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Evaluation and staging of endometrial and endocervical adenocarcinoma by contact hysteroscopy
GYNECOLOGIC
ONCOLOGY
9, 182-192 (1980)
Evaluation and Staging Adenocarcinoma MICHAEL
of Endometrial and Endocervical by Contact Hysteroscopy S. BAGGISH,
M.D.
Director, Obstetrics and Gynecology, Mount Sinai Hospital, 500 Blue Hills Avenue, Hartford. Connecticut 06112 Received May 28, 1979 Contact hysteroscopy is a new technique for examining the uterine cavity and endocervicat canal to aid in the diagnosis and staging of neoplasia. Direct visual examination of the endometrium may be accomplished without any distending medium and regardless of the presence of bleeding. The contact endoscope does not require any light source other than ambient room light because of an ingenious light trap which is built into the instrument. Fifteen cases of adenocarcinoma of the endometrium and endocervix are described in which contact hysteroscopy aided in identification, localization, and definition of spread of the tumors.
INTRODUCTION
Contact hysteroscopy is the newest endoscopic technique for viewing the interior of the uterus. The method of contact hysteroscopy was developed in France by Barbot [l-3] and introduced into the United States by Baggish [4]. Although the indications for use of the contact hysteroscope are numerous and the applications of the instrument varied, this communication will confine its scope to those uses for diagnosis and staging for endometrial and endocervical neoplasia. Compared to conventional methods of hysteroscopy, the contact method offers the following advantages: (1) No distension of the uterine cavity is necessary, (2) no special light source is required (the contact hysteroscope collects, traps, transmits, and receives ambient room light), (3) blood or other liquid w’ill not obstruct vision. The final and most significant advantage of this technique is its simplicity. Examination of the uterine cavity may be carried out with minimal preparation, in virtually any setting, e.g., physician’s office, emergency room, clinic, or operating room. Contact hysteroscopy is therefore ideally suited for investigative oncology. Previously cited concerns of spreading tumor cells by retrograde tubal spill is obviated since no distending medium is placed into the uterus. Since bleeding is a frequent accompaniment of malignant lesions, contact hysteroscopy is the only reliable technique for direct visualization of endometrial carcinoma. As with colposcopy direct observation of the lesion and directed sampling offer substantial advantages to the oncologist. 182 0090-8258/80/020182-11$01.00/0 Copyright All rights
@ 1980 by Academic Press. Inc. of reproduction in any form reserved.
ENDOMETRIAL
AND ENDOCERVICAL
MATERIALS
ADENOCARCINOMA
183
AND METHODS
The MT0 6- and 8-mm diameter (X 1.6) contact hysteroscopes, imported by Advanced Biomedical Instruments, were used in this study (Fig. 1). These models have an overall length of 200 mm and a focal length of 4 mm to contact surface. A focusing magnifier (x2.0) was usually attached to the eyepiece of the hysteroscope. Ambient room light was focused on the light trapping cylinder (Fig. 2); occasionally more intense light sources were utilized, e.g., a 250-W quartz lamp when photography was desired. Generally speaking an operating room or examining room light provide excellent illumination. All patients’ cervices and vaginas were prepared with betadine after a Pap smear had been obtained. The anterior lip of the cervix was grasped with a single tooth tenaculum and the cervix dilated to 27-29 French (for the 8-mm instrument). When the 6-mm scope was used, dilatation varied from none in multiparous women to 21 French for nulliparous patients. Dilatation was frequently accom-
FIG. 1. Two models of the contact hysteroscope are available, the 8-mm endoscope (right) and the 6-mm model (left.) The arrow points to the light collecting chamber.
184
FIG. 2. The contact hysteroscope’s unique design allows ambient room light to be collected, trapped, and transmitted to the focal point at the end of the endoscope. The latter is accomplished by a series of mirrors which selectively transmit light by virtue of thin coatings.
FIG. 3. Inspection of the uterus is carried out in a systematic fashion by first inspecting the endocervix, followed by exploration of either side wall, the fundus, and finally the anterior and posterior walls. Only in this fashion can the hysteroscopist be assured that the entire endometrial cavity and endocervical canal have been adequately inspected.
ENDOMETRIAL
AND
ENDOCERVICAL
185
ADENOCARCINOMA
plished with a paracervical block either in the office or clinic. The hysteroscope is inserted through the external OS of the cervix and visual examination of the endocervical canal is carried out. The junction of the endometrial and endocervical cavities is clearly seen as the instrument is passed through the internal OSof the cervix. Inspection of the endometrium is carried out in an organized fashion so as to see the entire cavity (Fig. 3). Suitable sampling by biopsy or dilatation and curettage is then carried out. Postcurettage inspection has proved valuable to determine the amount of tissue left behind and to decide whether further sampling is necessary. Interestingly, after every D&C, hysteroscopic inspection revealed approximately one-third of the endometrium to be left behind. Fifteen women ranging from 49 to 75 years of age were examined by contact hysteroscopy because of malignancy, suspected on the basis of a Pap smear and/or endometrial biopsy. All cases were subsequently found to have either endocervical or endometrial tumors corroborated by histopathologic examination of the curettage specimens. All hysteroscopic diagnoses were transcribed prior to pathologic diagnosis on the patient’s chart. All cases were further verified by photographs taken through the hysteroscope. Endoscopic examination times ranged from 10 to 15 min after which fractional D&C and cervical biopsy were done. A total of 250 contact hysteroscopic examinations have been performed between February and May, 1979, at Mt. Sinai Hospital, Hartford, Connecticut. Out of the total group the 15 cases cited above had either endocervical or endometrial malignancy. RESULTS
The pathologic diagnoses of the 15 malignancies are shown in Table 1. Tumors of the endometrium predominated 14 to 1 with the latter being a primary adenocarcinoma of the endocervix (Fig. 4).
TABLE 1 COMPARISON OF HYSTEROSCOPIC AND PATHOLOGIC DIAGNOSES 15 ENDOMETRIAL/ENDOCERVICAL MALIGNANCIES
Hysteroscopic diagnosis Polypoid endometrium with hyperplasia Atypical endometrial hyperplasia Adenocarcinoma endometrium Adenocarcinoma involving endocervix
L One metastatic to endocervix.
IN
Pathologic diagnosis
N
%
Mixed mesodermal tumor
1
6.7
Adenocarcinoma
2
13.3
Adenocarcinoma endometrium Primary adenocarcinoma of the endocervix
11” 1
73.3 6.7
Total
I5
100.0%
endometrium
186
MICHAEL
S. BAGGISH
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
187
188
MICHAEL
S. BAGGISH
IJIG. 5. A typical endometrial adenocarcinoma viewed through the contact hysteroscope . The tun 1or was festooned, raised, pale with hemorrhagic foci. The white, polypoid appearance is tj (pica1 for endometrial carcinoma.
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
189
FIG. 6. The schematic grid illustrated above is used in a similar fashion to a dentist’s cavity chart. The operating room nurse marks lesions as they are described by the surgeon. Subsequent biopsies are carried out by referring to the grid chart.
Hysteroscopic diagnosis was correct in 12 out of 15 cases or 80%. Of the three remaining cases, two patients were found to have adenocarcinoma although diagnosed by hysteroscopy as atypical hyperplasia. The last case which proved pathologically to be adenocarcinoma was diagnosed as polypoid endometrium with hyperplasia. No case was diagnosed as normal endometrium. Every case was associated with bleeding and in 10 cases the bleeding was brisk. This probably would have precluded conventional hysteroscopic techniques employing water, dextran, or CO, as distending media. The carcinomas were typically raised, waxy, silvery-white or pale lesions with folds (Fig. 5). Some of the lesions showed variegated deep red-yellow areas. In other cases a polypoid appearance was noted. Confusion with hyperplasia and old decidua was possible. However, the endometrium affected with tumor is firm and the tissue brittle when manipulated. TABLE SPREAD OF TUMOR
Hysteroscopic evaluation Diffuse spread Bight fundusicorpus Left funduslcorpus Corpus only Fundus only Endocervical spread
2
BASED ON HYSTEROSCOPIC
EVALUATION
Tumor type Mixed mesodermal Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma endometrium Adenocarcinoma endocervix Total
N 1 2 5 2 2 1 1 1 I5
190
MICHAEL
S. BAGGISH
FIG. 7A. View of the endocervical canal via contact hysteroscopy shows the mucosa at the level of the internal OS.
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
191
192
MICHAEL
S. BAGGISH
The tumors were mapped on a grid to allow more adequate sampling after the hysteroscopic inspection was completed (Fig. 6). Spread of the tumor could be accurately documented especially when involvement of the endocervix had occurred (Table 2). DISCUSSION
Contact hysteroscopy should be considered in a fashion analagous to colposcopy. The close examination of the endometrium allows precise localization of the cancer and enables the gynecologist to direct a biopsy to the appropriate location. Accurate visual appraisal for staging and ultimate prognosis are added advantages. Endocervical curettage, although better than no sampling at all, remains a blind procedure and fraught with limitations. Direct observation of endocervical tumor by hysteroscopy is the best method to stage malignancies, since the view of the endocervical canal is equally as good as the endometrium (Fig. 7). As with colposcopy, this procedure is learned by observing a lesion for color, contour, pattern, and consistency. The contact hysteroscope adds another dimension, i.e., contact or feeling which allows one to determine which lesions are firm, soft, fixed, or mobile. By correlating the physical findings with pathologic diagnosis, certain characteristics may be pieced together to form a composite picture which differentiates one lesion from another. After an experience of approximately 50 cases, the clinician should be able to diagnose with substantial confidence. Sterilization is carried out by soaking in cidex for 15 min and then washing thoroughly with distilled water. In the total of 250 cases no infections have occurred. Similarly, no perforations have occurred. Other indications for use of this instrument include noninvasive embryoscopy; diagnosis of incomplete abortion, amnioscopy, finding “lost IUD,” localization and diagnosis of polypi, myomas, synechia. Contact hysteroscopy has proved useful for diagnosing congenital abnormalities, e.g., double or bicornuate uterus. Recently a hydatidiform mole was diagnosed by direct examination and visualization of molar vesicles. The instrument may be utilized for urethroscopy, cystoscopy, and cervicovaginal examination of newborn and prepubescent females. As a result of this preliminary evaluation, the contact hysteroscope should be a worthwhile tool for the gynecologic oncolgist, especially to assess the location and spread of endometrial and endocervical malignancy. The engineering advantages of this instrument and its simplicity of design offer substantial advantages over conventional, older methods of hysteroscopy. The only possible disadvantage to the instrument is the lack of a panoramic view. REFERENCES 1. Barbot, J. L’Hysreroscopie de Contact ThPse, Paris, (197% 2. Parent, B., Doerler, B., Barbot, J., and Guedj, H. Mitrorragies Post-Mknopausiques: Diagnostic Par L’Hystkroscope de Contact, Acta Endosc. 8, 13 (1978). 3. Parent, B., Toubas, C., and Doerler, B. L’HystCroscopie de Contact,J. Gynecol. Biol. Rep. 3,511 (1974). 4. Baggish, M. Contact hysteroscopy: A new technique to explore the uterine cavity, Obster. Gynecol. 54, 350 (1979).
ONCOLOGY
9, 182-192 (1980)
Evaluation and Staging Adenocarcinoma MICHAEL
of Endometrial and Endocervical by Contact Hysteroscopy S. BAGGISH,
M.D.
Director, Obstetrics and Gynecology, Mount Sinai Hospital, 500 Blue Hills Avenue, Hartford. Connecticut 06112 Received May 28, 1979 Contact hysteroscopy is a new technique for examining the uterine cavity and endocervicat canal to aid in the diagnosis and staging of neoplasia. Direct visual examination of the endometrium may be accomplished without any distending medium and regardless of the presence of bleeding. The contact endoscope does not require any light source other than ambient room light because of an ingenious light trap which is built into the instrument. Fifteen cases of adenocarcinoma of the endometrium and endocervix are described in which contact hysteroscopy aided in identification, localization, and definition of spread of the tumors.
INTRODUCTION
Contact hysteroscopy is the newest endoscopic technique for viewing the interior of the uterus. The method of contact hysteroscopy was developed in France by Barbot [l-3] and introduced into the United States by Baggish [4]. Although the indications for use of the contact hysteroscope are numerous and the applications of the instrument varied, this communication will confine its scope to those uses for diagnosis and staging for endometrial and endocervical neoplasia. Compared to conventional methods of hysteroscopy, the contact method offers the following advantages: (1) No distension of the uterine cavity is necessary, (2) no special light source is required (the contact hysteroscope collects, traps, transmits, and receives ambient room light), (3) blood or other liquid w’ill not obstruct vision. The final and most significant advantage of this technique is its simplicity. Examination of the uterine cavity may be carried out with minimal preparation, in virtually any setting, e.g., physician’s office, emergency room, clinic, or operating room. Contact hysteroscopy is therefore ideally suited for investigative oncology. Previously cited concerns of spreading tumor cells by retrograde tubal spill is obviated since no distending medium is placed into the uterus. Since bleeding is a frequent accompaniment of malignant lesions, contact hysteroscopy is the only reliable technique for direct visualization of endometrial carcinoma. As with colposcopy direct observation of the lesion and directed sampling offer substantial advantages to the oncologist. 182 0090-8258/80/020182-11$01.00/0 Copyright All rights
@ 1980 by Academic Press. Inc. of reproduction in any form reserved.
ENDOMETRIAL
AND ENDOCERVICAL
MATERIALS
ADENOCARCINOMA
183
AND METHODS
The MT0 6- and 8-mm diameter (X 1.6) contact hysteroscopes, imported by Advanced Biomedical Instruments, were used in this study (Fig. 1). These models have an overall length of 200 mm and a focal length of 4 mm to contact surface. A focusing magnifier (x2.0) was usually attached to the eyepiece of the hysteroscope. Ambient room light was focused on the light trapping cylinder (Fig. 2); occasionally more intense light sources were utilized, e.g., a 250-W quartz lamp when photography was desired. Generally speaking an operating room or examining room light provide excellent illumination. All patients’ cervices and vaginas were prepared with betadine after a Pap smear had been obtained. The anterior lip of the cervix was grasped with a single tooth tenaculum and the cervix dilated to 27-29 French (for the 8-mm instrument). When the 6-mm scope was used, dilatation varied from none in multiparous women to 21 French for nulliparous patients. Dilatation was frequently accom-
FIG. 1. Two models of the contact hysteroscope are available, the 8-mm endoscope (right) and the 6-mm model (left.) The arrow points to the light collecting chamber.
184
FIG. 2. The contact hysteroscope’s unique design allows ambient room light to be collected, trapped, and transmitted to the focal point at the end of the endoscope. The latter is accomplished by a series of mirrors which selectively transmit light by virtue of thin coatings.
FIG. 3. Inspection of the uterus is carried out in a systematic fashion by first inspecting the endocervix, followed by exploration of either side wall, the fundus, and finally the anterior and posterior walls. Only in this fashion can the hysteroscopist be assured that the entire endometrial cavity and endocervical canal have been adequately inspected.
ENDOMETRIAL
AND
ENDOCERVICAL
185
ADENOCARCINOMA
plished with a paracervical block either in the office or clinic. The hysteroscope is inserted through the external OS of the cervix and visual examination of the endocervical canal is carried out. The junction of the endometrial and endocervical cavities is clearly seen as the instrument is passed through the internal OSof the cervix. Inspection of the endometrium is carried out in an organized fashion so as to see the entire cavity (Fig. 3). Suitable sampling by biopsy or dilatation and curettage is then carried out. Postcurettage inspection has proved valuable to determine the amount of tissue left behind and to decide whether further sampling is necessary. Interestingly, after every D&C, hysteroscopic inspection revealed approximately one-third of the endometrium to be left behind. Fifteen women ranging from 49 to 75 years of age were examined by contact hysteroscopy because of malignancy, suspected on the basis of a Pap smear and/or endometrial biopsy. All cases were subsequently found to have either endocervical or endometrial tumors corroborated by histopathologic examination of the curettage specimens. All hysteroscopic diagnoses were transcribed prior to pathologic diagnosis on the patient’s chart. All cases were further verified by photographs taken through the hysteroscope. Endoscopic examination times ranged from 10 to 15 min after which fractional D&C and cervical biopsy were done. A total of 250 contact hysteroscopic examinations have been performed between February and May, 1979, at Mt. Sinai Hospital, Hartford, Connecticut. Out of the total group the 15 cases cited above had either endocervical or endometrial malignancy. RESULTS
The pathologic diagnoses of the 15 malignancies are shown in Table 1. Tumors of the endometrium predominated 14 to 1 with the latter being a primary adenocarcinoma of the endocervix (Fig. 4).
TABLE 1 COMPARISON OF HYSTEROSCOPIC AND PATHOLOGIC DIAGNOSES 15 ENDOMETRIAL/ENDOCERVICAL MALIGNANCIES
Hysteroscopic diagnosis Polypoid endometrium with hyperplasia Atypical endometrial hyperplasia Adenocarcinoma endometrium Adenocarcinoma involving endocervix
L One metastatic to endocervix.
IN
Pathologic diagnosis
N
%
Mixed mesodermal tumor
1
6.7
Adenocarcinoma
2
13.3
Adenocarcinoma endometrium Primary adenocarcinoma of the endocervix
11” 1
73.3 6.7
Total
I5
100.0%
endometrium
186
MICHAEL
S. BAGGISH
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
187
188
MICHAEL
S. BAGGISH
IJIG. 5. A typical endometrial adenocarcinoma viewed through the contact hysteroscope . The tun 1or was festooned, raised, pale with hemorrhagic foci. The white, polypoid appearance is tj (pica1 for endometrial carcinoma.
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
189
FIG. 6. The schematic grid illustrated above is used in a similar fashion to a dentist’s cavity chart. The operating room nurse marks lesions as they are described by the surgeon. Subsequent biopsies are carried out by referring to the grid chart.
Hysteroscopic diagnosis was correct in 12 out of 15 cases or 80%. Of the three remaining cases, two patients were found to have adenocarcinoma although diagnosed by hysteroscopy as atypical hyperplasia. The last case which proved pathologically to be adenocarcinoma was diagnosed as polypoid endometrium with hyperplasia. No case was diagnosed as normal endometrium. Every case was associated with bleeding and in 10 cases the bleeding was brisk. This probably would have precluded conventional hysteroscopic techniques employing water, dextran, or CO, as distending media. The carcinomas were typically raised, waxy, silvery-white or pale lesions with folds (Fig. 5). Some of the lesions showed variegated deep red-yellow areas. In other cases a polypoid appearance was noted. Confusion with hyperplasia and old decidua was possible. However, the endometrium affected with tumor is firm and the tissue brittle when manipulated. TABLE SPREAD OF TUMOR
Hysteroscopic evaluation Diffuse spread Bight fundusicorpus Left funduslcorpus Corpus only Fundus only Endocervical spread
2
BASED ON HYSTEROSCOPIC
EVALUATION
Tumor type Mixed mesodermal Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma endometrium Adenocarcinoma endocervix Total
N 1 2 5 2 2 1 1 1 I5
190
MICHAEL
S. BAGGISH
FIG. 7A. View of the endocervical canal via contact hysteroscopy shows the mucosa at the level of the internal OS.
ENDOMETRIAL
AND
ENDOCERVICAL
ADENOCARCINOMA
191
192
MICHAEL
S. BAGGISH
The tumors were mapped on a grid to allow more adequate sampling after the hysteroscopic inspection was completed (Fig. 6). Spread of the tumor could be accurately documented especially when involvement of the endocervix had occurred (Table 2). DISCUSSION
Contact hysteroscopy should be considered in a fashion analagous to colposcopy. The close examination of the endometrium allows precise localization of the cancer and enables the gynecologist to direct a biopsy to the appropriate location. Accurate visual appraisal for staging and ultimate prognosis are added advantages. Endocervical curettage, although better than no sampling at all, remains a blind procedure and fraught with limitations. Direct observation of endocervical tumor by hysteroscopy is the best method to stage malignancies, since the view of the endocervical canal is equally as good as the endometrium (Fig. 7). As with colposcopy, this procedure is learned by observing a lesion for color, contour, pattern, and consistency. The contact hysteroscope adds another dimension, i.e., contact or feeling which allows one to determine which lesions are firm, soft, fixed, or mobile. By correlating the physical findings with pathologic diagnosis, certain characteristics may be pieced together to form a composite picture which differentiates one lesion from another. After an experience of approximately 50 cases, the clinician should be able to diagnose with substantial confidence. Sterilization is carried out by soaking in cidex for 15 min and then washing thoroughly with distilled water. In the total of 250 cases no infections have occurred. Similarly, no perforations have occurred. Other indications for use of this instrument include noninvasive embryoscopy; diagnosis of incomplete abortion, amnioscopy, finding “lost IUD,” localization and diagnosis of polypi, myomas, synechia. Contact hysteroscopy has proved useful for diagnosing congenital abnormalities, e.g., double or bicornuate uterus. Recently a hydatidiform mole was diagnosed by direct examination and visualization of molar vesicles. The instrument may be utilized for urethroscopy, cystoscopy, and cervicovaginal examination of newborn and prepubescent females. As a result of this preliminary evaluation, the contact hysteroscope should be a worthwhile tool for the gynecologic oncolgist, especially to assess the location and spread of endometrial and endocervical malignancy. The engineering advantages of this instrument and its simplicity of design offer substantial advantages over conventional, older methods of hysteroscopy. The only possible disadvantage to the instrument is the lack of a panoramic view. REFERENCES 1. Barbot, J. L’Hysreroscopie de Contact ThPse, Paris, (197% 2. Parent, B., Doerler, B., Barbot, J., and Guedj, H. Mitrorragies Post-Mknopausiques: Diagnostic Par L’Hystkroscope de Contact, Acta Endosc. 8, 13 (1978). 3. Parent, B., Toubas, C., and Doerler, B. L’HystCroscopie de Contact,J. Gynecol. Biol. Rep. 3,511 (1974). 4. Baggish, M. Contact hysteroscopy: A new technique to explore the uterine cavity, Obster. Gynecol. 54, 350 (1979).