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Could office endometrial biopsy be accurate as EBHR for assessing the preoperative tumor grade?
EJSO 33 (2007) 1047e1048
www.ejso.com
Correspondence
Could office endometrial biopsy be accurate as EBHR for assessing the preoperative tumor grade? Sir, First of all, we would like to congratulate Cutillo and his co-workers as they have tried to throw light on the role of hysteroscopy in the pre-operative work-up of endometrial cancer.1 According to their data, endometrial biopsy by means of the hysteroscopic resectoscope seems to be a ‘‘very accurate diagnostic procedure for assessing the preoperative tumor grade in patients with endometrial carcinoma’’ with a concordance with definitive pathologic examination of nearly 97%. Indeed the hysteroscopy resectoscope makes it possible to perform multiple, eye-mirated, 5-mm thick cancer biopsies, thus offering the pathologist ‘‘a surgical specimen which is highly representative of endometrial tumor’’. However a serious consideration arises from their study. As it emerges from their Materials and methods section, patients undergoing EBHR had been previously diagnosed with an early-stage endometrioid adenocarcinoma. In other words, it means that they had already undergone an endometrial assessment by the means of blind office endometrial biopsy or target office hysteroscopic biopsy or, at worst, by means of dilatation and curettage (D&C) under local or general anesthesia. Taking into account that all the patients then underwent first an EBHR under general anesthesia and second a definitive laparotomic surgery (with a median interval range between the two procedures of 10 days!), it results that every patient was subjected to three invasive procedures in a short time with at least two of them under general anesthesia! Furthermore we should consider that most patients with endometrial carcinoma are in old age and the risks of two general anesthetics in a short time should not be underestimated. As the main advantage of EBHR is to offer the pathologist an adequate specimen we propose to reach the same objective with a less invasive procedure and in an outpatient setting.2 DOI of original article: 10.1016/j.ejso.2006.11.020. 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.01.019
To collect enough endometrium (also including its deeper layers) for a correct histological examination, we perform the so-called ‘‘grasp biopsy’’ by means of 5Fr grasping forceps inserted through the operative channel of a 4 mm continuous-flow operative office hysteroscope with a 2.0 mm rod lens (Bettocchi office hysteroscope ‘‘size 4’’, Karl Storz, Tuttlingen, Germany). The grasping forceps are placed, with the jaws open, against the endometrium to be biopsed; then they are pushed into the tissue and along it for around 0.5e1 cm, avoiding touching the muscle fibers. Once a large portion of mucosa has been detached, the two jaws are closed and the whole hysteroscope is pulled out of the uterine cavity, without pulling the tip of the instrument back into the channel. In this way, not only the tissue inside the forceps jaws but also the surrounding tissue protruding outside the jaws can be retrieved, thus providing the pathologist with a large amount of tissue. Furthermore if the two jaws are placed profoundly in the endometrium to be biopsed, we should be sure to collect its deeper layers with a higher possibility that endometrial stroma tissue could also be represented in the biopsy specimen. Furthermore if we are not satisfied with the endometrium collected with the ‘‘grasp biopsy’’ we perform wide biopsies of endocavitary lesions by means of 5Fr bipolar Twizzle electrodes inserted through the operative channel of the hysteroscope. These electrodes are connected via a flexible cable with a versatile electrosurgical system dedicated to hysteroscopy (Versapoint Bipolar Electrosurgical System, Gynecare, Ethicon Inc., NJ, USA). We have already demonstrated that lowering the power of the generator to the mildest level and reducing the power setting by half (50 W), with the Twizzle electrode it is possible to produce minimal dissection of the tissue (resembling a precise ‘‘cut’’), with minimal generation of bubbles obscuring the visual field, and with high patient tolerance.3 In conclusion we agree with Cutillo and his co-workers regarding the need to further test the EBHR ‘‘for the evaluation of tumor grade and histotype’’, but we propose a randomized clinical trial comparing such technique not with D&C, but with standardized office hysteroscopic biopsy (‘‘grasp biopsy’’ plus bipolar electrodes).
1048
Correspondence / EJSO 33 (2007) 1047e1048
References 1. Cutillo G, Cignini P, Visca P, Vizza E, Sbiroli C. Endometrial biopsy by means of the hysteroscopic resectoscope for the evaluation of tumor differentiation in endometrial cancer: a pilot study. Eur J Surg Oncol 2006 Dec 22; [Epub ahead of print]. 2. Bettocchi S, Nappi L, Ceci O, Selvaggi L. What does ‘diagnostic hysteroscopy’ mean today? The role of the new techniques. Curr Opin Obstet Gynecol 2003;15(4):303–8. 3. Bettocchi S, Ceci O, Di Venere R, et al. Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5Fr bipolar electrode. Hum Reprod 2002;17(9):2435–8.
S. Bettocchi Department of General and Specialistic Surgical Sciences Section of Obstetrics and Gynaecology, University of Bari Bari, Italy
A. Di Spiezio Sardo* M. Guida G. Bifulco M. Borriello C. Nappi Department of Gynaecology and Obstetrics and Pathophysiology of Human Reproduction University of Naples ‘‘Federico II’’ Via Pansini 5, Naples, Italy *Corresponding author. Tel./fax: þ39 0817462905. E-mail address: [email protected] (A. Di Spiezio Sardo) Accepted 15 January 2007 Available online 2 March 2007
www.ejso.com
Correspondence
Could office endometrial biopsy be accurate as EBHR for assessing the preoperative tumor grade? Sir, First of all, we would like to congratulate Cutillo and his co-workers as they have tried to throw light on the role of hysteroscopy in the pre-operative work-up of endometrial cancer.1 According to their data, endometrial biopsy by means of the hysteroscopic resectoscope seems to be a ‘‘very accurate diagnostic procedure for assessing the preoperative tumor grade in patients with endometrial carcinoma’’ with a concordance with definitive pathologic examination of nearly 97%. Indeed the hysteroscopy resectoscope makes it possible to perform multiple, eye-mirated, 5-mm thick cancer biopsies, thus offering the pathologist ‘‘a surgical specimen which is highly representative of endometrial tumor’’. However a serious consideration arises from their study. As it emerges from their Materials and methods section, patients undergoing EBHR had been previously diagnosed with an early-stage endometrioid adenocarcinoma. In other words, it means that they had already undergone an endometrial assessment by the means of blind office endometrial biopsy or target office hysteroscopic biopsy or, at worst, by means of dilatation and curettage (D&C) under local or general anesthesia. Taking into account that all the patients then underwent first an EBHR under general anesthesia and second a definitive laparotomic surgery (with a median interval range between the two procedures of 10 days!), it results that every patient was subjected to three invasive procedures in a short time with at least two of them under general anesthesia! Furthermore we should consider that most patients with endometrial carcinoma are in old age and the risks of two general anesthetics in a short time should not be underestimated. As the main advantage of EBHR is to offer the pathologist an adequate specimen we propose to reach the same objective with a less invasive procedure and in an outpatient setting.2 DOI of original article: 10.1016/j.ejso.2006.11.020. 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.01.019
To collect enough endometrium (also including its deeper layers) for a correct histological examination, we perform the so-called ‘‘grasp biopsy’’ by means of 5Fr grasping forceps inserted through the operative channel of a 4 mm continuous-flow operative office hysteroscope with a 2.0 mm rod lens (Bettocchi office hysteroscope ‘‘size 4’’, Karl Storz, Tuttlingen, Germany). The grasping forceps are placed, with the jaws open, against the endometrium to be biopsed; then they are pushed into the tissue and along it for around 0.5e1 cm, avoiding touching the muscle fibers. Once a large portion of mucosa has been detached, the two jaws are closed and the whole hysteroscope is pulled out of the uterine cavity, without pulling the tip of the instrument back into the channel. In this way, not only the tissue inside the forceps jaws but also the surrounding tissue protruding outside the jaws can be retrieved, thus providing the pathologist with a large amount of tissue. Furthermore if the two jaws are placed profoundly in the endometrium to be biopsed, we should be sure to collect its deeper layers with a higher possibility that endometrial stroma tissue could also be represented in the biopsy specimen. Furthermore if we are not satisfied with the endometrium collected with the ‘‘grasp biopsy’’ we perform wide biopsies of endocavitary lesions by means of 5Fr bipolar Twizzle electrodes inserted through the operative channel of the hysteroscope. These electrodes are connected via a flexible cable with a versatile electrosurgical system dedicated to hysteroscopy (Versapoint Bipolar Electrosurgical System, Gynecare, Ethicon Inc., NJ, USA). We have already demonstrated that lowering the power of the generator to the mildest level and reducing the power setting by half (50 W), with the Twizzle electrode it is possible to produce minimal dissection of the tissue (resembling a precise ‘‘cut’’), with minimal generation of bubbles obscuring the visual field, and with high patient tolerance.3 In conclusion we agree with Cutillo and his co-workers regarding the need to further test the EBHR ‘‘for the evaluation of tumor grade and histotype’’, but we propose a randomized clinical trial comparing such technique not with D&C, but with standardized office hysteroscopic biopsy (‘‘grasp biopsy’’ plus bipolar electrodes).
1048
Correspondence / EJSO 33 (2007) 1047e1048
References 1. Cutillo G, Cignini P, Visca P, Vizza E, Sbiroli C. Endometrial biopsy by means of the hysteroscopic resectoscope for the evaluation of tumor differentiation in endometrial cancer: a pilot study. Eur J Surg Oncol 2006 Dec 22; [Epub ahead of print]. 2. Bettocchi S, Nappi L, Ceci O, Selvaggi L. What does ‘diagnostic hysteroscopy’ mean today? The role of the new techniques. Curr Opin Obstet Gynecol 2003;15(4):303–8. 3. Bettocchi S, Ceci O, Di Venere R, et al. Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5Fr bipolar electrode. Hum Reprod 2002;17(9):2435–8.
S. Bettocchi Department of General and Specialistic Surgical Sciences Section of Obstetrics and Gynaecology, University of Bari Bari, Italy
A. Di Spiezio Sardo* M. Guida G. Bifulco M. Borriello C. Nappi Department of Gynaecology and Obstetrics and Pathophysiology of Human Reproduction University of Naples ‘‘Federico II’’ Via Pansini 5, Naples, Italy *Corresponding author. Tel./fax: þ39 0817462905. E-mail address: [email protected] (A. Di Spiezio Sardo) Accepted 15 January 2007 Available online 2 March 2007