Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2012 | Month : April | Volume : 6 | Issue : 2 | Page : 313 - 315

Submucosal Leiomyoma in a Woman with Post–menopausal Bleeding – Diagnostic Dilemma, Ultrasound vs MRI: A Case Report

Rajneesh Madhok, Neera Agarawal, RuchiCa Goel

1. Department of Radiodiagnosis, Shri Ram MurtiSmarak Institute of Medical Sciences, Bareilly-243202, Uttar Pradesh, India. 2. Manas clinic & Infertility center, Janakpuri, Bareilly, India. 3. Department of Obst&Gynae, Shri Ram MurtiSmarak Institute of Medical Sciences, Bareilly-243202, Uttar Pradesh, India.

Correspondence Address :
Rajneesh Madhok, Department of Radiodiagnosis, Shri Ram
MurtiSmarak Institute of Medical Sciences, Bareilly-243202,
Uttar Pradesh, India.
Phone: 91-9897606172; Fax: 91-581-2582010


Introduction: We are reporting a case of submucosal leiomyoma in a post-menopausal women with a history of bleeding, which mimicked endometrial hyperplasia on ultrasound and was considered as a case of endometrial carcinoma.

Case Presentation: A 44-year-old female who had attained menopause 04 yrs back, presented with on and off bleeding per vagina since one month. An ultrasound which was done outside our hospital, reported a markedly hypertrophied endometrium (24mm). She was not on any hormonal medications. Endometrial carcinoma was considered as a cause. Dilatation and curettage was done and the histopathology report showed atypical cells which were suggestive of malignancy. She was referred for MRI of the pelvis for further evaluation. The MRI was suggestive of a large, pedunculated, submucosal leiomyoma which protruded into the endometrium. A panhystrectomy was performed and the histopathology reports confirmed the leiomyoma.

Conclusion: Ultrasound, as an initial modality of imaging, was not able to differentiate between the marked endometrial hypertrophy which was considered as endometrial carcinoma and the submucosal leiomyoma. MRI was helpful in reaching the diagnosis.


Submucosal leiomyoma. Endometrial carcinoma

Bleeding is the most common symptom of the endometrial carcinoma in post-menopausal woman. A transvaginal sonography or /and endometrial biopsy is performed as the initial procedure of the choice for the evaluation of the post-menopausal bleeding. An endometrial thickening which is seen on ultrasound is a non-specific finding. MRI can be helpful in further differentiating the causes of the endometrial thickening. The presence of a myometrium invasion should suggest a diagnosis of endometrial carcinoma or some other uterine malignancy. The diagnosis of benign lesions on MRI is favoured by a lack of invasion of the myometrium, the presence of a fibrous core and a well-defined sessile or pedunculated mass or the presence of an endometrial cyst.

Case Report

A 44-year-old woman had attained menopause 04 yrs back and she presented with on and off bleeding per vagina of one month’s duration. An ultrasound which was performed, reported a hypertrophied endometrial (approx width 24 mm). She was considered to be a case endometrial carcinoma and was subjected to a diagnostic dilatation and curettage. Her histopathology report revealed atypical cells which were suggestive of malignancy. The ultrasound was repeated after a few days and a similar status of the hypertrophied endometrium was reported. She was referred for MRI for further evaluation. The MRI study showed a large (approx size 3.5 × 2.4 cm), well-defined, hypointense mass on the T2Wt image, which was found to occupy the endometrial cavity and it was surrounded by a thin hyperintense fluid layer all around it, except on its left lateral location,Reportwhich showed flow voids entering into it from the left side of the adnexa. This led to the interpretation that it was a submucosal mass which protruded into the endometrial region with a small vascular pedicle at the left lateral aspect and that it was wrapped by the endometrium which was seen as a hyperintense layer all around it, except at the level of the pedicle, which had protruded towards the endometrium. The mass was found to be isointense on the T1Wt image, which was non-contributory. The diffusion B1000 images showed no brightness in the lesion and the thin layer of endometrium became less bright, which was suggestive of the presence of fluid in the endometrium. The ADC (apparent diffusion coefficient) showed a high value (1.036x10-3 mm2/sec) in the lesion, which was suggestive of a benign pathology. The ADC values are low (0.766 x 10–3mm2/ sec) in endometrial carcinoma. An MRI diagnosis of a submucosal leiomyoma with a vascular peduncle was made.

She was retrospectively reviewed by ultrasound and it showed a large slightly hyperechoic mass occupying the entire endometrial region, which was surrounded by a thin echogenic rim. It was difficult to make to differentiate between the hypertrophied endometrium and the submucosal fibroid. She was operated and the histopathological report confirmed the leiomyoma.


Leiomyomas (also called fibroids) are the most common uterine tumours. The incidence of leiomyoma by the age of 50 is more than 80% in pre-menopausal women (1). They shrink after menopause, in the absence of post-menopausal oestrogenreplacement therapy, as they are oestrogen dependent tumours (2). The post-menopausal incidence of leiomyomas is not lower than the premenopausal incidence, although post-menopausal leiomyomas are smaller and fewer (3). Leiomyomas are benign, well circumscribed, smooth muscle cell neoplasms and they are sharply demarcated from the surrounding myometrium or endometrium, depending upon their locations. Leiomyomas can be submucosal, intramural, subserosal or cervical in location. The least common of the various types of fibroid tumours are the submucosal fibroids (5%) (4). Submucous leiomyomas are located just under the uterine mucosa (endometrium) and they may be either pedunculated or sessile. The two most common symptoms of fibroids are abnormal uterine bleeding and pelvic pressure. Although abnormal bleeding can occur with any of the three classes of fibroids, women with submucous fibroids seem to be particularly prone to this complication. Some fibroid tumours don’t produce any symptoms at all.

Ultrasound remains the initial modality of choice for patients with suspected leiomyomas. However, ultrasound is neither as sensitive nor as specific as MRI. Ultrasound may not be able to differentiate leiomyomas from adnexal masses, congenital anomalies or fibroid like conditions, like adenomyosis, an endometrial polyp or a mass like appearance of the endometrial carcinoma. Although endovaginal ultrasonography increases the sensivity and the specificity of ultrasound in identifying and localizing leiomyomas, in our case, the ultrasound investigation could not differentiate submucosal leiomyoma from endometrial hyperplasia. MRI is the most accurate imaging technique which can be used for the detection and the localization of leiomyomas (5). The leiomyomas usually appear on the T2Wt images as sharply marginated homogeneous areas of decreased signal intensity (6). MRI may be used to identify the prolapsed submucosal leiomyomas with pedicles and it is helpful in identifying their vascularity, as in our case. The mean ADC value is further helpful in differentiating leiomyomas from endometrial carcinomas. 3Tesla MRI is better in determining the depth of the myometrial invasion of the endometrial carcinoma and it is equivalent to the use of 1.5Tesla MRI. Higher tesla MRI has a spatial Resolution and it provides a high gradient diffusion wt body imaging, which low tesla (0.2-0.5 Tesla) lacks. Our study was performed by using 3Tesla Siemens MRI.

A dynamic multiphase contrast study is performed for the staging of the endometrium carcinoma. The advantage is that it is more accurate than the T2Wt imaging for the assessment of the myometrium invasion, but the pitfall is that there is loss of junctional zone definition and that the band of subendometrial enhancement is seen in only 50-60% of the cases. A contrast study was not performed in our case. In endometrial carcinoma, the uterus may appear entirely normal or the endometrial stripe may appear to be homogeneously widened (>08mm) in post-menopausal women (7). In our case, the entire endometrium appeared to be thickened (24 mm) and hence, a diagnosis of endometrial hyperplasia (? endometrial carcinoma) was made, based on the ultrasound investigation. Alternatively, a heterogeneous signal intensity mass may be seen to be distended in the endometrial cavity. MRI is not recommended as a screening procedure in the diagnosis of endometrial carcinoma. On the T2Wt images, their signal intensity is commonly hyperintense; however, this is quite variable. Myometrial invasion is best visualized on the T2Wt images, where it appears as a disruption or an irregularity of the junctional zone which is caused by a mass of intermediate signal intensity. Diffusion-weighted MRI (DWI, b = 0 & 1000 sec/mm2) shows brightness in endometrial carcinoma and the mean ADC values are significantly lower in endometrial cancer (0.766 +/-0.16 x 10–3mm2/ sec) (8). It may also be able to demonstrate malignant tumours. The ADC value of the normal endometrium is 1.53 +/- 0.10 10-3 mm2/s and in endometrial hyperplasia, it is 1.27 +/- 0.22 10-3 mm2/sec. In our case, the mean ADC value was high (1.036x10-3 mm2/sec). DWI can provide excellent tissue contrast, based on the molecular diffusion and it may be able to demonstrate malignant tumours. Quantitative measurement of the apparent diffusion coefficient (ADC) may be valuable in distinguishing between the malignant and benign endometrial lesions. The DWI and ADC values provide additional information when they are added to the conventional MRI findings.

On MRI, the signal intensity of the endometrial polyps on the T2Wt images tends to be higher than that which is seen in endometrial carcinoma. The presence of a central focus of low signal intensity on the T2Wt images indicates a fibrous core, which suggests the diagnosis of an endometrial polyp (9). Although these imaging features can help in distinguishing polyps from endometrial carcinomas, they are often not specific enough to avoid the need for a biopsy. Moreover, these two conditions frequently coexist. In its focal form, adenomyosis appears as an ill-defined, poorly marginated area of a low signal intensity within the myometrium on the T2Wt images, whereas leiomyomas often appear as well-circumscribed masses. Small foci of high signal intensity in adenomyosis on the T2Wt images represent the endometrial glands. Some of these ectopic foci of the endometrium also have a high signal intensity on the T1-weighted images, a finding that corresponds to haemorrhage.


MR imaging is currently considered as the most accurate imaging technique for the detection and localization of leiomyomas. Because of its ability to clearly demonstrate individual tumours, MR imaging has been shown to be more sensitive than ultrasound in the detection of leiomyomas.


Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyomas in black and white women: ultrasound evidence. Am J Obstet Gynaecol. 2003 Jan;188(1):100-7.
Rein MS, Barbieri RL, and Friedman AJ. Progesterone: a critical role in the pathogenesis of uterine myomas. Am J Obstet Gynaecol 1995; 172:14-18.
Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol. 1990 Oct;94(4):435-38.
Panageas E, Kier R, McCauley TR, McCarthy S. Submucosal uterine leiomyomas: diagnosis of the prolapse into the cervix and vagina based on MR imaging. AJR 1992; 159:555-58.
Ueda H,Togashi K, Konishi I, et al. Unusal appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics 1999;19 Spec No:S131-45.
Zawin M, McCarthy S, Scoutt LM, Comite F. High-field MRI and US evaluation of the pelvis in women with leiomyomas. Magn Reson Imaging 1990; 8:371-76.
Chaudhary S, Reinhold C, Guermazi A, Khalili I, Maheshwari S. Benign and malignant disease of the endometrium. Top Magn Reson Imaging 2003; 14:339-57.
Lin Y-C, Lin G, Chen Y-R, Yen T-C, Wang C-C, Ng K-K. Role of magnetic resonance imaging and the apparent diffusion coefficient at 3t indistinguishing between adenocarcinoma of the uterine cervix and theendometrium. AJR February 2008; 481. 190.
Grasel RP, Outwater EK, et al. Endometrial polyps: MR imaging featuresand its distinction from endometrial carcinoma. Radiology2000;214: 47-52.

DOI and Others

DOI: JCDR/2012/4152:1999


Date Of Submission: Feb 14, 2012
Date Of Peer Review: Mar 04, 2012
Date Of Acceptance: Mar 21, 2012
Date Of Publishing: Apr 15, 2012

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