Is m a e l D a le C o trim G u e rre iro , P a u lo R o b e rto d e O liv e ira L im a C a s ta n h o , F a u s to F a ra h B a ra c a t
Endom etrial biopsy withuretral plastic No. 12 sonde
C a n c e r P re v e n tiv e S e rv ic e , G y n e c o lo g lc a l'O n c o lo g y D e p a rtm e n t,
In stitu to d e C a n c e r A n to n io V ie ira d e C a rv a lh ~ , E sc o la P a u lista d e M e d ic in a - S a o P a u lo , B ra zil
T h e a u th o rs d e m o n s tra te te c h n iq u e fo r o b ta in in g e n d o m e tria l fra g m e n ts in 2 5 p a tie n ts s e n t to G y n e c o lo g ic a l C a n c e r P re v e n tiv e S e rv ic e o f th e A rn a ld o V ie ira d e C a rv a lh o C a n c e ~ In s titu te , d u rin g th e p e rio d o f S e p te m b e r 1 9 9 1 th ro u g h J a n u a ry 1 9 9 2 , p re s e n tin g
a b n o rm a l u te rin e h e m o rrh a g e . .
T e c h n iq u e c o n s is ts in v a c u u m a s p ira tio n w ith th e s u p p o rt o f a N o . 1 2 u re tra l s o n d e , p ro v id e d w ith o n e la te ra l o p e n in g o n ly . C o rre la tio n w ith c u re tta g e w a s p o s itiv e in 8 8 % o f th e p a tie n ts ; b io p s y w ith s o n d e d id n o t re s u lt in c o n firm a tio n in th re e p a tie n ts o n ly .
N o c o m p lic a tio n s a t a ll w e re o b s e rv e d (in fe c tio n , h e m o rrh a g e o r u te ru s p e rfo ra tio n ).
A u th o rs u n d e rs ta n d th a t th is m e th o d is in c o n fo rm ity w ith a c o rre c t d ia g n o s tic p e rfo rm a n c e , b e in g a lo w c o s t p ro c e d u re , a lm o s t p a in le s s , e a s y to b e d o n e a n d fu rn is h in g s u ffic ie n t m a te ria l fo r th e h is to -p a th o lo g ic d ia g n o s is , in 8 8 % o f th e c a s e s s tu d ie d .
U N IT E R M S : E n d o m e tria l b io p s y . A b n o rm a l u te rin e h e m o rrh a g e .
IN T R O D U C T IO N
U
im portantterinecurettage,resource~oday, still continuesfor assessm ent being a veryof w om eninclined to an uterine cancer and diagnosis of
abnorm al hem orrhage (K A U N IT Z et aI., 1988).
A d d re s s fo r c o rre s p o n d e n c e :
F a u s to F a ra h B a ra c a t
A v . A n g e lic a , 916 - 79 -c j. 7 0 7
S a o P a u lo -.S P - B ra s il- C E P 0 1 2 2 8 -0 0 0
698
H ow ever, confinem ent and anesthesia needs m ake
this procedure not feasible to be done at am bulatory
prem ises. A s a result, other countless m ethods have been
tried, such as the V abra aspirator, rotating of a sm all brush
in the endom etrial cavity (D e B R U X ) and the N ovak
curette.
From these, the m ethod that m ore approaches nearly
to an uterine curettage is, w ithout any doubt, the V abra
aspirator, resulting in a correlation of 96% (JE N SE N ,
1970; G R IM E S, 1982), how ever, the need of a vacuum
electrically obtained, m akes this m ethod expensive and
difficult to perform (SL E D lV IE R E , 1981; B U T L E R , 1984).
So, w e proposed ourselves to test, here, a low cost
and easily applicable technique, consisting in the aspiration
of endom etrial fragm ents through an uretral sonde attached
to a 20 m l syringe and com pare the results obtained w ith
the uterine curettage already m ade in these sam e patients.
M A T E R I A L A N D M E T H O D S
T w e n ty - f iv e p a tie n ts , s e n t b y th e G y n e c o lo g ic a l C a n c e r P r e v e n tiv e S e r v ic e o f th e I C A V C , w e r e in c lu d e d in th e . s tu d y , d u r in g th e p e r io d o f S e p te m b e r 1 9 9 1 th r o u g h J a n u a r y 1 9 9 2 , p r e s e n tin g a b n o r m a l u te r in e h e m o r r h a g e .
A g e o f p a tie n ts v a r ie d f r o m 4 0 to 7 4 y e a r s , r e s u ltin g in a n a v e r a g e o f 5 2 .4 . F ir s t o f a ll, a n a c c u r a te g y n e c o lo g ic a l e x a m in a tio n is d o n e : v a lv a , v a g in a a n d u te r in e c o li a r e e x a m in e d w ith a c o lp o s c o p e , in o r d e r to e x c lu d e o th e r c a u s e s , b e s id e s th e a b n o r m a l e n d o m e tr ia l c a v ity b le e d in g .
A f te r v a g in a l e m b r o c a tio n w ith lu g o l, a N o . 1 2 s o n d e is in tr o d u c e d in th e u te r in e c a v ity , b y th e s u p p o r t o f a C h e r o n p in n a c e ; in 9 0 % o f th e c a s e s s e iz u r e o r e n la r g e m e n t o f th e u te r in e c o li w a s n o t n e c e s s a r y , a s th e s o n d e s u r p a s s e d e a s ily th e r e s is ta n c e o f b o th , th e e x te r n a l a n d in te r n a l c e r v ic a l o s tiu m s .
O n c e p la c e d in th e u te r in e c o li, s o n d e is f ix e d to th e s y r in g e - g r a s p s e t a n d , w ith th e h e lp o f o n e o f th e h a n d s , v a c u u m is c r a te d . R ig h t a f te r , w ith o u t d e s tr o y in g th e v a c u u m , w ith th e o th e r h a n d , s o n d e is b r o u g h t o u t o f th e e n d o m e tr ia l c a v ity . T h is p r o c e d u r e m u s t b e r e p e a te d 3 tim e s , a p p r o x im a te ly , in o r d e r to g e t m a te r ia l n e c e s s a r y f o r th e h is to p a th o lo g ic e x a m in a tio n . A f te r th e s e a s p ir a tio n s a r e p e r f o r m e d , e n d o m e tr ia l f r a g m e n ts a r e o b s e r v e d in th e in te r io r o f th e s o n d e , m ix e d to m u c u s a n d b lo o d .
M a te r ia l o f th e s o n d e is ta k e n o f f b y p a s s in g a 1 0 % f o r m o l s o lu tio n w ith th e a id o f a s y r in g e .
A v e r y im p o r ta n t d e ta il to b e o b s e r v e d w h e n th e s o n d e is m a d e o u t in p la s tic m a te r ia l is th a t it " m u s t h a v e o n ly o n e la te r a l o p e n in g " , a s m o d e ls p r e s e n tin g tw o o r m o r e o p e n in g s lo s s v a c u u m e a s ily , b e in g n o t p o s s ib le a n a d e q u a te c o lle c tio n o f m a te r ia l.
P a tie n ts w e r e s u b m itte d to c u r e tta g e p r o o f s d a y s a f te r b io p s y b y s o n d e w a s m a d e a n d r e s u lts w e r e c o m p a r e d .
R E S U L T S
R e s u lts s h o w e d a 8 8 % p o s itiv e c o r r e la tio n b e tw e e n b io p s y a n d c u r e tta g e p r o o f s ; b io p s y w ith s o n d e c o u ld n o t c o lle c t m a te r ia l o f s e v e n p a tie n ts .
I n f o u r o f th e m , th e p a th o lo g ic a n a to m y e x a m in a tio n o f th e c u r e tta g e m a te r ia l w a s h a r m o n io u s a n d , in o th e r th r e e p a tie n ts , e n d o m e tr ia l w a s o f a tr o p h ic ty p e .
T h e r e w e r e tw o e n d o m e tr ia l G la n d G 2 a d e n o c a r c in o m a c a s e s ; tw o a d e n o m a to s is h y p e r p la s ia w ith o u t a n y a ty p ia s a n d o n e o f c y s tic h y p e r p la s ia .
S e v e n c a s e s o f s e c r e to r y e n d o m e tr ia l, f o u r o f p r o lif e r a tiv e e n d o m e tr ia l a n d tw o o th e r s w h e r e a s p ir a tio n g o t e n d o c e r v ic a l g la n d s o n ly ( T a b le 1 ) .
N o c o m p lic a tio n s a t a ll w e r e o b s e r v e d c o n s id e r in g b o th o f th e m e th o d s ( h e m o r r h a g e , in f e c tio n o r p e r f o r a tio n ) . M o s t o f th e p a tie n ts s h o w e d a g o o d to le r a n c e to s o n d e b io p s y , b e in g th e u te r in e c o li s e iz u r e n e e d e d in o ~ ly 2 0 % o f th e c a s e s .
D I S C U S S I O N
S e v e r a l m e th o d s f o r o b ta in in g e n d o m e tr ia l m a te r ia l h a v e b e e n u tiliz e d ; th e s e te c h n iq u e s in v o lv e s u c tio n , ir r ig a tio n f o llo w e d b y a s p ir a tio n ( G r a v - L e e ) , 'r o ta tio n o f a
N r.o f c a s e s
T a b l e 1
R e s u l t s o f b i o p s y w i t h s o n d e c o m p a r e d t o t h e o b t a i n e d i n c u r e t t a g e p r o o f
B io p s y w ith s o n d e C u re tta g e p ro o f
0 2
0 2
0 1
0 7
0 4
0 4 0 2
0 3
E n d o m e tria l a d e n o c a rc in o m a
A d e n o m a to s is h ip e rp la s ia
W ith o u t a ty p ia s
C y s tid h ip e rp la s ia
E n d o m e tria l s e c re to ry
M u c u s a n d fib rin e
E r:td o c e rv ic a l g lu d s
M u c u s a n d fib rin e
E n d o m e tria l a d e n o c a rc in o m a
A d e n o m a to s is h ip e rp la s ia
W ith o u t a ty p ia s
C y s tid h ip e rp la s ia
E n d o m e tria l s e c re to ry
M u c u s a n d fib rin e
M u c u s a n d fib rin e
A tro p h ic e n d o m e tria l
sm all brush
in the endom etrial
cavity
(De Brux brush),
Novak
curette
and,
m ore
recently,
a new
device
for
aspirative
biopsy obtainance,
nam ed "endom etrial
pipelle"
(KAUNITZ
et aI., 1988).
These m ethods have shown
very accurate diagnostics
varying
from
70%
to 92%
(GUSBERG
et aI.,
1981;
BIBBO
et aI.,
1982;
KOSS
et aI.,
1982),
with
the
disadvantage
that,
cytological
techniques
(brushing,
irrigation,
etc.),
need
professional
trained
in this
area
(KOSS
et aI., 1981; KOSS
et aI., 1982; POISON
et aI.,
1984;
FERENCZY
et aI.,
1984)
as,
even
the
m ost
experients
face
difficulties
in the
correct
diagnosis
(KAUNITZ
et aI., 1988).
Until
hystereoscopy
does
not becom e
a widely
diffused
procedure
in our area, curettage
continues
being
as the standard
m ethod
for the endom etrial
cavity
study.
The
m ore
sim ilar
procedure
is the
Vabra
aspirator,
presenting
a correlation
of 96% with the uterine
curettage
(JENSEN,
1970;
GRIM ES,
1982).
This
procedure,
however, needs vacuum
electrically
obtained,
m aking this
m ethod
m ore
expensive
a~d
difficult
to be
applied
(SLEDM ERE,
1981; BUTLER,
1984).
C O N C L U S IO N
It is an easy m ethod, can be am bulatorily
perform ed,
alm ost
painless,
presenting
a m inim um
risk and at low
cost,
presenting
quite
satisfactory
results
(88% )
and,
consequently,
indicated
adequately
for diagnosis
purpose
in what refers to endom etrial
injuries.
Feasibility
justifies
propaedeutics.
... ::.::..::::.:.:...
