- Email: [email protected]
Reply to Barranger and Dara:
862
Letters to the Editor
endometrium during hysteroscopy and detected sentinel nodes (SN), by laparotomy, in 82% of cases. This article raises several concerns. The first is the choice of injection sites. Two injection sites—subserosal intraoperative myometrial and pericervical—have been used to detect SN in women with endometrial cancer. The former approach, using blue dye, was initially used because it reflected the anatomic drainage of the corpus uteri [2]. However, this technique is controversial, as combined detection is not possible, and the number and location of myometrial injection sites have not yet been standardized. The latter approach, which permits combined detection with patent blue and radiocolloid, is well standardized, simple, and reproducible; it yields a higher SN detection rate but does not reflect the anatomic drainage of the tumor [3,4]. Hence, intra-uterine injection, mimicking the natural lymphatic drainage of endometrial cancer, is an attractive alternative. Niikura et al. [1] injected radiocolloid under hysteroscopic guidance. They claimed that hysteroscopy accurately showed superficial tumor extension, permitting targeted injection. However, previous studies have shown that hysteroscopy is reliable for positive diagnosis of endometrial cancer but less so for evaluating its extension, particularly to the uterine corns and internal os of the cervix [5]. In our experience, patent blue injection under hysteroscopic guidance is difficult as the endometrium is obscured by dye diffusion. Moreover, injection ‘‘under the endometrium’’ probably corresponds in fact to injection in the superficial myometrium [2]. The risk of cancer cell dissemination into the abdominal cavity must also be discussed. Niikura et al. [1] did not mention the hysteroscopy operating time, the physiological saline volume used, or whether diffusion through the Fallopian tube into the abdominal cavity was evaluated by transvaginal sonography. Despite the controversial prognostic significance of positive cytology, previous studies have shown a risk of tumor cell dissemination and metastasis following hysteroscopy [6]. To avoid this risk, we inject patent blue under hysteroscopic guidance at the beginning of surgery after coagulating the Fallopian tubes. Niikura et al. [1] confirmed the value of the SN procedure in women with endometrial cancer but did not obtain a higher SN detection rate than in previous studies using dual labels injected pericervically or into the myometrium [4]. In our series of 17 cases, using dual-label pericervical injection and a laparoscopic SN procedure, the SN detection rate was 94%, and there were no falsenegative results [4]. Finally, contrary to the laparoscopic approach, the procedure used by Niikura et al. [1], involving cervix dilation with laminaria for 15 hours, followed by hysteroscopy and laparotomy, is not compatible with the concept of minimally invasive surgery, which is particularly beneficial for these often obese and elderly women with underlying general health disorders.
Reference [1] Niikura H, Okamura C, Utsunomiya H, Yoshinaga K, Akahira J, Ito K, Yaegashi N. Sentinel lymph node detection in patients with endometrial cancer. Gynecol Oncol 2004;92:669 – 74. [2] Burke TW, Levenback C, Tornos C, Morris M, Wharton JT, Gerhenson D. Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in patients with high risk endometrial cancer: results of a pilot study. Gynecol Oncol 1996;62:169 – 73. [3] Pelosi E, Arena V, Baudino B, et al. Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer. Nucl Med Commun 2003;24:971 – 5. [4] Barranger E, Cortez A, Grahek D, Callard P, Uzan S, Darai E. Laparoscopic sentinel node procedure using a combination of patent blue and radiocolloid in women with endometrial cancer. Ann Surg Oncol 2004;11:344 – 9. [5] Garuti G, De Giorgi O, Sambruni I, Cellani F, Luerti M. Prognostic significance of hysteroscopic imaging in endometrioid endometrial adenocarcinoma. Gynecol Oncol 2001;81:408 – 13. [6] Obermair A, Geramou M, Gucer F, et al. Does hysteroscopy facilitate tumor cell dissemination? Incidence of peritoneal cytology from patients with early stage endometrial carcinoma following dilatation and curettage (D & C) versus hysteroscopy and D & C. Cancer 2000;88: 139 – 43.
Emmanuel Barranger * Emile Darai Department of Gynecology and Obstetrics, Hoˆpital Tenon, 75020 AP-HP Paris, France E-mail address: [email protected] 19 December 2003 doi:10.1016/j.ygyno.2004.06.016 * Corresponding author. Service de Gyne´cologie-Obste´trique, Hoˆpital Tenon, 4 rue de la Chine, Paris 75020 France. Fax: +33-1-56-01-60-62.
Reply to Barranger and Darai (1) Barranger et al. asked a very reasonable question about inadequate visualization of the endometrial cavity if the blue dye with the isotope was injected into the endometrium. If the injected dye leaks from the endometrium, it may well interfere with successful visual acuity of the inspection. It takes a little experience to be familiar to the procedure, with the accumulation of our experience. The depth of injection was approximately 4 –5 mm from the endometrial surface. All the patients we selected were considered to have only focal lesions rather than intensive widespread tumor in the cavity. The pathology specimens of these cases confirmed our hysteroscopic observation. To the widespread tumor in the cavity, five sites injection as described should be selected. (2) The average time of the hysteroscopic surgery was about 10 min. Normal saline was used to expand the uterine cavity simply with gravity without any additional pressure. The amount of saline used for each case was about 1000 ml. Compared with previously reported studies, the positive cytology of peritoneal washing was seen in only two cases
Letters to the Editor
in our study (7.1). It seems that hysteroscopic inspection of the endometrial cavity without undue pressure did not affect the incidence of positive cytology [1]. (3) We believe firmly that it is very useful to identify SLN prior to the operation for endometrial cancer. Without previous isotope mapping, it is very difficult to identify SLN with simple dye injection just prior to the operation. We believe that if only blue dye is used, it rapidly flows away from the wide pelvic area so that it does not provide us adequate time to detect these nodes during the surgery. If the radioisotope was injected into the cervix, we believe that the lymphatic spread of the endometrial cancer is different from the way cervical cancer spread into the pelvic lymphatic system. With the knowledge of SLN sites obtained from hysteroscopic isotope injection, and combined with blue dye injection just prior to the operation, we may increase the detection rate of SLN for endometrial cancer. Eventually, this technique may provide us less invasive laparoscopic approach and avoid total pelvic or paraaortic lymph node dissection.
863
Reference [1] Gu M, ShiW Shi W, HuangJ Huang J, BarakatRR Barakat RR, ThalerHT Thaler HT, SaigoPE Saigo PE. Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washings in patients with endometrial carcinoma. Cancer 2000;90:143 – 7.
Hitoshi Niikura Nobuo Yaegashi * Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai 980-8574, Japan E-mail address: [email protected] 21 May 2004 doi:10.1016/j.ygyno.2004.06.017 * Department of Obstetrics and Gynecology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Sendai 980-8574, Japan. Fax: +81-22-7177258.
Letters to the Editor
endometrium during hysteroscopy and detected sentinel nodes (SN), by laparotomy, in 82% of cases. This article raises several concerns. The first is the choice of injection sites. Two injection sites—subserosal intraoperative myometrial and pericervical—have been used to detect SN in women with endometrial cancer. The former approach, using blue dye, was initially used because it reflected the anatomic drainage of the corpus uteri [2]. However, this technique is controversial, as combined detection is not possible, and the number and location of myometrial injection sites have not yet been standardized. The latter approach, which permits combined detection with patent blue and radiocolloid, is well standardized, simple, and reproducible; it yields a higher SN detection rate but does not reflect the anatomic drainage of the tumor [3,4]. Hence, intra-uterine injection, mimicking the natural lymphatic drainage of endometrial cancer, is an attractive alternative. Niikura et al. [1] injected radiocolloid under hysteroscopic guidance. They claimed that hysteroscopy accurately showed superficial tumor extension, permitting targeted injection. However, previous studies have shown that hysteroscopy is reliable for positive diagnosis of endometrial cancer but less so for evaluating its extension, particularly to the uterine corns and internal os of the cervix [5]. In our experience, patent blue injection under hysteroscopic guidance is difficult as the endometrium is obscured by dye diffusion. Moreover, injection ‘‘under the endometrium’’ probably corresponds in fact to injection in the superficial myometrium [2]. The risk of cancer cell dissemination into the abdominal cavity must also be discussed. Niikura et al. [1] did not mention the hysteroscopy operating time, the physiological saline volume used, or whether diffusion through the Fallopian tube into the abdominal cavity was evaluated by transvaginal sonography. Despite the controversial prognostic significance of positive cytology, previous studies have shown a risk of tumor cell dissemination and metastasis following hysteroscopy [6]. To avoid this risk, we inject patent blue under hysteroscopic guidance at the beginning of surgery after coagulating the Fallopian tubes. Niikura et al. [1] confirmed the value of the SN procedure in women with endometrial cancer but did not obtain a higher SN detection rate than in previous studies using dual labels injected pericervically or into the myometrium [4]. In our series of 17 cases, using dual-label pericervical injection and a laparoscopic SN procedure, the SN detection rate was 94%, and there were no falsenegative results [4]. Finally, contrary to the laparoscopic approach, the procedure used by Niikura et al. [1], involving cervix dilation with laminaria for 15 hours, followed by hysteroscopy and laparotomy, is not compatible with the concept of minimally invasive surgery, which is particularly beneficial for these often obese and elderly women with underlying general health disorders.
Reference [1] Niikura H, Okamura C, Utsunomiya H, Yoshinaga K, Akahira J, Ito K, Yaegashi N. Sentinel lymph node detection in patients with endometrial cancer. Gynecol Oncol 2004;92:669 – 74. [2] Burke TW, Levenback C, Tornos C, Morris M, Wharton JT, Gerhenson D. Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in patients with high risk endometrial cancer: results of a pilot study. Gynecol Oncol 1996;62:169 – 73. [3] Pelosi E, Arena V, Baudino B, et al. Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer. Nucl Med Commun 2003;24:971 – 5. [4] Barranger E, Cortez A, Grahek D, Callard P, Uzan S, Darai E. Laparoscopic sentinel node procedure using a combination of patent blue and radiocolloid in women with endometrial cancer. Ann Surg Oncol 2004;11:344 – 9. [5] Garuti G, De Giorgi O, Sambruni I, Cellani F, Luerti M. Prognostic significance of hysteroscopic imaging in endometrioid endometrial adenocarcinoma. Gynecol Oncol 2001;81:408 – 13. [6] Obermair A, Geramou M, Gucer F, et al. Does hysteroscopy facilitate tumor cell dissemination? Incidence of peritoneal cytology from patients with early stage endometrial carcinoma following dilatation and curettage (D & C) versus hysteroscopy and D & C. Cancer 2000;88: 139 – 43.
Emmanuel Barranger * Emile Darai Department of Gynecology and Obstetrics, Hoˆpital Tenon, 75020 AP-HP Paris, France E-mail address: [email protected] 19 December 2003 doi:10.1016/j.ygyno.2004.06.016 * Corresponding author. Service de Gyne´cologie-Obste´trique, Hoˆpital Tenon, 4 rue de la Chine, Paris 75020 France. Fax: +33-1-56-01-60-62.
Reply to Barranger and Darai (1) Barranger et al. asked a very reasonable question about inadequate visualization of the endometrial cavity if the blue dye with the isotope was injected into the endometrium. If the injected dye leaks from the endometrium, it may well interfere with successful visual acuity of the inspection. It takes a little experience to be familiar to the procedure, with the accumulation of our experience. The depth of injection was approximately 4 –5 mm from the endometrial surface. All the patients we selected were considered to have only focal lesions rather than intensive widespread tumor in the cavity. The pathology specimens of these cases confirmed our hysteroscopic observation. To the widespread tumor in the cavity, five sites injection as described should be selected. (2) The average time of the hysteroscopic surgery was about 10 min. Normal saline was used to expand the uterine cavity simply with gravity without any additional pressure. The amount of saline used for each case was about 1000 ml. Compared with previously reported studies, the positive cytology of peritoneal washing was seen in only two cases
Letters to the Editor
in our study (7.1). It seems that hysteroscopic inspection of the endometrial cavity without undue pressure did not affect the incidence of positive cytology [1]. (3) We believe firmly that it is very useful to identify SLN prior to the operation for endometrial cancer. Without previous isotope mapping, it is very difficult to identify SLN with simple dye injection just prior to the operation. We believe that if only blue dye is used, it rapidly flows away from the wide pelvic area so that it does not provide us adequate time to detect these nodes during the surgery. If the radioisotope was injected into the cervix, we believe that the lymphatic spread of the endometrial cancer is different from the way cervical cancer spread into the pelvic lymphatic system. With the knowledge of SLN sites obtained from hysteroscopic isotope injection, and combined with blue dye injection just prior to the operation, we may increase the detection rate of SLN for endometrial cancer. Eventually, this technique may provide us less invasive laparoscopic approach and avoid total pelvic or paraaortic lymph node dissection.
863
Reference [1] Gu M, ShiW Shi W, HuangJ Huang J, BarakatRR Barakat RR, ThalerHT Thaler HT, SaigoPE Saigo PE. Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washings in patients with endometrial carcinoma. Cancer 2000;90:143 – 7.
Hitoshi Niikura Nobuo Yaegashi * Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai 980-8574, Japan E-mail address: [email protected] 21 May 2004 doi:10.1016/j.ygyno.2004.06.017 * Department of Obstetrics and Gynecology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Sendai 980-8574, Japan. Fax: +81-22-7177258.