CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate

Consideration should be given to smoking, endometriosis, renal function (eGFR) and age when interpreting CA125 and HE4 in ovarian tumor diagnostics

OBJECTIVES

To evaluate the impact of different biologic, histopathologic and lifestyle factors on serum levels of human epididymis protein 4 (HE4) and Cancer antigen 125 (CA125) in the diagnostic work up of women with an ovarian cyst or pelvic tumor.

METHODS

The statistical evaluation was performed on a population of 445 women diagnosed with a benign ovarian disease, included in a large Swedish multicenter trial (ClinicalTrials.gov NCT03193671). Multivariable logistic regression analyses were performed to distinguish between the true negatives and false positives through adjusting for biologic, histopathologic and lifestyle factors on serum samples of CA125 and HE4 separately. The likelihood ratio test was used to determine statistical significance and Benjamini-Hochberg correction to adjust for multiple testing.

RESULTS

A total of 31% of the women had false positive CA125 but only 9% had false positive results of HE4. Smoking (OR 6.62 95% CI 2.93-15.12) and impaired renal function, measured by eGFR (OR 0.18 95% CI 0.08-0.39), were independently predictive of falsely elevated serum levels of HE4. Endometriosis was the only variable predictive of falsely elevated serum levels of CA125 (OR 7.96 95% CI 4.53-14.39). Age correlated with increased serum levels of HE4.

CONCLUSIONS

Smoking, renal failure, age and endometriosis are factors that independently should be considered when assessing serum levels of HE4 and CA125 in women with an ovarian cyst or pelvic mass to avoid false indications of malignant disease.

Comparison of clear cell carcinoma and benign endometriosis in episiotomy scar - two cases report and literature review

BACKGROUND

Malignant endometriosis in an episiotomy scar is rare; only seven cases have been reported previously. Here, we compare two cases of benign endometriosis and clear cell carcinoma.

CASE PRESENTATION

The first case was a 54-year-old woman who presented with a large perineal lesion in her episiotomy scar with high 18F-fluorodeoxyglucose uptake. This location had a history of endometriosis many years ago. She underwent radical excision of the mass and bilateral inguinal lymph node dissection. Histological and immunohistochemical analysis confirmed the presence of clear cell carcinoma arising from endometriosis. Assisted radiotherapy was performed after surgery due to a positive lymph node. No recurrence was detected over a 1-year follow-up period. The second case deals with a 3 × 2 cm mass in the episiotomy scar of a 33-year-old woman. Part of the anal sphincter was resected because of the close proximity of the lesion. Because the disease lay very close to the anus, she received anal sphincter reconstruction combined with mass excision. Pathology result showed typical endometrial glands and interstitial tissues.

CONCLUSIONS

Deleterious change only happens in patients experiencing perineal endometriosis. Complete excision is crucial for this form of disease; sometimes impairment of the anal sphincter is also necessary. Patients with malignancy required a combination of treatments in order to improve their prognosis.

In Estimated Good Prognosis Patients Could Unexpected "Hyporesponse" to Controlled Ovarian Stimulation be Related to Genetic Polymorphisms of FSH Receptor?

It has been reported that 10% to 15% of young normogonadotrophic women show suboptimal response to standard gonadotropin-releasing hormone-a long protocol. These patients require higher doses of exogenous follicle-stimulating hormone (FSH). This phenomenon could be associated with genetic characteristics. In this study, FSH receptor polymorphism was retrospectively evaluated in 42 normoresponder young women undergoing an in vitro fertilization/intracytoplasmic sperm injection cycle; patients were stratified according to recombinant human FSH (r-hFSH) consumption. We selected 17 normoresponder young patients who required a cumulative dose of recombinant FSH (rFSH) >2500 UI (group A). A control group was randomly selected among patients who required a cumulative dose of rFSH <2500 UI (group B). Follicle-stimulating hormone receptor (FSH-R) 307Ala and 680Ser variants were analyzed in all our patients. Our results show that the mean number of rFSH vials (36.3 ± 7.5 vs 28.6 ± 4.5, P = .0001) and days of stimulation (12.7 ± 2.4 vs 10.8 ± 2.8, P = .03) were significantly lower in group B, whereas the number of oocytes retrieved (7.1 ± 1.5 vs 9.6 ± 2.4; P = .0005) and the average number of embryos transferred (2.1 ± 0.7 vs 2.7 ± 0.4; P = .001) were significantly lower in group A. Estradiol serum levels on the human chorionic gonadotrophin day were significantly lower in group A (997.8 ± 384.9 pg/mL vs 1749.1 ± 644.4; P = .0001). The incidence of the Ser/Ser genotype was higher in patients with higher r-hFSH consumption (group A; P = .02). Based on our results, we hypothesize an association between the FSH-R polymorphisms and a "hyporesponse" to exogenous FSH.

Clear cell carcinoma arising in previous episiotomy scar: a case report and review of the literature

Background

Malignant transformation of endometriosis associated with episiotomy scar is a rare event, especially histological type of clear cell adenocarcinoma. There are only three clear cell carcinoma in episiotomy scar reported, no standard treatment established.

Case presentation

A 36-year-old woman presented with a two-month history of painless but puritic perineal lump which she noticed was gradually enlarging. She had undergone surgical excision of a mass in the episiotomy scar 9 year ago and resequently histological type of endometriosis. Physical examination revealed a 10 × 5 cm soft, purple scar which is closely related to the apex of the episiotomy.We underwent a local excision of the mass for a biopsy . The second surgery performed after one cycle of paclitaxel and cisplatin (TP) to permit clearance of tumor while preserving normal vaginal function.Pathological result was clear cell adenocarcinoma. Two cycles of TP adjuvant chemotherapy were administrated after surgery.

Conclusions

We report a case of primary clear cell carcinoma developing within a previous episiotomy scar in a patient with a history of endometriosis, along with a review of the literature. Accumulation of management data on these rare tumors and Long-term follow-up of such patients is therefore important.

May Underdiagnosed Nutrition Imbalances Be Responsible for a Portion of So-Called Unexplained Infertility? From Diagnosis to Potential Treatment Options

The aim of the study was to investigate whether women affected by unexplained infertility may have undiagnosed dietary imbalances which negatively affect fertility. Secondarily, we investigated whether varying degrees of nutritional abnormalities may benefit from different periconceptional dietary supplementations, evaluating the most effective intervention in improving pregnancy rate after in vitro fertilization (IVF). We conducted a survey on 2 cohorts of patients (group A: unexplained infertility and group B: healthy first trimester spontaneous pregnancies) with the scope of investigating and comparing their dietary status discriminating women without dietary abnormalities (cohort 1) from those with abnormalities exclusively in micronutrient intake (cohort 2) or combined abnormalities in both micronutrient and macronutrient intake and associated obesity (cohort 3). All women included in group A were offered the opportunity to receive a prescription for one of the 3 designated daily dietary supplementation schemes (subgroups A1, A2, and A3) which were to be implemented in the 3 months immediately prior to beginning IVF treatment. When compared with fertile women, patients having unexplained infertility showed significant abnormalities in dietary habits. These differences ranged from a minimal imbalance in micronutrient intake (potentially avoidable with dietary supplementation) to severe combined macronutrient and micronutrient imbalance frequently associated with obesity (partially amendable by inositol supplementation and frequently requiring long-term dietary reeducation before establishment of fertility). Nutritional investigation and treatment may explain and resolve a portion of cases of unexplained infertility, improving the outcome of IVF treatment and, with minimal imbalances, likely restore spontaneous fertility.

Ovarian damage due to cyst removal: a comparison of endometriomas and dermoid cysts

INTRODUCTION

Surgical treatment of endometriomas and potential damage to the ovary have been debated. Studies have described the inconsistent risk of unintended removal of ovarian tissue when a cystectomy of an endometrioma is performed. We evaluated the risk of inadvertently removed ovarian tissue during surgery by comparing specimens of endometriomas and dermoid cysts removed laparoscopically.

MATERIAL AND METHODS

The material included 326 women in a retrospective cohort study at Rigshospitalet, University hospital in Copenhagen, Denmark from 2011 to 2013. Surgery was performed laparoscopically for 393 benign cysts with a diagnosis of either endometrioma (n = 294) or dermoid cyst (n = 99). The microscopic existence of ovarian tissue in the cystectomy specimens were compared and correlation between CA 125 and size of cysts was examined.

RESULTS

In total, 80.3% endometrioma cystectomies disclosed ovarian stroma compared with 17.2% of the resected dermoid cysts (p < 0.001). The difference was found despite skilled laparoscopic surgeons performing the procedure in the endometriosis cohort. A significant positive correlation between the size of endometriomas and the value of CA 125 was found (p < 0.009).

CONCLUSION

The risk of removal of ovarian tissue during laparoscopic surgery is significantly higher for endometriomas than for dermoid cysts.

Acute immunomodulatory changes during controlled ovarian stimulation: evidence from the first trial investigating the short-term effects of estradiol on biomarkers and B cells involved in autoimmunity

PURPOSE

The aim of the present study was to evaluate the in vivo immunomodulatory effects of an acute short-term estradiol (E(2)) increase on serum levels of B cell-activating factor (BAFF), immunoglobulins (Ig), anti-nuclear antibodies (ANA), and the peripheral B cell phenotype.

METHODS

We conducted, at the Infertility Center of the University of Padua, a prospective case-control study on a cohort of infertile normo-responder women (group-A, 63 patients) undergoing controlled ovarian stimulation (COS) compared with an age-matched cohort of normo-ovulatory healthy women (group-B, 39 patients). Three serial blood sample assays were conducted in both groups, at T0, hypothalamic suppression; T1, ovulation induction; and T2, βhCG test in group A, and at T0, 2nd day; T1, 14th day; and T2, 21st day of cycle in group B, and serum levels of E(2) and BAFF, BAFF/E(2) ratio, circulating IgM, IgG, and IgA, ANA titer, and peripheral B cell phenotype were measured. We compared group-A versus group-B in terms of absolute and E(2) normalized values of BAFF at baseline (T0) to verify for possible differences between healthy and infertile women, at T1 to verify for possible differences occurring after spontaneous ovulation versus COS, and at T2 to evaluate differences in serum BAFF levels between pregnant versus non-pregnant patients (considering only group-A) and between non-pregnant women after spontaneous versus COS cycles (group-B versus group-A). In group-A, we also evaluated IgM, IgG, IgA levels, ANA titer, and peripheral B cell phenotype at T0 versus T1 versus T2.

RESULTS

With the exception of E(2) levels at T1 (as expected), no significant differences were found between the two groups for all outcome measures. In group-A, BAFF at T0 positively correlated with IgM levels; marginal zone CD19+/CD27+/IgD+ memory B cell compartment tended to be expanded at T1 when compared with T0.

CONCLUSIONS

Despite several mechanistic and clinical studies supporting a stimulatory role of E(2) on autoimmunity, the acute increase of E(2) during COS for infertility treatment does not seem to have a major impact on the immune system.

Pretreatment with oral contraceptive pills to identify poor responders that may benefit from rLH supplementation during GnRH-antagonist treatment for IVF: A pilot perspective study proposal

Controlled ovarian stimulation, using a gonadotrophin-releasing hormone (GnRH) antagonist protocol, is a potential treatment option for women with a low response to other fertility treatments as it appears to be at least as effective as GnRH agonists (long protocol). However, previous studies have indicated that the administration of GnRH antagonist may cause an excessive reduction in endogenous luteinizing hormone (LH) levels. The use of recombinant LH (rLH) supplementation during ovarian stimulation is controversial. The present article proposes a future study focused on women aged ≥40 years old, with the aim of identifying patients who are poor responders to GnRH-antagonist treatment that may benefit from rLH supplementation. We hypothesize that patients with suppressed hypothalamic-pituitary-axis activity may benefit from rLH supplementation, as GnRH-antagonist administration has the potential to induce a marked reduction in LH levels in such patients compared with that in patients that exhibit a regular recovery following the administration of oral contraceptive pills (OCPs). Furthermore, patients with hyper-responsive hypothalamic-pituitary-axis activity may be affected by ‘low-gonadotropin-responsiveness’, similar to that observed in patients with any mutation in the follicle-stimulating hormone (FSH) receptor, who are known to benefit from rLH supplementation. The proposed pilot study would include 120 women who are predicted to be poor responders to GnRH-antagonist treatment. All subjects will be allocated at random (using 2:1 computerized randomization) into two study groups: Group A (OCP-treated) and group B (control). For all patients, the serum values of FSH, LH and 17β estradiol (E2) will be detected on day 3 of the menstrual cycle preceding OCP treatment (baseline) and at day 4 following OCP treatment. The Δ-variation from baseline levels for all markers, the FSH/LH ratio and the E2/FSH ratio will be determined. Δ-variation from the baseline of the FSH and LH values will be used to further categorize group A patients into subgroups A1–4, based on respective quartile numbers (Q1–4). Patients admitted to each of the four subgroups A1–4, based on their FSH quartile, will be selected at random to receive rLH supplementation (ratio, 1:1) during ovarian stimulation. If the resulting data are able to identify women that may benefit from rLH supplementation during ovarian stimulation, a large part of inconclusive evidence regarding rLH supplementation will be clarified. If patients supplemented with rLH (according to abnormal recovery of hypothalamic-pituitary-axis activity after OCP treatment) exhibit an improved ovarian response during in vitro fertilization (IVF) and subsequent pregnancy rate, the pre-IVF OCP test could be adopted as a useful tool for improving the success rate of assisted reproductive technologies in poorly-responding patients.

Recombinant LH supplementation during IVF cycles with a GnRH-antagonist in estimated poor responders: A cross-matched pilot investigation of the optimal daily dose and timing

Although it is widely accepted that patients, who are considered poor responders to in vitro fertilization (IVF) benefit from recombinant luteinizing hormone (rLH) supplementation during an in vitro fertilization cycle, particularly when gonadotropin‑releasing hormone (GnRH)‑antagonist (ant) treatment is used the optimal administration timing and daily dose of rLH remains to be elucidated. The aim of the present study was to investigate the optimal timing of rLH‑supplementation to improve ovarian response, embryo quality, endometrial thickness and pregnancy rate in infertile, estimated poor responders to IVF, undergoing GnRH‑ant treatment. In addition, the present study aimed to evaluate the optimal daily dose to achieve the same outcomes. A prospective‑randomized‑cross‑matched investigation was performed on 40 patients undergoing a GnRH‑ant‑treatment‑cycle The patients were randomly assigned to either group A (rLH‑75 IU/day) or group B (rLH‑150 IU/day) and further randomized into subgroup A1/B1, in which rLH was administered at recombinant follicle stimulating hormone (rFSH) administration, and subgroup A2/B2, in which rLH was administered at GnRH‑ant administration. Patients who did not become pregnant during the first cycle (35 patients), were treated a second time, cross‑matched for groups and subgroups. Improved ovarian response, embryo quality and pregnancy rate were achieved by administering rLH at 150 IU/day, starting from GnRH‑ant administration, independently from the total rLH dose administered. Improved endometrial thickness at oocyte retrieval day was achieved by administering rLH at 150 IU from the start of rFSH administration. These data led to the hypothesis that ovarian responses are affected by the timing of administration more than the total‑dose of rLH. The optimal window to administer rLH appears to be the mid‑to‑late follicular phase, despite the fact that rLH‑supplementation in the early‑follicular phase appeared to increase endometrial thickness and to enhance its morphology. Standardization of the optimal daily dose and supplementation timing of rLH may resolve the debate regarding its efficacy in increasing the number of pregnancies and neonatal survival rates.

The Impact of Endometriosis across the Lifespan of Women: Foreseeable Research and Therapeutic Prospects

In addition to estrogen dependence, endometriosis is characterized by chronic pelvic inflammation. The impact of the chronic pelvic inflammatory state on other organ systems and women's health is unclear. Endometriosis associated chronic inflammation and potential adverse health effects across the lifespan render it imperative for renewed research vigor into the identification of novel biomarkers of disease and therapeutic options. Herein we propose a number of opportunities for research and development of new therapeutics to address the unmet needs in the treatment of endometriosis per se and its ancillary risks for other diseases in women across the lifespan.

Statins as Targeted "Magical Pills" for the Conservative Treatment of Endometriosis: May Potential Adverse Effects on Female Fertility Represent the "Dark Side of the Same Coin"? A Systematic Review of Literature

The aim of the study was to analyze all the available evidence from both in vitro and in vivo studies regarding the efficacy of statin therapy in the treatment of endometriosis, evaluating the potential efficacy, side effects, and contraindications of their administration in humans. We focused on defining the potential benefits that the administration of statins may have on patients affected by endometriosis and the possible adverse effects of such a therapy on ovarian function and fertility profile. According to our article selection criteria, we included in the review in vitro and in vivo studies performed on human or animal models. The systematic review of literature identified 24 eligible articles, 12 of which reported evidence regarding the effects of statins on endometrial/endometriotic cells and 12 regarding their effects on ovarian function and fertility. All articles seem to emphasize the utility of statin administration in the treatment of endometriosis due to their anti-proliferative/proapoptotic effects, their ability to reduce cell viability and migration, and the inhibition of angiogenesis and anti-inflammatory activities. Regarding the potential adverse effects on gonadal activities, steroidogenesis and fertility function, no conclusive data were collected in human models (excluding women affected by polycystic ovary syndrome in which significant decline of androgen levels was reported after statin treatment), while contrasting results were reported by studies conducted in in vitro and in vivo in animal models. Despite evidence supporting statins as the potential therapeutic agent for a targeted conservative treatment of endometriosis, the uncertainties regarding their impact on gonadal function may not define them as an appropriate therapy for all young fertile women.

Menstrual cycle length: a surrogate measure of reproductive health capable of improving the accuracy of biochemical/sonographical ovarian reserve test in estimating the reproductive chances of women referred to ART

BACKGROUND

Aim of the study was to investigate whether menstrual cycle length may be considered as a surrogate measure of reproductive health, improving the accuracy of biochemical/sonographical ovarian reserve test in estimating the reproductive chances of women referred to ART.

METHODS

A retrospective-observational-study in Padua' public tertiary level Centre was conducted. A total of 455 normo-ovulatory infertile women scheduled for their first fresh non-donor IVF/ICSI treatment. The mean menstrual cycle length (MCL) during the preceding 6 months was calculated by physicians on the basis of information contained in our electronic database (first day of menstrual cycle collected every month by telephonic communication by single patients). We evaluated the relations between MCL, ovarian response to stimulation protocol, oocytes fertilization ratio, ovarian sensitivity index (OSI) and pregnancy rate in different cohorts of patients according to the class of age and the estimated ovarian reserve.

RESULTS

In women younger than 35 years, MCL over 31 days may be associated with an increased risk of OHSS and with a good OSI. In women older than 35 years, and particularly than 40 years, MCL shortening may be considered as a marker of ovarian aging and may be associated with poor ovarian response, low OSI and reduced fertilization rate. When AMH serum value is lower than 1.1 ng/ml in patients older than 40 years, MCL may help Clinicians discriminate real from expected poor responders. Considering the pool of normoresponders, MCL was not correlated with pregnancy rate while a positive association was found with patients' age.

CONCLUSIONS

MCL diary is more predictive than chronological age in estimating ovarian biological age and response to COH and it is more predictive than AMH in discriminating expected from real poor responders. In women older than 35 years MCL shortening may be considered as a marker of ovarian aging while chronological age remains most accurate parameter in predicting pregnancy.

Borderline ovarian tumors and diagnostic dilemma of intraoperative diagnosis: could preoperative He4 assay and ROMA score assessment increase the frozen section accuracy? A multicenter case-control study

The aim of our study was to assess the value of a preoperative He4-serum-assay and ROMA-score assessment in improving the accuracy of frozen section histology in the diagnosis of borderline ovarian tumors (BOT). 113 women presenting with a unilateral ovarian mass diagnosed as serous/mucinous BOT at frozen-section-histology (FS) and/or confirmed on final pathology were recruited. Pathologists were informed of the results of preoperative clinical/instrumental assessment of all patients. For Group_A patients, additional information regarding He4, CA125, and ROMA score was available (in Group_B only CA125 was known). The comparison between Group A and Group B in terms of FS accuracy, demonstrated a consensual diagnosis in 62.8% versus 58.6% (P: n.s.), underdiagnosis in 25.6% versus 41.4% (P < 0.05), and overdiagnosis in 11.6% versus 0% (P < 0.01). Low FS diagnostic accuracy was associated with menopausal status (OR: 2.13), laparoscopic approach (OR: 2.18), mucinous histotype (OR: 2.23), low grading (OR: 1.30), and FIGO stage I (OR: 2.53). Ultrasound detection of papillae (OR: 0.29), septa (OR: 0.39), atypical vascularization (OR: 0.34), serum He4 assay (OR: 0.39), and ROMA score assessment (OR: 0.44) decreased the probability of underdiagnosis. A combined preoperative assessment through serum markers and ultrasonographic features may potentially reduce the risk of underdiagnosis of BOTs on FS while likely increasing the concomitant incidence of false-positive events.

Total Laparoscopic Hysterectomy: Overtreatment for Misdiagnosed Organic cause or Undertreatment for Idiopathic Chronic Pelvic Pain?

Background

Chronic pelvic pain (CPP) is considered a symptom but also a syndrome with misunderstood pathophysiology and treatment options ranging from conservative management to opioid analgesia and surgical intervention. The aim of this study was to evaluate the role of gynecological surgery in modifying presurgical pain status and reducing the postoperative analgesic use of patients suffering CPP. The second aim of the study was to analyze intraoperative and histological differences in patients who benefited from surgery versus those without benefit.

Methods

An observational study was conducted in 16 fertile women affected by CPP, treated by total laparoscopic hysterectomy (TLH) to solve their pelvic pain. In 7 cases, undetected pelvic endometriosis was found.

Results

A complete resolution of pre-operative pain symptoms (score 0) occurred in 9 patients (56.2%), an occasional pelvic discomfort (score 1) in 2 cases (12.5%), 2 patients reported minimal benefit of pelvic pain (score 2), while in 3 cases, severe pain persisted (score 3). The correlation between intraoperative/histological features and reported symptoms after surgery showed that 7 of 9 patients (77.7%) who benefited from surgery were affected by an organic cause; while 5 women with minimal or no benefits from the surgery did not have any organic disease (idiopathic CPP).

Conclusions

If conservative treatment fails to treat CPP, investigative laparoscopy represents a necessary step to discriminate patients with misdiagnosed organic from idiopathic CPP, selecting those who will potentially benefit from hysterectomy. The role of concomitant appendectomy needs to be defined in surgical treatment of idiopathic CPP.

Expression of the transmembrane mucins, MUC1, MUC4 and MUC16, in normal endometrium and in endometriosis

STUDY QUESTION

Are the transmembrane mucins, MUC1, MUC4 and MUC16, differentially expressed in endometriosis compared with normal endometrium?

SUMMARY ANSWER

This study revealed that transmembrane mucin expression does not vary significantly in normal endometrium during the menstrual cycle and is not altered in endometriosis relative to the epithelial marker, cytokeratin-18 (KRT18).

WHAT IS KNOWN ALREADY

Increased serum levels of the transmembrane mucin fragments MUC1, MUC4 and MUC16 that normally dominate the apical surface of simple epithelia are found in several pathological conditions, including endometriosis. Altered mucin expression in gynecologic diseases may promote infertility or endometrial pathologies.

STUDY DESIGN, SIZE, DURATION

This was a laboratory-based study of samples from 12 endometriosis patients as well as non-endometriosis control samples obtained from 31 patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Total RNA was isolated from endometrial biopsies of ectopic and eutopic endometrium from women with endometriosis and control patients from different stages of the menstrual cycle. Quantitative (q)-RT-PCR analyses were performed for the mucins, MUC1, MUC4 and MUC16, relative to the epithelial marker, cytokeratin-18 (KRT18), or β-actin (ACTB). Frozen sections from endometrial biopsies of proliferative and mid-secretory stage women with endometriosis were immunostained for MUC1, MUC4 and MUC16.

MAIN RESULTS AND THE ROLE OF CHANCE

qRT-PCR analyses of MUC1 and MUC16 mRNA revealed that these mucins do not vary significantly during the menstrual cycle nor are they altered in women with endometriosis relative to the epithelial marker, KRT18. MUC4 mRNA is expressed at very low levels relative to MUC1 and MUC16 under all conditions. There was little difference in MUC1 and MUC16 expression between eutopic endometrial and ectopic endometriotic tissues. MUC4 expression also was not significantly higher in the ectopic endometriotic tissues. Immunostaining for all three mucins reveals robust expression of MUC1 and MUC16 at the apical surfaces of endometrial epithelia, but little to no staining for MUC4.

LIMITATIONS, REASONS FOR CAUTION

qRT-PCR analysis was the main method used for mucin detection. Additional studies with stage III-IV endometriotic tissue would be useful to determine if changes in MUC1 and MUC16 expression occur, or if MUC4 expression increases, at later stages of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

We report a comprehensive comparative profile of the major transmembrane mucins, MUC1, MUC4 and MUC16, relative to the epithelial marker, KRT18, in normal cycling endometrium and in endometriosis, and indicate constitutive expression. Previous studies have profiled the expression of individual mucins relative to β-actin and indicate accumulation in the luteal phase. Thus, these differences in interpretation appear to reflect the increased epithelial content of endometrium during the luteal phase.

STUDY FUNDING

This study was supported by: NIH R01HD29963 to D.D.C.; NIH U54HD007495 to S.M.H.; and NIH R01HD067721 to S.L.Y. and B.A.L. The authors have no competing interests to declare.

A rare case of sigmoid colon obstruction in patient with ulcerative colitis: role of transabdominal ultrasound-guided biopsy

INTRODUCTION

Endometriosis is a common chronic gynaecological disease affecting 10 % of women of reproductive age. Of these 5-12 % may present bowel endometriosis that may be asymptomatic or associated with aspecific symptoms even bowel obstruction.

CASE PRESENTATION

The case of a 41-year-old woman with history of ulcerative colitis, previous diagnosis of ovarian endometriosis, recurrent abdominal pain not related to the menstrual cycle, with abdominal pain and obstinate constipation for 2 weeks was referred. The patient underwent colonoscopy, transabdominal ultrasound and ultrasound-guided fine-needle biopsy to have a diagnosis.

DISCUSSION

Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with gastrointestinal or abdominal symptoms. As demonstrated in our case and by the burgeoning literature in this field, we believe that the role of transabdominal ultrasound should be reconsidered in the management of abdominal diseases because this examination associated with ultrasound-guided fine-needle biopsy allows, in expert hands, to obtain adequate histological samples avoiding patients to undergo more invasive tests to get a diagnosis.

Which luteal phase support is better for each IVF stimulation protocol to achieve the highest pregnancy rate? A superiority randomized clinical trial

In vitro fertilization (IVF) cycles generate abnormalities in luteal-phase sex steroid concentrations and this represent an important limiting factor to achieve a good pregnancy rate. Although there are evidences about the usefulness of luteal phase support (LPS) after IVF cycles, no consensus exist about the best dose and way of progesterone (PG) administration, the advantages of estradiol (E2) supplementation and which IVF protocol could benefit from one more than other LPS scheme. Aim of the study was to assess the best LPS (low-dose PG, high-dose PG, high-dose PG and E2 supplementation) to achieve the highest clinical/ongoing pregnancy rate according to stimulation protocol, E2 at ovulation induction, endometrial thickness at pick-up and women's age. We conducted a randomized trial on 360 women undergoing IVF (180 treated by long-GnRH agonist, 90 by short-GnRH agonist and 90 by short-GnRH antagonist protocol) and stimulated by recombinant follicle-stimulating hormone alone. Our data demonstrated that high-dose PG is better than low-dose to increase both clinical and ongoing pregnancy rate. E2 supplementation are mandatory in case of short-GnRH antagonist protocol and strongly suggested in all protocols when E2max <5 nmol/l and endometrial thickness <10 mm. In long-GnRH agonist protocols, as well as in patients >35 years, the real advantages of E2 supplementation remain debatable and require further confirmation.

A metabonomics approach as a means for identification of potential biomarkers for early diagnosis of endometriosis

Our present study focuses on the identification of predictive biomarkers in serum for the early diagnosis of endometriosis in a minimally invasive manner using (1)H-NMR based metabonomics. PLS-DA modeling of bins obtained from CPMG spectra of serum samples discriminated endometriosis patients from controls with sensitivity and specificity levels of about 80% and 90%, respectively. Compared with those from controls, serum samples from endometriosis patients showed increased levels of lactate, 3-hydroxybutyrate, alanine, leucine, valine, threonine, lysine, glycerophosphatidylcholine, succinic acid and 2-hydroxybutyrate as well as decreased levels of lipids, glucose, isoleucine and arginine. Our work offers valuable information for non-invasive diagnosis of endometriosis and may be of potential benefit to understand pathogenesis of the disease.

Ultrasound criteria and CA 125 as predictive variables of ovarian cancer in women with adnexal tumors

OBJECTIVES

To evaluate the capacity to predict malignancy in women with adnexal tumors using CA 125 measurement and ultrasound criteria.

METHODS

This was a cross-sectional study including 103 women with a total of 110 adnexal tumors. CA 125 level was measured in a sample of peripheral blood. Lesions were classified by ultrasound, using standardized predetermined criteria, as benign (B) or malignant (M). Those that could not be classified by these criteria were assessed subjectively. Histopathologic examination of surgical specimens was used as the gold standard.

RESULTS

Of 110 tumors, 79 (71.8%) were benign and 31 (28.2%) were malignant on histopathology. Ultrasound criteria could be applied to 91 (82.7%) tumors, resulting in a sensitivity of 90%, specificity of 87%, positive predictive value (PPV) of 69% and negative predictive value (NPV) of 97%. In tumors not classifiable according to ultrasound criteria, subjective sonographic assessment gave a sensitivity of 67%, specificity of 80%, PPV of 75% and NPV of 73%. At a cut-off point of 37.4 U/mL, CA 125 had a sensitivity of 69%, a specificity of 87.8%, a PPV of 69% and a NPV of 88% for detection of malignancy. When CA 125 was associated with age and ultrasound criteria in a logistic regression model, the sensitivity and specificity increased in the subset of sonographically malignant tumors.

CONCLUSION

The majority of tumors were correctly classified using ultrasound criteria. CA 125 alone performed worse than did ultrasound in discriminating malignant from benign adnexal tumors. CA 125 measurement contributed to the diagnosis of malignancy, improving overall specificity, only in sonographically malignant tumors.

Extracts of Salvia miltiorrhiza Bunge on the cytokines of rat endometriosis models

Endometriosis is a common mysterious and fascinating gynaecological condition with diverse clinical manifestations, highly variable and unpredictable clinical course with decreased quality of life. Clinically, Salvia miltiorrhiza Bunge (SMB, Chinese Danshen) has been applied to treat endometriosis and get satisfactory results. The present study was aimed to explore the effects of the extracts of SMB (ESMB) on the serum levels of cancer antigen 125 (CA-125) and the levels of interleukin (IL)-13, IL-18 and tumor necrosis factor-alpha (TNF-alpha) in the peritoneal fluids of rat endometriosis models. Three extraction methods for SMB were compared, which are the sample extracted with conventional method, the sample extracted with espresso coffee machine and the commercial condensed powder of natural products. We determined tanshinone IIA, salvianolic acid B and danshensu in the ESMB of different extraction methods. Forty female Sprague-Dawley (SD) rats were randomly divided into ESMB group, Danazol (positive control) group, model group and the sham-operation group (Sham group). After all the treatment ended, the serum levels of CA125 and the levels of IL-13, IL-18 and TNF-alpha in the peritoneal fluids of rat endometriosis models were measured using enzyme-linked immune-sorbent assay (ELISA) as directed by the manufacturer. The extraction efficiency of the ESMB samples extracted with coffee machine ranged from 600µm to 710µm was the highest. The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly lower than those of the Model group (P<0.05). The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of Danazol group and ESMB group were significantly higher than those of Sham group, respectively (P<0.05), and no marked difference existed between them (P>0.05). The levels of IL-13 in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly higher than those of the Model group (P<0.05). The levels of IL-13 in the peritoneal fluids of ESMB group and Danazol group were significantly lower than those of Sham group (P<0.05), and there was no marked difference between ESMB group and Sham group (P>0.05). ESMB shows promises in treating endometriosis by markedly decreasing the serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids and significantly increasing the levels of IL-13 in the peritoneal fluids.

Serum HE4 levels are less frequently elevated than CA125 in women with benign gynecologic disorders

OBJECTIVE

The human epididymis protein 4 (HE4) is a novel biomarker for ovarian cancer. This study measured the HE4 and CA125 levels in women with benign gynecological disorders.

STUDY DESIGN

Sera were obtained from women prior to surgery for a pelvic mass and HE4 and CA125 levels were determined. The proportions of patients with elevated biomarker levels were compared.

RESULTS

There were 1042 women with benign disease. HE4 levels were less often elevated than CA125 (8% vs 29%, P < .001). A marked difference was observed in patients with endometriosis in which HE4 was elevated in 3% of patients and CA125 in 67% (P < .0001). Serous ovarian tumors were associated with elevated levels of HE4 in 8% of patients and CA125 in 20% (P = .0002); uterine fibroids in 8% vs 26% (P = .0083); dermoids in 1% vs 21% (P = .0004); and inflammatory disease in 10% vs 37% (P = .014).

CONCLUSION

HE4 is elevated less frequently than CA125 in benign disease, particularly in premenopausal patients.

Diagnostic value of serum activin A and follistatin levels in women with peritoneal, ovarian and deep infiltrating endometriosis

BACKGROUND

Activin A is a growth factor, produced by the endometrium, whose actions are modulated by the binding protein follistatin. Both proteins are detectable in the peripheral serum and their concentrations may be increased in women with endometriosis. The present study was designed to evaluate whether serum levels of activin A and follistatin are altered, and therefore have a potential diagnostic value, in women with peritoneal, ovarian and deep infiltrating endometriosis.

METHODS

We performed a multicenter controlled study evaluating simultaneously serum activin A and follistatin concentrations in women with and without endometriosis. Women with endometriosis (n = 139) were subdivided into three groups: peritoneal endometriosis (n = 28); ovarian endometrioma (n = 61) and deep infiltrating endometriosis (n = 50). The control group (n = 75) consisted of healthy women with regular menstrual cycles. Blood samples were collected from a peripheral vein and assayed for activin A and follistatin using commercially available enzyme immunoassay kits.

RESULTS

The ovarian endometrioma group had serum activin A levels significantly higher than healthy controls (0.22 ± 0.01 ng/ml versus 0.17 ± 0.01 ng/ml, P < 0.01). None of the endometriosis groups had serum follistatin levels which were significantly altered compared with healthy controls; however, levels found in the endometrioma group (2.34 ± 0.32 ng/ml) were higher than that in the deep endometriosis group (1.50 ± 0.17 ng/ml, P < 0.05). The area under the receiver operating characteristic curve of activin A was 0.700 (95% confidence interval: 0.605-0.794), while that of follistatin was 0.620 (95% confidence interval: 0.510-0.730) for the diagnosis of ovarian endometrioma. The combination of both markers into a duo marker index did not improve significantly their diagnostic accuracy.

CONCLUSIONS

The present study demonstrated that serum activin A and follistatin are not significantly altered in peritoneal or deep infiltrating endometriosis and have limited diagnostic accuracy in the diagnosis of ovarian endometrioma.