Tamer Seckin, MD
Diagnosis of occult and stromal endometriosis: The blue dye technique
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
Thank you again and for late comers, welcome.
Apart from multiple doctors, delayed diagnosis, all those things that we know my presentation is going to be about accurate diagnosis and visual precision and how we can increase that. In general there are readmissions, recurrence of pain and repeat surgeries for about one third of all endometriosis patients. There is one Canadian study here in these slides, the first slide probably, which is going to say that in a four year follow up of 6,000 patients diagnosed with endometriosis, almost 30 percent of these are re-operated on, ten percent with hysterectomies.
From Vercellini’s studies of 2006 we failed mostly on early disease treatment. Is this improper surgical technique, or incomplete surgery? Maybe both – probably both. In our foundation we consider the proper surgery of endometriosis is not burning, not ablation but excision. The word excision is really stolen from the breast cancer concept. The tumor has to be, the borders have to be, free that is how we relate to it. Incomplete surgery; maybe we are not recognizing the disease enough, we are missing and one of the things we may be missing is that probably the disease does not usually come in color format. The disease is something else. We know for years, 50 years, all black and blueberry, and then along came Dr. Redwine and obviously Dr. Martin. In the 1980s Dr. Martin brought the concept of atypical endometriosis and we started recognizing non-colored lesions. This is Vercellini’s study. As you see, the black line is stage one disease. It comes with symptoms more than the advanced disease.
When you look at the slides again, the black is very obvious, the white is very obvious but there are more things happening. Look at the brown areas where the capillary almost gets lost. You see the discoloration there. Those are the areas I want to pay attention to for you and I am going to show you some pictures.
The successful treatment really starts with doctors and visual recognition of the disease. In endometriosis surgery it is very easy to lose good visualization because for maybe thirty years, maybe throughout all laparoscopic technique, the overpowering of light is perhaps our biggest enemy because it absorbs, it shines and you get tired in long surgeries. There have been filters and such but they have not been very practical. This is a very simple technique that I will show you. With numbers I can tell you this. We just presented this at the AAGL. I compared the cul-de-sac and pelvic sidewall. In 2014 there were 775 specimens we excised in 115 patients. Advanced endometriosis, which is endometrioma, and deep DIA were excluded. We looked at only peritoneal endometriosis. This technique is very simple, methylene blue dye and submerged in hydrodilatation and near-contact inspection – my residents know, and then retroperitoneal hydrodistention with blue dye completely eliminating the sub-peritoneal muscle and redness reflection that comes to the peritoneum.
We looked at this and out of 775, 663 specimens versus 112 specimens, almost five to six times as many specimens, were removed from the pelvic sidewall. All of sudden you can tell we have an increase in specimens on the sidewalls. So, if you have two sidewalls, it is again, three times it reflects to each side. That is the percentage. We look at the numbers of the histological findings on these specimens and only 407, which is 53 percent, are typical endometriosis. Six percent is stromal. Look at the inflammation and how much there is, 31 percent defined by the pathologists, and fibrosis. When we look at only the cul-de-sac removal without any ABCt we have 112 specimens, typical is 58 to 2, 39, 13. Look at how little stromal endometriosis is there without an ABCt. When we look at the sidewall suddenly the numbers obviously increase, 663 on the sidewall, excluding the pure cul-de-sac, and look at how many stromal endometriosis, 47. Inflammation is 198 and typical 349. When we compare we have a significant number of specimens removed from the sidewalls. But more importantly and statistically significant is that there is almost 20 times more cul-de-sac specimens, stromal endometriosis removed with using this dye technique. So, simple Methylene Blue in three liters of Ringer’s Lactate, it has to be warm. The ovaries are suspended with grainy needles – my residents know how I do that. Basically, submerged hydroflotation, you see wonderful pictures under the water. Look at these vessel formations. They are fantastic.
What happens is this is just a contrast. It is really nice to recognize these vessels during the cases. Scope is less than one cm closer to these lesions. What happens is the elimination of gas pressure, obviously, elimination of light reflection and the red and yellow spectrum of light is gone.
This is an example, these flattened lesions with gas pressure and how they float. You see it there. Look at this. This is the earliest lesion, I showed this yesterday. Look at this nipple like popping out angiogenesis budding and these floating lesions. You see these little grape-like buddings are visible. These are all early endometriosis.
As we move I am going to show you more pictures. This is a patient that has been re-operated on. This is the area excised before. People say endometriosis does not come back really, but it does come back. And it comes back in the excised area, within the center of the excised area; it does not really come at the edges. Those are incomplete removals. You see these lesions? So, underwater you see some of these lesions are floating. This is the floating one, there is one that is not floating; two types of lesions. I excised this very carefully and it went to pathology. When I go to pathology the pathologists run away from me – I do not let them go until I get my answers. They did make this cut for me. This is the floating lesion. You see the stroma. This showed the floating lesion up here, on top, you see it. And this is the stroma positive. There is no gland, only stroma. We did the CD-10 and S-100 – that is the way it showed, pure stroma.
The flattened lesion showed gland. This is the flattened lesion, gland with stroma. Even at the earliest phase we can catch these lesions. That is how we do the hydrodistention.
Basically, when you look at it you see one lesion up there and a little bit more maybe white areas, right? You do not see them. There is one lesion there. When you do the hydrodistention the ovaries are suspended, basic irrigation fluid, under pressure you distend this. Now let us look at this very carefully. What happened here is all of a sudden the white lesions are more prominently there. But around the white lesions you are going to see multiple peritoneal defect, we sometimes call this leopard skin sign in some cases but you see how the central lesion has contracted the other part of the peritoneum.
Normal peritoneum is very shiny, almost transparent, very good texture. There is nothing smooth and is CD-10 negative. The peritoneum that is more visible with the illumination of background redness is defective. Texture is gone, you see almost holes there and these are CD-10 positive. This is an actual pathologist slide of the same patient that you see there, with macrophages, eosinophil, digestive – all stromal inflammation, the same patient.
This is a very interesting patient. There is recent excitement about new-born endometriosis, the new-born vaginal bleeding, new-born retrograde period versus embryological – whatever that is. This patient is not a new-born. She is an acute abdomen emergency room patient operated on at Lenox Hill last year, maybe one of the residents might be there. Hemoperitoneum, there is no source of blood. The patient is 62 years old and in menopause for the last ten years, a Hollywood lady on a massive dose of ERT and bioidenticals – massive. This is how her peritoneum looked, just not much after you suck the blood you look everywhere. This is how it looked with the retrograde – how thickened this peritoneum was, like leather almost. We took this peritoneum and put it on a form. I went to pathology where they do our cuttings. We do cuttings – this is how it is, we pin it on a form and we slice it like this. We looked at the same specimen that you saw. You see the gland, nice stroma, beautiful stroma and some inflammation around it; tri-chrome staining, smooth muscles. Then we go to the area where there is no gland. This thickening, we will look at that too.
The same woman was exposed to estrogen for ten years, a hyper dose. You see blood vessels, significant nerves and primitive smooth muscle all over. We looked at the mesothelium and specially stained its calretinin, very thickened mesothelium, very thickened sub-mesothelial layer with nerves, perineural inflammatory cells and guess what? The thickened mesothelium is positive for estrogen. That tells you the element of stem cells or wound healing does bring estrogen positive cells there. These are the cells that most likely become the stroma.
This is the end of my presentation. I hope you will retain something that maybe you can use in your practice. You will see how you can benefit. Thank you very much.