Endometriosis-associated Malignancy

MCP-1 exerts the inflammatory response via ILK activation during endometriosis pathogenesis

AIMS

MCP-1 has been shown to be elevated in endometriosis. ILK functions in several cellular events and interacts with MCP-1-signaling. In the current study, we evaluated the role of MCP-1-ILK signaling in human endometriotic cell's (Hs832(C).TCs) potential for colonization, invasion, adhesion, etc. and differentiation of macrophage along with inflammation in an endometriosis mouse model.

MATERIALS AND METHODS

A mouse model of endometriosis with elevated levels of MCP-1 was developed by injecting MCP-1. We examined the migration, adhesion, colonization and invasion of Hs832(C).TCs in response to MCP-1-ILK signaling. We also examined the differentiation of THP-1 cells to macrophage in response to MCP-1-ILK signaling.

KEY FINDINGS

We observed that MCP-1 increased Ser246 phosphorylation of ILK in Hs832(C).TCs and enhanced the migration, adhesion, colonization, and invasion of Hs832(C).TCs. In the mouse model of endometriosis, we found elevated chemokines (CCL-11, CCL-22 and CXCL13) levels. An increased level of MCP-1 mediated ILK activation, leading to increased inflammatory reaction and infiltration of residential and circulatory macrophages, and monocyte differentiation, but suppressed the anti-inflammatory reaction. The inhibitor (CPD22) of ILK reversed the MCP-1-mediated action by restoring Hs832(C).TCs and THP-1 phenotype. ILK inhibition in a mouse model of endometriosis reduced the effects of MCP-1 mediated pro-inflammatory cytokines, but increased anti-inflammatory response along with T-regulatory and T-helper cell restoration.

SIGNIFICANCE

Targeting ILK restores MCP-1 milieu in the peritoneal cavity and endometrial tissues, reduces the inflammatory response, improves the T-regulatory and T-helper cells in the endometriosis mouse model and decreases the migration, adhesion, colonization and invasion of endometriotic cells.

The PD-1/PD-L1 Gateway: Peripheral Immune Regulation in the Pathogenesis of Endometriosis

Endometriosis is a chronic inflammatory disease characterized by the presence of endometrial-like tissue outside the uterine cavity, causing pain and infertility. Despite the rather unclear etiopathogenesis, recent studies suggest the involvement of the immune system in the development and progression of endometriosis. The role of the PD-1/PD-L1 axis in the modulation of the immune response in this disease seems to be particularly interesting. This preliminary study aimed to investigate the expression of PD-1 and PD-L1 on T and B lymphocytes in peripheral blood in patients with endometriosis to assess their potential impact on disease progression. Our study involved peripheral blood samples from 80 patients diagnosed with endometriosis and 20 healthy women as a control group were analyzed. Flow cytometry was used to assess the expression of PD-1 and PD-L1 on T and B lymphocytes, and enzyme-linked immunosorbent assays were used to assess their soluble forms in serum and peritoneal fluid.in our research we observe significantly higher expression of PD-1 and PD-L1 on T and B lymphocytes was found in patients with endometriosis compared to the control group. Higher expression of both tested molecules correlated with the stage of endometriosis. The results of our preliminary studies indicate a potential role of the PD-1/PD-L1 axis in the modulation of the immune response in endometriosis. Modified expression of these proteins may contribute to immune evasion by ectopic tissues, supporting their survival and proliferation. These findings suggest that targeting PD-1/PD-L1 could be explored as a therapeutic option for the treatment of endometriosis, though further research with larger sample sizes is necessary to confirm these results and clarify the role of PD-1/PD-L1 in the pathogenesis of the disease.

The "Road" to Malignant Transformation from Endometriosis to Endometriosis-Associated Ovarian Cancers (EAOCs): An mTOR-Centred Review

Ovarian cancer is an umbrella term covering a number of distinct subtypes. Endometrioid and clear-cell ovarian carcinoma are endometriosis-associated ovarian cancers (EAOCs) frequently arising from ectopic endometrium in the ovary. The mechanistic target of rapamycin (mTOR) is a crucial regulator of cellular homeostasis and is dysregulated in both endometriosis and endometriosis-associated ovarian cancer, potentially favouring carcinogenesis across a spectrum from benign disease with cancer-like characteristics, through an atypical phase, to frank malignancy. In this review, we focus on mTOR dysregulation in endometriosis and EAOCs, investigating cancer driver gene mutations and their potential interaction with the mTOR pathway. Additionally, we explore the complex pathogenesis of transformation, considering environmental, hormonal, and epigenetic factors. We then discuss postmenopausal endometriosis pathogenesis and propensity for malignant transformation. Finally, we summarize the current advancements in mTOR-targeted therapeutics for endometriosis and EAOCs.

Rare Mullerian adenosarcoma of the uterine cervix arising on a background of endometriosis: A diagnostic challenge with risk of malignant transformation-A case report and review of the current literature

Endometriosis may contribute to Mullerian adenosarcoma development but makes diagnosis challenging given similar symptoms. Survival benefit has not been definitively shown for chemotherapy, hormonal therapy, or radiotherapy, consolidating surgery as the mainstay treatment. Local excision may be a treatment option for patients with confined tumors wishing to preserve their fertility.

Genetic Links between Endometriosis and Endometriosis-Associated Ovarian Cancer-A Narrative Review (Endometriosis-Associated Cancer)

Endometriosis is a frequent, estrogen-dependent, chronic disease, characterized by the presence of endometrial glands and stroma outside of the uterine cavity. Although it is not considered a precursor of cancer, endometriosis is associated with ovarian cancer. In this review, we summarized the evidence that clear-cell and endometrioid ovarian carcinomas (endometriosis-associated ovarian carcinoma-EAOC) may arise in endometriosis. The most frequent genomic alterations in these carcinomas are mutations in the AT-rich interaction domain containing protein 1A (ARID1A) gene, a subunit of the SWI/SNF chromatin remodeling complex, and alterations in phosphatidylinositol 3-kinase (PI3K) which frequently coexist. Recent studies have also suggested the simultaneous role of the PTEN tumor-suppressor gene in the early malignant transformation of endometriosis and the contribution of deficient MMR (mismatch repair) protein status in the pathogenesis of EAOC. In addition to activating and inactivating mutations in cancer driver genes, the complex pathogenesis of EAOC involves multiple other mechanisms such as the modulation of cancer driver genes via the transcriptional and post-translational (miRNA) modulation of cancer driver genes and the interplay with the inflammatory tissue microenvironment. This knowledge is being translated into the clinical management of endometriosis and EAOC. This includes the identification of the new biomarkers predictive of the risk of endometriosis and cancer, and it will shape the precision oncology treatment of EAOC.

Immune pathway through endometriosis to ovarian cancer

Endometriosis is an estrogen-dependent inflammatory disease, defined by the presence of functional endometrial tissue outside of the uterine cavity. This disease is one of the main gynecological diseases, affecting around 10%-15% women and girls of reproductive age, being a common gynecologic disorder. Although endometriosis is a benign disease, it shares several characteristics with invasive cancer. Studies support that it has been linked with an increased chance of developing endometrial ovarian cancer, representing an earlier stage of neoplastic processes. This is particularly true for women with clear cell carcinoma, low-grade serous carcinoma and endometrioid. However, the carcinogenic pathways between both pathologies remain poorly understood. Current studies suggest a connection between endometriosis and endometriosis-associated ovarian cancers (EAOCs) via pathways associated with oxidative stress, inflammation, and hyperestrogenism. This article aims to review current data on the molecular events linked to the development of EAOCs from endometriosis, specifically focusing on the complex relationship between the immune response to endometriosis and cancer, including the molecular mechanisms and their ramifications. Examining recent developments in immunotherapy and their potential to boost the effectiveness of future treatments.

Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review

Background: Malignant-associated abdominal wall endometriosis (AWE) is a rare pathology, likely to occur in 1% of scar endometriosis. The objectives of this study were to update the evidence on tumor degeneration arising from AWE to notify about the clinical characteristics, the different treatments offered to patients and their outcomes. Methods: A comprehensive systematic review of the literature was conducted. PubMed, Embase and Cochrane Library databases were used. Prospero (ID number: CRD42024505274). Results: Out of the 152 studies identified, 63 were included, which involved 73 patients. The main signs and symptoms were a palpable abdominal mass (85.2%) and cyclic pelvic pain (60.6%). The size of the mass varied between 3 and 25 cm. Mean time interval from the first operation to onset of malignant transformation was 20 years. Most common cancerous histological types were clear cell and endometrioid subtypes. Most widely accepted treatment is the surgical resection of local lesions with wide margins combined with adjuvant chemotherapy. The prognosis for endometriosis-associated malignancy in abdominal wall scars is poor, with a five-year survival rate of around 40%. High rates of relapse have been reported. Conclusions: Endometrial implants in the abdominal wall should be considered as preventable complications of gynecological surgeries. Special attention should be paid to women with a history of cesarean section or uterine surgery.

Association between Endometriosis and the Risk of Ovarian, Endometrial, Cervical, and Breast Cancer: A Population-Based Study from the U.S. National Inpatient Sample 2016-2019

OBJECTIVE

We investigated the potential relationship between endometriosis and risk of ovarian, endometrial, cervical, and breast cancers using the National Inpatient Sample (NIS) database.

METHODS

We utilized the International Classification of Diseases (ICD-10) system to identify relevant codes from the NIS database (2016-2019). Univariate and multivariate regression analyses (adjusted for age, race, hospital region, hospital teaching status, income Zip score, smoking, alcohol use, and hormonal replacement therapy) were conducted to evaluate the association between endometriosis and gynecologic cancers and summarized as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

In the examined dataset, there were 1164 and 225,323 gynecologic cancer patients with and without endometriosis, respectively. Univariate analysis showed endometriosis was significantly associated with a higher risk of ovarian (OR = 3.42, 95% CI: 3.05-3.84, p < 0.001) and endometrial (OR = 3.35, 95% CI: 2.97-3.79, p < 0.001) cancers. There was no significant association between endometriosis and cervical cancer (OR = 1.05, 95% CI: 0.85-1.28, p = 0.663). Interestingly, endometriosis was significantly associated with a low risk of breast cancer (OR = 0.12, 95% CI: 0.10-0.17, p < 0.001). Multivariate analysis after Bonferroni correction (p < 0.006) showed that endometriosis was significantly associated with a high risk of ovarian (adjusted OR = 3.34, 95% CI: 2.97-3.75, p < 0.001) and endometrial (adjusted OR = 3.61, 95% CI: 3.12-4.08, p < 0.001) cancers. Conversely, there was no significant association between endometriosis and cervical cancer (OR = 0.80, 95% CI: 0.65-0.99, p = 0.036).

CONCLUSIONS

Patients with endometriosis exhibited unique gynecologic cancer risk profiles, with higher risks for ovarian and endometrial cancers, and no significant risk for cervical cancer. The observed connection between endometriosis and a reduced risk of breast cancer remains a perplexing phenomenon, which cannot be put into context to date.

All groin swellings are not lipoma

An interesting case of an abdominal wall swelling near an old operative scar showing epithelial and stromal cells. In this present paper, fine needle aspiration cytology of an inguinal swelling is discussed which may often create diagnostic confusion.

Extrauterine Undifferentiated Uterine Sarcoma Arising from Bladder Endometriosis in a Postmenopausal Woman: A Case Report

Endometriosis (EMS) is a rare condition in postmenopausal women. The incidence of transition from EMS to malignancy is as low as 1%, with endometrial stromal tumors (ESTs) occurring at an even lower incidence of 0.7%. Undifferentiated uterine sarcomas (UUSs) are a subtype of ESTs that account for 25% of all ESTs. Extrauterine UUSs are exceptionally rare, with only a few reported cases in the literature. We present the case of a woman who underwent surgery for deep infiltrating EMS and was later diagnosed with UUS, which originated from the bladder after surgical menopause.

QS ENDO Pilot - A Study by the Stiftung Endometrioseforschung (SEF) on the Quality of Care Provided to Patients with Endometriosis in Certified Endometriosis Centers in the DACH Region

Introduction Endometriosis significantly reduces patients' quality of life and is additionally a burden on healthcare and social security systems. There are currently no quality indicators for the treatment of endometriosis. The care of patients with endometriosis must be considered inadequate. QS ENDO aims to record the quality of care available in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis as part of providing quality assurance in endometriosis care. The first phase, QS ENDO Real, recorded the reality of current care using a questionnaire. The second phase, QS ENDO Pilot, investigated the treatment of 435 patients who underwent surgical treatment within a defined one month period in certified endometriosis centers. Material and Methods An online tool was used to gather information about 9 points which covered both prior patient history and the process of clinical diagnosis. Surgery reports were reviewed to obtain information about the surgical approach, the investigated sites, findings of any histological examinations, the use of classification systems, and information about resection status. Results 85.3% of patients were asked all 4 questions about their prior medical history. All 5 diagnostic steps were carried out in 34.5% of patients. The 3 areas needed to describe potential sites of disease were recorded in 67.1% of patients. Samples for histological examination were taken in 84.1% of patients. The endometriosis stage was classified in 94.7% of surgeries. A combination of the rASRM and the ENZIAN classifications, which is needed for complex cases, was used in 46.1% of patients. Complete resection was achieved in 81.6% of surgical procedures. Conclusion For the first time, the quality of care in certified endometriosis centers has been recorded using QS ENDO Pilot. Despite the high certification standards, a substantial number of required indicators were omitted.

Feasibility of periprocedural decision on the administration of intravenous contrast media in MRI for endometriosis

PURPOSE

To assess the feasibility of a periprocedural decision on the administration of intravenous contrast media in MRI for endometriosis and to evaluate the frequency and reasons of contrast administrations, the corresponding MRI diagnoses, and outcome.

METHODS

In this retrospective, descriptive cross-sectional single-center study all patients were included, who received a pelvic MRI for evaluation of endometriosis between April 2021 and February 2023. Frequency and reasons of optional intravenous administration of contrast media, corresponding MRI diagnoses and clinical outcome data were noted after re-review of all images, review of radiology reports and review of patients' medical records. The decision on the administration of intravenous contrast media had been made by experienced radiologists, depending on the findings of the non-contrast sequences and the presence of ancillary questions.

RESULTS

303 consecutive patients (mean age, 33.4 years +/- 8.3 [standard deviation]) were evaluated. Periprocedural decision on the administration of intravenous contrast media had been made in all cases. For 219/303 (72.3%) patients, it was decided after review of the non-contrast sequences and exclusion of ancillary questions that contrast administration was not required. 84/303 (27.7%) patients received contrast media, and the most frequent reasons were indeterminate ovarian lesion (41/84 cases, 48.8%) or suspicion of pelvic venous congestion syndrome (26/84 cases, 31.0%). No relevant differences in patient outcomes could be noted (non-contrast/contrast MRI).

CONCLUSIONS

A periprocedural decision on the administration of contrast media in MRI for endometriosis is feasible with little effort. It allows the administration of contrast media to be avoided in most cases. If the administration of contrast media is deemed necessary, repeat examinations can be avoided.

Association of endometriosis with genital human papillomavirus infection in US women: a national population-based study

The prevalence of genital human papillomavirus (HPV) in women with endometriosis has never been reported in a national representative survey. We aimed to investigate the association of endometriosis with the prevalence of HPV. We analyzed the data on 1768 women (representing 43,824,157 women) in the United States aged 20-54 years from the National Health and Nutrition Examination Survey in the prevaccination era (2003-2006). The diagnosis of endometriosis was based on a self-report. The prevalence of any HPV in women with endometriosis did not differ from that in women without endometriosis after controlling for potential confounders such as age, ethnicity, family income, marital status, and the number of deliveries (adjusted prevalence ratio (aPR) 0.84, 95% confidence interval (CI) 0.61-1.15). No significant association was found between the prevalence of high-risk HPV and the diagnosis of endometriosis (aPR 0.71, 95% CI 0.44-1.14). If the participants were not covered by health insurance, the prevalence of any HPV infection in women with endometriosis was higher than in those without endometriosis (aPR 1.44, 95% CI 0.94-2.20). In contrast, in a subgroup who had health insurance, a lower prevalence of any HPV infection was observed in women with endometriosis (aPR 0.71, 95% CI 0.50-1.03), and P for interaction was statistically significant (P = 0.01). There was no association between endometriosis and HPV infection in this study of HPV vaccine-naïve women of reproductive age. The association was not different by the type of HPV. However, access to healthcare may modify the association between endometriosis and HPV infection.

Does endometriosis increase the risks of endometrial hyperplasia and endometrial cancer?

OBJECTIVE

The risk of developing endometrial hyperplasia after diagnosis of endometriosis has not been determined. Moreover, the risk of endometrial cancer associated with endometriosis is unclear. This nationwide population-based study investigated the associations of endometrial hyperplasia and endometrial cancer with endometriosis, after adjusting for covariates.

METHODS

This population-based observational study analyzed data from the Korean National Health Insurance (NHI) database, including 147,869 women who were diagnosed with endometriosis from 2002 to 2017, with each patient matched to 20 control women without endometriosis. Cox proportional hazard regression analyses were performed to estimate the hazard ratios (HRs) of endometrial hyperplasia, endometrial cancer, and mortality from endometrial cancer.

RESULTS

Among three million women in this population, 16,377 women were diagnosed with endometrial hyperplasia, and 1795 women were diagnosed with endometrial cancer over 19,931,794 person-years of follow-up. Women with endometriosis were at significantly higher risks of endometrial hyperplasia (adjusted hazard ratio [aHR] 1.85, 95% confidence interval [CI] 1.75-1.95), and endometrial cancer (aHR 1.35, 95% CI 1.12-1.63) were compared with control women after adjustment for covariates. A diagnosis of endometriosis did not affect survival in patients with endometrial cancer.

CONCLUSION

The risks of endometrial hyperplasia and endometrial cancer were found to be significantly higher in women with than without endometriosis. The presence of endometriosis did not affect overall survival in women with endometrial cancer. Additional long-term prospective studies with adequate control of confounders are needed.

Clear Cell Adenocarcinoma Arising from Endometriosis in Abdominal Wall Cesarean Section Scar: A Case Report and Literature Review

Background

Endometriosis developing in a cesarean section (CS) scar is an unusual event. Malignant transformation arising on the background of scar endometriosis in the abdominal wall is extremely rare. Herein we report a case of clear cell carcinoma (CCC) arising in the abdominal wall from endometriosis tissues following CS and review previous literature.

Case Presentation

A 48-year-old gravida 2 para 1 female presented with an abdominal wall mass at her CS scar, which increased in size and became painful in the last 2 years. Physical examination showed a multilocular solid mass of about 13 cm, at the previous CS scar. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 12.8cm × 7.7cm multi-septate cystic lesion on the anterior abdominal wall, and histological examination showed that CCC was caused by the transformation of abdominal wall endometriosis (AWE).

Conclusion

An endometriosis-associated malignancy should be considered in the differential with any enlarging mass in the abdominal wall scar.

Two Cases of Mesonephric-like Carcinoma Arising From Endometriosis: Case Report and Review of the Literature

Endometriosis is a common condition in reproductive age women that is defined as the presence of endometrial tissue (epithelial and/or stromal) outside the uterine corpus. While not a premalignant lesion, it is a condition with a potential for malignancy, especially in the ovaries. Notable endometriosis-associated neoplasms include clear cell carcinoma and endometrioid adenocarcinoma of the ovaries. There have been recent reports of mesonephric-like adenocarcinoma (MLA) of the ovary, a very rare neoplasm with similar morphologic and immunophenotypic characteristics as mesonephric adenocarcinoma, however, without an association with mesonephric remnants. Some of these cases have been associated with endometriosis. Here, we describe 2 cases of MLA arising directly from endometriosis. In both cases, there was evidence of endometriosis contiguous with the tumor and invasion from other sources was excluded. The immunophenotypes of both tumors were typical of mesonephric adenocarcinoma except PAX-8 was strongly positive suggesting a Mullerian origin. Molecular testing on one of the cases revealed KRAS and P53 mutations. We review published findings of MLA and associated endometriosis. This report describes the sixth and seventh reported cases of MLA associated with endometriosis and the first reported cases of MLA arising directly from endometriosis and associated with other forms of epithelial proliferation within endometriosis. These 2 cases provide potential evidence that MLA should be considered an endometriosis-associated neoplasms.

O-RADS Ultrasound Version 1: A Scenario-Based Review of Implementation Challenges

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.

The many faces of endometriosis

Endometriosis is a common disease; however, unusual findings may cause diagnostic difficulties. We present herein three cases illustrating different morphological appearances of endometriosis: 1) endometriosis with atypical hyperplasia associated with bilateral ovarian carcinoma (mixed clear cell/endometrioid in the left ovary and endometrioid in the right ovary); 2) deep infiltrating endometriosis with intravascular spread, polypoid configuration in peritoneal surfaces, and involvement of a lymph node; and 3) decidualized endometriosis with prominent myxoid/mucinous change and multivacuolated (pseudoxanthoma) cells. Awareness of uncommon morphological manifestations of endometriosis is important to avoid improper consideration of malignancy.

Clear cell carcinoma of the abdominal wall: A case report with a review of the literature

Introduction and importance

Clear cell carcinoma of abdominal wall is a very rare and aggressive disease. It is mostly related to malignant transformation of abdominal wall endometriosis. This paper provides a new case report and a literature review of primitive abdominal wall clear cell carcinoma.

Case presentation

A 45-year-old woman with a history of a two previous caesarian section presented to the outpatient department with a tumor mass evolving since 10 years in the lower right quadrant of her abdomen. Imaging studies revealed a voluminous subcutaneous mass developing at the expense of the anterior abdominal wall. Surgical resection of the mass was performed. Histopathological examination along with immunohistochemical analysis were consistent with clear cell carcinoma. Biopsies of the endometrium and ovaries were performed and were negative for malignancy. The patient underwent therefore a hysterectomy with bilateral salpingo-oophorectomy which did not reveal any disease. The diagnosis of primitive clear cell carcinoma of the abdominal wall was then confirmed.

Clinical discussion

Primitive clear cell carcinoma of the abdominal wall is an extremely rare form of cancer with usually poor prognosis. Clinicians must be aware of the possibility of malignancy of any swelling mass occurring near or within a caesarean section scar.

Conclusion

Reporting more such cases is still needed to further progress in the understanding of this malignancy in addition to the development of treatment strategies.

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Clear cell carcinoma (CCC) occurring in the anterior abdominal wall is an extremely rare but aggressive tumor.

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It is usually secondary to malignant transformation of abdominal wall scar endometriosis.

•

Caesarean section is the major factor of developing abdominal wall scar endometriosis.

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Treatment is mainly based on extensive surgery with free margins.

Malignant Mixed Mullerian Tumor Arising from Endometriosis in the Groin: A Case Report and Literature Review

This was a 57-year-old woman who presented with mild discomfort in the right groin. Physical examination revealed a mass in the right groin, and by ultrasound, the mass was hypoechoic and solid with some internal vascularity. The clinical differential diagnosis included lymphoma and others. The mass was excised for pathologic evaluation. Gross examination of the specimen revealed a 3 × 2.4 × 2 cm, solid and cystic mass. Microscopically, it was a biphasic tumor consisting of carcinomatous and sarcomatous components. The tumor was seen contiguous with endometriosis and atypical endometrioid hyperplasia. The histologic findings were consistent with malignant mixed Mullerian tumor (MMMT) arising from endometriosis in the right groin. The tumor involved the resection margin. Subsequent chest/abdominal/pelvic computed tomography did not reveal evidence of tumors, and diagnostic peritoneal/pelvic laparoscopy did not show diseases. Postoperatively, the patient received 6 cycles of chemotherapy consisting of carboplatin and paclitaxel, followed by radiation in the right groin. Malignant transformation from endometriosis occurs in less than 1% of endometriosis cases, and about 80% of the transformed tumors occur in the ovaries. The most commonly transformed malignant tumors are endometrioid and clear cell carcinomas, with rare adenosarcoma and endometrial stromal sarcoma reported. To our knowledge, we are reporting the first case of MMMT arising from endometriosis in the groin.

Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation

Background

A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use of laparoscopic in-bag morcellation. One criticism regarding the use of in-bag morcellation is the additional surgical time associated with this procedure.

Objectives

In this retrospective study we compared the total surgical time in LASH with laparoscopic in-bag morcellation (107 cases from 2016-2018) and LASH with uncontained morcellation (47 cases from 2015-2017).

Materials and Methods

All surgeries were performed in the same department of minimally invasive gynaecological surgery by a total of three experienced surgeons for the indication of bleeding disorder and / or dysmenorrhea.

Main outcome measures

We measured and compared total surgical time, surgical outcome, blood loss and complications in LASH with in-bag morcellation and with uncontained morcellation.

Results

Total surgical time in both procedures do not show a significant difference. Considering the learning curve in laparoscopic bag use, the total surgical time in LASH with laparoscopic in-bag morcellation is shorter than total surgical time in LASH with uncontained morcellation. Laparoscopic in-bag morcellation consumes time for bag use and handling, but saves time as it eliminates the need for meticulous sampling of lost tissue fragments and the complex lavage of the peritoneal cavity after morcellation. There is no difference between both groups in terms of blood loss, complications and surgical results.

Conclusion/What is new?

We conclude that LASH with in-bag morcellation is not related to additional surgical time when compared to LASH with uncontained morcellation.

Endometriosis-associated Clear Cell Carcinoma of the Abdominal Wall After Caesarean Section: A Case Report and Review of the Literature

BACKGROUND/AIM

Clear cell carcinoma of the abdominal wall is a sporadic event. To date, about thirty cases have been reported in the literature. This article provides a case report and literature review of an infrequent occurrence with poor prognosis.

CASE REPORT

A 45-year-old woman with pelvic pain and an abdominal mass came to our attention. Her medical history was notable for two previous cesarean sections. Physical examination revealed a smooth, multilocular mass measuring about 20 cm, arising from the previous surgical scar. Histology revealed clear-cell carcinoma resulting from the transformation of abdominal wall endometriosis. Given the disease extent, the patient underwent front-line chemotherapy. After several and multiple chemotherapy regimens, there was a disease progression that resulted in the death of the patient in 7 months. The literature review showed that a previous cesarean section was present in 91% of cases. Besides, approximately 26.5% of women died within 12 months of being diagnosed. The mean age of women was 45.88 years, while the average size of the lesion was 11 cm.

CONCLUSION

Clear cell carcinoma is a rare but occurring event. Middle-aged women showing an abdominal wall mass in close relation with a surgical scar from a previous cesarean section must be promptly investigated. Treatment options usually include surgery and chemotherapy with poor results.

Endometriosis-associated epithelial ovarian cancer: Primary synchronous different cellular type on each ovary

OBJECTIVE

Endometriosis-associated epithelial ovarian cancer (EOC) is a specific category of EOC, containing either endometrioid or clear cell carcinoma subtype. The characteristic of endometriosis-associated EOC includes an early stage at the diagnosis, presence of single histology type, and better prognosis. The synchronous two subtypes of endometriosis-associated EOC and presentation of far-advanced stage status at the initial diagnosis is rarely reported.

CASE REPORT

We reported a 60-year-old postmenopausal woman with FIGO IA endometriosis-associated endometrioid carcinoma at right ovary and FIGO IVA endometriosis-associated clear cell carcinoma at left ovary, right tube, omentum, lymph node and cytology of pleural effusion and ascites treated with optimal debulking surgery and dose-intensity taxane/platinum based chemotherapy.

CONCLUSION

This case report confirms the long-term concept that clear cell carcinoma has much more aggressive behavior than endometrioid cell carcinoma does, regardless of association of endometriosis or not.

Endometriosis and malignancy: The intriguing relationship

OBJECTIVE

To determine the prevalence and study the association of ovarian, uterine, and breast cancers with endometriosis.

METHODS

A cross-sectional study of all women with a tissue-proven diagnosis of endometriosis postoperatively in a tertiary care hospital between January 1, 2010, and December 31, 2019, was conducted to determine the prevalence of coexistent malignancy. Patient details were obtained from electronic clinical records. Univariate analysis followed by multivariate analysis was done to find independent risk factors associated with malignancy.

RESULTS

Out of 800 patients, 104 (13.0%) were found to have coexistent malignancy: ovarian (50, 6.2%); endometrial (33, 4.1%); synchronous ovarian and endometrial (7, 0.9%); and breast (14, 1.8%). Increasing age (odds ratio [OR] 1.13; 95% confidence interval [CI] 1.09-1.16), higher levels of cancer antigen 125 (CA 125) (OR 1.002; 95% CI 1.001-1.005), postmenopausal status (OR 6.2; 95% CI 2.0-19.2), duration of endometriosis over 5 years (OR 4.7; 95% CI 2.5-9.0), and endometriomas larger than 8 cm (area under the curve 0.83) were predictive of coexistent malignancy.

CONCLUSION

Endometriosis is associated with an increased risk of ovarian, endometrial, and breast malignancy. Increasing age, postmenopausal status, higher levels of CA 125, larger endometrioma, and long-standing disease are predictive risk factors.

Endometriosis-associated colorectal carcinosarcoma: A case report and review of the literature

•Endometriosis associated intestinal tumors are rare, with 5 cases documented.•Endometriosis associated intestinal tumors might present like colorectal carcinoma.•Endometriosis associated intestinal Carcinoma is associated with poor prognosis.

The Many Faces of Endometriosis-Related Neoplasms in the Same Patient: A Brief Report

INTRODUCTION

Endometriosis is a common benign gynecological condition that can be associated with a slightly increased risk of developing a wide range of malignancies.

CASE PRESENTATION

We herein report a singular case of a 62-year-old woman with a history of pelvic endometriosis, referred to our institution for chronic pelvic pain and uterine bleeding, with clinical and radiological evidence of left ovarian mass of 18 cm in largest diameter and multiple nodular mural lesions of the uterine cavity. The patient underwent exploratory laparotomy followed by hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with pelvic lymph-node sampling. The histological examination of the ovarian mass revealed a clear-cell ovarian carcinoma arising from an endometriotic cyst. The microscopic examination of the uterine cavity showed multiple conventional leiomyomas, diffuse foci of adenomyosis, and a 1.5-cm yellow nodule diagnosed as low-grade endometrial stromal sarcoma associated with glandular atypical differentiation and with extension into parametrial and omental tissues. Following the diagnosis, the patient was treated with chemotherapy, radiation therapy, and hormonal therapy and after 9 months of follow-up is alive without local recurrences and distant metastases.

DISCUSSION/CONCLUSIONS

To the best of our knowledge, the present case represents the first evidence of the simultaneous occurrence of clear-cell carcinoma and low-grade endometrial stromal sarcoma arising within ovarian and uterine endometriotic foci, respectively.

Understanding malignant transformation of endometriosis: imaging features with pathologic correlation

PURPOSE

Transformation of benign endometriosis to endometriosis-associated ovarian carcinoma (EAOC) is rare; however, women with endometriosis are four times more likely to develop EAOC which can present 20 years earlier than de novo ovarian cancer. Presenting symptoms are often vague and the radiologist's role in recognizing EAOC is critical for early detection and treatment. Histopathologic evaluation remains the mainstay for definitive diagnosis.

METHODS

Using a case-based approach, this article will review the sonographic, CT, and MRI features of EAOC with an emphasis on MRI. Histopathologic correlation of benign and malignant endometriosis will be reviewed.

RESULTS

Multiple factors contribute to the malignant transformation of endometriosis including genetic alterations, hormonal influences, oxidative stress, and inflammation. Malignancy most often occurs in ovarian endometriomas with less common sites involving the rectovaginal septum, rectosigmoid colon, and abdominal wall scars. The most common pathologic subtypes are endometrioid adenocarcinoma and clear cell carcinoma. MRI is the most specific imaging modality for evaluating EAOC. Key MR features include solid enhancing nodules (accentuated by subtraction imaging), nodular septations, loss of T2 shading within the endometrioma, and diffusion restriction.

CONCLUSIONS

EAOC is a distinct disease that affects women with benign endometriosis at younger ages than classic ovarian cancer. Understanding the imaging features of malignant transformation of endometriosis is essential for early diagnosis and timely definitive treatment.

Endometrioid Carcinoma Arising from an Endometriosis-Associated Abdominal Wall Scar

Patient: Female, 45-year-old

Final Diagnosis: Endometrial cancer

Symptoms: Abdominal discomfort • abdominal distension

Medication: —

Clinical Procedure: Hormone therapy • surgery removal

Specialty: Oncology

[Abnormal gut microbiota-induced hypoestrogenemia as a possible risk factor for malignancy in endometrioid heterotopia]

This paper reveals the pathogenetic impact of the abnormal gut microbiota on the development of female reproductive system diseases. A dynamic imbalance between the altered microbiota and the macroorganism has many manifestations as hormonal homeostatic disorders, one of which is dysbiosis-induced hypoestrogenemia. Using endometrioid heterotopia as an example, the authors trace the possibility of its progression and malignancy due to the occurrence of primary breakdown of the PTEN tumor-suppressor gene with subsequent genetic abnormalities in the ARID1A and TP53 genes. PTEN mutation in both endometriosis itself and its malignancy indicates that dysbiosis-induced hypoestrogenemia may be implicated in the pathogenesis of endometriosis. Thus, the relationship between female reproductive system diseases and gut microbiome disorders may be more significant; and the possibility of correcting the gut microbiota with prebiotics and probiotics opens new horizons not only in the prevention, but also in the treatment of many gynecological diseases associated with hormone disorders.

Malignant extra-ovarian endometriosis: A case series of ten patients and review of the literature

BACKGROUND

The malignant transformation of endometriosis within the ovary is a recognised condition. There is less literature surrounding the malignant transformation of extra-ovarian endometriosis (MEOE).

AIMS

We report our experience with MEOE in ten patients and present a review of the literature regarding this rare malignancy.

MATERIALS AND METHODS

For this retrospective case series, patients were identified from a practice-based database. Where required, operative notes and pathology reports were reviewed.

RESULTS

Ten patients diagnosed with MEOE between 1991 and 2014 were identified. In each case, the tumour was localised to the pelvis and centred on the pouch of Douglas, broad ligament, obturator fossa, parametrium and rectovaginal septum. Tumour histology was endometrioid adenocarcinoma (six), clear cell carcinoma (two), and adenosarcoma (two). Five patients had a history of endometriosis and four had received oestrogen-only hormone replacement therapy after hysterectomy and bilateral salpingo-oophorectomy. Treatments included surgery (one), surgery and radiotherapy (one), surgery and chemotherapy (one), surgery, radiotherapy and chemotherapy (three), and radiotherapy and chemotherapy (four). Maintenance hormonal therapy was also used in three patients. Curative doses of radiotherapy 45 Gy or more resulted in in-field control in five patients. Six patients had no evidence of disease at a mean follow up period of 15 years (5.5-24 years). Severe G3 long-term bladder morbidity occurred in three patients after radical surgery and radiotherapy.

CONCLUSION

MEOE is a rare condition for which treatment needs to be individualised. Multicentre studies and registries will hopefully define optimal treatment.

Endometriosis-It is not just benign

Endometriosis is a common disease, not uncommonly debilitating with severe negative impact on all domains of life for women. The long-standing approach is that endometriosis is one of many gynecological benign conditions. Nevertheless, there is a growing body of evidence linking endometriosis and invasiveness. The aim of this commentary is to address the topic of the attitude toward endometriosis as a benign disease while summarizing the current literature regarding the debate that surrounds this topic.

QS ENDO Real - A Study by the German Endometriosis Research Foundation (SEF) on the Reality of Care for Patients with Endometriosis in Germany, Austria and Switzerland

Endometriosis affects a significant number of young premenopausal women. Quite apart from the medical challenges, endometriosis is a relevant burden for healthcare and social security systems. Standardized quality indicators for the treatment of endometriosis have not previously been systematically verified. The three-stage study QS ENDO was initiated to record and improve the reality and quality of care. One of its aims is to create quality indicators for the diagnosis and treatment of endometriosis. For the first stage of QS ENDO Real, letters were sent to all 1014 gynecological departments in the German-speaking area of Europe (the DACH region) which included a questionnaire as a means of surveying the current state of care. A total of 296 (29.2%) of the centers which received the questionnaire participated in the survey. The subsequent evaluation of the completed questionnaires showed that the majority of patients with endometriosis (around 60%, based on estimates from the data) are not treated in hospitals which have been certified by the SEF. The guidelines recommend the use of specific classification systems (rASRM, ENZIAN) but, depending on the level of care offered by the hospital, only around 44.4 to 66.4% of departments used the rASRM score and only 27% of hospitals used the ENZIAN classification system to describe deep-infiltrating endometriosis. When taking patientsʼ medical history, some centers (6.6 – 17.9%) considered questions about leading symptoms such as dyschezia, dysuria and dyspareunia to be unimportant. QS ENDO Real has made it possible, for the first time, to get an overview of the reality of care provided to patients with endometriosis in the German-speaking areas of Europe. The findings indicate that several of the measures recommended in international guidelines as the gold standard of care are only used to treat some of the patients. In this respect, more efforts will be needed to provide more advanced training. The approach used for treatment must be guideline-based, also in not-certified centers, to improve the quality of care in the treatment of patients with endometriosis.

Abdominal wall endometriosis (a narrative review)

One of the rarest forms of endometriosis is abdominal wall endometriosis (AWE), which includes caesarean scar endometriosis. AWE remains a challenging condition because some issues related to this topic are still under debate. The increasing number of caesarean sections and laparotomies will expect to increase the rate of AWE. The current incidence in obstetrical and gynaecological procedures is still unknown. The disease is probably underestimated. The pathogenic mechanism involves local environment at the implant site including local inflammation and metalloproteinases activation due to local growth factors, estrogen stimulation through estrogen receptors and potential epigenetic changes. However, the underlying mechanisms are not fully explained, and we need more experimental models to understand them. The clinical presentation is heterogeneous; the patient may be seen by a gynaecologist, an endocrinologist, a general surgeon, an imaging specialist, or even an oncologist. No particular constellation of clinical risk factors has been identified, and the histological report is the major diagnostic tool for confirmation. Surgery is the first line of therapy. Further on we need protocols for multidisciplinary investigations and approaches.

High-Grade Serous Carcinoma Resulting From Rectal Endometriosis and Complicated With Ovarian Cancer

Endometriosis is one of the most common benign gynecological diseases. It shows similar attributes to those of some fatal tumors if it is becomes malignant. These attributes include invasion, implantation, and recurrence. Epidemiological, clinicopathological, molecular biological, and genetic evidence suggest that malignancy of endometriosis, referred to as endometriosis-associated malignancy (EAM), is histologically closely related to endometriosis. Atypical endometriosis, which usually causes EAM, is considered a transitional condition from benign endometriosis to cancer. Approximately 80% of EAMs occur in the ovary and are known as endometriosis-associated ovarian cancer (EAOC). However, extragonadal endometriosis is not common, and no earlier study reported an association between malignant transformation of rectal endometriosis and high-grade serous cancer. We report a rare case of high-grade serous carcinoma resulting from rectal endometriosis and complicated with ovarian cancer. A 63-year-old Chinese woman was admitted with a complaint of abdominal distension. We diagnosed the patient with ovarian carcinoma and decided on elective cytoreductive surgery as treatment for the patient. During the surgery, we found a solid mass of diameter 12 cm in the anterior rectal wall containing sticky brown fluid. Postoperative histopathological examination revealed high-grade serous carcinoma resulting from rectal endometriosis and complicated with ovarian cancer. The patient postoperatively received 6 cycles of chemotherapy consisting of carboplatin and paclitaxel and was followed up for 1 year with no recurrence of the condition.

Identification of differentially expressed genes and signaling pathways involved in endometriosis by integrated bioinformatics analysis

Endometriosis is a common gynecological disease characterized by the presence and growth of endometrial tissue outside the uterus, including the pelvis and abdominal cavity. This condition causes various clinical symptoms, such as non-menstrual pelvic pain, dysmenorrhea and infertility, seriously affecting the health and quality of life of women. To date, the specific mechanism and the key molecules of endometriosis remain uncertain. The purpose of the present study was to elucidate the mechanisms involved in the development and persistence of the disease. A number of mRNA expression profile datasets (namely GSE11691, GSE23339, GSE25628 and GSE78851) were downloaded from the Gene Expression Omnibus (GEO) database. These gene expression profiles were normalized, and the differentially expressed genes (DEGs) were identified by integrated bioinformatics analysis. A total of 103 DEGs were screened upon excluding the genes that exhibited inconsistency of expression (P<0.05). Furthermore, the Gene Ontology analysis, Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis, and construction of protein-protein interaction networks of DEGs were performed using online software. The results revealed that the DEGs were closely associated with cell migration, adherens junction and hypoxia-inducible factor signaling. In addition, immunohistochemical assay results were found to be consistent with the bioinformatics results. The present study may help us understand underlying molecular mechanisms and the development of endometriosis, which has a great clinical significance for early diagnosis of the disease.

Extragonadal Giant Endometrial Cyst with Endometrioid Borderline Tumor

We describe an extremely rare case of a borderline tumor arising from an extragonadal giant endometrial cyst. A 41-year-old woman complaining of abdominal pain was referred to our hospital with a diagnosis of large ovarian tumor. Magnetic resonance imaging revealed a large cystic tumor approximately 27 cm × 9 cm in area. The cyst contents were largely removed by suction, and then the tumor was resected laparoscopically. Both adnexa were normal in size and location. The tumor did not originate from the ovaries, and it was adherent only to the bilateral uterosacral ligaments and uterine body. The postoperative histopathological evaluation confirmed the presence of endometrioid borderline tumor with transition from endometriosis. Staging laparotomy was performed, and no remnant tumor was detected. This case is extremely unusual because such a large cystic tumor originating from extragonadal endometriosis is very rare, as is endometrioid borderline tumor arising from endometriosis.

Endometriosis Malignant Transformation Review: Rhabdomyosarcoma Arising From an Endometrioma

Background:

Endometriosis is a widely known benign disease, but 0.5%–1% of cases are associated with malignancy. It has been linked with ovarian neoplasms, particularly endometrioid and clear cell adenocarcinoma histology. Rhabdomyosarcomas are rarely associated with endometriosis.

Case:

A 35-year-old patient underwent surgical management of endometriomas to optimize infertility treatment. She later developed abdominal pain with rapid recurrence of ovarian masses. This prompted additional surgery with biopsies diagnosing ovarian rhabdomyosarcoma. Retroactive review of pathologic specimens from her prior surgery demonstrated the neoplasm originated from her prior endometrioma. Focal areas suggested possible underlying ovarian adenosarcoma with stromal overgrowth.

Discussion:

The incidence of rhabdomyosarcoma arising from endometriosis is exceedingly rare. The accuracy of diagnosing endometriosis and ruling out neoplasm requires coordinated efforts of a multidisciplinary team, involving radiologists, pathologists, oncologists, and gynecologic surgeons.

Endometriosis-associated ovarian cancer is a single entity with distinct clinicopathological characteristics

Objective: To compare the clinicopathological features and chemotherapy response of ovarian clear cell carcinoma (CCC) and endometrioid carcinoma (EC) associated with endometriosis or not. Methods: This was a retrospective study of 128 patients diagnosed with CCC and EC from 2002 to 2017. Clinicopathological features and chemotherapy response were analyzed. Results:There were 34 women with endometriosis-associated ovarian cancer (EAOC) and 94 with non-endometriosis associated ovarian cancer (non-EAOC) according to Sampson's and Scott's criteria. The mean diagnosis age in the EAOC group was 48.65 vs. 54.39 years in non-EAOC (p = 0.002). Compared with non-EAOC, the EAOC patients were more likely to have an earlier menarche age (13 vs. 14 years, p = 0.001), a higher incidence of infertility (26.47% vs. 10.64%, p = 0.026), and an earlier stage tumor (91.18% vs. 73.40% in stages I-II, p = 0.032). At a median follow-up time of 32.9 months, overall survival among patients with EAOC was significantly longer (109.8 vs. 47.4 months, p = 0.007). Association with endometriosis (p = 0.033) was the significant favorable prognostic factors associated with survival. However, stratifying by stage, the overall survival advantage of EAOC was not significant. Although EAOC had a better prognosis, no difference was observed in chemotherapy response between the two groups (p = 0.535). Conclusions: The EAOC patients were often diagnosed at a younger age, an earlier stage, and related to nulliparity and infertility. Patients with EAOC had a better prognosis than non-EAOC, early stage rather than association with endometriosis may be the driver of survival.

Ultrasound of Pelvic Pain in the Nonpregnant Woman

Pelvic ultrasound with endovaginal ultrasound is often the imaging test of choice in the initial evaluation of nonpregnant women with pelvic pain. This article considers the sonographic observations and techniques useful in diagnosis of a variety of gynecologic causes of pelvic pain in these women, including ovarian hemorrhage, ovarian torsion, pelvic inflammatory disease, endometriosis (particularly deeply infiltrating endometriosis), endometriomas, adenomyosis, pelvic congestion syndrome, and malpositioned intrauterine contraceptive devices. Sonographic observations regarding a number of non-gynecologic causes of pelvic pain are also described.

Long-Term Follow-Up after Surgical Management for Atypical Endometriosis: A Series of Nine Cases

Background and Objective

Atypical endometriosis is reported to possess a precancerous potential attributed to premalignant changes characterized by cytological atypia and architecture proliferation. Although the coexistence of atypical endometriosis and neoplasms has been reported, cases of atypical endometriosis transformation to carcinoma are rarely reported. The purpose of this case series was to evaluate the prognosis of atypical endometriosis.

Subjects and Methods

Data from nine women who underwent surgical treatment including cystectomy and salpingo-oophorectomy with or without hysterectomy and diagnosed with atypical endometriosis was analyzed. Between January 2006 and January 2018, the clinical characteristics and prognosis of atypical endometriosis were evaluated.

Results

During the follow-up period, eight of nine patients with atypical endometriosis did not develop malignant epithelial tumors, although one patient developed endometrioid carcinoma, grade 1, 48 months after her right laparoscopic cystectomy. The median overall survival period for all patients was 68 (range 13–131) months.

Conclusion

When we encounter the cases of atypical endometriosis, it is necessary to consider the possibility of ovarian cancer and carefully follow those cases for long periods.

Synchronous occurrence of primary right ovarian endometrioid adenocarcinoma and primary left ovarian clear cell adenocarcinoma: A case report

RATIONALE

Ovarian malignancy is associated with one of the highest rates of death among gynecological reproductive system malignancies. While progress has been made in surgical and postoperative adjuvant treatment approaches, the early atypical clinical manifestations, quick progression, and lack of the effective early screening means imply that the prognosis remains poor. Bilateral ovarian cancers are common, but different types of primary bilateral ovarian carcinomas are extremely rare.

PATIENT CONCERNS

According to clinical pathologic, immunohistochemistry, and medical imaging data, a 51-year-old Chinese woman with abdominal pain was diagnosed as having right ovarian well-differentiated endometrioid adenocarcinoma with mucinous adenocarcinoma and left ovarian clear cell adenocarcinoma.

DIAGNOSES

Immunohistochemistry confirmed the diagnosis of primary bilateral ovarian cancers.

INTERVENTIONS

She received multimodal treatment including surgery and chemotherapy.

OUTCOMES

The patient's recovery was uneventful, and she responded well to the chemotherapy.

LESSONS

We speculate that the different types of primary bilateral ovarian carcinomas presented in this case may be due to different malignant transformations of the endometriotic lesions. Therefore, clinicians should pay special attention to the possible malignant transformation of endometriosis.

Müllerian carcinosarcoma arising from atypical pelvic endometriosis

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Mullerian Carcinosarcoma (MC) is one of the rarest endometriosis associated malignancies (EAM).

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Atypical endometriosis can undergo variety of metaplastic changes causing diagnostic dilemma.

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Atypical endometriosis possibly represents a precursor lesion in the development of EAM.

Epithelial Ovarian Cancer with Endometriosis is not Associated with Menopausal Status: a Co-Association Study at Prapokklao Hospital

Objective: To determine any association between the menopausal status and epithelial ovarian cancer coexisting with endometriosis (EOC-E). In addition, the prevalence and possible risk factors were assessed. Methods: Medical records of 172 women with epithelial ovarian cancer between January 2011 and December 2016 at Prapokklao Hospital were reviewed and divided into two groups: EOC-E defined as the case group and without endometriosis (EOC-NE) as the control group. Results: The proportion of EOC-E was 18% (31/172). There were no significant differences between the two groups in baseline clinical characteristics and presenting symptoms except for history of smoking and abnormal uterine bleeding found more often in EOC-E cases. Most EOC-E were of clear cell histological type followed by endometrioid and serous types (35.5, 25.8 and 22.6 %; respectively). The clear cell type was 8 times more likely in the EOC-E than in the EOC-NE (OR 8.0, 95% CI 2.97-21.89, p-value <0.001) group. Nulliparity and smoking increased risk of EOC-E 2 and 7 times, respectively (OR 2.3, 95%CI 1.03-5.00, p-value 0.041 and OR 7.4, 95%CI 1.18-46.63, p-value 0.032). Conclusions: EOC-E are relatively common. Abnormal uterine bleeding is the only significant presenting symptom in the EOC-E as compared with the EOC-NE group. Endometriosis was a predictive factor for clear cell and endometrioid type I EOC. Menopausal status and age were not associated with a presentation of endometriosis with EOC

Adhesion in Physiological, Benign and Malignant Proliferative States of the Endometrium: Microenvironment and the Clinical Big Picture

Although the developments in cellular and molecular biology over the last few decades have significantly advanced our understanding of the processes and players that regulate invasive disease, many areas of uncertainty remain. This review will discuss the contribution of dysregulated cell⁻cell and cell⁻matrix adhesion to the invasion in both benign and malignant contexts. Using the endometrium as an illustrative tissue that undergoes clinically significant invasion in both contexts, the adhesion considerations in the cells ("seed") and their microenvironment ("soil") will be discussed. We hope to orientate this discussion towards translational relevance for the diagnosis and treatment of endometrial conditions, which are currently associated with significant morbidity and mortality.

The Many Guises of Endometriosis: Giant Abdominal Wall Endometriosis Masquerading as An Incisional Hernia

Endometriosis is defined by the presence of ectopic endometrial tissue outside the uterine cavity. Although it is a leading cause of chronic pelvic pain and infertility, its clinical presentation can vary, resulting in diagnostic and therapeutic challenges. Extrapelvic endometriosis is particularly difficult to diagnose owing to its ability to mimic other conditions. Endometrial tissue in a surgical scar is uncommon and often misdiagnosed as a granuloma, abscess, or malignancy. Cyclical hemorrhagic ascites due to peritoneal endometriosis is exceptionally rare. We report the case of a pre-menopausal, nulliparous 44-year-old woman who presented with ascites and a large abdominal mass that arose from the site of a lower midline laparotomy scar. Five years previously, she had undergone open myomectomy for uterine fibroids. Soon after her initial operation she developed abdominal ascites, which necessitated percutaneous drainage on multiple occasions. We performed a laparotomy with excision of the abdominal wall mass through an inverted T incision. The extra-abdominal mass consisted of mixed cystic and solid components, and weighed 1.52 kg. It communicated with the abdominopelvic cavity through a 2 cm defect in the linea alba. The abdomen contained a large amount of odourless, brown fluid which drained into the mass. There was a large capsule that covered the small and large bowel, liver, gallbladder, and stomach. Final histology reported a 28×19×5 cm mass of endometrial tissue with no evidence of malignant transformation. The patient recovered well post-operatively and has remained asymptomatic. Our case illustrates that, despite being a common disease, endometriosis can masquerade as several other conditions and be missed or diagnosed late. Delay in diagnosis will not only prolong symptoms but can also compromise reproductive lifespan. It is therefore paramount that endometriosis is to be considered early in the management of premenopausal women who present with an irregular pelvic mass or hemorrhagic ascites.

Endometriosis-associated malignant transformation in abdominal surgical scar: A PRISMA-compliant systematic review

BACKGROUND

Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival.

METHODS

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review based on prior reviews and case reports regarding the phenomenon published as abstracts in English, from January 1980 to November 2016. Overall, we identified 47 cases, and we included another case from our institution. We further contacted previous investigators to receive updated follow-up regarding their patients. We analyzed the data, focusing on risk factors that might affect overall survival.

RESULTS

All the patients reported in the literature had a uterine surgery, mainly caesarean section. The median time-lag from first surgery to the diagnosis of cancer was about 19 years. Clear-cell carcinoma (CCC) was the most prevalent histology (67%), followed by endometrioid adenocarcinoma (15%). Most of the patients were treated by extensive surgery and chemotherapy and/or radiation. Overall 5 years survival was about 40%. Median overall survival was 42 months (95% confidence interval of [18.7, 65.3]). Although our review is currently the largest in the literature, we cannot draw any statistical significant results due to the limited number of patients reported. According to univariate Cox-regression models, a tendency toward worse prognosis was shown for 3-year disease-free survival clear cell histologic-type (P = .169), and tumor diameter ≥8 cm in nonclear-cell histology, 18 months postdiagnosis (P = .06).

CONCLUSION

EAMTAS is a rare and aggressive disease. It is mostly related to cesarean section scars and is diagnosed many years postsurgery. Clear-cell histology tends to endure from the worse prognosis. The treatment is mainly extensive surgery and adjuvant chemotherapy and/or radiotherapy.

Laparoscopic Supracervical Hysterectomy with In-Bag Morcellation in Very Large Uterus

Laparoscopic supracervical hysterectomy (LASH) is a safe and fast minimally invasive approach in hysterectomy. In order to extract the uterine body from the abdominal cavity, one condition for LASH is the morcellation of the tissue. The intra-abdominal dissemination of benign and occult malignant uterine cells is a possible risk of this method, which can be avoided by the use of special bags for laparoscopic in-bag morcellation. We present a case of laparoscopic supracervical hysterectomy with in-bag morcellation in a uterus of more than 1400 g. and describe that this minimal-access surgery is safe and feasible even in very large uteri. This case report is registered in Research Registry under the UIN researchregistry1810.

Factors that Differentiate between Endometriosis-associated Ovarian Cancer and Benign Ovarian Endometriosis with Mural Nodules

Purpose:

Mural nodules and papillary projections can be seen in benign ovarian endometriosis (OE) and malignant transformation of OE (endometriosis-associated ovarian cancer [EAOC]), which can pose a challenging diagnostic dilemma to clinicians. We identify the preoperative imaging characteristics helpful to the differential diagnosis between benign OE with mural nodules and EAOC.

Materials and Methods:

This was a retrospective study of 82 patients who were diagnosed pathologically to have OE with mural nodules (n = 42) and malignant transformations of these tumors (n = 40) at the Nara Medical University Hospital from January 2008 to January 2015. All patients were assessed with contrast-enhanced MRI before surgery. Patient demographics, and clinical and pathologic features were analyzed to detect the significant differences between the two groups.

Results:

Histological examinations of resected OE tissue specimens revealed that a majority (78.6%) of the mural nodular lesions were retracted blood clots. We found that the patients with malignant mural nodules, when compared to those with benign nodules, were older, had larger cyst diameters and larger mural nodule sizes, and were more likely to exhibit a taller than wider lesion. They were also more likely to present with various signal intensities on T₁-weighted images (T₁WI), high-signal intensity on T₂-weighted images (T₂WI), a lower proportion of shading on T₂WI, and were more likely to show an anterior location of the cyst. In the multivariate logistic regression analysis, “Height” (>1.5 cm) and “Height-Width ratio (HWR)” (>0.9) of mural nodules, maximum diameter of the cyst (>7.9 cm), and age at diagnosis (>43 years) were independent predictors to distinguish EAOC from OE with mural nodules.

Conclusion:

The “Height” and “HWR” of the mural nodules in the cyst may yield a novel potential diagnostic factor for differentiating EAOC from benign OE with mural nodules.