Tertiary prevention strategies for micrometastatic lymph node cervical cancer: A systematic review and a prototype of an adapted model of care

PURPOSE

We found a need for balancing the application of clinical guidelines and tailored approaches to follow-up of cervical cancer (CC) patients in the lymph node micrometastatic (MICs) setting. This review aimed to determine the current knowledge of management of MIC-positive CC cases.

METHODOLOGY

We addressed prognostic and risk of recurrence monitoring impacts associated with MIC+ cases. The electronic databases for literature and relevant articles were analysed.

RESULTS

Fifteen studies, (4882 patients), were included in our systematic review. While the results show that MICs significantly worsen prognosis in early CC. A tertiary prevention algorithm for low volume lymph node disease may stratify follow-up according to the burden of nodal disease and provide data that helps improve follow-up performance.

CONCLUSION

MICs worsen prognosis and should be managed as suggested by the algorithm. However, this algorithm must be externally validated. The clinical impact of isolated tumor cells (ITC) remains unclear.

To drain or not to drain: A propensity score analysis of abdominal drainage after colorectal surgery for endometriosis

AIM

To assess the benefit of prophylactic abdominal drainage (AD) after colorectal surgery for endometriosis.

METHODS

We conducted a retrospective study of 215 patients who underwent colorectal surgery for endometriosis using a mini-invasive approach in our center from February 2019 to July 2023. A propensity score matched (PSM) analysis (1:1 ratio) identified two groups of patients with similar characteristics. Postoperative outcomes were then compared.

RESULTS

In the unmatched cohort, 151 patients (70 %) had AD at the end of surgery and 64 (30 %) did not. Clinical characteristics and surgical procedures were comparable between the groups after PSM. After PSM, AD was associated with a longer hospital stay (p < 0.001) and a greater number of postoperative complications (p = 0.03). There were no differences for readmission, repeat surgery, or severe postoperative complications.

CONCLUSION

In this retrospective cohort of patients undergoing colorectal resection for endometriosis using a mini-invasive approach, prophylactic AD was not found to be beneficial.

Bowel endometriosis: Surgical customization is demanding

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Surgical treatment of deep endometriosis: Impact on spontaneous conception

Deep endometriosis (DE) is the most severe form of endometriosis and is commonly associated with infertility. Surgical treatment of DE appears to increase chances of spontaneous conception in appropriately selected patients wishing to conceive. Identifying, however, the exact impact of DE, and its surgical removal, on natural conception is highly challenging. The surgical approach should be favoured in symptomatic patients with pregnancy intention. Limited data from infertile patients suggest that outcomes may not differ from patients without known infertility. Complex DE surgery carries a risk of serious complications, therefore, it should be performed in centers of expertise. Such complications may, however, not have a significant negative impact on fertility outcomes, according to limited available data. Data on obstetric outcomes of spontaneous conceptions after DE surgery are too scarce. In asymptomatic, infertile patients the debate between primary surgery or Artifial Reproductive Technology is ongoing, until randomized studies report their results.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81 min vs 240 ± 79 min, p = 0.010, and 216 ± 78 min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4 days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

Changes in hospital consumption of opioid and non-opioid analgesics after colorectal endometriosis surgery

The aim of this study was to analyze postoperative consumption of analgesics during hospitalization following colorectal surgery for endometriosis. We conducted a retrospective study at Tenon University Hospital, Paris, France from February 2019 to December 2021. One hundred sixty-two patients underwent colorectal surgery: eighty-nine (55%) by robotic and seventy-three (45%) by conventional laparoscopy. The type of procedure had an impact on acetaminophen and nefopam consumed per day: consumption for colorectal shaving, discoid resection, and segmental resection was, respectively, 2(0.5), 2.1(0.6), 2.4(0.6) g/day (p = 10-3), and 25(7), 30(14), 31(11) mg/day (p = 0.03). The total amount of tramadol consumed was greater following robotic surgery compared with conventional laparoscopy (322(222) mg vs 242(292) mg, p = 0.04). We observed a switch in analgesic consumption over the years: tramadol was used by 70% of patients in 2019 but only by 7.1% in 2021 (p < 10-3); conversely, ketoprofen was not used in 2019, but was consumed by 57% of patients in 2021 (p < 10-3). A history of abdominal surgery (OR = 0.37 (0.16-0.78, p = 0.011) and having surgery in 2020 rather than in 2019 (OR = 0.10 (0.04-0.24, p < 10-3)) and in 2021 than in 2019 (OR = 0.08 (0.03-0.20, p < 10-3)) were the only variables independently associated with the risk of opioid use. We found that neither clinical characteristics nor intraoperative findings had an impact on opioid consumption in this setting, and that it was possible to rapidly modify in-hospital analgesic consumption modalities by significantly reducing opioid consumption in favor of NSAIDS or nefopam.

ENDOGRADE: A four level classification to rate surgical complexity in endometriosis

OBJECTIVES

We studied a post operative classification of surgical complexity in endometriosis.

STUDY DESIGN

Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels.

RESULTS

Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively.

CONCLUSION

ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.

Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve

STUDY

Objective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE).

DESIGN

Observational study.

SETTING

Tivoli-Ducos Clinic, Bordeaux.

PATIENTS

Sixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE.

INTERVENTIONS

Laparoscopic sclerotherapy with 95% ethanol solution and DIE surgery.

MEASUREMENTS AND MAIN RESULTS

Antimüllerian hormone (AMH) levels before and at least 6 months after surgery, recurrences, and pregnancies. Mean AMH (ng/mL) levels were 3.4 (2.3) before surgery and 2 (1.7) after surgery (p <.001). Mean difference was 1.29 ng/mL. Preoperative AMH level was the only variable independently associated with an additive decrease in AMH. Mean (standard deviation) follow-up period was 17.5 months (4.6) (range 9-26 months); 18 of 44 patients (40.1%) with pregnancy intent conceived. Of 51 patients who underwent postoperative pelvic ultrasound, 6 (6 of 51, 11.8%) had a recurrence of endometrioma.

CONCLUSION

Laparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.

Clinical impact of low-volume lymph node metastases in early-stage cervical cancer: A comprehensive meta-analysis

OBJECTIVE

In order to define the clinical significance of low-volume metastasis, a comprehensive meta-analysis of published data and individual data obtained from articles mentioning micrometastases (MIC) and isolated tumor cells (ITC) in cervical cancer was performed, with a follow up of at least 3 years.

METHODS

We performed a systematic literature review and meta-analysis, following Cochrane's review methods guide and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was the disease-free survival (DFS), and the secondary outcome was the overall survival (OS). The hazard ratio (HR) was taken as the measure of the association between the low-volume metastases (MIC+ITC and MIC alone) and DFS or OS; it quantified the hazard of an event in the MIC (+/- ITC) group compared to the hazard in node-negative (N0) patients. A random-effect meta-analysis model using the inverse variance method was selected for pooling. Forest plots were used to display the HRs and risk differences within individual trials and overall.

RESULTS

Eleven articles were finally retained for the meta-analysis. In the analysis of DFS in patients with low-volume metastasis (MIC + ITC), the HR was increased to 2.60 (1.55-4.34) in the case of low-volume metastasis vs. N0. The presence of MICs had a negative prognostic impact, with an HR of 4.10 (2.71-6.20) compared to N0. Moreover, this impact was worse than that of MIC pooled with ITCs. Concerning OS, the meta-analysis shows an HR of 5.65 (2.81-11.39) in the case of low-volume metastases vs. N0. The presence of MICs alone had a negative effect, with an HR of 6.94 (2.56-18.81).

CONCLUSIONS

In conclusion, the presence of MIC seems to be associated with a negative impact on both the DFS and OS and should be treated as MAC.

Using a new diagnostic tool to predict lymph node metastasis in advanced epithelial ovarian cancer leads to simple lymphadenectomy decision rules: A multicentre study from the FRANCOGYN group

OBJECTIVE

The aim of this study was to develop a new diagnostic tool to predict lymph node metastasis (LNM) in patients with advanced epithelial ovarian cancer undergoing primary cytoreductive surgery.

MATERIALS AND METHOD

The FRANCOGYN group's multicenter retrospective ovarian cancer cohort furnished the patient population on which we developed a logistic regression model. The prediction model equation enabled us to create LNM risk groups with simple lymphadenectomy decision rules associated with a user-friendly free interactive web application called shinyLNM.

RESULTS

277 patients from the FRANCOGYN cohort were included; 115 with no LNM and 162 with LNM. Three variables were independently and significantly (p<0.05) associated with LNM in multivariate analysis: pelvic and/or para-aortic LNM on CT and/or PET/CT (p<0.00), initial PCI ≥ 10 and/or diaphragmatic carcinosis (p = 0.02), and initial CA125 ≥ 500 (p = 0.02). The ROC-AUC of this prediction model after leave-one-out cross-validation was 0.72. There was no difference between the predicted and the observed probabilities of LNM (p = 0.09). Specificity for the group at high risk of LNM was 83.5%, the LR+ was 2.73, and the observed probability of LNM was 79.3%; sensitivity for the group at low-risk of LNM was 92.0%, the LR- was 0.24, and the observed probability of LNM was 25.0%.

CONCLUSION

This new tool may prove useful for improving surgical planning and provide useful information for patients.

Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management

STUDY QUESTION

Is an MRI classification of deep pelvic endometriosis (DE) able to correctly predict the risk of DE surgery.

SUMMARY ANSWER

A new radiological classification, that we have called the deep pelvic endometriosis index (dPEI) classification, is accurate and reproducible to assess the extension of the disease in central and lateral compartments and well correlated with operating time, hospital stay duration and the risk of voiding dysfunction.

WHAT IS KNOWN ALREADY

Few imaging classifications are currently available to predict the extent of DE to help preoperative assessment of surgical outcomes and provide the patient with objective information about the risk of surgical complications.

STUDY DESIGN, SIZE, DURATION

Retrospective monocentric observational study was conducted between 01 January 2017 and 31 December 2018 and included 150 women (mean age = 34.5 years, 20-52 years) with DE on MRI and who subsequently underwent surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two radiologists independently graded the disease according to MRI-based Enzian classification (A (rectovaginal septum and vagina locations), B (uterosacral locations) and C (rectosigmoid locations)) and a new radiological classification, that we have called the dPEI, that grades the severity of DE as: mild, moderate or severe DE. MRI findings and classification were correlated with surgical and pathological results.

MAIN RESULTS AND THE ROLE OF CHANCE

MRI-based and surgical Enzian classifications were concordant for A lesions in 78.7% (118/150), for B lesions in 34.7% (52/150) and for C lesions in 82.7% (124/150). Operating time and hospital stays were longer in Group A2 (rectovaginal septum and vagina, 1-3 cm) compared to A0, B2 (uterosacral, 1-3 cm) compared to B0, C3 (rectosigmoid >3 cm) compared to C2 (rectosigmoid 1-3 cm) or C0 (P < 0.001), in severe compared to moderate DE patients, and in moderate compared to mild extensive patients (P < 0.01). Patients with vaginal or rectosigmoid involvement were respectively six and three times more likely to experience high-grade complications according to Clavien-Dindo classification than patients without vaginal or rectosigmoid disease (P < 0.001). Postoperative voiding dysfunction was correlated with A lesions (odds ratio (OR) = 6.82, 95% CI 2.34-20.5), moderate or severe DE (OR = 4.15, 95% CI 1.26-17.9), the presence of at least unilateral lateral pelvic involvement (OR = 3.6, 95% CI 1.14-11.2, P = 0.03) and C lesions (OR = 2.6, 95% CI 1.03-6.8, P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

The study was conducted in an expert center and needs to be validated in a multicenter study. There is a limited number of patients with lateral pelvic endometriosis beyond the parietal fascia, probably due to the low prevalence of this disease presentation.

WIDER IMPLICATIONS OF THE FINDINGS

MRI imaging can be used to accurately predict postoperative complications for women with DE. This may help the clinician to preoperatively inform a patient about the risks of surgery. Larger clinical studies are required to validate these results.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. I.T.N.: Remunerated lecture GE, Hologic, Guerbet, Canon; Advisory board: Siemens - These relationships are on the topic of breast imaging, not related to the topic of this paper. Other coauthors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

A short anogenital distance on MRI is a marker of endometriosis

STUDY QUESTION

Could the anogenital distance (AGD) as assessed by MRI (MRI-AGD) be a diagnostic tool for endometriosis?

SUMMARY ANSWER

A short MRI-AGD is a strong diagnostic marker of endometriosis.

WHAT IS KNOWN ALREADY

A short clinically assessed AGD (C-AGD) is associated with the presence of endometriosis.

STUDY DESIGN SIZE DURATION

This study is a re-analysis of previously published data from a case-control study.

PARTICIPANTS/MATERIALS SETTING METHODS

Women undergoing pelvic surgery from January 2018 to June 2019 and who had a preoperative pelvic MRI were included. C-AGD was measured at the beginning of the surgery by a different operator who was unaware of the endometriosis status. MRI-AGD was measured retrospectively by a senior radiologist who was blinded to the final diagnosis. Two measurements were made: from the posterior wall of the clitoris to the anterior edge of the anal canal (MRI-AGD-AC), and from the posterior wall of the vagina to the anterior edge of the anal canal (MRI-AGD-AF).

MAIN RESULTS AND THE ROLE OF CHANCE

The study compared MRI-AGD of 67 women with endometriosis to 31 without endometriosis (controls). Average MRI-AGD-AF measurements were 13.3 mm (±3.9) and 21.2 mm (±5.4) in the endometriosis and non-endometriosis groups, respectively (P < 10-5). Average MRI-AGD-AC measurements were 40.4 mm (±7.3) and 51.1 mm (±8.6) for the endometriosis and non-endometriosis groups, respectively (P < 10-5). There was no difference of MRI-AGD in women with and without endometrioma (P = 0.21), or digestive involvement (P = 0.26). Moreover, MRI-AGD values were independent of the revised score of the American Society of Reproductive Medicine and the Enzian score. The diagnosis of endometriosis was negatively associated with both the MRI-AGD-AF (β = -7.79, 95% CI (-9.88; -5.71), P < 0.001) and MRI-AGD-AC (β = -9.51 mm, 95% CI (-12.7; 6.24), P < 0.001) in multivariable analysis. Age (β = +0.31 mm, 95% CI (0.09; 0.53), P = 0.006) and BMI (β = +0.44 mm, 95% CI (0.17; 0.72), P = 0.001) were positively associated with the MRI-AGD-AC measurements in multivariable analysis. MRI-AGD-AF had an AUC of 0.869 (95% CI (0.79; 0.95)) and outperformed C-AGD. Using an optimal cut-off of 20 mm for MRI-AGD-AF, a sensitivity of 97.01% and a specificity of 70.97% were noted.

LIMITATIONS REASONS FOR CAUTION

This was a retrospective analysis and no adolescents had been included.

WIDER IMPLICATIONS OF THE FINDINGS

This study is consistent with previous works associating a short C-AGD with endometriosis and the absence of correlation with the disease phenotype. MRI-AGD is more accurate than C-AGD in this setting and could be evaluated in the MRI examination of patients with suspected endometriosis.

STUDY FUNDING/COMPETING INTERESTS

N/A.

TRIAL REGISTRATION NUMBER

The protocol was approved by the 'Groupe Nantais d'Ethique dans le Domaine de la Santé' and registered under reference 02651077.

Hyperthermic intraperitoneal chemotherapy (HIPEC): Should we look closer at the microenvironment?

The age of cancer as an isolated single-cell concept is now behind us. It is now established that epithelial ovarian cancer, like other cancers, interacts with the healthy bystander cells to influence them and takes advantage of their nutritional, immunological, disseminating and other capacities. This interaction has become a therapeutic target, as shown by the numerous studies on this subject. Intraperitoneal chemo-hyperthermia has been part of the therapeutic armamentarium for some time yet its efficiency in ovarian cancer has only been recently proven in a randomized controlled trial. However, its therapeutic performance is not revolutionary and epithelial ovarian cancer maintains a high mortality. In this review, we studied the impact of HIPEC on the microenvironment and vice versa to determine whether it could be the key to this lukewarm efficacy. We began by exploring the modalities of HIPEC and establishing the reasons that make this treatment topical. Then, we examined its impact on each element of the tumor environment to obtain a global view of the resistance mechanisms at work in HIPEC.

Magnetic Resonance and Ultrasound Fusion Imaging to Characterise Ovarian Masses: A Feasibility Study

BACKGROUND/AIM

Magnetic resonance (MR) and ultrasound (US) fusion imaging (MR-US fusion) is already used to guide prostate biopsies and has been proven accurate for diagnosing cervical cancer. In this study, we aimed to evaluate the feasibility and performance of MR-US fusion for characterizing adnexal masses.

PATIENTS AND METHODS

A retrospective study was conducted between 2014 and 2018 including women referred to our Gynaecological Oncology Department for characterization of an adnexal mass (n=106). Performance of MR-US fusion was evaluated in a subgroup of patients who underwent surgery (n=26). Two readers, blinded to final histology, performed and rated US findings according to the International Ovarian Tumor Analysis simple rules score, MR according to Ovarian-Adnexal Reporting Data System Magnetic score, and MR-US fusion through a tailored score. The reference outcome was the final pathology.

RESULTS

MR-US fusion had a sensitivity of 100% (95%CI=80-100), specificity of 89% (95%CI=52-99), positive likelihood ratio of 9 (95%CI=1.4-57), and accuracy of 96% (95%CI=80-99).

CONCLUSION

MR-US fusion is feasible for characterizing adnexal masses to predict ovarian cancer.

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.

4-Methylcoumarins with cytotoxic activity against T24 and RT4 human bladder cancer cell lines

4-Methylcoumarins were synthesized by microwave-assisted synthesis via Pechmann condensation and their cytotoxic activity against human bladder cancer cell lines was investigated.

Occurrence and seasonal variation of airborne gram negative bacteria in a sewage treatment plant

A study was carried out to determine the microbial density and the seasonal variation of airborne Gram negative bacteria in a sewage treatment plant. Sampling was made at 16 sites and the settle plate technique was used. Of the 201 samples examined, 43.2% revealed fecal coliforms (mean value = 14 cfu/p/h), 53% Pseudomonas spp. (mean value = 11 cfu/p/h), 46.5% Shigella spp. (mean value = 13 cfu/p/h), 3% Legionella spp. (mean value = 2 cfu/p/h) and 2% Salmonella (mean value = < 1 cfu/p/h). 72% of the samples contained "other" Gram negative bacteria such as Aeromonas hydrophila, Serratia marcescens, Enterobacter cloacae and others. With the exception of Legionella spp. and Salmonella, all other bacteria were more frequent and numerous in the October-March period, when temperatures were lower and humidity higher. Although the oxidation tanks were covered overall contamination was nevertheless high, thus presenting a potential health risk for plant workers.

Phacotrabeculectomy with or without punch: preliminary results comparing the two techniques

The authors report their experience in the combined surgery, for glaucoma and cataract, by using the Crozafon-De Laage punch. 24 patients affected by open-angle glaucoma and cataract have been enrolled in the study. 12 underwent a combined operation of phacoemulsification and trabeculectomy according to Cairns, and 12 underwent phacoemulsification and protective filtering surgery executed with the Crozafon-De Laage punch. Comparing the two methods we noted as advantage of the punch its easiness of use, through the sclerocorneal tunnel of the phacoemulsification, to create a filtering fistula; this shortened the duration of surgery. As a disadvantage of punch use we noted a lower filtering gradability as opposed to Cairns' trabeculectomy.