Izhodišča: Slovenska priporočila za obravnavo bolnic z rakom endometrija svetujejo različen obseg preiskav za kirurško oceno o napredovanju bolezni glede dileme, ali ob standardni odstranitvi ...maternice s priveski opustiti limfadenktomijo oz. opraviti zgolj biopsijo varovalne bezgavke, ali pa opraviti kompletno pelvično in paraaortno limfadenektomijo glede na stopnjo tveganja za širjenje bolezni zunaj maternice. Bolnice razvrstimo v različne skupine glede tveganja na podlagi histološkega gradusa po biopsiji maternice ter glede na slikovno oceno razširjenosti bolezni (magnetno resonančno slikanje ali ekspertna ultrazvočna preiskava). V Univerzitetnem kliničnem centru Ljubljana smo leta 2015 uvedli ekspertno ultrazvočno preiskavo (TVUZ) za oceno razširjenosti rakavih bolezni. Naš namen je bil oceniti zanesljivost preiskav, ki jih opravimo ob diagnozi raka endometrija v UKC Ljubljana pred operacijo.
Metode: Pregledali smo dokumentacijo 79 bolnic s histološko potrjenim rakom endometrija, ki so opravile TVUZ od januarja 2016 do septembra 2017. Histološko diagnozo pred posegom in oceno razrasta (invazije) s TVUZ v miometrij in stromo materničnega vratu smo primerjali s končnim histološkim izvidom.
Rezultati: Ultrazvočna ocena razrasta (invazije) raka v miometrij je imela 76 % (95 % IZ, 58 – 89 %) občutljivost in 81 % (95 % IZ, 67 – 91 %) specifičnost. Ultrazvočna ocena razrasta raka (invazije) v stromo materničnega vratu je imela 54,5 % (95 % IZ, 23 – 83 %) občutljivost in 75 % (95 % IZ, 63 – 85 %) specifičnost. Ocena histološke stopnje diferenciacije je bila po operaciji višja (angl. upgrading) v 11,3 %, nižja (angl. downgrading) pa v 7,5 %. Ocena ujemanja preiskav pred operacijo z dokončnim izvidom z uporabo koeficienta kappa je bila za histopatološko preiskavo 0,699, za razrast v miometrij 0,564 in za razrast v stromo materničnega vratu 0,203. Ena bolnica je prestala na osnovi izvidov pred operacijo preobsežno zamejitveno operacijo; ostale pa so bile ustrezno kirurško obravnavane.
Zaključki: Kot najbolj zanesljiva se je izkazala patohistološka preiskava, sledi ji ultrazvočna ocena razrasta (invazije) v miometrij, medtem ko je bila ultrazvočna ocena razrasta (invazije) v stromo materničnega vratu manj zanesljiva.
Izhodišče: Ocena razširjenosti raka endometrija pred operaciji s slikovnimi metodami ni zanesljiva. Od ocene je odvisno, ali naj kirurško zdravljenje vključuje pelvično limfadenektomijo ali ne. ...Biopsija varovalne bezgavke lahko varno nadomesti radikalno pelvično limfadenektomijo pri bolnicah z nizkim in zmernim tveganjem za ponovitev bolezni.Metode: Od januarja 2016 do junija 2017 je bilo na Ginekološki kliniki v Ljubljani v pregled začetnih kliničnih rezultatov ob uvedbi biopsije v varovalni bezgavki v rutinsko klinično prakso vključenih 35 bolnic. Beležili smo zanesljivost histološke in ultrazvočne ocene pred operacijo ter stopnjo uspešne kirurške detekcije v varovalni bezgavki s cervikalno aplikacijo zelenila indocianin. Vsa odstranjena tkiva so bila poslana na histološko preiskavo z barvanjem po metodi hematoksilin in eozin (H&E).Rezultati: Enostranska uspešnost kirurške detekcije varovalne bezgavke je bila 85,7 % (75–93 %), obojestranska pa 80,0 % (63–92 %). Varovalna bezgavka je bila histološko pozitivna v dveh primerih. Ultrazvočna ocena invazije v miometrij je imela občutljivost 100 % (15,8–100 %) in specifičnost 78,9 % (54,4–93,9 %), ultrazvočna ocena invazije v stromo materničnega vratu pa le 33 % (0,8–90,6 %) občutljivosti in 94,4 % (72,7–99,8 %) specifičnosti. Ocena histološke stopnje diferenciacije je bila po operaciji višja (angl. upgrading) v 5,7 %, nižja (angl. downgrading) pa v 8,6 %.Zaključek: Odstranjevanje varovalne bezgavke omogoča individualnejši pristop k zdravljenju bolnic z rakom endometrija in varnejšo opustitev pelvične limfadenektomije pri bolnicah z nizkim in zmernim tveganjem za ponovitev bolezni. Za dokončno umestitev v smernice zdravljenja bodo v našem prostoru potrebne dodatne izkušnje glede izbire bolnic, sledenja kakovosti kirurške obravnave in nujna uvedba res poadrobnega histološkega pregleda – t. i. ultrastaginga (angl. ultrastaging) odstranjene varovalne bezgavke.
Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 ...mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4-60), patient pain estimation with VAS was 2.3 (0-8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and β-hCG levels up to 80 U/L did not affect the outcome.
Impact statement
What is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC.
What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data.
What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal.
Background: Preoperative assessment of the depth of endometrial cancer invasion is not reliable. Surgical treatment consists of hysterectomy and pelvic lymphadenectomy. Sentinel lymph node (SLN) ...biopsy can replace radical pelvic lymphadenectomy in patients with a low and intermediate risk of disease recurrence. Methods: From January 2016 to June 2017, 35 patients were included in the clinical audit of SLN biopsy at the UMC Ljubljana’s Division of Gynaecology and Obstetrics. We recorded the reliability of the preoperative histological and ultrasound estimates and the degree of surgical detection of the SLN with an intracervical application of indocyanine green (ICG). All the removed tissues were sent for histological examination by hematoxylin and eosine (H & E) staining method. Results: Unilateral and bilateral success rate of the surgical detection of SLN was 85.7 % (75 %–93 %) and 80.0 % (63 %–92 %) respectively. The sentinel lymph node was histologically positive in two cases. Ultrasound assessment of myometrial invasion had 100 % (15.8 %–100 %) sensitivity and 78.9 % (54.4 %–93.9 %) specificity, whereas the ultrasound assessment of cervical stromal invasion only had 33 % (0.8 %–90.6 %) sensitivity and 94.4 % (72.7 %–99.8 %) specificity. Postoperative histological differentiation was upgraded in 5.7 % and downgraded in 8.6 % of cases. Conclusion: SLN biopsy at the time of surgery allows a personalized treatment approach in patients with endometrial cancer and a secure abandonment of pelvic lymphadenectomy in patients at low and intermediate risk of recurrence. Its final inclusion in the treatment guidelines will require additional experience regarding patient selection, surgical treatment quality tracking, as well as urgent implementation of histological ultrastaging of the removed SLN.
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