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We present a patient with systemic lupus erythematosus receiving long-term steroid therapy, who had myometrial thinning, markedly thickened placenta, and fetal growth restriction (FGR). Blood flow profiles of the myometrium, decidua and placental villous vessels (VV) were described using superb microvascular imaging (SMI) at 35 weeks' gestation. Images showed no decidual blood flow underneath the placenta sitting on a thin myometrium and sparse VV distribution and non-visualization of peripheral VV flow. Emergency cesarean hysterectomy was performed at 36 weeks. Histological findings showed missing decidua on the thin myometrium, which indicated placenta accreta spectrum, and massive perivillous fibrin deposition and increased numbers of syncytial knots in the placenta. We speculated that the thick placenta and peculiar VV flow profiles resulted from congestion of the intervillous space and intervillous underperfusion/low intraplacental oxygenation, respectively, resulting in FGR. Superb microvascular imaging is useful for diagnosing placenta accreta spectrum and understanding the pathophysiology of thick placenta and FGR.

We present a case of a 34-year-old pregnant woman with a prior cesarean delivery presenting with placenta previa. Placenta previa accreta was diagnosed from missing decidual flow signals using superb microvascular imaging (SMI). At 31 weeks' gestation, B-mode ultrasonography showed that the placenta was attached to the anterior uterine segment, extending over the internal cervical os. In normally appearing myometrium, SMI demonstrated double layers of flow signals underneath the placental basal plate, corresponding to myometrial and decidual flows. The thin myometrium located on the bladder where sonolucent zones were not visible revealed three different flow patterns in the Doppler signals underneath the basal plate as follows: double layers (both myometrium and decidual tissues present); a single layer (myometrium alone) or no layers (decidual tissues missing). A cesarean hysterectomy was performed at 37 weeks, and histology confirmed the presence of placenta accreta.

The term "MELF-pattern myometrial invasion" (MELF pattern) denotes an unusual morphology of myometrial invasion in endometrioid carcinomas, and is associated with frequent lymphovascular invasion and lymph node metastasis. In this study, tumor cells were directly collected from a MELF pattern site, using laser microdissection. Comprehensive microarray analysis of the genes was conducted, and based on the results, expression of a metastasis progression gene, CXCR4, and its ligands CXCL14 and CXCL12, was further investigated. In vitro studies of endometrioid carcinoma cell lines revealed elevated invasion activity in a manner dependent on the CXCL14-CXCR4 or CXCL12-CXCR4 axis. Immunohistochemical analysis of 93 (MELF group, 46; non-MELF group, 47) cases illustrated CXCR4 was expressed in all endometrioid carcinomas, while based on CXCL14 and CXCL12 expression score, high proportions of cells were positive at the sites of the MELF pattern (P