Tirso Pérez-Medina

Predicting Atypia Inside Endometrial Polyps

Objective. To evaluate the efficacy of color Doppler exploration for assessing atypia inside endometrial polyps. Methods. A prospective study was conducted in a tertiary university hospital. Eight hundred six patients with endometrial polyps were studied with color Doppler sonography, and the resistive index inside the polyp stalk was obtained. The patients were then referred for hysteroscopic resection, and pathologic analysis was performed. Results. Thirty‐five polyps with sonographic indications of atypia were pathologically confirmed. Sonographic indications of atypia inside 16 polyps were not confirmed. Three nonquestionable endometrial polyps had atypia inside them. Conclusions. Low Doppler resistance is highly predictive of atypia inside endometrial polyps.

Six thousand office diagnostic-operative hysteroscopies.

Objective: To compare CO2 and normal saline as distention media in office diagnostic hysteroscopy. Methods: The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated. Results: The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92.4% with CO2 and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO2 and in three patients (0.1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients. Conclusion: Saline office diagnostic hysteroscopy offers at least all the advantages of the CO2 hysteroscopy, and gives the possibility to easily ‘find and treat in situ’ many of the lesions observed.

True osseous metaplasia of the endometrium: the bone is not from a fetus.

OBJECTIVE To identify the origin of calcified tissue in endometrial ossification. DESIGN DNA analyses from the ossified tissue and from the woman were studied to compare both genotypes. SETTING University and general hospitals. PATIENT(S) A 27-year-old infertile woman diagnosed of osseous metaplasia of the endometrium. INTERVENTION(S) Hysteroscopic resection of the endometrial osseous metaplasia for DNA analysis. MAIN OUTCOME MEASURE(S) DNA comparison between the patient and the osseous tissue extracted from the uterus. RESULT(S) All markers produced the same allele length for both blood and endometrial biopsy (including bones), thus confirming the same genetic origin. CONCLUSION(S) Endometrial ossification is derived from the patient, resulting in a true osseous metaplasia.

Which endometrial polyps should be resected

STUDY OBJECTIVE To evaluate the efficacy of color Doppler exploration after diagnostic hysteroscopy in choosing which endometrial polyps can be safely left in situ. DESIGN Prospective, long-term follow-up study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS Two hundred twenty women with hysteroscopically confirmed endometrial polyps. INTERVENTIONS Transvaginal ultrasonographic surveillance with color Doppler mapping and hysteroscopic resection. MEASUREMENTS AND MAIN RESULTS We removed 126 (57.2%) polyps because of positive color Doppler map, and 29 (13.1%) with a negative color Doppler map because of symptoms. Sixty-five (29.5%) polyps were not removed because they did not cause symptoms and no Doppler map was found. At follow-up, six were removed because of hemorrhagic episodes. At 3 years, 59 patients with endometrial polyps remained asymptomatic by clinical and ultrasonographic follow-up. CONCLUSION In this series, 59 patients (26.8%) avoided surgical removal of polyps. (J Am Assoc Gynecol Laparosc 6(1):71-74, 1999)

Variables that predict the success of labor induction

Background.  To analyze the clinical and sonographic variables that affect the success of labor induction.

The labor induction: integrated clinical and sonographic variables that predict the outcome

Objective:To analyze the clinical and sonographic variables that predicts the success of labor induction.Study design:We studied the Bishop score, cervical length and parity in 196 pregnant women in the prediction of successful vaginal delivery within 24 h of induction. Logistic regression and segmentation analysis were performed.Results:Cervical length (odds ratio (OR) 1.089, P<0.001), Bishop score (OR 0.751, P=0.001) and parity (OR 4.7, P<0.001) predict the success of labor induction. In a global analysis of the variables studied, the best statistic sequence that predicts the labor induction was found when we introduced parity in the first place. The success of labor induction in nulliparous was 50.8 and 83.3% in multiparous women (P=0.0001).Conclusions:Cervical length, Bishop score and parity, integrated in a flow chart, provide independent prediction of vaginal delivery within 24 h of induction.

Hemodynamic changes during pregnancy and postpartum: a prospective study using thoracic electrical bioimpedance.

Objective. To describe hemodynamic changes in normal pregnancy and postpartum by means of thoracic electrical bioimpedance (TEB). Methods. Eighteen healthy pregnant women were included in the study. Eight different hemodynamic variables were measured by thoracic electrical bioimpedance, from 12th week of gestation until 6th month of postpartum period. Data along pregnancy and postpartum were analyzed with SAS statistical software to compare the different values, so normality curves are reported. Results. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and peripheral vascular resistances (PVRs) seem to significantly decrease until 24th week of gestation, and then they seem to increase until delivery, recovering normal values gradually during postpartum period. End-diastolic volume (EDV), systolic volume (SV), cardiac output (CO), and ejection fraction (EF) seem to decrease until 48 h after delivery; statistical significance was found. Conclusions. Thoracic electrical bioimpedance may be the most appropriate and accurate technique to measure normal hemodynamic changes during pregnancy and postpartum.

International Federation of Gynecology and Obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum; Estimation of survival in patients with node-positive epithelial ovarian cancer

Objective The objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system. Materials and Methods We performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed. Results The distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001). Conclusions The current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.

Tibolone and risk of endometrial polyps: a prospective, comparative study with hormone therapy.

Objective To assess the incidence of endometrial polyps during postmenopausal replacement therapy with tibolone, using an appropriate control group. Design A total of 485 postmenopausal women were included in this open, prospective, comparative study for a duration of 36 months. Of this group, 249 women received 2.5 mg/day of tibolone and 244 women served as controls, receiving continuous-combined estrogen-progestogen therapy (HT). Transvaginal ultrasound, hysteroscopy, and directed biopsies were performed before treatment was initiated and at the end of the study. Results Two hundred twenty-one of the women receiving tibolone and 203 receiving continuous-combined HT completed the study. Endometrial polyps were detected in 74 women (33.4%) from the tibolone group and in 22 women (10.8%) from the HT group (P < 0.01). The vaginal bleeding rate did not differ between the groups. The frequency of atrophic polyps was significantly higher in the tibolone group (P < 0.01). No difference was found in the size of the polyps. Conclusions Tibolone increases by threefold the risk for endometrial polyps.

The role of lymphadenectomy in node-positive epithelial ovarian cancer

Objective To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV). Methods Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis. Results The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29–0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival. Conclusions There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.