Laparoscopic Recognition of EndometriosisLaparoscopic Recognition of Endometriosis

DDan C. Martin, M.D.an C. Martin, M.D.

University of Tennessee Health Science CenterUniversity of Tennessee Health Science CenterMemphis, TennesseeMemphis, Tennessee

--------------------------------------------IX Congreso Nacional de Endoscopia GinecológicaIX Congreso Nacional de Endoscopia Ginecológica

July 4 to 7, 2007 July 4 to 7, 2007 Puerto Vallarta, Jalisco, Mexico, California Puerto Vallarta, Jalisco, Mexico, California

Diagnosis of EndometriosisDiagnosis of EndometriosisThese may be clinical or research.These may be clinical or research.

• History– Is “pain” adequate?

• Physical Examination– Is “focal tenderness” adequate?

• Laboratory (Immunology)• Radiology (Sonography, MRI)• Laparoscopy• Laparotomy• Histology*

– * Please see the $100 reward information.

Blind SpotsBlind 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 LevelConfirmation at a Research Level

Year 1982 1983 1984 1985 1986.1 1986.2Cumulative Number 97 188 279 376 426 495 of Patients by One GynPositive for Endo 62% 50% 91% 93% 96% 99% when ExcisedNOTE: 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 ProtocolResearch 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 ProtocolResearch Confirmation Protocol• 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?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 BiopsyClinical Purpose of Biopsy

• Rule out cancer

• Establish diagnosis in confusing cases

• May guide further evaluation or therapy

Research Purpose of BiopsyResearch Purpose of Biopsy

• Add to science

• Establish histologic diagnosis in all cases

• Develop conclusions

• Develop additional research

Limitations of BiopsyLimitations 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?Who Needs a Biopsy?

Dark ScarredPuckered PigmentedMixed Color- > No biopsy needed.

Dark ScarredPuckered Pigmentedand Vesicles. - > Biopsy!

Asymptomatic patient having tubal sterilization. (Moen)

Who Needs a Biopsy?Who Needs a Biopsy?

EndometriosisEndosalpingiosisPsammoma Bodies- > Biopsy needed?

Same plusLMPT andCancer - > Biopsy!

Asymptomatic patient having tubal sterilization. (Moen)

Who Needs a Biopsy?Who Needs a Biopsy?

Psammoma Bodies Endosalpingiosis- > Biopsy needed?

Same plusLMPT andCancer - > Biopsy!

Asymptomatic patient having tubal sterilization. (Moen)

Who Needs a Biopsy?Who Needs a Biopsy?

Clear and OpaqueTubal Nodules- > Biopsy needed?

Asymptomatic patient having tubal sterilization. (Moen)

Who Needs a Biopsy?Who Needs a Biopsy?

Clear and OpaqueTubal Nodules- > Biopsy needed?

Walthard Rest - > Biopsy?What if infertilitypatient? - > No!

Asymptomatic patient having tubal sterilization. (Moen)

Other PathologyOther Pathology

Other PathologyOther Pathology

Hemangiomatosis

• Psammoma BodiesEndosalpingiosisLow Malignant Potential TumorCancer

Other PathologyOther Pathology

Other PathologyOther Pathology

Psammoma Bodies

Endosalpingiosis

Low Malignant Potential Tumor

Cancer

Other PathologyOther PathologyMetastatic breast cancer

Other PathologyOther Pathology

Metastatic breast cancer

Pouch Of DouglasPouch Of Douglas

O

Pouch Of DouglasPouch Of Douglas

Pouch Of DouglasPouch 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 TestRing Forceps Test

Harry Reich

Ring Forceps TestRing Forceps Test

Harry Reich

Ring Forceps TestRing Forceps Test

Harry Reich

Ring ForcepsRing Forceps

Harry Reich

Endometriosis with Forceps in Vagina

Rectum

ConclusionsConclusions

Purpose of BiopsyPurpose 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

BiopsyBiopsy

• White nodules

• Clusters of vesicles

• Mixed color endometriosis.

• Anything you do not recognize.

BowelBowel

• Rectovaginal endometriosis is often retrocervical.

• These may not involve the bowel.

• Ring forceps test

Web UpdatesWeb Updates

IX Congresso National de Endoscopia Ginecológica• http://danmartinmd.com/cneg2007.htm

Reward Information• http://www.memfert.com/reward.htm