Endometriosis

Deep Infiltrating Endometriosis: Imaging Features and Laparoscopic Correlation

Endometriosis usually affects reproductive-aged women and can be responsible for pain symptoms and infertility. Deep infiltrating endometriosis may involve the uterine ligaments (utero-sacral and/or round ligaments), the retrocervical area, the rectovaginal septum, the rectum, the vagina, and the bladder. The pre-operative assessment of such lesions is required to plan full surgical excision of the disease. Endometriotic lesions have some typical imaging patterns on transvaginal ultrasound and magnetic resonance imaging enabling pre-operative mapping of the disease. In this paper the authors report the imaging features of deep infiltrating endometriosis and the laparoscopic correlation of such lesions.

Creation of immortalised epithelial cells from ovarian endometrioma

Background:

Epithelial cells of endometriotic tissues are difficult to propagate in vitro as experimental material is scarce owing to their limited life span. However, there is an increasing concern regarding their malignant transformation in ovaries. The present study sought to generate their stable culture system.

Methods and results:

Purified epithelial cells isolated from ovarian endometriomas using microscopic manipulation were successfully immortalised by combinatorial transfection of human cyclinD1, cdk4 and human telomerase reverse transcriptase (hTERT) genes, whereas the introduction of hTERT alone, or together with cdk4, was insufficient for immortalisation, leading to cellular senescence. We confirmed stable cytokeratin expression in the immortalised cells, proving their epithelial origin. These cells expressed progesterone receptor B and showed significant growth inhibition by various progestins. Oestrogen receptor (ER) expression was detected in these cells, albeit at low levels. Additional overexpression of ERα generated stable cells with oestrogen-dependent growth activation. Soft-agar colony formation assay and nude mice xenograft experiments demonstrated that these cells, even those with additional inactivation of p53, did not have transformed phenotypes.

Conclusion:

We for the first time generated immortalised epithelial cells from ovarian endometrioma that retained sex steroid responsiveness. These cells are invaluable tools not only for the consistent in vitro work but also for the study of molecular pathogenesis or carcinogenesis of endometriosis.

Beyond the boundaries-endometriosis: typical and atypical locations

Endometriosis is characterized by the presence of endometrial glands and stroma in an ectopic location outside the endometrial cavity. This condition affects women during their reproductive years. Ovaries are by far the commonest location of endometriosis and have peculiar imaging features. However, the imaging diagnosis of extraovarian endometriosis is difficult to make both clinically and radiologically. The purpose of this article is to review the imaging features of endometriosis at typical and atypical sites on different modalities and to describe the commonly encountered complications. Atypical sites for endometriosis include the gastrointestinal tract, urinary tract, soft tissues, and chest. Depending on the site, they can present with varied symptoms, including bowel obstruction, melena, hematuria, dysuria, dyspnea, and swelling in the soft tissues, respectively. The endometriotic implant in the extraovarian location is a challenging diagnosis. It is important to be aware of the sites, radiologic appearances, and complications of ovarian and extraovarian endometriosis while evaluating a woman in the reproductive age group with appropriate symptomatology. Endometriosis at extraovarian locations is a challenging diagnosis clinically and radiologically. Clinical symptomatology with characteristic imaging features in the appropriate patient population is helpful in reaching the diagnosis. Precise diagnosis regarding presence, location, and extent of endometriosis is useful for preoperative evaluation and surgical planning of endometriosis.

Laparoscopic rectal resection of deep infiltrating endometriosis

PURPOSE

Deep infiltrating endometriosis with colorectal involvement is a complex disorder, often requiring segmental bowel resection. Complete removal of all visible lesions is considered the adequate treatment of infiltrating endometriosis in order to reduce recurrence. In this article, we describe our experience with laparoscopic management of deep infiltrating endometriosis with involvement of the rectum.

METHODS

A retrospective analysis of data from patients with deep infiltrating endometriosis with rectal involvement who underwent a laparoscopic surgery in the years 2002-2009 at the Department of Obstetrics and Gynecology at our institution was done.

RESULTS

Between 2002 and 2009, a laparoscopic partial rectal resection was performed in 52 patients, and laparoscopic disk resection was performed in 4 cases with deep infiltrating endometriosis. The mean age of patients was 34.4 years (range, 22-62 years). Preoperative symptoms included dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. The laparoscopic procedure was converted to formal laparotomy in 3 patients (5.4%). The mean duration of surgery was 145 minutes. Postoperative complications included 3 cases of anastomotic leakage with rectovaginal fistula in two cases and intraabdominal bleeding in 1 case. The mean hospital stay was 7 days. Postoperatively, nine patients had a normal delivery, two of them after in vitro fertilization treatment.

CONCLUSION

Laparoscopic rectal resection for deep infiltrating endometriosis is a relatively safe procedure, when performed by a surgeon and a gynecologist with sufficient experience in laparoscopic colorectal surgery.

Fasudil inhibits the proliferation and contractility and induces cell cycle arrest and apoptosis of human endometriotic stromal cells: a promising agent for the treatment of endometriosis

CONTEXT

During the development of endometriotic lesions, excess fibrosis may lead to scarring and to the alterations of tissue function that are the characteristic features of this disease. Enhanced extracellular matrix contractility of endometriotic stromal cells (ECSC) mediated by the mevalonate-Ras homology (Rho)/Rho-associated coiled-coil-forming protein kinase (ROCK) pathway has been shown to contribute to the pathogenesis of endometriosis.

DESIGN

To assess the use of fasudil, a selective ROCK inhibitor, for the medical treatment of endometriosis-associated fibrosis, the effects of this agent on the cell proliferation, apoptosis, cell cycle, morphology, cell density, and contractility of ECSC were investigated. The effects of fasudil on the expression of contractility-related, apoptosis-related, and cell cycle-related molecules in ECSC were also evaluated.

RESULTS

Fasudil significantly inhibited the proliferation and contractility of ECSC and induced the cell cycle arrest in the G2/M phase and apoptosis of these cells. Morphological observation revealed the suppression of ECSC attachment to collagen fibers and decrease of cell density by fasudil. The expression of α-smooth muscle actin, RhoA, ROCK-I, and ROCK-II proteins was inhibited by fasudil administration. The expression of the antiapoptotic factors, Bcl-2 and Bcl-X(L), in two-dimensional cultured ECSC were down-regulated by the addition of fasudil, whereas, the expression of p16(INK4a) and p21(Waf1/Cip1) was up-regulated by the addition of fasudil.

CONCLUSIONS

The present findings suggest that fasudil is a promising agent for the treatment of endometriosis. The inhibition of cell proliferation, contractility, and myofibroblastic differentiation, the attenuation of attachment to collagen fibers, the decrease of cell density, and the induction of cell cycle arrest and apoptosis of ECSC are involved in the active mechanisms of fasudil.

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.

Endometriosis - morphology, clinical presentations and molecular pathology

Endometriosis is found predominantly in women of childbearing age. The prevalence of endometriosis is difficult to determine accurately. Laparoscopy or surgery is required for the definitive diagnosis. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsen during menses. Endometriosis occurring shortly after menarche has been frequently reported. Endometriosis has been described in a few cases at the umbilicus, even without prior history of abdominal surgery. It has been described in various atypical sites such as the fallopian tubes, bowel, liver, thorax, and even in the extremities. The most commonly affected areas in decreasing order of frequency in the gastrointestinal tract are the recto-sigmoid colon, appendix, cecum, and distal ileum. The prevalence of appendiceal endometriosis is 2.8%. Malignant transformation is a well-described, although rare (<1% of cases), complication of endometriosis. Approximately 75% of these tumors arise from endometriosis of the ovary. Other less common sites include the rectovaginal septum, rectum, and sigmoid colon. Unopposed estrogens therapy may play a role in the development of such tumors. A more recent survey of 27 malignancies associated with endometriosis found that 17 (62%) were in the ovary, 3 (11%) in the vagina, 2 (7%) each in the fallopian tube or mesosalpinx, pelvic sidewall, and colon, and 1 (4%) in the parametrium. Two cases of cerebral endometriosis and a case of endometriosis presenting as a cystic mass in the cerebellar vermis has been described. Treatment for endometriosis can be expectant, medical, or surgical depending on the severity of symptoms and the patient's desire to maintain or restore fertility.

The association between endometriosis and ovarian cancer: a review of histological, genetic and molecular alterations

OBJECTIVE

This article represents a review of histologic and genetic findings in endometriosis and describes the mechanisms whereby genetic and non-genetic factors potentially contribute to the neoplastic progression of endometriosis.

METHODS

Literature review of the English language literature based on searching in the MEDLINE (PubMed) database and additional collection of reports by systematically reviewing all references from retrieved papers.

RESULTS

Atypical endometriosis seems to represent a transition from benign endometriosis to carcinoma. Endometriosis is characterized by genetic instability: like neoplasms endometriosis seems to be monoclonal in origin, several studies have documented loss of heterozygosity (LOH) in endometriosis, data suggest that mutation of the tumor suppressor gene PTEN play a part in the malignant transformation of endometriosis, some studies have revealed TP53 mutations in endometriotic lesions, and mutation of ARID1A seems to be an important early event in the malignant transformation of endometriosis to endometrioid and clear cell carcinomas. Heme and iron induced oxidative stress, inflammation, and hyperestrogenism are possible links between endometriosis and cancer.

CONCLUSIONS

The histological and genetic alterations in endometriosis seem to explain why endometriosis can be a precursor of some ovarian cancers, especially clear cell and endometrioid carcinomas. However, the exact molecular mechanisms that may lead to this malignant transformation of endometriosis are not completely understood. More and larger studies are needed to clarify how exactly endometriotic tissue undergoes malignant transformation.

Female Perspectives on Endometriosis: Findings from the Uterine Bleeding and Pain Women'S Research Study

Purpose

The symptoms of endometriosis are heterogeneous and overlap with those of other conditions, resulting in misdiagnoses and/or delayed diagnosis and treatment. The Uterine Bleeding and Pain Women's Research Study (UBP-WRS) collected data to elucidate differences in diagnoses and treatment experiences of women, and to assess the impact of endometriosis on their quality of life.

Methods

The UBP-WRS interviewed women aged 15 to 49 in eight countries using an online methodology. Quotas were applied for the age, region, level of education, and income of respondents. Questions assessed menstruation, diagnoses of endometriosis or other gynecological conditions (e.g., uterine fibroids), symptoms, impact on life, and perceptions of treatments.

Results

Of the total of 21 749 women, 2.7% reported surgically diagnosed endometriosis, 2.4% reported nonsurgically diagnosed endometriosis, 5.5% had physician-suspected endometriosis, and 6.2% reported symptoms indicative of endometriosis but no diagnosis. Prevalence of the different diagnoses was comparable between countries. Mean age at diagnosis was 28 years and estimated time-to-diagnosis was 6.1 years. Pain symptoms were generally more common and severe in women with diagnosed endometriosis than in those with suspected disease, whereas the reverse was true for their quality-of-life. Of women receiving treatment for diagnosed endometriosis, 60% were satisfied and 40% were dissatisfied with efficacy. However, 29% of women with diagnosed endometriosis were not receiving any treatment.

Conclusions

Approximately 17% of women in the UBP-WRS reported diagnosed, suspected or symptoms of endometriosis; this is comparable to previously published studies. The UBP-WRS – among the largest surveys of its kind – may help to improve understanding of this enigmatic disease and guide therapeutic practices.

Polymorphism of the estrogen receptor β gene is related to infertility and infertility-associated endometriosis

OBJECTIVE

To determine the frequency of the estrogen receptor b gene (ERβ) +1730 G/A polymorphism in infertile women with and without endometriosis and controls.

SUBJECTS AND METHODS

Case-control study that included 136 women with endometriosis, 69 women without endometriosis and 209 fertile women as controls. The ERβ gene + 1730 G/A polymorphism was identified by RFLP-PCR (Restriction Fragment Length Polymorphism - Polymerase Chain Reaction).

RESULTS

Genotypes GG, GA and AA of the ERβ gene presented frequencies of 60.3%, 38.2% and 1.5%, respectively, in the women with endometriosis (p < 0.0022). Of the infertile women without endometriosis, 63.8% presented the normal homozygous genotype GG, 30.4% the GA heterozygous genotype, and 5.8% the homozygous mutated genotype AA (p < 0.0275). In the control group, 77.5% presented the normal homozygous genotype GG, 21.1% the heterozygous genotype GA, and 1.4% the homozygous mutated genotype AA.

CONCLUSION

The data suggest that the estrogen receptor β gene (ERβ) +1730 G/A polymorphism can be associated with risk of infertility and endometriosis-associated infertility.

Association of ethnicity with involuntary childlessness and perceived reasons for infertility: baseline data from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

To evaluate whether ethnicity is associated with involuntary childlessness and perceived reasons for difficulties in becoming pregnant.

DESIGN

Cross-sectional analysis of baseline data from a longitudinal cohort.

SETTING

Multiethnic, community-based observational study of US women.

PATIENT(S)

Women in midlife (3,149), aged 42-52 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Involuntary childlessness and perceived etiology of infertility.

RESULT(S)

One hundred thirty-three subjects (4.2%) were involuntarily childless, defined by a reported history of infertility and nulliparity. Ethnicity was significantly associated with self-reported involuntary childlessness. After controlling for economic and other risk factors, African American (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.15-0.59) and Chinese women (OR 0.36; 95% CI 0.14-0.90) were less likely to suffer from involuntary childlessness compared with non-Hispanic white women. In addition, 302 subjects reported a perceived etiology of infertility. An unexpectedly large proportion of these women (24.5%, 74 of 302) reported etiologies not known to cause infertility (i.e., tipped uterus, ligaments for tubes were stretched), with African American women having been most likely to report these etiologies (OR 2.81; 95% CI 1.26-6.28) as the reason for not becoming pregnant.

CONCLUSION(S)

Ethnicity is significantly associated with involuntary childlessness and perceived etiology of infertility. Misattribution of causes of infertility is common and merits further consideration with respect to language or cultural barriers, as well as possible physician misattribution.

Ruptured endometrial cysts as a rare cause of acute pelvic pain: can we differentiate them from ruptured corpus luteal cysts on CT scan?

PURPOSE

To evaluate the usefulness of CT in the differentiation of ruptured endometrial cysts and corpus luteal cysts.

METHODS

Sixteen patients (mean age, 26 years) with a surgically proven ruptured endometrial cyst and 19 patients (mean age, 28 years) with a surgically proven corpus luteal cyst were included in this study. All patients had undergone portal phase contrast-enhanced computed tomographic (CT) scans. We retrospectively analyzed the CT findings on the ovarian cysts for the size and shape of the ovarian cyst, the thickness of the cyst wall, the attenuation of the cyst content, the presence of a discontinuity of the cyst wall, and on the peritoneum for the amount and attenuation of the ascites and the presence of hazy infiltration in the peritoneal fat. We compared the CT imaging characteristics in patients with ruptured endometrial cysts and corpus luteal cysts, using the Mann-Whitney U test.

RESULTS

Ruptured endometrial cysts tend to show larger, multilocular cysts with a thicker wall compared to ruptured corpus luteal cysts (P < 0.05). A distorted shape of the cyst was more commonly seen in ruptured endometrial cyst, but direct CT findings that can suggest a rupture of an ovarian cyst, such as a discontinuity of the cyst wall and hemoperitoneum, were more commonly seen in ruptured corpus luteal cysts than in endometrial cysts (P < 0.05).

CONCLUSIONS

Computed tomography is useful in the differentiation of ruptured endometrial cysts and corpus luteal cysts in a patient with acute pelvic pain.

Hypermethylation of the CpG island spanning from exon II to intron III is associated with steroidogenic factor 1 expression in stromal cells of endometriosis

Endometriosis is an estrogen-dependent disease. Steroidogenic factor 1 (SF-1), a transcription factor, is essential for the activation of multiple steroidogenic genes for estrogen biosynthesis in endometriosis-derived stromal cells.

OBJECTIVE

Unravel the mechanism for differential SF-1 expression in endometrial and endometriotic stromal cells.

DESIGN

We identified a novel CpG island in the SF-1 gene, which spans from exon II to intron III. We evaluated the methylation status of this CpG island.

PATIENTS

Eutopic endometrium from disease-free participants (n = 8) and the walls of cystic endometriosis lesions of the ovaries (n = 8). None of the patients had received any preoperative hormonal therapy. Stromal cells were isolated from these 2 types of tissues.

RESULTS

SF-1 messenger RNA (mRNA) levels in endometriotic stromal cells were significantly higher than those in endometrial stromal cells. Bisulfite sequencing showed strikingly increased methylation in endometriotic cells compared with endometrial cells (P < .001). A strong correlation between mRNA levels and percentage methylation of the exon II/intron III are observed. Specifically, the Pearson correlation coefficient was .98 (P < .001) for this association.

CONCLUSIONS

We demonstrated that methylation of a coding exon/intron sequence in the SF-1 gene positively regulated its expression in endometriosis, whereas its hypomethylation in normal endometrium was associated with drastically lower SF-1 levels.

Puerarin suppresses invasion and vascularization of endometriosis tissue stimulated by 17β-estradiol

BACKGROUND

Puerarin, a phytoestrogen with a weak estrogenic effect, binds to estrogen receptors, thereby competing with 17β-estradiol (E2) and producing an anti-estrogenic effect. This study was to investigate whether puerarin could suppress the invasion and vascularization of E2-stimulated endometriotic tissue.

METHODOLOGY/PRINCIPAL FINDINGS

The endometriotic stromal cells (ESCs) were successfully established and their invasive ability under different treatments was assessed through a Transwell Assay. Simultaneously, matrix metallopeptidase 9 (MMP-9) and tissue inhibitor of metalloproteinase 1 (TIMP-1) were detected by western blotting. Vascularization of endometriotic tissues was observed by chicken chorioallantoic membrane (CAM) assay. The staining of MMP-9, intercellular adhesion molecule 1 (ICAM-1), TIMP-1, and vascular endothelial growth factor (VEGF) in grafted endometriotic tissues was examined using immunohistochemistry analysis. The purity of ESCs in isolated cells was >95%, as determined by the fluoroimmunoassay of vimentin. E2 (10(-8) mol/L) promoted the invasiveness of ESCs by increasing MMP-9 accumulation and decreasing TIMP-1 accumulation. Interestingly, puerarin (10(-9) mol/L) significantly reversed these effects (P<0.01). The CAM assay indicated that puerarin (10(-9) mol/L) also inhibited the angiopoiesis of endometriotic tissue stimulated by the E2 (10(-8) mol/L) treatment (P<0.05). Accordingly, immunohistochemistry showed that the accumulation of MMP-9, ICAM-1, and VEGF was reduced whereas that of TIMP-1 increased in the combination treatment group compared with the E2 treatment group.

CONCLUSIONS/SIGNIFICANCE

This study demonstrated that puerarin could suppress the tissue invasion by ESCs and the vascularization of ectopic endometrial tissues stimulated by E2, suggesting that puerarin may be a potential drug for the treatment of endometriosis.

The association between endometriosis and gynecological cancers and breast cancer: a review of epidemiological data

OBJECTIVE

This article critically reviews the literature on the association between endometriosis and gynecological cancers and breast cancer, based on epidemiologic data.

METHODS

Literature review of the English language literature based on searching in the MEDLINE (PubMed) database and additional collection of reports by systematically reviewing all references from retrieved papers.

RESULTS

Data from large cohort and case-control studies indicate that endometriosis patients only have an increased risk of ovarian cancer among the gynecological malignancies and breast cancer, although most of the observed associations are modest. Data on the association between endometriosis and breast cancer are inconsistent. Endometriosis patients have a reduced risk of cervical cancer, and there is no association between endometriosis and endometrial cancer. Endometriosis-associated ovarian cancer seems to be a distinct clinical entity; patients are younger, diagnosed in earlier stages, have lower grade lesions and a better survival. Further, endometriosis-associated ovarian cancers are predominantly clear cell and endometrioid histologic subtypes.

CONCLUSIONS

Endometriosis seems to be a precursor of epithelial ovarian cancer, especially clear cell and endometrioid adenocarcinomas. However, current evidence is insufficient to draw any definitive conclusions whether this association represents causality or the sharing of similar risk factors and/or antecedent mechanisms.

Incidence of endometriosis by study population and diagnostic method: the ENDO study

OBJECTIVE

To estimate the incidence of endometriosis in an operative cohort of women seeking clinical care and in a matched population cohort to delineate more fully the scope and magnitude of endometriosis in the context of and beyond clinical care.

DESIGN

Matched-exposure cohort design.

SETTING

Surgical centers in the Salt Lake City, Utah, and San Francisco, California, areas.

PATIENT(S)

The operative cohort comprised 495 women undergoing laparoscopy/laparotomy between 2007 and 2009, and the population cohort comprised 131 women from the surgical centers' catchment areas.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Incidence of endometriosis by diagnostic method in the operative cohort and by pelvic magnetic resonance imaged (MRI) disease in the population cohort.

RESULT(S)

Endometriosis incidence in the operative cohort ranged by two orders of magnitude by diagnostic method: 0.7% for only histology, 7% for only MRI, and 41% for visualized disease. Endometriosis staging was skewed toward minimal (58%) and mild disease (15%). The incidence of MRI-diagnosed endometriosis was 11% in the population cohort.

CONCLUSION(S)

Endometriosis incidence is dependent on the diagnostic method and choice of sampling framework. Conservatively, 11% of women have undiagnosed endometriosis at the population level, with implications for the design and interpretation of etiologic research.

Coital Retrograde Menstruation as a Risk Factor for Pelvic Endometriosis

To investigate coitus during menstruation as a possible predisposing factor for endometriosis 78 patients were asked about their coital habitus during menstruation and subsequently were examined by ultrasound transabdominally, transvaginally or both, before laparoscopy or surgery. MR! was used in six patients only. There was a statistically significant relationship between endometriosis and coital practice during menstruation. The incidence of endometriosis in patients with history of coitus in menses was 66% while the incidence was 34 % in patients with no such history. It is concluded that coitus during menses could be a predisposing factor for endometriosis.

The expression of human leukocyte antigens class I and II in women with endometriosis or adenomyosis

OBJECTIVES

The human leukocyte antigen (HLA) system has been implicated in the aetiology of endometriosis. We aimed to compare the HLA class I and II expression in endometrial specimens from women with endometriosis or adenomyosis.

METHODS

We studied the HLA class I and II expression in endometrial specimens from 16 women with endometriosis and 15 with adenomyosis which were compared with 15 specimens from women without endometriosis or adenomyosis. Immunohistochemistry was performed using mouse antihuman IgG2a monoclonal antibody for HLA I and IgG1 for HLA II.

RESULTS

Women with endometriosis had significantly higher HLA I and II expression in stroma (100% and 87.5% vs. 66.7% and 40%, p < 0.02 and p = 0.007, respectively) and glands (87.5% and 56.3% vs. 46.7% and 20%, p < 0.02 and p = 0.04, respectively) compared to controls, while in the adenomyosis group the expression of HLA I was comparable with controls and the HLA II expression was increased in stromal cells (73.3% vs. 40%, p = 0.03) and decreased in glands (6.6% vs. 20%, p = NS).

CONCLUSION

Women with endometriosis had a significantly higher expression of HLA molecules whereas in adenomyosis there was a tendency of lower expression of these molecules. This could explain the suppression of cellular immunity in the peritoneal cavity.

Acute appendicitis caused by endometriosis: a case report

Introduction

Endometriosis is a well-recognized gynecological condition in the reproductive age group. Surgical texts present the gynecological aspects of the disease in detail, but the published literature on unexpected manifestations, such as appendiceal disease, is inadequate. The presentation to general surgeons may be atypical and pose diagnostic difficulty. Thus, a definitive diagnosis is likely to be established only by the histological examination of a specimen.

Case presentation

We report a case of endometriosis of the appendix in a 25-year-old Caucasian woman who presented with symptoms of acute appendicitis and was treated by appendectomy, which resulted in a good outcome.

Conclusions

We discuss special aspects of acute appendicitis caused by endometriosis to elucidate the pathologic entity of this variant of acute appendicitis.

Deep rectosigmoid endometriosis: "mushroom cap" sign on T2-weighted MR imaging

PURPOSE

The purpose of this study is to evaluate the "mushroom cap" sign on T2-weighted MR imaging in patients with submucosal tumors in the rectosigmoid colon.

METHODS

From January 2001 to August 2009, 12 patients with four different diseases presenting or mimicking submucosal tumors in the rectosigmoid colon underwent colonic resection. All patients with deep endometriosis (n = 6), gastrointestinal stromal tumor (n = 4), metastasis from ovary cancer (n = 1), and carcinoid tumor (n = 1) had either an MRI of the rectum or pelvis before surgery. We evaluated the MRI findings and compared them with the macroscopic and microscopic observations in the resected specimens.

RESULTS

In all six cases of deep endometriosis, a characteristic "mushroom cap" shaped appearance was found on T2-weighted MR imaging. Heterogeneous low signal intensity of the hypertrophic muscularis propria, covered with high signal intensity of the mucosa and submucosa on T2-weighted MR images, looked like a "mushroom cap" with the pattern of intraluminal endophytic growth. In histological findings, deep endometriosis involved the submucosa (n = 4) or mucosa (n = 2). The "mushroom cap" sign was not present in any of the six other tumors.

CONCLUSION

The "mushroom cap" sign on T2-weighted MR imaging may be a characteristic sign for diagnosing deep rectosigmoid endometriosis.

T helper (Th)1, Th2, and Th17 interleukin pathways in infertile patients with minimal/mild endometriosis

In the present study, interleukin (IL)-10, IL-12, IL-17, and IL-23 levels were measured in serum and peritoneal fluid of women with minimal or mild endometriosis and compared with levels in controls without endometriosis. Higher IL-23 levels were encountered in the peritoneal fluid of women with endometriosis, suggesting a possible role of this cytokine in these women's infertility.

Immunohistochemical study of the ubiquitin-nuclear factor-kB pathway in the endometrium of the baboon (Papio anubis) with and without endometriosis

The aim of the present study was to conduct a semiquantitative immunohistochemical investigation into the levels of intermediary proteins within the nuclear factor (NF)-kappaB pathway throughout the menstrual cycle in a non-human primate, namely the baboon (Papio anubis), with and without endometriosis. Formalin-fixed eutopic (n = 2-4) and ectopic (n = 6-7) endometrial tissues from baboons at the mid-luteal phase were embedded in paraffin and examined for NF-kappaB pathway components (i.e. IkappaB kinase (IKK) alpha, IKKbeta, phosphorylated (phospho-) IkappaBalpha and phospho-NF-kappaB p65 subunit), ubiquitin, 19S proteasome and the NF-kappaB activator tumour necrosis factor (TNF)-alpha. Similarly, endometrial tissues from baboons at the late follicular, mid-luteal and menses phase (n = 2-4) were investigated to determine the levels of these proteins throughout the menstrual cycle. Cytoplasmic stromal IKKalpha and glandular 19S proteasome immunostaining was elevated in the ectopic endometrium, whereas levels of ubiquitin, phospho-p65, IKKbeta, TNF-alpha and nuclear 19S proteasome were similar in the eutopic and ectopic endometrium. A significant decrease in phospho-IkappaBalpha nuclear immunostaining was observed within glandular cells of the ectopic endometrium. In the eutopic endometrium, IKKalpha, ubiquitin and 19S proteasome immunostaining was elevated in different phases of the menstrual cycle, whereas levels of phospho-p65, IKKbeta, phospho-IkappaBalpha and TNF-alpha remained unchanged. We have demonstrated that, in the baboon endometriosis model, levels of IKKalpha immunostaining are elevated, whereas those of phospho-IkappaBalpha are reduced, consistent with the hypothesis that excessive NF-kappaB activity plays a role in reducing ectopic endometrial apoptosis, which contributes to the pathophysiology of endometriosis. Further studies are required to confirm a causal association between elevated IKKalpha levels and reduced endometrial apoptosis.

The ovarian dysgenesis syndrome

New thinking has arisen about the origin of adult onset diseases stemming from a collective body of evidence commonly referred to as the developmental origins of health and disease. This conceptual paradigm posits that certain adult onset diseases arise during critical or sensitive windows of human development or even transgenerationally. The testicular dysgenesis hypothesis (TDS) postulates an in utero origin for adverse male reproductive outcomes, and is an excellent example of the early origins of the paradigm. Despite similarities in the development of the male and female reproductive tracks, noticeably absent is a collective body of evidence focusing on the plausibility of an early origin for gynecologic outcomes and later onset of adult diseases. Using the TDS paradigm, we synthesized the available literature relative to the ovarian dysgenesis syndrome (ODS), which we define as alterations in ovarian structure or function that may manifest as fecundity impairments, gynecologic disorders, gravid diseases or later onset adult diseases. We evaluated environmental exposures, particularly the role of endocrine disrupting chemicals, in relation to these outcomes, and found evidence (although fragmented) consistent with an in utero origin of gynecologic outcomes, which in turn is associated with later onset of adult diseases. The findings are interpreted within the ODS paradigm while delineating methodological challenges and future research opportunities designed to answer critical data gaps regarding the origin of fecundity, gravid health and chronic diseases affecting the female population.

Endometriosis as a prognostic factor for cancer survival

Studies have shown an increased risk of malignancies in women with endometriosis. Little is known about the impact of endometriosis on cancer survival. We investigated whether the survival after a diagnosis of a malignancy differs in women with a previously diagnosed endometriosis compared to other women. Women with a first time diagnosis of a malignancy in 1969-2005, were identified using the National Swedish Cancer Register (NSCR). By use of the National Swedish Patient Register (NSPR) we identified all women with a diagnosis of endometriosis during the same period and linked these patients with the data from the NSCR. The cohort comprised 4,278 women with endometriosis and a malignancy, and 41,831 randomly selected matched women without endometriosis. Cox regression was used for all calculations to obtain crude and adjusted cause specific mortality rates, measured as hazard ratios (HR) with 95% confidence intervals (CI). A total of 46,109 women entered the study. There was a statistically significant better survival for women with endometriosis for all malignancies combined (HR=0.92) and for breast cancer (HR=0.86) and ovarian cancer (HR=0.81) specifically. For breast cancer the survival enhancing effect in women with endometriosis decreased with increasing parity. There was poorer survival in malignant melanoma for women with endometriosis (HR=1.52). The survival in a malignancy is better in women with a previously diagnosed endometriosis compared to women without endometriosis especially for breast and ovarian cancers. The prognosis of malignant melanoma is poorer in women with endometriosis.

Deep pelvic endometriosis: MR imaging

OBJECTIVE

The purpose of the pictorial essay is to show the MR imaging (MRI) findings associated with deep pelvic endometriosis.

CONCLUSION

MRI is an excellent imaging modality for the evaluation of patients with deep pelvic endometriosis, showing high accuracy in the diagnosis and prediction of disease extent. Its multiplanar capabilities and superior soft tissue contrast are extremely useful in the detection of deeply infiltrating endometriotic implants, even in the setting of intense desmoplastic response that may result in complete obliteration of the posterior cul-de-sac and fixed retroversion of the uterus, which limits the scope of laparoscopy. The use of endovaginal and rectal contrast is helpful to better delineate the anatomy of interest and map out the extent of disease, contributing to more effective treatment planning.

Attachment to extracellular matrices is enhanced in human endometriotic stromal cells: a possible mechanism underlying the pathogenesis of endometriosis

OBJECTIVE

Endometriosis is characterized by the ectopic growth of endometrial tissue. One of the first steps to the spread of endometriosis in the peritoneal cavity is the attachment of endometriotic cells to peritoneal surfaces after they have been released into the peritoneal fluid from pre-existing endometriotic lesions. The increased adhesive and proliferative potential of endometriotic cells in response to specific extracellular matrix (ECM) components has been suggested to contribute to the pathogenesis of endometriosis.

STUDY DESIGN

Adhesive properties of endometriotic stromal cells (ECSC) and normal eutopic endometrial cells (NESC) to various extracellular matrix proteins were investigated by in vitro cell adhesion assays. The expression levels of integrins in these cells were also examined by Western blot analysis.

RESULTS

Both ECSC and NESC significantly adhered to collagen type I and collagen type IV. ECSC revealed higher adhesive properties to these ECM proteins than NESC did. ECSC, but not NESC, adhered to fibronectin and laminin. Higher levels integrin of α1, α2, αv, β1, and β3 protein expression were observed in ECSC than in NESC. On the other hand, the levels of integrin α3 and αL proteins were lower in ECSC than in NESC.

CONCLUSIONS

The results suggest that endometriotic cells possess stronger adhesion to ECM proteins, and that increase may be mediated, in part, through integrins. These findings may elucidate one of the mechanisms underlying the formation of peritoneal endometriotic lesions.

Variation in hyaluronan-binding protein 2 (HABP2) promoter region is associated with unexplained female infertility

We set up to analyze polymorphisms in hyaluronan-binding protein 2 (HABP2) gene in healthy fertile women (n = 158) and in women with unexplained infertility (n = 116) and to investigate the potential role of HABP2 in receptive endometrium. Minor rs1157916 A and the major rs2240879 A alleles together with AA genotypes were significantly less frequent in infertile women than in controls. Immunohistochemistry analysis of endometrial HABP2 expression at the time of implantation identified significantly lower HABP2 protein level in infertile women in stroma and vessels than in fertile women. Migration assay analysis of cultured trophoblast and endothelial cells toward HABP2 protein referred to the function of HABP2 in endometrial endothelial cells. In conclusion, our results indicate that polymorphisms in the regulatory region of HABP2 gene could influence gene expression levels in the receptive endometrium and could thereby be one reason for infertility complications in women with unexplained infertility. Additionally, HABP2 protein involvement in endometrial angiogenesis is proposed.

Endometriosis of the appendix: Report of three cases

Endometriosis of the appendix is an entity of extragonadal endometriosis. It commonly affects women in the childbearing age with a wide spectrum of clinical manifestations. Women can present with symptoms mimicking acute appendicitis or chronic pelvic pain. The surgical management varies from simple appendectomy to right hemicolectomy depending on the clinical findings. We report 3 cases of endometriosis of the appendix presenting with appendiceal intussusception. The surgical literature is reviewed and current surgical management is discussed.

Endometriosis-associated infertility: a decade's trend study of women from the Estrie region of Quebec, Canada

Endometriosis (ENDO) has been believed to increase during the last years, but recent data supporting this trend are lacking. The aim of this study was to verify whether the incidence of ENDO, infertility (INF) and the both increased during the last 10 years among women living in the Estrie region of Quebec. This retrospective cross-sectional study was realised using data from the CIRESS (Centre Informatisé de Recherche Evaluative en Services et Soins de Santé) system, the database of the CHUS (Centre Hospitalier Universitaire de Sherbrooke), Sherbrooke, Canada. Among the 6845 studied patients, 2564 had ENDO, 4537 were infertile and 256 suffered from both. According to the last 10 years, a significant increase in the number of cases with ENDO (r2 = 0.717, p = 0.001) and endometriosis-associated infertility (r2 = 0.601, p = 0.003) was noted, while INF remained stable (r2 = 2813 e-005, p = 0.987). We showed a prevalence of ENDO of 10.91%. Women with ENDO were at increased risk for being infertile (OR = 2.30; 95% CI = 2.014-2.626, p <0.0001). An increase of ENDO in women 18-24 years of age has been shown (r2 = 0.418, p = 0.023), suggesting an earlier onset of the disease.

Concentrations of receptor for advanced glycation end products, VEGF and CML in plasma, follicular fluid, and peritoneal fluid in women with and without endometriosis

The etiology and pathogenesis of endometriosis is largely unknown. It has been reported that advanced glycation end products-receptor for advanced glycation end products regulation relates to oxidative stress, inflammatory reaction, apoptosis, and angiogenesis through vascular endothelial growth factor activation. The purpose of this study was to examine whether advanced glycation end products-receptor for advanced glycation end products regulation contributes to the pathogenesis of endometriosis. Plasma, follicular, and peritoneal fluid samples were collected from women with or without endometriosis, and soluble receptor for advanced glycation end products, vascular endothelial growth factor and carboxymethyl lysine levels were measured by enzyme-linked immunosorbent assay. Vascular endothelial growth factor and soluble receptor for advanced glycation end products concentrations were similar in plasma; however, their concentrations in follicular fluid were significantly increased in endometriosis patients (soluble receptor for advanced glycation end products was 132 + 31 pg/mg of protein vs. 105 + 27 pg/mg; vascular endothelial growth factor was 70 + 3 pg/mg vs. 49 + 18 pg/mg, expressed as the mean + standard deviation). Increased soluble receptor for advanced glycation end products and vascular endothelial growth factor levels in a local environment suggest that the advanced glycation end products-receptor for advanced glycation end products may contribute to the pathogenesis of endometriosis.

Pelvic endometriosis diagnosed in an entire nation over 20 years

The annual incidence of pelvic endometriosis among women aged 15-49 years and up to age 69 years was ascertained for the Icelandic population between 1981 and 2000 by using Iceland's extensive record linkage systems. Comprehensive, state-financed health care and unique personal identification numbers enabled care to be tracked from first diagnosis. To identify cases, a centralized discharge-code registry was searched, as well as all hospital databases and, for individual patients, all hospital records. Each case of visually diagnosed and histologically verified endometriosis was cross-checked against the nationwide pathology registry. The revised American Society for Reproductive Medicine classification system was used for staging. Recorded was type of operation at diagnosis and presence of disease at 5 sites: deep pelvis, appendages, central pelvis, vesicouterine pouch, and ovaries. A total of 1,383 women were diagnosed surgically, with histologic verification of 811 (58.6%). All but 6 cases could be staged; 297 (36.9%) had minimal/mild and 508 (63.1%) had moderate/severe disease. The estimates of crude annual incidence were 0.1% for visually confirmed and 0.06% for histologically verified endometriosis, and respective age-standardized annual incidence was 0.1% and 0.05% for women aged 15-49 years. The most common site was the ovary, followed by deep pelvis, central pelvis, appendages, and vesicouterine pouch.