Anogenital distance in adult women is a strong marker of endometriosis: results of a prospective study with laparoscopic and histological findings

STUDY QUESTION

Could anogenital distance (AGD) be a non-invasive marker of endometriosis and correlated to the American Society for Reproductive Medicine revised score (r-ASRM) and ENZIAN classifications?

SUMMARY ANSWER

Surgically and histologically proven endometriosis is associated with a short AGD in women of reproductive age but not correlated either to the severity or to the location of the disease.

WHAT IS KNOWN ALREADY

AGD is a marker of intrauterine androgen exposure and exposure to oestrogen-like chemicals such as phthalates. Moreover, exposure to endocrine disruptors, such as organochlorine chemicals, is associated with endometriosis. It has been suggested that a short AGD in women is associated with an increased risk of endometriosis based on clinical and ultrasound exams.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from January 2018 to June 2019 in a tertiary-care centre including 168 adult women undergoing pelvic surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 168 women included, 98 patients had endometriosis (endometriosis group) and 70 did not (non-endometriosis group). An operator (not the surgeon) measured the distance from the clitoral surface to the anus (AGD-AC) and from the posterior fourchette to the anus (AGD-AF) before surgery using a millimetre accuracy ruler. Endometriosis was diagnosed on exploration of the abdominopelvic cavity, and the r-ASRM and ENZIAN scores were calculated. All removed tissues underwent pathological examination.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean (±SD) AGD-AF measurements were 21.5 mm (±6.4) and 32.3 mm (±8.1), and average AGD-AC measurements were 100.9 mm (±20.6) and 83.8 mm (±12.9) in the endometriosis and non-endometriosis groups (P < 0.001), respectively. Mean AGD-AF and AGD-AC measurements were not related to r-ASRM stage (P = 0.73 and 0.80, respectively) or ENZIAN score (P = 0.62 and 0.21, respectively). AGD-AF had a better predictive value than AGD-AC for discriminating the presence of endometriosis (AUC = 0.840 (95% CI 0.782–0.898) and 0.756 (95% CI 0.684–0.828)), respectively. For AGD-AF, an optimal cut-off of 20 mm had a specificity of 0.986 (95% CI 0.923–0.999), sensitivity of 0.306 (95% CI 26.1–31.6) and positive predictive value of 0.969 (95% CI 0.826–0.998). In multivariable analysis, the diagnosis of endometriosis was the only variable independently associated with the AGD-AF (β = −9.66 mm 95% CI −12.20–−7.12), P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The sample size was relatively small with a high proportion of patients with colorectal endometriosis reflecting the activity of an expert centre. Furthermore, we did not include adolescents and the AGD-AF measurement could be particularly relevant in this population.

WIDER IMPLICATIONS OF THE FINDINGS

The measurement of AGD could be a useful non-invasive tool to predict endometriosis. This could be especially relevant for adolescents and virgin women to avoid diagnostic laparoscopy and empiric treatment.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Invasive and in situ cervical cancer associated with pregnancy: analysis from the French cancer network (CALG: Cancer Associé à La Grossesse)

PURPOSE

To describe the oncologic and obstetric outcomes of patients diagnosed with invasive cervical cancer (ICC) and in situ adenocarcinoma (ISA) during pregnancy or during the year following delivery.

METHODS

This retrospective observational study involved a cohort of 28 patients diagnosed with invasive cervical cancer (20 patients) or in situ adenocarcinoma (eight patients) during pregnancy or during the year following delivery who received expert opinion from physicians of the Cancer Associé à La Grossesse (CALG) network between 2005 and 2018. Descriptive results were expressed in median, range and interquartile range (IQR).

RESULTS

Between 2005 and 2018, 20 patients with ICC and eight with ISA received expert opinion from physicians of the CALG network. Both ICC and ISA were mostly diagnosed during pregnancy with a median term at diagnosis of 23.3 weeks of gestation (WG) for ICC and 7.3 WG for ISA. Overall, the median age at diagnosis for both ICC and ISA was 33 years. Most ICCs (n = 9) had FIGO stage ≥ IB2 and five underwent neoadjuvant chemotherapy at a median term of 22.5 WG. Seventeen patients with ICC underwent surgery. Three patients had medical termination of the pregnancy. Two patients experienced recurrence and three died. Median time of follow-up was 59.3 months (IQR 30.5-129.2).

CONCLUSION

Management of cervical cancer during pregnancy is challenging especially in terms of maternal outcomes with a relative poor prognosis requiring a multidisciplinary expert advice.

[Expert centre Cancer du sein et Grossesse (CALG): Concordance between the proposed therapeutics and those finally received]

OBJECTIVE

Breast cancer associated with pregnancy (CSAG) is a rare condition whose management justifies the use of expert center. The Pregnancy-Associated Cancer Network (CALG) was created in France to optimize therapeutic management. The objective of our study was to evaluate its impact on the therapeutic management of CSAGs and the discrepancy rate between the CALG proposal and the treatment performed.

METHOD

A retrospective study including 58 CSAGs for which the opinion of the CALG network was solicited between January 2015 and November 2017. A questionnaire was addressed to the practitioner requesting the network. These practitioners were contacted to know the treatments received by the patient to assess the discrepancy rate.

RESULTS

In 70% of the cases, the CALG network was solicited before any therapeutic treatment. When the opinion was requested after initiation of therapy, the discrepancy rate between the CALG proposal and the one practiced was 47%. Of the 46 physicians contacted, the response rate was 62.5% (30/46). In 90% of cases, the therapy proposed by the CALG network was the one received by the patient.

CONCLUSION

This study emphasizes the need to refer to an expert center before treatment of a CSAG and the need for the contribution of doctors requesting the expert center to inform them of the follow-up of patients and children.