Is it possible to obtain a presurgical Lasmar score for hysteroscopic myomectomy by ultrasound alone?

OBJECTIVE: To determine whether a Lasmar score obtained entirely by the use of two-dimensional (2D) and three-dimensional (3D) ultrasound provides results similar to those obtained using the original hysteroscopic technique. METHODS: This was a prospective study performed on a series of patients presenting with symptomatic submucous fibroids and scheduled for hysteroscopic myomectomy. Ultrasound Lasmar scores were obtained by a single physician, a specialist in ultrasonography, in the luteal phase of the menstrual cycle. 3D images were evaluated by offline examination using multiplanar analysis. Classical Lasmar scores were obtained by a different physician, a specialist in hysteroscopy, during the follicular phase of the subsequent cycle. Surgery was performed by a third physician in the follicular phase who also reported a Lasmar score, which we considered as the gold standard. The concordance between group classifications (I-III, relating to difficulty of hysteroscopic resection) according to the three methods used to obtain the Lasmar score (ultrasound, classical and surgery) was calculated using Cohen's κ statistic. RESULTS: Thirty-four women, with a mean age of 43 ± 4.9 years, were enrolled in the study. Thirty-six submucous fibroids were identified by both ultrasound and diagnostic hysteroscopy. The mean diameter of fibroids evaluated was 28 ± 13.2 mm. The concordance between the three methods of classifying patients according to Lasmar score was high: classical vs. surgery, κ = 0.88; ultrasound vs. surgery, κ = 0.93; and classical vs. ultrasound, κ = 0.77. CONCLUSION: The Lasmar score can be obtained solely by ultrasound examination performed in the luteal phase of the menstrual cycle, avoiding office hysteroscopy without a loss of diagnostic accuracy.

Spatial analysis of the distribution of endometriosis in northwestern Italy.

OBJECTIVE: The aim of this study is to estimate the incidence of endometriosis in a northwestern region of Italy. The potential sources of geographical variations in the incidence of endometriosis within the region are discussed. METHODS: The patients selected were women between 18 and 45 years of age, born and residing in Piedmont who had undergone medical or surgical treatment for endometriosis between 2000 and 2005. The data were obtained from official hospital discharge records. RESULTS: The number of women contributed to the study was 3,929. The age-standardized incidence rate of endometriosis was 81.8/100,000 patient-years (95% CI 79.1-84.2). The distribution of relative risks showed some areas with an increased rate of around 30% (southern and central Piedmont), while for other areas the disease risk was lower (southwestern Piedmont). These areas have greater exposure to environmental risk due to the presence of chemical pollutants. CONCLUSION: In order to achieve reliable data and good management of the disease, there is great need for national registers, as well as networks of excellence for the treatment of endometriosis. Our findings suggest that environmental factors may be associated with the development of the disease, but the observed results need to be cautiously interpreted in the context of ineligible biases.

Axillary dissection in breast cancer patients with metastatic sentinel node: to do or not to do? Suggestions from our series.

Several studies have put to question and evaluated the indication and prognosis of sentinel lymph node biopsy (SNLB) as sole treatment in human breast cancer. We reviewed 1588 patients who underwent axillary surgery. In 239 patients, axillary lymph node dissection (ALND) was performed following positive fine needle aspiration cytology (FNAC), and, in 299 cases, ALND was executed after positive SNLB. The most dramatic result from our data is that patients with either micrometastasis of the sentinel lymph node (SLN) or only metastatic SLN have, respectively, an 84.5% and a 75.0% chance of having no other nodal involvement. We believe a more refined patient selection is neccessary when considering ALND. Where the primary tumor is larger than 5 cm, where radio or adjuvant therapies are not indicated, in cases of FNAC+ nodes, and in cases presenting more than one metastatic sentinel node, we prefer to carry out ALND. Having thus said, however, our data suggests that it is wise not to perform ALND in almost all cases presenting positive SLNs.

Hysteroscopic management of large symptomatic submucous uterine myomas.

STUDY OBJECTIVE: To evaluate the feasibility of hysteroscopic resection of large submucous uterine myomas. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: Surgery unit of minimally invasive gynecology. PATIENTS: Thirty-three women with submucous myomas 5 cm or larger in diameter with menorrhagia, dysmenorrhea, or infertility. INTERVENTION: Hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Satisfaction with the surgery and an improvement in symptoms were the primary outcomes. Possibility of 1-step resection; complication rate, and disease recurrence were also considered. Menorrhagia was the most frequent indication (91%). According to the Wamsteker classification, 84.8% were type II myomas, whereas 93.9% scored 5 or higher according to the classification of Lasmar and colleagues. Mean operating time was 50 minutes (interquartile range, 35-65). One-step excision was achieved in 81.8% of patients. Of 5 women with incomplete resection, 3 needed a second surgery, and 2 were symptom-free. Patients with myomas larger than 5 cm or with a Lasmar score higher than 7 were more likely to undergo a 2-step procedure. In patients with myomas larger than 6 cm, recovery time was significantly longer than in those with smaller myomas. We recorded 3 complications: intravasation, uterine perforation, and postoperative anemia, in 1 patient each; at present, all 3 women are symptom-free. Median (range) follow-up was 10 (6-22) months. Twenty-seven patients (81.2%) reported they were very satisfied; 5 patients (15.2%) were satisfied; and 1 patient (3%) was dissatisfied. CONCLUSIONS: Hysteroscopic myomectomy can be the treatment of choice in symptomatic patients with a submucous myoma with diameter of 6 cm or less. Although this technique raises the possibility that complete resection may require 2 surgical sessions, it is a feasible surgical procedure. However, for myomas 6 cm or larger in diameter, this approach is less attractive. Nevertheless, we believe that all of the limiting criteria defined in the available literature should be evaluated individually, bearing in mind each patient's particular condition and the surgeon's experience and skill.

Long-term treatment with cabergoline, a new long-lasting ergoline derivate, in idiopathic or tumorous hyperprolactinaemia and outcome of drug-induced pregnancy.

Cabergoline (CAB), a new long-acting ergoline derivative, was shown to be very effective in reducing PRL levels in normal volunteers and in hyperprolactinemic patients. We evaluated the hormonal changes after discontinuation of long-term therapy with CAB as well as the safety of drug exposure during pregnancy both for mothers and babies. We therefore studied 48 patients (47 females and one male) with pathological hyperprolactinaemia (mean +/- SE, 117.2 +/- 15.2: median 73.2 micrograms/l), treated for 1-82 months (mean +/- SE, 28.3 +/- 3; median 18). After long-term treatment, CAB was withdrawn in 11 patients and PRL levels were persistently normal for almost 15 days and significantly lower (p < 0.05) than basal at 30, 45, 60, 90, 120 days. Three patients had normal PRL levels still at 45 days after treatment discontinuation. Nine patients became pregnant after 1-37 months (mean 12.4) of therapy. In two patients the pregnancy was interrupted spontaneously in one case and voluntarily in the other. In all but one patients after delivery or three-month breast feeding, PRL levels trended towards reduction. In two cases (one with microadenoma and one with idiopathic hyperprolactinaemia) PRL remained in the normal levels for 1-3 years after delivery. In conclusion CAB is able to inhibit plasma PRL levels for long time (up to 120 days) after withdrawal in patients with pathological hyperprolactinaemia treated with long-term therapy.

Carboplatin plus etoposide regimen in advanced breast cancer. A phase II study.

Carboplatin is used in many kind of tumors with similar results to cisplatin but without the same toxicity. We decided to use it, in combination with etoposide, for metastatic breast cancer. Eighteen women with advanced breast disease entered this phase II study. Each of them received, every 28 days, carboplatin on day 1, at a dose calculated with the Calvert formula, and etoposide on days 1, 2, 3 at a dose of 100 mg/m2. For 12 women this treatment was the first-line chemotherapy, while for the other six it was the second-line therapy, after the administration and the failure, in 4 cases out of 6, of regimens based on anthracycline. In each group we obtained an objective response of 50%, with a complete response of 25% in the first and of 33% in the second. On the whole, 11 patients died (one not from the disease) (10/18, 55%). Toxicity was extremely mild, with only one patient with grade III anemia. Our data suggest that a carboplatin/etoposide combination could be active and well-tolerated in patients with metastatic breast cancer, but the few number of patients in this study makes further research necessary for confirmation.