Arterial balloon occlusion of the hypogastric arteries: a life-saving procedure for severe obstetric hemorrhage

In this case report we describe two patients with life-threatening postpartum hemorrhage who were treated successfully with arterial balloon occlusion of the hypogastric arteries. Arterial balloon occlusion is easy to perform and is applicable under difficult circumstances. The technique should be available in all hospitals that provide obstetric services. Obstetricians should know about it so they can ask their radiologic colleagues to perform the procedure.

Declining trend in major gynaecological surgery in The Netherlands during 1991-1998. Is there an impact on surgical skills and innovative ability?

OBJECTIVES

To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed.

DESIGN

Observational study.

SETTING

Hospital care in The Netherlands.

SAMPLE

Data from a national hospital discharge database, from all 119 hospitals in The Netherlands.

METHODS

When a patient is discharged from the hospital. data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3% of all admissions. Data on gynaccological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1,000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics.

RESULTS

The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-24 %) in 1998 (chi2 for trend 1,245.1. P < 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625%) cases per year (chi2 for trend 2,459.2, P < 0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (-16%) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty-three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair.

CONCLUSIONS

The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.

Distinguishing the benign and malignant adnexal mass: an external validation of prognostic models

OBJECTIVE

Because external validation of the present models has not been reported, the purpose of the present study was to assess existing diagnostic models that are used to distinguish malignant from benign masses.

METHODS

We tested the performance of existing models in a prospectively assembled data set of 170 patients with an adnexal mass. Twenty-one models that have been reported previously were assessed. The models were based on combinations of ultrasound findings, color Doppler tests, CA-125 measurement, age, and/or menopausal status. For each model, we constructed ROC curves and calculated an area under the ROC curve.

RESULTS

Of the 170 adnexal masses that were operated on, 30 (18%) were malignant. The area under the ROC curve of 21 models that were externally validated varied between 0.69 and 0.90. We found the performance of the existing models to be inferior to the performance reported in the initial studies. Even models that incorporated multiple diagnostic tools and that were developed using logistic regression models or neural networks had an area under the ROC curve of 0.86 at maximum. In the case where we focused on almost perfect sensitivity, the highest specificities varied between 0.45 and 0.60.

CONCLUSION

Although diagnostic models might be of value in the preoperative assessment of the adnexal mass, their diagnostic performance is not as good as that reported in the original publications.

Vaginal vault suspension by abdominal sacral colpopexy for prolapse: a follow up study of 40 patients

OBJECTIVES

Vaginal vault prolapse is a rare event after hysterectomy. Vaginal repair often results in a narrowed and shortened vagina with diminished function. Abdominal sacral colpopexy attaches the vaginal apex to the sacral promontory and restores the physiological position of the vagina. The objective of the study was to evaluate follow up results of the abdominal sacral colpopexy in 40 patients by a questionnaire and a gynaecologic examination.

METHODS

We performed a cohort study. Between 1992 and 1998, 45 consecutive patients with a vaginal vault prolapse treated with an abdominal sacral colposcopy were included.

RESULTS

Forty patients were included in the study. No serious complications occurred during surgery. Two patients per- or postoperative hemorrhage required blood transfusion. In two patients, one with a concomittant hysterectomy, the Gore-tex graft infected within 3 months after the operation. If vaginal 'protrusion' was the only preoperative complaint, in 93% (13/14) of the cases, surgery resulted in a condition without any complaint, related to the vaginal prolapse. If initially a combination of complaints (vaginal protrusion, urinary incontinence, defecation problems, sexual dysfunction) was the reason for surgery, only ten of 27 (37%) patients were symptom-free at follow up (P=0.002, Yates corrected). In the whole group 34 (85%) patients noticed before the operation a feeling of vaginal protrusion. At follow-up, 23 patients (56%) had no symptoms at all that could be related to the vaginal prolapse. Problems concerning defecation, like constipation were present before surgery in eight patients. In six of them, these complaints were resolved after surgery. However, in five patients de novo constipation developed after surgery. There were no cases of de novo urinary incontinence. At gynaecological examination in three patients, the vaginal vault prolapse recurred within the follow-up period, accounting for a success rate of 93%. In ten more patients a moderate enterorectocele developed or persisted. No reoperations were performed for that reason.

CONCLUSIONS

Abdominal sacral colpopexy is a safe and efficacious treatment of the posthysterectomy vaginal vault prolapse. To prevent the persistence or development of an enterorectocele, a culdoplasty according to Halban or McCall might possibly be helpful. Peritonisation of the graft seems not to be necessary. The use of banked collagen tissue as graft material is promising and needs further investigation.

The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis

BACKGROUND

Endometrial assessment by means of biopsy or sampling of endometrial cells is a minimally invasive alternative for dilatation and curettage (D&C) or hysteroscopy. The use of this technique is believed to reduce the cost of the diagnostic work-up for abnormal uterine bleeding without reducing accuracy. Because the authors were not aware of any systematic review of this test, they performed a meta-analysis to assess the accuracy of endometrial sampling devices in the detection of endometrial carcinoma and atypical hyperplasia.

METHODS

The authors searched the literature for studies published between 1966 and 1999 comparing the results of endometrial sampling with findings at D&C, hysteroscopy, and/or hysterectomy. They found 39 studies that included 7914 women. For each study, the fraction of patients was calculated in which endometrial sampling failed. Furthermore, the authors calculated the fraction of cases of endometrial carcinoma and atypical hyperplasia that were identified correctly as well as the fraction of women in whom these diseases were diagnosed false positively.

RESULTS

The detection rate for endometrial carcinoma was higher in postmenopausal women compared with premenopausal women. In both postmenopausal and premenopausal women, the Pipelle was the best device, with detection rates of 99. 6% and 91%, respectively. For the detection of atypical hyperplasia, there was only one study that reported explicitly on postmenopausal women, thereby hampering the possibility of subgroup analysis. Again, the Pipelle was the most sensitive technique with a sensitivity of 81%. The specificity of all devices was > 98%.

CONCLUSIONS

Endometrial biopsy with the Pipelle is superior to other endometrial techniques in the detection of endometrial carcinoma and atypical hyperplasia. The accuracy of the Pipelle is higher in postmenopausal women compared with premenopausal women.

A severe case of myasthenia gravis during pregnancy

Myasthenia gravis is characterised by muscle weakness and fatigability, particularly of the facial and extremity muscles, deteriorating during the day. During pregnancy, myasthenia gravis is rare and the course of illness is unpredictable. The present case illustrates that first diagnosed during pregnancy, recurrent exacerbations can appear and lead to life-threatening situations.

Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding

PURPOSE

Saline infusion sonography (SIS) is a relatively new technique in the evaluation of abnormal uterine bleeding. We compared the diagnostic accuracy of SIS with that of transvaginal sonography (TVS) in the detection of intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.

METHODS

In this prospective study, consecutive premenopausal women who underwent a hysteroscopy for abnormal uterine bleeding also underwent TVS and SIS. The findings at TVS and SIS were compared with the hysteroscopic and histologic findings. Sensitivity, specificity, and likelihood ratios were calculated. Receiver operating characteristic curves were constructed to assess the performance of endometrial thickness measured using TVS.

RESULTS

Sixty-two patients were included in the study. TVS demonstrated 60% sensitivity in directly visualizing intracavitary abnormalities and 93% specificity. The likelihood ratio of the presence of an intracavitary abnormality was 8, and the likelihood ratio of the absence of an intracavitary abnormality was 0.43. Defining an abnormality at TVS as direct visualization of an intracavitary abnormality or an endometrial thickness greater than 5 mm, TVS had an 85% sensitivity and a 21% specificity, with corresponding likelihood ratios of 1.1 and 0.71, respectively. For SIS, the sensitivity, specificity, and likelihood ratios of the presence and absence of intracavitary abnormalities were 88%, 95%, 10, and 0.13, respectively.

CONCLUSIONS

SIS is more accurate in the diagnosis of intracavitary abnormalities in premenopausal women than is TVS. An approach using endometrial thickness measurement by TVS and reserving SIS for patients who have an endometrial thickness greater than 5 mm or an intracavitary abnormality visualized by TVS would be the most effective method to reduce the number of hysteroscopies.

Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities in premenopausal women

OBJECTIVE

To compare the diagnostic accuracy of transvaginal sonography (TVS) and saline infusion sonography (SIS) for detecting intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.

METHOD

Consecutive premenopausal women who underwent hysterectomy for abnormal uterine bleeding were included. All women underwent TVS and SIS before their hysterectomy. The findings at TVS and SIS were compared with the findings of the hysterectomy specimen. Sensitivity, specificity, and likelihood ratios were calculated.

RESULTS

The results of 50 patients with abnormal uterine bleeding were evaluated. Histological examination revealed normal endometrial histology in 27 patients, submucous myomas in 13 patients and intracavitary polyps in 10 patients. The sensitivity of TVS in directly visualizing intracavitary abnormalities was 61% for a specificity of 96%. The likelihood ratio of presence of an intracavitary abnormality was 16 and the likelihood ratio of absence of such a finding was 0.41. When defining abnormality at TVS as direct visualization of an intracavitary abnormality or an increased endometrial thickness (cut-off level 5 mm), the sensitivity of TVS was 87% for a specificity of 56%, with corresponding likelihood ratios of 2 and 0.23, respectively. The sensitivity and specificity of SIS was 100% and 85% with likelihood ratios of 6 and 0.0, respectively. No intracavitary abnormality was missed by SIS.

CONCLUSION

The diagnostic accuracy of SIS is higher than the accuracy of TVS. A combined approach using endometrial thickness measurement by TVS and, reserving SIS for patients with increased (> 5 mm) endometrial thickness, or endometrium inadequately visualized on TVS, is the optimal method of reducing the hysteroscopy rate.

Is balloon ablation as effective as endometrial electroresection in the treatment of menorrhagia?

BACKGROUND

Hot-fluid balloon therapy is a recently introduced, relatively simple endometrial ablation procedure for menorrhagia. Because it is thought to be safer than other ablation procedures, it would be superior to other types of ablation if it is equally effective. The purpose of the present study was therefore to compare the safety and effectiveness of balloon ablation and transcervical resection of the endometrium (TCRE) for the treatment of menorrhagia.

PATIENTS AND METHODS

We performed a prospective cohort study comparing TCRE and hot-fluid balloon ablation in consecutive patients suffering from menorrhagia and not responding to medical treatment. Between 1992 and 1994, all patients had TCRE, whereas from 1995 onward, all patients had balloon therapy. Outcome measures were surgical reintervention, menstrual pattern, and patient satisfaction. Assuming a 9% reintervention rate after TCRE, a series of 150 patients was required to show balloon ablation to be equally effective.

RESULTS

Of the 152 patients who were included, 75 underwent TCRE and 77 had balloon ablation. The procedure had to be abandoned in 13 patients in the TCRE group (17%) and in 8 patients in the balloon ablation group (10%). In the TCRE group, four patients underwent a second resection, whereas hysterectomy was performed in 15 patients (3-year cumulative reintervention rate 26%). In the balloon-ablation group, there were no reresections, whereas hysterectomy was performed in 9 patients (3-year cumulative reintervention rate 13%) (log-rank test P = 0.11). The relative risk for any reintervention was 0.36 (95% confidence interval 0.05-2.5). At 3 months' follow-up the duration of menstruation was significantly shorter after TCRE than after balloon ablation, but at 6, 12, and 24 months, the duration of menstruation in the two groups appeared to be equal. No difference in patient satisfaction could be detected between the two groups, but there appeared to be a statistically significant decline in patient satisfaction over time for both therapies. This decline was stronger after TCRE than after balloon ablation.

CONCLUSIONS

Because endometrial ablation with a hot-fluid balloon seems to be as effective as endometrial resection, with a lower complication rate, balloon ablation might become the procedure of choice for endometrial ablation.

Nifedipine versus ritodrine for suppression of preterm labor; a meta-analysis

BACKGROUND

Since large randomized clinical trials comparing the effectiveness of nifedipine and ritodrine in the suppression of preterm labor are lacking, we performed a meta-analysis on the subject.

METHODS

We searched the databases Medline and EMBASE using the keywords 'nifedipine', 'ritodrine' and 'randomized' or 'randomised'. The studies were scored for blinding, method of randomization and type of analysis ('intention-to-treat' versus 'par protocol'). Subsequently, two by two tables were constructed using 'delay of labor by 48 hours or more', 'delay of labor beyond 36 weeks gestation', perinatal mortality, respiratory distress syndrome and admission to a neonatal intensive care unit as end points. Homogeneity between the studies was tested with a Breslow-Day test. Pooled odds ratios were calculated in case homogeneity could not be rejected.

RESULTS

We could detect ten studies that were published between 1986 and 1998, incorporating data of 681 patients. Nifedipine reduced the risk of delivery within 48 hours compared to ritodrine, but this difference was not statistically significant (odds ratio 0.85, 95% confidence interval 0.54 to 1.1). Nifedipine also reduced the risk of delivery before 36 weeks compared to ritodrine, and this difference was statistically significant (odds ratio 0.59, 95% confidence interval 0.39 to 0.90). We are not aware of studies reporting on long-term outcome.

CONCLUSION

Since studies reporting on long-term outcome are lacking, the choice between nifedipine and ritodrine can only be based on obstetrical and short-term neonatal outcomes. From that perspective, nifedipine should be the drug of first choice for the suppression of preterm labor.

The effect of hysterectomy and endometrial ablation on follicle stimulating hormone (FSH) levels up to 1 year after surgery

OBJECTIVES

In this study the hypothesis was tested, that in premenopausal patients FSH-levels would rise after 'simple hysterectomy'. As endometrial ablation is not supposed to compromise ovarian bloodflow, there would be no such change in ablated patients.

METHODS

Between January 1995 and April 1996, consecutive premenopausal patients with dysfunctional uterine bleeding who were scheduled for hysterectomy or endometrial ablation were asked to participate in the study. Bloodsamples were drawn before surgery, six weeks, six months and one year after surgery. FSH and oestradiol (E2) were assayed. In all patients data about length and weight were collected to calculate Body Mass Index (BMI). Every visit patients filled in a questionnaire, containing questions about typical climacteric complaints, combined in a five-point scale.

RESULTS

Except for a significant difference in preoperative FSH-level between both groups, there were no significant differences regarding age, Body Mass Index (BMI), oestradiol (E2) or the percentage of women with vasomotor complaints. Compared to the preoperative starting level, six weeks, six months and one year after surgery a significant rise in serum FSH in the hysterectomy group, as well as in the ablation group was found. However there was no significant difference in FSH increase between both groups. One third of the patients in both groups had typical climacteric complaints as flushing and nocturnal sweating.

CONCLUSIONS

Assaying serum FSH-levels before and after uterine surgery and comparing hysterectomized patients and patients after endometrial ablation, we found a significant rise in FSH-level up to one year after surgery in both groups postoperatively, indicating impaired ovarian function. There was no difference in FSH-levels between both groups. Therefore major uterine surgery (hysterectomy, ablation) may prelude an earlier onset of menopause.

A randomized comparison of nifedipine and ritodrine for suppression of preterm labor

OBJECTIVES

To compare the efficacy and safety of nifedipine and ritodrine in preventing preterm labor, and to evaluate maternal side effects and neonatal outcome.

STUDY DESIGN

Non-blind, randomized controlled trial

RESULTS

A randomized trial of 102 pregnant women with gestational ages under 34 weeks, including 24 with twin pregnancies and 45 on betasympathicomimetic drugs, who had regular uterine contractions with either observed cervical changes or preterm rupture of membranes. After stratification women were randomly assigned to receive either ritodrine intravenously or nifedipine orally. Fifty-five women were randomized to the nifedipine group and 47 to the ritodrine group. As expected, both groups were comparable in terms of several entry variables, including mean gestational age, ruptured membranes, treatment with tocolytic drugs, cervical examination, contraction frequency, age, and twin gestation. Delivery of women in the nifedipine group was delayed for 48 h, 7 days, and until 34 weeks gestation in 33 (60%), 26 (47%) and 21(38%) cases, respectively, compared with 31 (66%), 21(45%) and 11(23%) women in the ritodrine group (no significant difference). Maternal side effects were significantly less common in the nifedipine group than in the ritodrine group, however after 7 days of therapy there was no difference between the two groups. Neonatal outcome was similar in the two groups, with four neonatal deaths in the nifedipine and five in the ritodrine group.

CONCLUSIONS

Nifedipine seems to be as effective as ritodrine in the treatment of preterm labor and is associated with less frequent side effects.

Postoperative radiotherapy for endometrial carcinoma. Stage I. Wide variation in referral patterns but no effect on long-term survival in a retrospective study in the southeast Netherlands

The aim of this study was to assess the referral pattern and the impact on long-term survival of postoperative radiotherapy in patients with adenocarcinoma of the endometrium stage I. This was a retrospective study performed in a regional cancer registry which covers a population of approximately 1,000,000 persons. All 724 patients registered between 1975 and 1992 in the Comprehensive Cancer Centre South, Eastern Section, The Netherlands, were analysed. All patients had received surgery as primary treatment which was performed in one of the seven community hospitals of the region. Radiotherapy was given in one regional department. All pathology reports were checked for data on tumour differentiation and myometrial invasion. Almost half the patients (45%) were referred for postoperative radiotherapy. The depth of myometrial invasion and the degree of tumour differentiation were the main factors (P < 0.0001) influencing referral for postoperative radiotherapy. The referral pattern varied between the different hospitals, but became more similar during 1985-1988, to diverge again in recent years. In patients younger than 60 years, the depth of myometrial invasion was significantly (P = 0.01) correlated with survival. In patients older than 60 years, tumour differentiation (P = 0.05) and age (P < 0.001) were correlated with survival, but not the depth of myometrial invasion. After adjustment for known prognostic factors, a survival benefit of postoperative radiotherapy could not be established. The studied group had an excess death rate over the normal Dutch female population. This excess death rate did not decrease during follow-up, as even after 10 years an excess death rate was found. A prospective randomised trial is ongoing in The Netherlands.

Transvaginal ultrasonography and endometrial changes in postmenopausal breast cancer patients receiving tamoxifen

OBJECTIVES

To assess an estrogenic effect of tamoxifen on the uterus and to evaluate the usefulness of transvaginal ultrasonography for identifying tamoxifen-induced endometrial pathology.

METHODS

One hundred and two postmenopausal breast cancer patients without gynecological symptoms were examined by transvaginal ultrasonography. Forty-eight patients were treated with tamoxifen and 54 patients served as reference. An endometrial thickness of > or = 6 mm (double-layer) was used as cut-off point for further hysteroscopic and histologic examination.

RESULTS

Thirty percent of the women taking tamoxifen had evidence of an abnormal postmenopausal endometrium compared with 6% in the reference group (P = 0.005). Those patients receiving tamoxifen had a significantly thicker endometrium (median 6.0 mm versus 2.0 mm; P < 0.001), a larger uterine volume (median 93 cm3 versus 72 cm3; P = 0.03) and more uterine fluid (12% versus 2%; P = 0.005). Furthermore, an ultrasonographic suspect 'Swiss-cheese' endometrial pattern was noted in almost a quarter of the patients treated with tamoxifen, but this was clearly not associated with intracavitary pathology.

CONCLUSIONS

Our data indicate that tamoxifen stimulates the uterine body and endometrium. The data also indicate that the ultrasonographic endometrial appearance during tamoxifen therapy may be misleading and that a high percentage (46%) of false-positive results occur. Therefore, in asymptomatic postmenopausal breast cancer patients taking tamoxifen, the findings on ultrasonography should be interpreted with caution.

The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities

OBJECTIVE

To evaluate the diagnostic accuracy of transvaginal ultrasonography for endometrial abnormalities in women with abnormal uterine bleeding.

METHODS

In a prospective study, 136 consecutive patients underwent transvaginal ultrasonography, hysteroscopy, and endometrial sampling through suction curettage or directed biopsy. The ultrasonographic findings were evaluated on the basis of the final diagnosis established by hysteroscopy and histologic examination. Receiver operating characteristic curve analysis and likelihood ratios were used. Likelihood ratios algebraically combine sensitivity and specificity to describe more than the independent values themselves, specifically the change in odds favoring disease given a particular test result.

RESULTS

In 21 of the 136 patients, hysteroscopy detected polyps or submucous myomas, which curettage failed to detect. In 67 premenopausal women, ultrasonography demonstrated a sensitivity in diagnosing endometrial abnormalities of 88% and a specificity of 68%, using a cutoff point of 5 mm of single-layer endometrial thickness. The positive likelihood ratio was 2.8 (95% confidence interval [CI] 1.66-4.55) and negative likelihood ratio 0.18 (95% CI 0.07-0.46). In 69 postmenopausal women, using a cutoff point of 3 mm, the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio were 97%, 74%, 3.7 (95% CI 2.18-6.38), and 0.04 (95% CI 0.01-0.28) respectively.

CONCLUSIONS

Transvaginal ultrasonography is an excellent first-step diagnostic method of excluding the endometrial abnormalities in women with postmenopausal bleeding but is of limited use in premenopausal women with irregular bleeding. Ultrasonography may reduce the number of invasive endometrial investigations by approximately 40%.

Endometrial electrosurgical resection by hysteroscopy in 32 menorrhagic patients: endometrial preparation with a GnRH agonist may have some effect on results

Our objective was to evaluate the effect of endometrial thinning by GnRH agonists on the results of hysteroscopic endometrial electrosurgical resection. In a prospective study, 32 women were treated with the GnRH agonist goserelin (Zoladex) before hysteroscopic endometrial resection. Endometrial thickness was measured before and after GnRH-a therapy by ultrasound. Short-term results in diminished vaginal blood loss and patient satisfaction were registered. The mean endometrial thickness (ET) before GnRH-a is 3.7 mm and after GnRH-a is 1.9 mm. In 24 cases, ET was reduced by a mean of 2.6 mm, in 1 case, no change was seen, and in 7 cases, ET increased by a mean 1.1 mm. The mean thickness rate (TR = ET before and after GnRH) is 2.7 (range 0.3-11). Fluid resorption during hysteroscopic surgery does not relate to ET or TR. Although the ET after GnRH-a therapy is not related to success or failure of the endometrial resection, there is some evidence that the TR is, probably expressing a more active state of the endometrium. Endometrial thinning by GnRH-a may have an effect on the results of hysteroscopic endometrial resection. In light of the present study and the literature, there seems to be no justification for abandoning preparation of the endometrium before hysteroscopic surgery.

[Adjuvant postoperative radiotherapy in patients with endometrial carcinoma; no effect on length of survival in retrospective study in the Southeastern Netherlands]

OBJECTIVE

To assess the use of postoperative radiotherapy in patients with adenocarcinoma of the endometrium.

DESIGN

Retrospective study.

SETTING

Catharina Hospital Eindhoven, the Netherlands.

METHOD

An assessment was made of referral, survival in relation to patient factors and postoperative radiotherapy treatment, in 422 patients registered in the Eindhoven Cancer Registry between January 1975 and December 1984 with carcinoma of the endometrium.

RESULTS

Half the patients (54%) were referred for postoperative radiotherapy, patients over 70 years old less frequently (p = 0.004), patients with deeply infiltrating tumours (p < 0.001) or tumours with poor grade of differentiation (p = 0.03) more frequently. The referral percentages varied between 36% for patients with well differentiated superficial tumours and 83% for patients with poorly differentiated tumours with deep infiltration. Age, postoperative tumour stage and depth of infiltration for patients under 60 showed a statistically significant association with overall survival. A benefit from postoperative radiotherapy with respect to survival could not be established.

CONCLUSION

It appears that the variation in referral is also due to differences of opinion concerning appropriate treatment between the referring gynaecologists. This study did not demonstrate a beneficial effect from postoperative radiotherapy. This should be confirmed in a prospective study.

[Ultrasonographic diagnosis of endometrial disorders: correlation with the histological results in 112 patients]

The diagnosis of endometrial lesions hitherto was mainly made on the basis of histological examination. The objective of this study was the assessment of the diagnostic accuracy of transvaginal ultrasound investigation by comparison with the usual histological investigation, which implies painful endometrial sampling. 112 perimenopausal women with irregular vaginal blood loss were examined by transvaginal ultrasound. Shortly afterwards endometrial sampling was performed by means of aspiration, conventional curettage or hysteroscopically guided biopsies. The group of 112 patients included 11 women who had previously received hormone substitution therapy (10%). The other patients (without previous hormone substitution therapy) were divided into a premenopausal group (n = 47) and a postmenopausal group (n = 54). In case of an endometrial thickness (single layer) of less than 3 mm in postmenopausal patients, no (pre)malignant lesions were found. In the pre- and postmenopausal group, using this cut-off-level two of the five endometrial hyperplasias were ultrasonographically missed. All fourteen endometrial carcinomas in 112 patients were ultrasonographically detected by an endometrial thickness > or = 4 mm. In the postmenopausal group specificity was 73% (16/22) using a cut-off-level of 3 mm, in the premenopausal patients it was only 36% (11/31). Regular echo-density or a clear alignment between endo- and myometrium hardly had any value in the diagnosis of (pre)malignant lesions of the endometrium. If our patients with an endometrial thickness of less than 3 mm would not have had an endometrial curettage, 38 of 112 (34%) endometrial samplings might have been avoided. According to our view, transvaginal endometrial examination can be of distinct value in the detection of (pre)malignant endometrium.

[Diathermy excision using a metal loop in the treatment of cervical intra-epithelial neoplasms; short-term results in 154 patients]

Intraepithelial neoplasia of the uterine cervix (CIN), proven in colposcopically guided biopsies, can be treated in several ways. With the destruction techniques the lesion is treated by laser evaporation or by cryocoagulation. With the excision methods the transformation zone is excised by cold knife conisation, by laser exconisation or by large loop excision (LLETZ). LLETZ was developed by Cartier in 1977 and can be performed under local anaesthesia on an outpatient basis. In the current investigation 154 women with CIN were treated by LLETZ. In four patients microinvasion was suspected after pathological examination and cold knife conisation was performed, so that 150 patients were available for cytological follow-up after three and six months. After 1989 larger loops and more loops of different sizes were used. Therefore the results in both groups are presented separately. In 22 women CIN residue was found. The treatment in the first period of the study (1985-1988) was effective in 36 of the 55 cases (65%), that in the second period (1989-1991) in 87 of the 95 cases (93%). In the first period the size and endocervical localisation of the lesion significantly affected predict the result of the LLETZ, in the second half of the study these were no longer relevant. Destruction methods lack the possibility of pathological investigation, which is possible with the excision methods. In this way underestimation by the colposcopist of a (micro)invasive carcinoma does not necessarily delay adequate treatment.

Improved prognosis of ovarian cancer in The Netherlands during the period 1975-1985: a registry-based study

Survival of 568 patients with ovarian cancer, diagnosed in 1975-1985, was studied by means of a population-based registry in the Southeast Netherlands. Patients diagnosed in the period 1981-1985 had a significantly better prognosis than patients diagnosed in 1975-1980. This improvement of survival declined with advancing age of the patients. In women younger than 60 years, mortality from ovarian cancer decreased, while incidence remained stable. Apart from the effect of new treatment methods, consisting of more extensive tumor reduction and cisplatin-based combination chemotherapy, advances in supportive care as well as a trend toward earlier diagnosis, possibly in combination with an increasing proportion of less malignant tumors, may explain the improvement in prognosis. Survival was strongly related to stage at diagnosis and to age, the prognosis of younger patients being more favorable. Patients with tumors of either germ cell or stromal origin generally survived longer than patients with epithelial tumors, but this difference disappeared after adjustment for stage and age. Patients still alive after 6 years did not have a survival significantly different from that of the general female population.

[Shoulder dystocia; a retrospective study]

A retrospective study was made of the incidence in The Netherlands in 1987 of shoulder dystocia in women delivered vaginally of a child with cephalic presentation and a birth weight of 2,500 g or more. Patient data were obtained from the LVR (Landelijke Verloskundige Registratie, National Obstetric Registration). Shoulder dystocia, coded in the LVR form as 'problems with the shoulders', was reported for 844 out of 54,820 parturitions (1.5%). Study of files of the St. Joseph Hospital, Eindhoven, for the period 1983-1987 revealed a frequency of shoulder dystocia of 1.5% (56 out of 3,642 births), in good agreement with the nationwide incidence. The concordance between the LVR code 'problems with the shoulders' and shoulder dystocia as mentioned in the childbirth reports of our hospital was 94%. It is pointed out that familiarization with the manipulations for shoulder dystocia is desirable, and that these should be carried out in a fixed sequence.

Primary melanoma of the cervix uteri, an avis rara? A review of the literature

A primary melanoma of the uterine cervix is presented. Diagnostic approaches and therapeutic procedures are discussed following a review of the literature.