Comparison of 3-Tesla to 1.5-Tesla Magnetic Resonance Enterography to assess multifocal and multicentric bowel endometriosis: Results in routine practice.

STUDY OBJECTIVE: To compare 1.5-Tesla (1.5 T) to 3-Tesla (3 T) Magnetic resonance enterography (MRE) in assessing multifocal (multiple lesions affecting the same segment) and multicentric (multiple lesions affecting several digestive segments) bowel endometriosis in patients with suspected-colorectal endometriosis, in routine practice. STUDY DESIGN: We conducted a retrospective, comparative study in Tenon University Hospital, Paris, France. We included patients scheduled for colorectal resection from April 2014 to February 2018. All patients underwent 1.5 T or 3 T MRE before surgery and endometriosis lesions were confirmed by surgery. The diagnostic performance of 1.5 T and 3 T MRE was evaluated by sensitivity, specificity, positive and negative predictive values (PPV and NPV), accuracy, positive and negative likelihood ratios (LR) and area under the curve of receiver operating curves (AUC ROC). RESULTS: Ninety-eight patients were included. Fifty-two (53%) patients presented unifocal lesions, 31 (32%) multifocal lesions, and 23 (24%) multicentric lesions. In assessment of multifocal lesions, the sensitivity, specificity, positive and negative LRs were 0.57 (12/21), 0.89 (23/26), 4.95 and 0.58 for 1.5 T MRE, and 0.10 (1/10), 0.95 (39/41), 2.05 and 0.95 for 3 T MRE. For the diagnosis of multicentric lesions, 1.5 T MRE showed sensitivity, specificity, positive and negative LRs of 0.46 (5 of 11), 0.92 (33 of 36), 5.45 and 0.60 respectively and 3 T MRE showed sensitivity, specificity, and negative LRs of 0.33 (4/12), 1.00 (39/39), and 0.67, respectively. 1.5 T MRE was more accurate than 3 T MRE for diagnosing multifocal lesions (p = 0.02), but there was no difference for multicentric lesion assessment (p = 0.66). CONCLUSION: In routine conditions, 3 T MRE and 1.5 T MRE are of similar low performance for diagnosing multifocal and multicentric bowel endometriosis.

Uteroabdominal Wall Fistula After Cesarean Section in a Patient With Prior Colorectal Resection for Endometriosis: A Case Report and Systematic Review.

Uteroabdominal wall fistula (UAWF) is a very rare complication of cesarean section. We report an unusual case of a UAWF occurring in a 37-year-old woman 4 years after a cesarean section and previous radical surgery for deep infiltrating endometriosis with bowel resection. The patient presented with persistent purulent discharge of the Pfannenstiel scar and noted that the discharge was blood stained during menstruation. Magnetic resonance imaging confirmed the diagnosis of UAWF. Surgery was performed by laparotomy and was complicated by a postoperative rectovaginal fistula, which was successfully treated by the placement of a biological mesh via the vagina route. The postoperative course was favorable at 6 months with disappearance of painful symptoms and good quality of the colorectal anastomosis. A systematic review was conducted, and 18 case reports were found from 1939 to 2016. This case report highlights the risk of postdelivery complications in women with deep infiltrating endometriosis and colorectal involvement, especially after cesarean section. Persistent abdominal discharge in this context should suggest a diagnosis of UAWF despite its low incidence. Finally, the vaginal route for rectovaginal fistula might be considered an option for patients with prior multiple laparotomies.

A suggested modification to FIGO stage I endometrial cancer.

OBJECTIVE: FIGO stage I endometrial cancers are divided into two substages, regardless of the presence or absence of lymphovascular space invasion (LVSI). The aim of this study was to investigate whether stratification based on the LVSI status would better predict mortality. METHODS: Using a multicentric database, we identified patients who underwent endometrial cancer operations between 2000 and 2010. The staging performance was quantified with respect to discrimination. RESULTS: The study cohort included 508 patients (198 with LVSI-positive tumors and 310 with LVSI-negative tumors). The survival difference between the stage I patients with LVSI-positive and LVSI-negative tumors was highly significant (81% and 97%, respectively P=.009), whereas the difference between the stage I patients with tumors invading greater or less than half of the myometrium was not (87% and 96%, respectively P=0.09). The 5-year OS rates for the patients with LVSI-negative tumors invading less than half of the myometrium, with LVSI-negative tumors invading more than half of the myometrium and with LVSI-positive invading more than or less than half of the myometrium were 98%, 95%, and 81%, respectively (P=.03). Separating the LVSI-negative and LVSI-positive tumors would improve discrimination (concordance index, 77% vs. 75%, respectively, using the actual staging system). CONCLUSION: A LVSI-positive status has a significantly worse prognosis. In this study, the distinction by LVSI status appears to be more relevant than the distinction between stages IA and IB for predicting survival in stage I endometrial cancer. This difference in prognosis would favor restaging these two entities.

Impact of lymphovascular space invasion on a nomogram for predicting lymph node metastasis in endometrial cancer.

OBJECTIVE: The aim of this study was to evaluate the impact of lymphovascular space invasion (LVSI) on nomogram-based predictions of lymph node (LN) metastasis in endometrial cancer. METHODS: The data from 485 patients with presumed stage I or II endometrial cancer who underwent hysterectomy and lymphadenectomy were analyzed. Calibration curves were designed and compared for three different subgroups: LVSI-positive tumors (n=113), LVSI-negative tumors (n=213) and LVSI-undetermined tumors (n=159). RESULTS: In the entire population, the nomogram showed good discrimination with an area under the receiver operating characteristic curve (AUC) of 0.80 and was well calibrated. In the subgroup analyses, in LVSI-positive, LVSI-negative and LVSI-undetermined patients, the nomogram was not well calibrated (p of the U index of 0.028, 0.087 and 0.011, respectively) with underestimation in LVSI-positive patients and overestimation in LVSI-negative and LVSI-undetermined patients of LN metastasis. In the univariate analysis and after adjusting for the LN metastasis probability provided by the nomogram, LVSI-positive tumors were associated with an increased risk for LN metastasis compared with LVSI-negative tumors (RR=7.29 [3.87-13.7] and 5.04 [2.30-11.08], respectively). In contrast, the univariate analysis and after adjusting for the LN metastasis probability provided by the nomogram showed that LVSI-undetermined tumors were not associated with an increased risk for LN metastasis compared with LVSI-negative tumors (RR=0.73 [0.32-1.69] and 1.26 [0.47-3.37], respectively). CONCLUSIONS: Our results suggested that LVSI should be considered to be an independent risk factor for LN metastasis. In this multicenter study, the risk for LN metastasis is similar when the LVSI is negative or is not detailed in the pathological report.