Utilidad de la resonancia magnética en la estadificación prequirúrgica del cáncer de endometrio

Objective

To evaluate the usefulness of magnetic resonance imaging (MRI) for preoperative staging of endometrial carcinoma.

Materials and methods

We performed a retrospective study of 71 endometrial neoplasms diagnosed in Hospital Sant Joan de Déu. The results of preoperative MRI scans were compared with those of the definitive histological examination.

Results

The preoperative stage obtained by MRI and the final stage were concordant in 69% of cases.

Conclusion

MRI is the most useful diagnostic method for preoperative staging of endometrial carcinoma     

Evaluación morfológica endometrial histeroscópica

Objective

To determine the prevalence of endometrial hyperplasia and adenocarcinoma in distinct groups of endometrial morphology defined by hysteroscopy, and to study the validity of hysteroscopic diagnosis in identifying endometrial tumors.

Materials and methods

We performed a prospective study of 830 hysteroscopies carried out between June 1, 2004 and December 31, 2005 in the Gynecology Outpatient Clinic of Hospital Donostia in San Sebastian, northern Spain. Hysteroscopy was used to classify endometria into atrophic, hypotrophic, active, hypertrophic, suspicious for adenocarcinoma and adenocarcinoma, according to a series of morphological criteria. The findings were later correlated with the histopathological diagnoses obtained through endometrial biopsy.

Results

The sensitivity, specificity and negative predictive value (NPV) of hysteroscopic evaluation of endometrial morphology in diagnosing malignant and premalignant disease were extremely high. Sensitivity was 87.5% (95% CI 0.753-0.941), specificity was 94.8% (95% CI 0.925-0.965) and NPV was 98.7% (95% CI 0.971-0.994). The specificity of morphological diagnosis of adenocarcinoma was 99.9%, sensitivity was 74.3%, and the likelihood ratio for a positive result was 625,486. When the groups of adenocarcinoma and suspicious for adenocarcinoma were combined, sensitivity was 100% and specificity was 96.3%.

Conclusions

The prevalence of premalignant disease is very low in the hysteroscopic morphological groups of atrophic, hypotrophic and active endometria. Premalignant disease is slightly more prevalent in hypertrophic endometria and is significantly more prevalent in cases in which the hysteroscopic diagnosis is of suspicious adenocarcinoma and adenocarcinoma. In these cases, the prevalence of adenocarcinoma is very high. Hysteroscopic evaluation of endometrial morphology alone, without biopsy, is a valid tool to exclude or confirm endometrial disease in some groups.     

Evaluation of the accuracy of intra-operative gross examination for the surgical management of endometrial cancer

Objective

The aim of this study was to explore the clinical value of intra-operative gross examination for the surgical management of endometrial carcinoma.

Study design

A retrospective study was conducted in 424 women who underwent surgical treatment for endometrial carcinoma between January 2002 and December 2006. The results of myometrial invasion and cervical infiltration as assessed by intra-operative gross examination were compared with the final microscopic histopathological results in 401 patients. The accuracy, sensitivity, and specificity were calculated. Chi-squared or Fisher’s exact tests were used for the comparison of categorical variables.

Results

Intra-operative gross examination correctly identified the depth of microscopic myometrial invasion in 90.3% of patients. The sensitivity in detecting myometrial invasion was 80.6% and the specificity was 92.4%. With regard to cervical involvement, gross examination had an overall accuracy of 84.3%. The sensitivity in detecting cervical involvement was 32.6% and the specificity was 99.0%. Usually, cervical involvement cannot be correctly identified by intra-operative gross examination in patients with diffuse foci.

Conclusion

The data suggest that intra-operative gross examination is a simple and good method of predicting myometrial invasion, but it may not be the ideal way to assess cervical involvement in endometrial carcinoma.     

Preoperative assessment of myometrial and cervical invasion in endometrial carcinoma by transvaginal ultrasound

Objective

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in preoperative assessment of the depth of myometrial infiltration and the presence of cervical invasion in endometrial carcinoma.

Methods

298 consecutive patients with a diagnosis of endometrial cancer were evaluated by TVS within 3 days of surgical intervention. The depth of myometrial invasion was classified into two groups: no or < 50% invasion and ≥ 50% invasion. Invasion of cervix was diagnosed when the neoplastic tissue distended the cervix and showed ill-defined borders with the cervical stroma.

Results

The sensitivity, specifity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy of TVS in evaluation of the depth of myometrial infiltration were 68.4%, 82%, 65.1%, 84.1% and 77.5%, respectively. While the sensitivity and PPV were significantly higher among grade 3 tumors, the specifity, NPV and accuracy were significantly higher among grade 1 tumors.The sensitivity, specifity, PPV, NPV, and overall diagnostic accuracy of TVS in assessment of the presence or absence of neoplastic tissue in cervix were 76.5%, 99.3%, 86.7%, 98.2% and 98%, respectively. While the sensitivity and PPV were significantly higher among grade 1 tumors, the NPV and accuracy were significantly lower among grade 3 tumors.

Conclusion

TVS can be considered as a feasible, economical and simple imaging modality with a high diagnostic accuracy for the prediction of cervical involvement. However, it is not a reliable method in estimating the depth of myometrial infiltration.     

Aplicabilidad de la técnica de identificación y biopsia del ganglio centinela en el cáncer de vulva

Objectives

To assess the percentage detection of sentinel-lymph-node in vulval cancer, its sensitivity and negative predictive value (NPV). To ascertain the adverse effects of this technology and long term relapses of tumour.

Material and methods

Systematic review of literature and subsequent critical appraisal of the evidence.

Results

A total of 29 studies were selected, all of which were observational in nature. The sentinel lymph node was detected by Tc⁹⁹-colloid and combined technique in 98% of patients. The percentage of false negatives observed was less than 2%, the sensitivity values and NPV were over 95% and the lymph node relapse rate around 3%.

Conclusions

Sentinel-lymph-node technique would seem to be a reasonable alternative to inguinal lymphadenectomy in patients with early stages of vulval cancer. When it comes to implementing the technique, a series of factors must be borne in mind with respect to the work team, patient selection, detection technique, surgical and anatomopathological techniques and learning curve.     

Concurrent endometrial carcinoma following hysterectomy for atypical endometrial hyperplasia

Objective

To evaluate the prevalence of concurrent endometrial carcinoma in women diagnosed with atypical endometrial hyperplasia (AEH) by endometrial biopsy.

Study design

We retrospectively analyzed the medical records of 126 patients who underwent hysterectomies for AEH diagnosed by endometrial biopsy from 1999 to 2008. AEH was initially diagnosed by dilatation and curettage (98 cases) or endometrial biopsy with a Z-sampler (24 cases). The remaining four cases were diagnosed by hysteroscopic polypectomy. The results of the endometrial biopsies were graded on an ordinal scale and were compared with pathologic features obtained at the hysterectomy.

Results

In patients preoperatively diagnosed with AEH by biopsy, hysterectomy specimens revealed a rate of simple or complex endometrial hyperplasia without atypia of 27% with AEH and normal proliferative phases found in 54.7 and 7.9% of specimens, respectively. The incidence of endometrial carcinoma was considerably high (13/126, 10.3%). Eleven of 13 cases were confined to the endometrium and the remaining two were located at the adenomyosis without myometrial invasion. All patients with endometrial carcinoma displayed coexisting atypical complex hyperplasia following hysterectomy.

Conclusions

Biopsy specimens showing AEH, particularly atypical complex hyperplasia, are associated with a risk of coexisting endometrial carcinoma. When considering management strategies for women with a biopsy diagnosis of AEH, clinicians should take into account the considerable rate of concurrent endometrial cancer and the discrepancy with pathologic diagnosis. Treatment modalities may differ depending on population as the rates of concurrent endometrial cancer with AEH and myometrial invasion vary by geographical location.     

Utilidad de la determinación del virus del papiloma humano en el primer control tras una conización

Objective

To estimate the negative predictive value of human papilloma virus (HPV) status in the first visit at 3 months after conization.

Material and methods

We evaluated the first follow-up visit in 208 patients who underwent conization in Hospital Donostia between January 1, 2003 and December 31, 2006.

Results

The negative predictive value of HPV status at 3 months after conization was 97.99% (95% CI 95.40-100), the positive predictive value was 47.92% (95% CI 32.74-63.09), sensitivity was 88.46% (95% CI 74.26-100) and specificity was 85.38% (95% CI 79.79-90.97).

Conclusions

Negative HPV status 3 months after conization is useful to evaluate cervical disease and could reduce the number of cytological examinations.     

Primeros resultados de la disección del ganglio centinela en los carcinomas epidermoides vulvares

Objective

The aim was to analyse our first results in the sentinel lymph node procedure in vulvar cancer, as regards the detection rate, false negative cases and relation with cancer recurrence or not.

Material and methods

Retrospective study of first 9 cases of sentinel lymph node detection in vulvar squamous cell carcinoma, between June 2004 and December 2007.

Results

We identified the sentinel node in 8 out of 9 patients (88% detection rate). There were no false negative cases, giving a negative predictive value of 100%. Only one patient with a negative sentinel node died of vulvar cancer. She also had Fanconi anaemia.

Conclusions

Sentinel lymph node detection in patients with squamous cell carcinoma of the vulva is feasible, and can be an alternative to conventional inguinofemoral lymphadenectomy.     

Magnetic resonance imaging to identify risk of lymph node metastasis in patients with endometrial cancer

Objective

To assess the value of magnetic resonance imaging (MRI) to identify endometrial cancer patients at risk of lymph node metastasis.

Methods

Retrospective review of data from 108 patients with clinical stage I endometrial cancer who underwent preoperative MRI and were treated surgically. Patients at risk of lymph node metastasis were defined as those who had more than 50% myometrial infiltration or cervical invasion. Preoperative MRI reports were compared with final pathologic results.

Results

The mean age of the patients was 69.5 years and most patients had endometrioid cancer. On final pathologic analysis, 59 patients had deep myometrial infiltration or cervical invasion. For diagnosis of deep myometrial infiltration, cervical invasion, or both, MRI sensitivity and specificity were 56% and 85%; 47% and 83%; and 67% and 77%, respectively.

Conclusion

MRI has limited value in identifying patients with endometrial cancer who are at risk of lymph node metastasis. Minimally invasive laparoscopic lymph node staging should be undertaken when it is feasible.     

Accuracy of frozen-section examination for myometrial invasion and grade in endometrial cancer

Objective

To evaluate the accuracy of frozen section (FS) analysis in endometrial cancer.

Study design

The medical records of 816 patients with stage IA–IVB endometrial carcinoma were evaluated. Concordance of the frozen section examination and postoperative evaluation in terms of the depth of myometrial invasion (MI) and grade was assessed.

Results

The mean age of the patients was 58.1 years. Postoperative pathology revealed endometrioid type tumor in 756 patients. Concordance of intraoperative and postoperative pathology results in terms of grade was 89%. This rate was 96.8% for grade 1, 86% for grade 2 and 91.3% for grade 3 tumors. Sensitivity and specificity of intraoperative evaluation for grade 1, grade 2 and grade 3 were 89.3%, 91.2%, 77.8% and 93.1%, 96.1%, 99.5%, respectively. Intraoperative and postoperative determination of MI was consistent in 85.4% of patients. MI was assessed accurately in 78.5% of patients with no involvement of myometrium and in 90.5% and 95.3% of patients with myometrial invasion <1/2 and ≥1/2, respectively. Sensitivity and specificity of FS in prediction of the absence of MI, MI < 1/2 and ≥1/2 were 60%, 91.5%, 88.8% and 96.6%, 88.3%, 98.3%, respectively. The accuracy of myometrial invasion was affected by the postoperative grade. Concordance was higher in grade 2 and 3 than grade 1 tumors.

Conclusion

The accuracy of intraoperative pathologic evaluation in endometrial cancer is reasonably high. For that reason, results of the intraoperative pathologic examination should be taken into consideration primarily in the management for lymphadenectomy.     

Evidence of measles virus antigens and RNA in endometrial cancer

Objectives

To look for an association between the measles virus and endometrial carcinoma, the most frequent cancer of the female genital tract in our area.

Study design

Thirty-six of 49 patients with endometrial carcinoma were studied to detect fingerprints of the measles virus. Immunohistochemistry with the avidin–biotin complex method and in situ hybridization were used to demonstrate the association. The clinicopathological correlations were carried out to support a relationship between the virus and the cancer if any was found.

Results

Twenty-six of the 36 cases (72%) of endometrial cancer showed the presence of measles virus antigens in the tumor cells. Sixteen of 21 cases were positive for measles virus RNA by in situ hybridization. Although type I endometrial carcinoma was more positive for viral particles than type II, type II cancer, when allied with the measles virus, was more often associated with the depth of myometrial invasion and with death from tumor.

Conclusions

We demonstrate for the first time a link between endometrial cancer and the presence of viral antigens and RNA of the measles virus, although these findings do not necessarily signify a causal relationship between the cancer and the virus.     

Determinación de ácido láctico intraamniótico y relación con distocia

Objectives

To evaluate the relationship between intra-amniotic lactic acid levels in pregnant women during labor and the risk of dystocia.

Material and methods

Between December 2009 and June 2010, we determined two lactic acid values in the amniotic fluid of intrapartum women at the Hospital de Cabueñes, Gijón (Spain) and their association with the type of delivery.

Results

We found no statistically significant differences between lactic acid levels and the type of delivery for our sample size. When the lactic acid value was higher than 9.30 mmol/l, the risk of dystocia increased by 33% (sensitivity 85%, specificity 40%), and if both values were higher than 9.30 mmol/l, the increase was 41% (sensitivity 71%, specificity 65%), with a negative predictive value of 88%

Conclusions

High concentrations of intra-amniotic lactic acid could be a good predictor of dystocia. However, additional studies are needed because, for our sample size, the association was not significant.     

Mucinous differentiation does not impact stage or risk of recurrence among patients with grade 1, endometrioid type,endometrial carcinoma

Objective

To evaluate whether the presence of mucinous differentiation influences histopathologic findings, stage distribution, or rate of recurrence among women with grade 1, endometrioid type, endometrial carcinoma.

Methods

This was a retrospective cohort study of all patients with grade 1, endometrioid type, endometrial carcinoma between January 2005 and December 2012. Patients were separated by the presence or absence of mucinous differentiation and then compared.

Results

Of 655 patients, mucinous differentiation was present in 137 (20.9%) and absent in 518 (79.1%) patients. Compared to the group without mucinous differentiation, the group containing mucinous differentiation was older at diagnosis (mean: 61.1 vs. 58.5 years, OR, 95% CI; 1.03, 1.01–1.05) and more likely to have myometrial invasion (61.3% vs. 51.5%, OR, 95% CI; 1.49, 1.01–2.19). Additional histopathologic findings including: tumor size, cervical stromal invasion, adnexal involvement, LVI and/or the presence of positive lymph nodes were similar between groups. Mucinous differentiation did not affect stage distribution, as most patients were stage 1A (85.4% vs. 86.3%). The median PFS for the entire group has yet to be reached. The mean PFS for the entire study sample was 94.7 months. There was no difference in mean PFS when comparing the group with mucinous differentiation to the group without mucinous differentiation (98 vs. 93.4 months, p = 0.07).

Conclusions

In the setting of grade 1, endometrioid type, endometrial carcinoma, mucinous differentiation is more common in older patients and is associated with an increased likelihood of myometrial invasion. However, stage distribution and risk of recurrence are not affected.     

Combined use of preoperative transvaginal ultrasonography and intraoperative gross examination in the assessment of myometrial invasion in endometrial carcinoma

Objective

To evaluate the diagnostic performance of gross examination and transvaginal ultrasonography in the assessment of the depth of myometrial infiltration when they are used alone or together as a combined test.

Study design

The data of 219 consecutive patients with a diagnosis of endometrial cancer were evaluated retrospectively. Transvaginal ultrasound was carried out as a part of the routine preoperative work-up within three days of surgical intervention in all cases. All patients underwent hysterectomy with bilateral salpingo-oophorectomy and routine surgical staging and all uterine specimens were examined immediately after hysterectomy. The depth of myometrial invasion was classified into two groups: no or <50% invasion and ≥50% invasion. The findings of ultrasound and intraoperative gross examination were compared with the final histopathological results. The data of these two methods were integrated to evaluate the diagnostic performance of the combined test. If the results of myometrial invasion evaluation were different for the same patient, the deeper one (the depth of invasion ≥50%) was accepted.

Results

Sensitivity, specificity, PPV, NPV and accuracy of preoperative ultrasonography in predicting myometrial infiltration ≥50% were 62%, 81%, 60%, 82%, and 75% respectively. The corresponding rates for intraoperative gross examination were 61%, 88%, 70%, 83% and 79%, respectively. For the combined test they were 78%, 76%, 60%, 88% and 70% respectively. There was no statistically significant difference in sensitivity and specificity between ultrasound and gross examination. The sensitivity of the combined test was significantly higher than that of ultrasound and gross examination (p = 0.001 and p < 0.0001, respectively). The specificity of the combined test was significantly lower than that of TVS and gross examination (p = 0.008 and p < 0.0001, respectively).

Conclusion

Combining ultrasonography and intraoperative gross examination may be a good option to assess the depth of myometrial invasion, as it has a higher sensitivity and negative predictive value in comparison to using these methods alone.     

Estudio aleatorizado del dispositivo liberador de levonorgestrel frente a resección endometrial para el tratamiento de la menorragia

Objective

To asses the efficacy of endometrial resection and the levonorgestrel intrauterine system (LNG-IUS) in the treatment of menorrhagia.

Material and methods

Fifty women were randomized to either insertion of a LNG-IUS or endometrial resection. Hemoglobin levels, menstrual bleeding patterns and degree of satisfaction were evaluated during a 12-month follow-up.

Results

Hemoglobin levels increased in both groups. The most frequent bleeding patterns were amenorrhea and hypomenorrhea. The most common adverse effect in the LNG-IUS group was the presence of spotting. Ninety-four percent of the patients in the resection group and 86% of those in the LNG-IUS group were satisfied with the treatment.

Conclusions

Both treatments were effective in reducing menstrual blood loss.     

Cribado con resonancia magnética de la mama contralateral en pacientes con cáncer de mama

Case report

We report the case of a woman with an invasive carcinoma of the right breast, in whom magnetic resonance imaging (MRI) identified a ductal carcinoma in situ in the contralateral breast. This tumor had not been detected by other diagnostic tests.

Discussion

The authors review recent series that discuss the issue of MRI screening of the contralateral breast. The clinical impact of MRI screening is assessed.

Conclusions

MRI of the contralateral breast in breast cancer patients detects a small, but significant, number of breast cancers that would have been missed if MRI had not been performed. The effect of these findings on prognosis remains uncertain.     

Alteración ecográfica del endometrio en mujeres menopáusicas sin metrorragia

Objective

To determine the incidence of endometrial cancer in asymptomatic postmenopausal women with a sonographic endometrial thickness above 5 mm.

Materials and methods

We performed a retrospective study of 270 asymptomatic postmenopausal women with endometrial thickness > 5 mm on sonography. All women underwent hysteroscopy with histological evaluation if required. The incidence of endometrial cancer was evaluated.

Results

Five cases of endometrial cancer were diagnosed in the 270 women, representing an incidence of 1.85%. Of the 106 patients with a sonographic image leading to suspicion of polyp, four were diagnosed with endometrial cancer (3.77%), all of which were stage I tumors. None of the 270 women was receiving hormone replacement therapy.

Conclusions

The incidence of endometrial cancer in asymptomatic postmenopausal women with sonographic suspicion of polyp was 3.77%. Patients with this sonographic finding should undergo thorough hysteroscopy and biopsy to rule out malignancy. We believe that the cut-off value for endometrial thickness in postmenopausal women without vaginal bleeding should be determined.     

Hiperplasia ductal atípica de mama: correlación de la biopsia percutánea y los resultados de la biopsia quirúrgica

Objetive

The purpose was to evaluate the prevalence of carcinoma found at surgical biopsy of llesions identified as atypical ductal hyperplasia by percutaneous breast biopsy.

Methods

We performed a retrospective study of all asymptomatic patients with a result of atypical ductal hyperplasia on percutaneous breast biopsy and who underwent surgical excision from January 2002 to December 2010.

Results

Sixty-eight patients were found to have atypical ductal hyperplasia at percutaneous breast biopsy and were evaluated with surgical biopsy. Seventeen patients (25%) had carcinoma at surgical excision, 10 had ductal carcinoma in situ, and 7 patients had invasive carcinoma. The mammographic characteristics associated with malignancy were analyzed.

Conclusions

A finding of atypical ductal hyperplasia at percutaneous breast biopsy frequently corresponds to cancer and is therefore an indication for surgical excision.