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How to use CA-125 More Effectively in the Diagnosis of Deep Endometriosis?
S112
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
dometriosis such as white lesions, clear lesions and red lesions as well as the effects of scarification caused by endometriosis are presented. In particular, this video illustrates some of the laparoscopic techniques used in the evaluation and treatment of endometriosis such as peritoneal excision, transperitoneal ureterolysis and oophoropexy. Finally, the video poses the question of endometriosis as a chronic disease requiring not only a multimodal approach, but also the expectation of possible repeat surgical interventions over time.
332
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
present. Pathology from staging procedure showed benign uterus with adenomyosis and leiomyomata. lymph nodes, omental biopsy, and small bowel mesenteric nodule all returned benign fibroadipose tissue. Conclusion: Endometriosis although benign, shares pathophysiological features with cancer. Both histologic and epidemiologic evidence suggest that ovarian endometriosis may lead to malignant ovarian tumors primarily epithelial in origin. Primary extrauterine stromal sarcoma is a rare but reported diagnosis. Adequate sampling of suspected implants may aid in this rare diagnosis.
334
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
9:57 AM – STATION F Ethanol Sclerotherapy for the Treatment of Ovarian Endometrioma Moon HS, Kim SG, Koo J, Nam GI. Center for Minimally Invasive Surgery, Department of Ob/Gyn, Good Moonhwa Hospital, Busan, Republic of Korea Objective: To present our experience of ultrasound-guided sclerotherapy with 95% ethanol for the treatment of ovarian endometrioma. Method: Under anesthesia, an 18 gauge ovum aspiration needle is penetrated into the cystic cavity under ultrasound guidance and the aspirated fluid is collected by applying constant indirect negative pressure through a specially designed silicone plug.. Once adequately drained, the cystic cavity is flushed with normal saline until clear and intact cystic wall is confirmed throughout irrigation. Then the cystic cavity is irrigated with 40 cc of 95% ethanol and another 40 cc was instillated in the cyst. Conclusion: Our experience suggests that ethanol sclerotherapy is a safe and effective procedure in premenopausal women with ovarian endometrioma who are anticipating pregnancy. Instillation of 95% ethanol contributes to the low recurrence rate through sclerosis of the possibly remaining functional endometrial tissue.
333
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
9:57 AM – STATION H How to use CA-125 More Effectively in the Diagnosis of Deep Endometriosis? Raymundo TS, Oliveira MAP, Soares LC, Pereira TR, Demôro AE. Gynecology, State University of Rio de Janeiro, Rio de Janeiro, Brazil Study Objective: The main objective of this study is to evaluate the performance of CA-125 measurement in the menstrual and mid-cycle phases of the cycle, as well as the difference in its levels between the two phases in patients with DIE. Design: A prospective study from January 2012 to January 2016. Setting: Endometriosis Treatment Center in Pedro Ernesto University Hospital (Rio de Janeiro State University). Patients: Fifty four patients were included, 34 with deep infiltrative endometriosis (DIE) and 20 for tubal ligation. Intervention: Two serum samples of CA-125 were collected during the preoperative period: during menses (between the 2nd and 4th days of the menstrual cycle) and in the mid-cycle (between the 13th and 15th days). Both dosages were made no more than 3 months prior to surgery. Serum CA-125 concentrations were measured by an immunoradiometric kit using M11 specific monoclonal antibody (Centocor, Malvern, PA, USA). Measurements and Main Results: Area Under the Curve (AUC) of CA125 in menstrual phase and of the difference between menstrual and midcycle phases had the best performance (both with AUC = 0.96).
9:57 AM – STATION G Extrauterine Stromal Sarcoma in a Foci of Endometriosis Grant A, Beale S, Nimaroff M. Obstetrics and Gynecology, North Shore University Hospital Northwell Health, Manhasset, New York Study Objective: To review case of endometrial stromal sarcoma incidentally found in woman with endometriosis and pelvic pain. Design: Case report. Setting: Academic Affiliated Hospital. Patients: This is a case report of a 42 year old patient with pelvic pain and history of endometriosis. Patient’s history was significant for laparoscopy with removal of endometriosis in her mid 20s. Her pain was previously improved on oral contraceptives, however she no longer desired hormonal therapy and developed worsening pain. Pelvic sonogram was normal. Intervention: Patient underwent an uncomplicated laparoscopy and excision of endometriosis. Intraoperative findings showed scattered peritoneal implants and a nodule on the right uterosacral ligament. Pathology from the uterosacral excision revealed endometrial stromal sarcoma in the background of endometriosis. Pathology sent out for second opinion with the same conclusion. Repeat pelvic sonogram was normal. Endometrial biopsy normal. Patient referred to gynecology oncology and underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node sampling and additional biopsies. Intraoperative findings of cystic nodules on small bowel mesentery, final pathology benign. Measurements and Main Results: Pathology from laparoscopy showed benign fibroadipose tissue in right and left peritoneal biopsies. A biopsy of the right uterosacral ligament showed atypical endometrial stromal proliferation most consistent with low grade endometrial stromal sarcoma; background endometriosis
The ratio between menstrual and mid-cycle phases had the worst performance. The best cutoff point in AUC for Δ CA-125 was the 8.5 value for the difference between CA-125 in menstruation and in mid-cycle. When menstrual serum CA-125 levels were less than 35 IU/mL in women with DIE, four had Δ CA-125 above 8.5 IU/ml. The only patient in the control group
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 with serum CA-125 level in menstruation > 35 IU/mL, had a Δ CA-125 less than 8.5 IU/mL. The specificity of this test was 100%. Comparison of Controls and Patients with DIE in menstrual and mid-cycle phases using 35 IU/ml as a cutoff of CA-125 CA-125 Controls (n=20) DIE (n=34) Total Both negatives a Both positives b Menstrual Positive Only Total
19 0 1 20
5 18 11 34
24 18 12 54
DIE = Deep Infiltrative Endometriosis. a - menstrual and mid-cycle phases (CA-125 <35 IU/ml). b - menstrual and mid-cycle phases (CA-125 >35 IU/ml); (p <.00001). Conclusion: CA-125 may be useful for the diagnosis of deep endometriosis, especially when both are collected during menstruation and in midcycle. Multicentric studies with larger samples should be performed to better evaluate the cost-effectiveness of measuring CA-125 in two different phases of the menstrual cycle.
S113
Bladder endometrioma is relative rare, and may be originated from retrograde menstruation implant, direct extension from uterine adenomyosis, metaplasia, or from iatrogenic route (such as direct invasion from Cesarean section scar defect). We present this unusual case with huge bladder base endometrioma near bladder trigone originated from previous Cesarean scar defect, extended anteriorly and laterally all the way to left inguinal area. After careful development of left retroperitoneal space and complete ureterolysis, bladder trigone was exposed, and entire anterior deep infiltrating endometriosis mass was mobilized. An en-bloc excision (full-thickness partial cystectomy) was performed, removing the left half of bladder (including cutting down the left superior vesical artery), while preserving the trigone area and both ureters. 2-layer watertight suture was applied to repair the bladder wound. Although the bladder had being halved, with small bladder capacity immediately after operation, bladder capacity can reach 350 cc 3 months after the surgery.
337
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION C
Laparoscopic Low Anterior Resection for Bowel Endometriosis Using a Natural Orifice Lee CE,1 Leyland NA2. 1Obstetrics, Gynecology & Reproductive Sciences, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 2 Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada A 31-year-old nulligravid women presented to the minimally invasive gynecology clinic with a longstanding history of dysmenorrhea, dyschezia, and constipation. She had a previous laparoscopic procedure where she was diagnosed with stage IV endometriosis. Following extensive investigations and imaging, a large endometriotic tumor was found involving the rectosigmoid and rectovaginal septum with invasion into the vagina. A preoperative colonoscopy revealed intrinsic compression of the rectosigmoid junction, presumably secondary to the pelvic mass. We demonstrate the feasibility of a laparoscopic low anterior resection of bowel endometriosis using a natural orifice technique.
338
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION D
Laparoscopic Management of Abdominal Wall Endometriosis Piszczek C,1 Mittal P,2 Fogelson N3. 1Minimally Invasive Gynecology, Legacy Health System, Portland, Oregon2Radiology, Emory University, Atlanta, Georgia; 3Pearl Surgicenter, Portland, Oregon
335 Abstract Withdrawn
336
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION B
Laparoscopic Excision of Huge Bladder Base Endometrioma Near Trigone Originated from Cesarean Scar Defect Sun C-H. Ob/Gyn, Lucina Women & Children Hospital, Kaohsiung City, Kaohsiung, Taiwan
Objective: To demonstrate a case of complex AWE with laparoscopic management. Case: 38 year old G1P1 with persistent left abdominal wall pain following resection of AWE. Patient’s pain started in 2013, three months following a robotic SCH with uncontained power morcellation. A mass overlying the left iliac arty was removed and found to be an endometrioma. Pain continued. A laparotomy with excision of AWE was performed. Pain persisted. The patient presented to our clinic. MRI images read by an expert suggested two sites of AWE, both at sites of robotic ports from the initial hysterectomy. Our video showcases the robotic resection of AWE. Results: Pathology returned with endometriosis at both sites. The patient’s pain resolved following surgery. Conclusion: In this case, the likely mechanism of disease is AWE seeded during uncontained power morcellation. AWE can be managed laparoscopically in select cases. Expert radiology review can increase sensitivity of AWE detection.
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
dometriosis such as white lesions, clear lesions and red lesions as well as the effects of scarification caused by endometriosis are presented. In particular, this video illustrates some of the laparoscopic techniques used in the evaluation and treatment of endometriosis such as peritoneal excision, transperitoneal ureterolysis and oophoropexy. Finally, the video poses the question of endometriosis as a chronic disease requiring not only a multimodal approach, but also the expectation of possible repeat surgical interventions over time.
332
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
present. Pathology from staging procedure showed benign uterus with adenomyosis and leiomyomata. lymph nodes, omental biopsy, and small bowel mesenteric nodule all returned benign fibroadipose tissue. Conclusion: Endometriosis although benign, shares pathophysiological features with cancer. Both histologic and epidemiologic evidence suggest that ovarian endometriosis may lead to malignant ovarian tumors primarily epithelial in origin. Primary extrauterine stromal sarcoma is a rare but reported diagnosis. Adequate sampling of suspected implants may aid in this rare diagnosis.
334
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
9:57 AM – STATION F Ethanol Sclerotherapy for the Treatment of Ovarian Endometrioma Moon HS, Kim SG, Koo J, Nam GI. Center for Minimally Invasive Surgery, Department of Ob/Gyn, Good Moonhwa Hospital, Busan, Republic of Korea Objective: To present our experience of ultrasound-guided sclerotherapy with 95% ethanol for the treatment of ovarian endometrioma. Method: Under anesthesia, an 18 gauge ovum aspiration needle is penetrated into the cystic cavity under ultrasound guidance and the aspirated fluid is collected by applying constant indirect negative pressure through a specially designed silicone plug.. Once adequately drained, the cystic cavity is flushed with normal saline until clear and intact cystic wall is confirmed throughout irrigation. Then the cystic cavity is irrigated with 40 cc of 95% ethanol and another 40 cc was instillated in the cyst. Conclusion: Our experience suggests that ethanol sclerotherapy is a safe and effective procedure in premenopausal women with ovarian endometrioma who are anticipating pregnancy. Instillation of 95% ethanol contributes to the low recurrence rate through sclerosis of the possibly remaining functional endometrial tissue.
333
Virtual Posters – Session 1 (9:45 AM - 10:45 AM)
9:57 AM – STATION H How to use CA-125 More Effectively in the Diagnosis of Deep Endometriosis? Raymundo TS, Oliveira MAP, Soares LC, Pereira TR, Demôro AE. Gynecology, State University of Rio de Janeiro, Rio de Janeiro, Brazil Study Objective: The main objective of this study is to evaluate the performance of CA-125 measurement in the menstrual and mid-cycle phases of the cycle, as well as the difference in its levels between the two phases in patients with DIE. Design: A prospective study from January 2012 to January 2016. Setting: Endometriosis Treatment Center in Pedro Ernesto University Hospital (Rio de Janeiro State University). Patients: Fifty four patients were included, 34 with deep infiltrative endometriosis (DIE) and 20 for tubal ligation. Intervention: Two serum samples of CA-125 were collected during the preoperative period: during menses (between the 2nd and 4th days of the menstrual cycle) and in the mid-cycle (between the 13th and 15th days). Both dosages were made no more than 3 months prior to surgery. Serum CA-125 concentrations were measured by an immunoradiometric kit using M11 specific monoclonal antibody (Centocor, Malvern, PA, USA). Measurements and Main Results: Area Under the Curve (AUC) of CA125 in menstrual phase and of the difference between menstrual and midcycle phases had the best performance (both with AUC = 0.96).
9:57 AM – STATION G Extrauterine Stromal Sarcoma in a Foci of Endometriosis Grant A, Beale S, Nimaroff M. Obstetrics and Gynecology, North Shore University Hospital Northwell Health, Manhasset, New York Study Objective: To review case of endometrial stromal sarcoma incidentally found in woman with endometriosis and pelvic pain. Design: Case report. Setting: Academic Affiliated Hospital. Patients: This is a case report of a 42 year old patient with pelvic pain and history of endometriosis. Patient’s history was significant for laparoscopy with removal of endometriosis in her mid 20s. Her pain was previously improved on oral contraceptives, however she no longer desired hormonal therapy and developed worsening pain. Pelvic sonogram was normal. Intervention: Patient underwent an uncomplicated laparoscopy and excision of endometriosis. Intraoperative findings showed scattered peritoneal implants and a nodule on the right uterosacral ligament. Pathology from the uterosacral excision revealed endometrial stromal sarcoma in the background of endometriosis. Pathology sent out for second opinion with the same conclusion. Repeat pelvic sonogram was normal. Endometrial biopsy normal. Patient referred to gynecology oncology and underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node sampling and additional biopsies. Intraoperative findings of cystic nodules on small bowel mesentery, final pathology benign. Measurements and Main Results: Pathology from laparoscopy showed benign fibroadipose tissue in right and left peritoneal biopsies. A biopsy of the right uterosacral ligament showed atypical endometrial stromal proliferation most consistent with low grade endometrial stromal sarcoma; background endometriosis
The ratio between menstrual and mid-cycle phases had the worst performance. The best cutoff point in AUC for Δ CA-125 was the 8.5 value for the difference between CA-125 in menstruation and in mid-cycle. When menstrual serum CA-125 levels were less than 35 IU/mL in women with DIE, four had Δ CA-125 above 8.5 IU/ml. The only patient in the control group
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 with serum CA-125 level in menstruation > 35 IU/mL, had a Δ CA-125 less than 8.5 IU/mL. The specificity of this test was 100%. Comparison of Controls and Patients with DIE in menstrual and mid-cycle phases using 35 IU/ml as a cutoff of CA-125 CA-125 Controls (n=20) DIE (n=34) Total Both negatives a Both positives b Menstrual Positive Only Total
19 0 1 20
5 18 11 34
24 18 12 54
DIE = Deep Infiltrative Endometriosis. a - menstrual and mid-cycle phases (CA-125 <35 IU/ml). b - menstrual and mid-cycle phases (CA-125 >35 IU/ml); (p <.00001). Conclusion: CA-125 may be useful for the diagnosis of deep endometriosis, especially when both are collected during menstruation and in midcycle. Multicentric studies with larger samples should be performed to better evaluate the cost-effectiveness of measuring CA-125 in two different phases of the menstrual cycle.
S113
Bladder endometrioma is relative rare, and may be originated from retrograde menstruation implant, direct extension from uterine adenomyosis, metaplasia, or from iatrogenic route (such as direct invasion from Cesarean section scar defect). We present this unusual case with huge bladder base endometrioma near bladder trigone originated from previous Cesarean scar defect, extended anteriorly and laterally all the way to left inguinal area. After careful development of left retroperitoneal space and complete ureterolysis, bladder trigone was exposed, and entire anterior deep infiltrating endometriosis mass was mobilized. An en-bloc excision (full-thickness partial cystectomy) was performed, removing the left half of bladder (including cutting down the left superior vesical artery), while preserving the trigone area and both ureters. 2-layer watertight suture was applied to repair the bladder wound. Although the bladder had being halved, with small bladder capacity immediately after operation, bladder capacity can reach 350 cc 3 months after the surgery.
337
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION C
Laparoscopic Low Anterior Resection for Bowel Endometriosis Using a Natural Orifice Lee CE,1 Leyland NA2. 1Obstetrics, Gynecology & Reproductive Sciences, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 2 Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada A 31-year-old nulligravid women presented to the minimally invasive gynecology clinic with a longstanding history of dysmenorrhea, dyschezia, and constipation. She had a previous laparoscopic procedure where she was diagnosed with stage IV endometriosis. Following extensive investigations and imaging, a large endometriotic tumor was found involving the rectosigmoid and rectovaginal septum with invasion into the vagina. A preoperative colonoscopy revealed intrinsic compression of the rectosigmoid junction, presumably secondary to the pelvic mass. We demonstrate the feasibility of a laparoscopic low anterior resection of bowel endometriosis using a natural orifice technique.
338
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION D
Laparoscopic Management of Abdominal Wall Endometriosis Piszczek C,1 Mittal P,2 Fogelson N3. 1Minimally Invasive Gynecology, Legacy Health System, Portland, Oregon2Radiology, Emory University, Atlanta, Georgia; 3Pearl Surgicenter, Portland, Oregon
335 Abstract Withdrawn
336
Virtual Posters – Session 1 (9:45 AM - 10:45 AM) 10:03 AM – STATION B
Laparoscopic Excision of Huge Bladder Base Endometrioma Near Trigone Originated from Cesarean Scar Defect Sun C-H. Ob/Gyn, Lucina Women & Children Hospital, Kaohsiung City, Kaohsiung, Taiwan
Objective: To demonstrate a case of complex AWE with laparoscopic management. Case: 38 year old G1P1 with persistent left abdominal wall pain following resection of AWE. Patient’s pain started in 2013, three months following a robotic SCH with uncontained power morcellation. A mass overlying the left iliac arty was removed and found to be an endometrioma. Pain continued. A laparotomy with excision of AWE was performed. Pain persisted. The patient presented to our clinic. MRI images read by an expert suggested two sites of AWE, both at sites of robotic ports from the initial hysterectomy. Our video showcases the robotic resection of AWE. Results: Pathology returned with endometriosis at both sites. The patient’s pain resolved following surgery. Conclusion: In this case, the likely mechanism of disease is AWE seeded during uncontained power morcellation. AWE can be managed laparoscopically in select cases. Expert radiology review can increase sensitivity of AWE detection.