Transcript Rectovaginal Endometriosis

Laparoscopic Recognition of Endometriosis
Dan C. Martin, M.D.
University of Tennessee Health Science Center
Memphis, Tennessee
---------------------IX Congreso Nacional de Endoscopia Ginecológica
July 4 to 7, 2007
Puerto Vallarta, Jalisco, Mexico, California
Diagnosis of Endometriosis
These may be clinical or research.
• History
– Is “pain” adequate?
• Physical Examination
– Is “focal tenderness” adequate?
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Laboratory (Immunology)
Radiology (Sonography, MRI)
Laparoscopy
Laparotomy
Histology*
– * Please see the $100 reward information.
Blind Spots
• Clarification of purposes
– Research
– Clinical
• Decisions on endometriosis therapy are based on several
definitions that are not always related.
– We do not know if this is reasonable.
– It implies we can ignore or discount patients who have a laparoscopic
diagnosis but are histologically negative.
• There is a large body of literature on accuracy of confirmation of
endometriosis but not a corresponding literature on histologic
diagnosis of peritoneal and pelvic abnormalities.
– Psammoma bodies, endosalpingiosis, Walthard Rests, low malignant
potential tumor and other pathology have been identified as
endometriosis.
– If we think it is endometriosis then other significant pathology may
not be detected if we fail to do biopsies.
Confirmation at a Research Level
Year
1982
Cumulative Number 97
1983
1984
1985
1986.1 1986.2
188
279
376
426
495
50%
91%
93%
96%
99%
of Patients by One Gyn
Positive for Endo
62%
when Excised
NOTE: My 99% was in the last 69 of 495 cases over 60 months (8.2 per month)
Martin 1987, Stripling 1988, Martin 1990
45% Positive Predictive Value in 44 cases over 20 months (2.2.per month)
Walter, 2001
61% of lesions in first 46 cases over 34 months (1.4 per month)
68% of lesions in next 56 cases over 36 months (1.6 per month)
Stratton 2003, Stegmann 2005, the NIH group
88% in Webb’s study in 72 cases over 7 months (10.1 cases per month)
Webb presented at AAGL 2006 and a paper is in preparation.
Research Confirmation Protocol
• Anticipation of a high histologic clinical
confirmation rates requires attention to many
of the steps used in a research protocol.
• The research protocol is more demanding than
clinical protocols.
• Data is needed before we conclude that
research protocol need to be applied clinically.
Research Confirmation Protocol
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No Expectation of Appearance
Biopsy Techniques
Adequate Number of Biopsies
Signal to Noise Ratio
Tagging the Specimen Location
Marking the Specimen Side
Notations on Pathology Request
Uniform Specimen Size in Container
Cell Block
Transferring the Specimen to Container
Processing by the Surgeon
Communications with the Cutters
Communications with the Pathologist
Re-cutting Specimens
Requiring Histologic Description
Histologic Criteria (Batt 1989)
Reviewing Slides
Surgeon Experience
Fixed Protocol with Blinding
What Can We Do with a Biopsy?
• Rule Out Cancer
• Determine a Histologic Diagnosis
• Research
• This does not include deciding on therapy of
endometriosis.
– Therapeutic conclusions in the literature are based on
appearance or history but not histology.
– The literature says to treat it like endometriosis
if it looks like endometriosis.
– Histology is used to clarify other concerns.
– See $100 reward information.
Clinical Purpose of Biopsy
• Rule out cancer
• Establish diagnosis in confusing cases
• May guide further evaluation or therapy
Research Purpose of Biopsy
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Add to science
Establish histologic diagnosis in all cases
Develop conclusions
Develop additional research
Limitations of Biopsy
• Biopsy results do not commonly help with
decisions on therapy.*
– * Please see the $100 reward information.
• A negative biopsy does not exclude
endometriosis or other pathology.
• Biopsies can create complications.
Who Needs a Biopsy?
Asymptomatic patient having tubal sterilization. (Moen)
Dark Scarred
Puckered Pigmented
Mixed Color
- > No biopsy needed.
Dark Scarred
Puckered Pigmented
and Vesicles.
- > Biopsy!
Who Needs a Biopsy?
Asymptomatic patient having tubal sterilization. (Moen)
Endometriosis
Endosalpingiosis
Psammoma Bodies
- > Biopsy needed?
Same plus
LMPT and
Cancer
- > Biopsy!
Who Needs a Biopsy?
Asymptomatic patient having tubal sterilization. (Moen)
Psammoma Bodies
Endosalpingiosis
- > Biopsy needed?
Same plus
LMPT and
Cancer
- > Biopsy!
Who Needs a Biopsy?
Asymptomatic patient having tubal sterilization. (Moen)
Clear and Opaque
Tubal Nodules
- > Biopsy needed?
Who Needs a Biopsy?
Asymptomatic patient having tubal sterilization. (Moen)
Clear and Opaque
Tubal Nodules
- > Biopsy needed?
Walthard Rest
- > Biopsy?
What if infertility
patient? - > No!
Other Pathology
Other Pathology
Hemangiomatosis
Other Pathology
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Psammoma Bodies
Endosalpingiosis
Low Malignant Potential Tumor
Cancer
Other Pathology
Psammoma Bodies
Endosalpingiosis
Low Malignant Potential Tumor
Cancer
Other Pathology
Metastatic breast cancer
Other Pathology
Metastatic breast cancer
Pouch Of Douglas
O
Pouch Of Douglas
Pouch Of Douglas
• Vagina is generally in the upper half of
the Pouch of Douglas.
• Bowel is generally in the lower half of the
Pouch of Douglas.
Ring Forceps Test
Harry Reich
Ring Forceps Test
Harry Reich
Ring Forceps Test
Harry Reich
Ring Forceps
Endometriosis with
Forceps in Vagina 
Rectum 
Harry Reich
Conclusions
Purpose of Biopsy
• Clinical Care
– Laparoscopy is the gold standard
– Exceptions
• Vaginal Endometriosis
• Sciatic, pulmonary, etc. endometriosis
• Research
– Laparoscopy has been the gold standard
– Histology is needed
Biopsy
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White nodules
Clusters of vesicles
Mixed color endometriosis.
Anything you do not recognize.
Bowel
• Rectovaginal endometriosis is often
retrocervical.
• These may not involve the bowel.
• Ring forceps test
Web Updates
IX Congresso National de Endoscopia Ginecológica
• http://danmartinmd.com/cneg2007.htm
Reward Information
• http://www.memfert.com/reward.htm