Santiago Dexeus

Role of Color Doppler Ultrasonography in the Diagnosis of Endometriotic Cyst

We studied the role of color Doppler ultrasonography in the distinction between endometriomas and other adnexal masses. Three hundred and fifty‐two ovarian lesions were studied, comparing sonographic diagnosis with pathologic findings. On color Doppler sonography, an endometriotic cyst usually appeared as a cystic lesion with diffuse internal echoes and low vascularization. The sensitivity and specificity of color Doppler transvaginal sonography in detecting endometriotic cysts were 91.8% and 95.3%, respectively. The positive and negative predictive values were 95.5% and 91.5%, respectively. In our experience, transvaginal sonography with color Doppler interrogation is a useful technique in the diagnosis of pathologic ovarian conditions, including cystic endometriosis.

Ecografía 3D/4D en ginecología: técnica y metodología

Resumen La gran aportacion de la ecografia tridimensional respecto a la ecografia convencional (bidimensional) es el plano coronal. Hasta ahora mediante la ecografia convencional se disponia del corte longitudinal y del corte transversal. La aportacion de este tercer plano coronal es lo que permite hacer una reconstruccion volumetrica de los organos estudiados. La ecografia 3D/4D permite establecer una metodologia de adquisicion de la region que se quiere estudiar. Estos datos adquiridos se pueden almacenar y/o enviar y transferir mediante sistema DICOM ( digital imaging and communication in medicine ) lo que permite reconstruir y analizar los volumenes adquiridos tantas veces como sea necesario, por cuantos observadores se quiera y en cualquier lugar geografico. En consecuencia, la ecografia en esta modalidad deja de ser una tecnica dependiente del operador, siempre y cuando el proceso de adquisicion se haya realizado con los parametros debidamente protocolizados. El objetivo de este articulo es explicar una vision de conjunto de la metodologia en 3D y 4D, empezando con la adquisicion de imagenes en 3D, con el analisis de planos escaneados, tecnicas especiales tales como el VOCAL™ y consejos para optimizar el sistema.

Método Essure: contracepción definitiva por vía histeroscópica

Resumen Objetivo Describir el procedimiento Essure de contracepcion por via histeroscopica y compararlo con los ya existentes en el armamentario actual de contracepcion definitiva. Sujetos y metodo Se han analizado tanto los estudios multicentricos previos a su aprobacion como la experiencia referida en trabajos posteriors de grupos expertos en histeroscopia. Resultados Los resultados de dos estudios multicentricos internacionales, prospectivos y aleatorizados publicados en 2003 demuestran que el metodo Essure presenta una elevada eficacia en la prevencion del embarazo, superior al 99% con tasas de complicaciones menores inferiores al 3%. Conclusiones La contracepcion definitive mediante el metodo Essure, apoyada en una curva de aprendizaje y en una adecuada experiencia en histeroscopia permiten convertirlo en una tecnica factible en regimen de consulta y exitosa en el 95% de los casos.

Adenocarcinoma endometrioide en pólipo endometrial

Resumen Introduccion En raras ocasiones se diagnostica un adenocarcinoma originado en un polipo endometrial. Material y metodos De un total de 1.989 polipos endometriales diagnosticados en 8 anos y medio, 6 presentaban un adenocarcinoma endometrioide. Se analizan sus caracteristicas clinicopatologicas y evolucion. Resultados La histeroscopia diagnostico un polipo en todas las pacientes, y en 3 de ellas con signos sospechosos de malignidad. En todas las ocasiones la lesion estaba confinada al polipo y no se observo infiltracion miometrial en ningun caso. Los carcinomas fueron de la variedad endometrioide, y el endometrio adyacente era normal. Todas las pacientes estan vivas y libres de enfermedad tras un seguimiento medio de 45 meses (entre 6 y 96 meses). Conclusion Los polipos endometriales pueden albergar un adenocarcinoma que en muchas ocasiones esta confinado al polipo, y que es de bajo grado de malignidad, por lo que se puede plantear un tratamiento conservador.

Microcolpohysteroscopy: myth or reality?

Objectives Our aim was to compare the diagnostic accuracy of microcolpohysteroscopy (MCH) and colposcopy-directed biopsies in the detection of precancer and cancer of the uterine cervix. Patients and Methods Between January and December 1994, a total of 174 patients underwent colposcopic and MCH examinations. Direct biopsies were obtained under colposcopic and MCH guidance. Diagnostic accuracies of the two methods were compared using the chisquare test and the kappa coefficient. Results Colposcopy showed an overall diagnostic accuracy of 39.7% (69 of 174) with a sensitivity of 50.5%, specificity of 23.2%, positive predictive value of 50%, and negative predictive value of 23.5%. The percentage of agreement between MCH diagnosis and histological findings was 92.4% for cervical intraepithelial neoplasia lesions, 92.5% for human papillomavirus, and 100% for invasive cancer. Of the total 174 cases, colposcopy examination was considered satisfactory in 134 (77%) and unsatisfactory in 40 (23%). In the 40 cases when the limits of the squamocolumnar epithelium could not be seen at colposcopy, satisfactory MCH examinations were obtained in cervical lesions measuring no more than 10 mm in endocervical depth (29 cases), and unsatisfactory MCH examinations were obtained in cervical lesions measuring at least 10 mm of endocervical depth (11 cases). The overall MCH failure rate was 6.3% (11 of 174). Conclusions MCH appears more reliable than colposcopy and is capable of showing lesions undetectable by colposcopy.

Colposcopy carried out by experts in multidisciplinary teams provides the best results

Taking a historical view of cervical pathology over the last 30 years, the first concept appearing in the literature that represented a novelty with respect to the preceding years was that of specialization in the lower genital tract (LGT). The article in this issue of Cytopathology, presenting Part 1 of Chapter 6 in the European Guidelines for Quality Assurance in Cervical Cancer Screening, takes this further by combining the experience of international experts in this field. Although the term is now obsolete, in earlier days we referred to dysplasia clinics, which started when the most advanced gynaecology departments, introduced into their organisations a group of experts to treat the emerging pathology of the uterine cervix. The terminology of dysplasia has now been replaced by the Bethesda system for cytology and by the term cervical intraepithelial neoplasia (CIN) for histology. The latter was introduced during the 1980s having been proposed by Ralph Richart. Knowledge of the causal role of the human papillomavirus (HPV) in practically all carcinomas of the cervix has obliged us to reconsider not only the natural history of the illness but also the diagnostic modalities and treatment that should be employed in the LGT. It is also true that the enthusiasm evoked in certain circles by the introduction of any novel treatment exaggerates the excellence of the new to the detriment of what is already known. The pioneers of colposcopy have demonstrated its efficacy and utility in conjunction with cytology, realising an efficacy of almost 100% by combining both diagnostic techniques. We know that this situation would not be applicable to a mass screening programme, but in the last few years it has focused attention on constantly questioning the value of cytology. One hears constantly that the rate of false negatives in cytology can reach up to 25% or more and false positives up to 12%! Discussion of these figures is useless but I can bring to you the figures from my laboratory, which are much better: 12% and 5% respectively. This perhaps allows me to say that the efficiency of cytology suggested by the earlier figures would call for a large audit of the laboratory or the smear-takers. On reading the guidelines, one notices that in the version published in this issue the authors have avoided continuing to call all of the cytology samples ‘‘Pap smears’’, reflecting the need for multiple instruments designed to collect an endocervical scraping, amongst which the brush is the most effective. The guidelines are evidently directed at gynaecological colposcopists but I daresay one should not assume that all colposcopists are gynaecologists, nor indeed that they are gynae-colposcopists without a solid basis in the pathology of the LGT. I understand perfectly that the situation in the world of colposcopy is very diverse. European countries that take their influence directly from the Hinselmann theories consider that colposcopy is part of a routine gynaecological examination. It is true that colposcopy in inexpert hands converts itself to no more than a beam of light. It is also obvious that when colposcopy is carried out by experts, working in multidisciplinary teams dedicated to the LGT as recommended in the guidelines, the results will be excellent. In summary my point of view on the subject at present is to consider routine colposcopy as an investigation that enriches gynaecological consultation, picking up signs of occult pathology in the patient. For subsequent treatment. I consider that all pathology of the LGT should be managed by gynaecologists expert in colposcopy, in direct contact with cytopathologists and histopathologists. The colposcopist should be a ‘‘director of the orchestra’’ who knows how to assemble the contributions of other specialists and on whose shoulders lies the responsibility for treatment and follow-up. In the guidelines it is clearly specified that ‘‘in some countries colposcopy is used as a screening tool but because of its low specificity, it should not be used for primary screening but reserved for those women who have been shown to have abnormal cytology.’’ The guidelines cite statements as simple as – ‘‘the cervical epithelium needs time to regenerate after cytology. Repeat cytology should not be performed less than three months after a previous Pap smear’’. This is not a triviality and, as stated in the guidelines, requires the provision of full information to the patient whose anxiety is exaggerated for a short time over any cytological abnormality. The guidelines offer

Leiomiomatosis difusa del útero: aspectos clinicopatológicos en 5 casos

Resumen Introduccion La leiomiomatosis difusa del utero es una entidad rara que cursa con un aumento del tamano uterino. Descripcion de los casos Se revisan las caracteristicas clinicopatologicas de 5 casos. La sintomatologia mas frecuente fue por sangrado uterino. Tres de las pacientes tenian hijos, y 2 de ellas habian tenido algun aborto. En 3 ocasiones se efectuo una histerectomia subtotal. En las otras 2 se practico una reseccion parcial por deseos de la paciente de conservar la fertilidad. Conclusion La leiomiomatosis difusa uterina es una lesion benigna que puede afectar a la fertilidad o complicar de forma significativa el parto.