Creation of a scoring system to determine endometrial cancer risk using the International Endometrial Tumor Analysis (IETA) features / Philippine Journal of Obstetrics and Gynecology

GENERAL OBJECTIVE: To determine endometrial cancer risk among patients with abnormal uterine bleeding based on the International Endometrial Tumor Analysis (IETA) features.SPECIFIC OBJECTIVES: 1. To described the profile of patients with AUB suspected of having endometrial pathology; 2. To describe sonologic features of patients with AUB suspected of endometrial cancer using IETA features; and 3. To determine the association of a scoring system and endometrial cancer risk.METHODS: We prospectively studied 542 participants who came in the CWCU of CSMC with a diagnosis of AUB from July 1, 2016 to December 31, 2016. We excluded patients with endometrial thickness of less than 4 mm on gray-scale sonography, those with technical difficulties in assessing the endometrium such as in cases of very large myomas, absence of histopathological diagnosis, and those whose sampling was done as an office procedure. A total of 98 participants were included, 89 (90.8%) had benign pathologies and 9 (9.2%) were malignant. Patient characteristics including, age, gravidity, BMI, medical history, and endometrial assessment using IETA were tabulated with each characteristic given a score of 0-3 depending on the degree of risk factor. Percentages, Pearson Chi-square Test with corresponding P-value and ROC curve analysis were performed.RESULTS: The best predictors for endometrial cancer were age more than 50 years, nulligravid, BMI of more than 25, and presence of hypertension and diabetes mellitus. Sonographic features based on IETA showed an endometrial thickness of more than 20mm, irregular endometrial-myometrial junction, heterogenous endometrium, presence of multiple and large vessels on doppler analysis, contributed to endometrial cancer risk. These variables were used to create a scoring system with an area under the curve of 0.974 giving the best cut-off value of more than or equal to 9, with 100% sensitivity and 89% specificity.CONCLUSION: Among patients with abnormal uterine bleeding and endometrial thickness of more than 4mm, we can predict the risk for endometrial cancer and aid the clinician in decision making on who may be managed conservatively or aggressively based on the value obtained from the scoring system. The study, however, needs to be validated prior to use in clinical practice.

Pregnancy in Herlyn-Werner-Wunderlich syndrome: A case report and review of literature / Philippine Journal of Obstetrics and Gynecology

Herlyn-Werner-Wunderlich Syndrome (HWWS) is a triad of uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis.In the review of the locally published literature, there have been seven HWWS cases reported, none of whom were pregnant.A 24-year-old was diagnosed with Herlyn-Werner-Wunderlich Syndrome during caesarean section of a term pregnancy, occupying the right hemiuterus with obstructed hemivagina. Ultrasound showed uterus didelphys with communicating endometrial cavities. MRI revealed uterus didelphys, two cervices and an obstructed right hemivagina. The patient refused excision of vaginal septum. Two years later, she delivered spontaneously to a live fetus, occupying the hemiuterus with the unobstructed hemivagina.In pregnant women with HHWS, who did not undergo prior surgical intervention, the mode of delivery depends on the side of pregnancy. If it is located on the obstructed hemivagina, caesarean section is inevitable. If it is on the unobstructed side, there is hope for vaginal delivery.

Predicting pre-malignant and malignant endometrial conditions among postmenopausal Filipino women based on ultrasound measurement of ovarian volume / Philippine Journal of Obstetrics and Gynecology

BACKGROUND: Clinical studies showed a correlation between postmenopausal women with large ovaries and endometrial cancer. Considering the different average ovarian volumes among various races, it is prudent to identify the most valid ovarian volume among symptomatic menopausal women in our population and classify their probability of having a benign or malignant endometrium. OBJECTIVE: To determine the relation of ovarian volume measurements using a reference value generated by an ROC curve with endometrial tissue biopsy diagnosis of pre-malignant and malignant endometrium among Filipino postmenopausal women. METHODOLOGY: Fifty menopausal women with vaginal bleeding were included in a six-year review from January 2008 to December 2013. All had transvaginal ultrasonography and underwent endometrial sampling. A receiver operating characteristic (ROC) curve was generated and the most valid ovarian volume was obtained. The ROC curve -- generated ovarian volume was used as the cut-off value and was correlated with histopathologic diagnoses. RESULTS:  Among the fifty patients, 30 with benign endometrium had an ovarian volume of 3.51 ml. Among the 10 patients with malignant endometrium, 9 had an ovarian volume of > 3.51 ml, and one had an ovarian volume of 3.51 ml as cut-off is 90% (95% Cl 55.46 % to 98.34%), while the specificity is 75% (95% Cl of 58.80% to 87.29%). Using the chi-square test, it showed a significant association between ovarian volume of > 3.51 ml and malignant endometrium (P=0.0001). CONCLUSION: The ROC curve - generated cut-off value of > 3.51 ml for Filipino postmenopausal women may serve as a useful diagnostic tool for classifying patients with pre-malignant and malignant endometrial conditions.

Cervical agenesis: a case report

A 24 year-old patient, single, with cervical agenesis and imperforate hymen is presented. She underwent hymenectomy for hematosalpinx and right oophorectomy for endometriosis, before finally undergoing hysterectomy. Cervical agenesis is a rare anatomic developmental abnormality and proposed guidelines in managing similar conditions are reviewed in this report. The management of choice will defend on the condition of the patient and the availability of resources. The patient underwent multiple surgeries in the past. However, despite all efforts to address her medical condition, due to the complications, the small chance of getting pregnant, and the absence of an experienced surgeon capable of performing a reconstructive procedure, she was eventually convinced to undergo hysterectomy. With cervical agenesis, the patient is faced with psychological difficulties that should be addressed. One can only hope that the future will hold a more optimistic outlook for young girls with this rare congenital abnormality.

Association between ovarian volume and endometrial malignancy in women with postmenopausal bleeding / Philippine Journal of Obstetrics and Gynecology

OBJECTIVE: This is a prospective case control study which aimed to determine the correlation of ovarian volume measurements with endometrial tissue diagnosis such as benign, premalignant and malignant conditions in women with postmenopausal bleeding.METHODS: Thirty four postmenopausal women with bleeding underwent transvaginal ultrasound for ovarian volume measurements prior to dilatation and curettage. The presence of benign (Group I), premalignant and malignant endometrial. conditions (Group II) were correlated with ovarian volume.RESULTS: Mean endometrial stripe thickness for group I (N= 19; 1.16ml+/- SD 0.88ml) was not significantly different from group II (N = 15; 1.58ml +/- SD 0.53ml). Mean ovarian volume among patients with premalignant and malignant histology (5.70ml +/- SD 1.91ml) was significantly higher than those with benign histology (2.04ml +/- SD?1.10ml) (P = 0.023). Linear regression analysis showed an association between ovarian volume and premalignant and malignant endometrial conditions (P=0.000). Using the mean ovarian volume cut-off of 5.8ml for postmenopausal women with bleeding, the sensitivity, specificity, positive predictive value and negative predictive value for premalignant and malignant endometrial conditions were 100%, 67.87%,40% and 100%,respectively.CONCLUSION: Large ovaries among postmenopausal women may represent a marker of risk for endometrial cancer and may be used as an adjunct to endometrial thickness in ruling endometrial malignancy.