xccount of profuse bleeding. R. Hysteroradium twatmmt. Patient symptom free.

In case of large pelvic tumors wc have found the met,hod useful in differentiating between those displacin g t,he uterus and those involving it. The former are characterized by the presence of a uterine shadow

MENEES-MILLEK

:

593

HTSTEKOORAPHT

of normal size and shape in an abnormal position. The latter show va‘ rYing degrees of distortion of the uterine cavity. The examination of cabes in which intr:;uterinc lesions were susped ;ed has yielded much intcrestin g information. Hyperplasia has been di; sg-

A.

Fig.

Fig.

4.-A,

radium

5.-A,

cornu.

Malignancy application;

Demonstration B, Good

B.

in cornu of uterus (adenocarcinoma). radium tube held in the inwlred comu

of unsuccessful attempt to place application of radium showing tubes

B, Demonstration close to the lesion

one radium in proper

of

tube in e ach position.

nosed by extreme enlargement of the folds without loss of smooth otutline. With the broadening of the folds there is a corresponding decre ase in their number.

59-t

AMERICAN

.JOUR,NAL

OF

OXWJ’tiTRT(‘S

AND

OY NEt’OLOGT

Frequently snmH polppoid elovatious ilrc showu on such films in t,hc form of tiny, smo:,thly rounded shadows, Larger polyps have beer1 located in other cases. They arc characterized by clear circular shadows surrounded by rings of cont.rast material. 11’ l.he hnw of the [Jd;vl’ is broad it may be caught in profile on some of the films. Small submucous fibroids, if protrudin, 0’ far inlo Ihe uterine cavity, may produce the same type of shadow. The indent at ioil caused by protrusion of most submucous fibroids is sharp]!7 drfined and with smooth margins. The cndometrium is stretched and shows a few faint markings over the lesion. l-larger fibroids show marked dt!formity of’ the cavity on the films. Some cases (of fibroids) hart been examined six months after radium treatment. Marked shrinking of the lesion has been shown wit,h decrease in size of the cavity and atrophy of the endometrium. On account of the unusually smooth surface and the diminished production of mucus, ver) little contrast material will adhere to the surface and the shadows arc faint. Other defects in the shadow of the corpus have been detected. They do not produce the clean-cut margins characteristic cf fibroids. Endometrioma has been found and masses of retained products located. In case of small flat lesions, like the former, we feel t,hat radiologic diagnosis alone is not safe and that immediate biopsy is indicated. In the latter instance the ovoid shape of the cavity is the clue to diagnosis. Carcinoma produces irregularity in the uterme outline. In the cervical canal the early lesion exhibits only a localized narrowing and slight irregularity. Occasionally a sma.11 crater can be demonstrated. In more advanced lesions the shadows may be broader, the margins more irregular and deep ulceration shown by flecks of material which have penetrated into the small crevices. The margins of the lesion are frequently elevated. By defining the local limits of the iesion and its depth of ulceration, we have felt that the quantity and distribution of radium could be more accurately gauged. The proper application of the radium tubes can be accurately demonstrated by injecting immediately before or after radium insertion. The outline of cervix and corpus can be shown, the limits of the local lesion defined: and the relation of the radium tubes to the lesion demonstrated. In the body of the uterus, carcinoma produces only slight irregularity of outline in its early stages. Crn.ter formation has been shown in the region of the internal OS. Advanced lesions produce increasing irregularity with evidence of erosion. Radium application is more difficult without plates for control as the radium might easily be placed far This point is well illustrated from the lesion in the enlarged fundus. by the following case:

MENEES-MILLsER

Mrs. months. showed diagnosis

:

.595

HTSTERO~RAPHI

C. D., aged fifty She had passed a large irregular of adenoearcinoma.

years, gave a history of irregular bleeding for eighteen the climacteric seven years previously. Tlie hysterogram defect of the fundus. Biopsy from this area proved the This patient was a poor operative risk and radium A 50 mg. tube of radium attached t,reatment was seleetecl as the method of choice. to an empty tube to hold it in position in the fundus was inserted into the uterine cavity and the lower tube fixed to the cervix with a clip. Fortunately it passed into its proper position close to the lesion. Treatment was given in this manner Aft,er a twenty-four-hour rest, two tubes, each containing 50 mg., for 600 mg. hours.

were fastened to wire applicators and inserted at angles designed to pass one into each cornu. A cheek of the placement showed both tubes in the same cornu, the second one slightly lower than the first inserted. The second tube, therefore, was removed, the applicator wire bent to a difforent angle and inserted in proper position. Both were fastened by a lead clip at lhe cervix. It is easy to understand how the radium might all bc placed more than 2 cm. from the lesion in cases similar to this and the greater poor results

part of obtained

the benefit of treatment lost. This ma.y from irradiation of lesions in the fun&s.

explain

some

of

the

SUMMARY

1. A recent method of hysterography has been described which permits the demonstration of the surface markings of the endometrium. 2. Findings on investigation of cases of uterine bleeding have been described. The result,s have been checked by biopsy or by gross and microscopic examination. 3. Some results of irradiation have been shown. 4. A technic for demonstrating placement has been discussed.

Qu6nu Sot.

J., and d’Obst.

B&l&e, C.: et de Gyn4e.

the control

Metrorrhagia 23:

686,

in

Young

and accuracy of radium

Women

and

Curettage,

Bull.

1934.

The authors curetted 30 young women for metrorrhagia. In 21 per cent of the cases as definite causes for the excessive bleeding were discovered: cancer of the body of the uterus, small submucous fibroids, polyps, and dermoid cysts. In 78 per cent of the cases no histologic lesions could be demonstrated. However, in :nore than half of these cases there existed a chronic infection of the genitalia most likely responsible for the bleeding. In not a single instance did curettement lead to any complication. A follow-up after seven years showed that five patients had to have further operations because the bleeding returned. Four were operated upon and one was treated I)y roentgen ray therapy. In five more patients irregular bleeding recurred but apparently no further treat,ment,s were given. In two women the profuse bleeding ceased but abdominal pains persisted. Only in seven women did the menstrual periods become regular and normal. Four of these patients subsequently became pregnant. This means that 50 ptr cent of the pztiznta had recurrences. Therefore, eurettement alone is not a satisfaeiory treatment. J. P. GREENHILL.