Endometriosis

Evaluation of Deeply Infiltrating Endometriosis by Preoperative Magnetic Resonance Imaging in Patients with Adenomyosis

Objectives

Before endometriosis surgery, it is important to identify deep infiltrating endometriosis (DIE) to assess the surgical difficulty. Preoperative magnetic resonance imaging (MRI) was used to determine which findings are useful in predicting DIE.

Materials and Methods

Between 2008 and 2016, 54 patients with adenomyosis underwent total laparoscopic hysterectomy at our hospital. We retrospectively evaluated the intraoperative findings and magnetic resonance imaging (MR) images. The MR images were scored based on the presence of five findings: retroflexed uterus, elevated posterior vaginal fornix, intestinal tethering in the direction of the uterus, faint strands between the uterus and intestine, and fibrotic nodules covering the serosal surface of the uterus.

Results

Of the five findings, intestinal tethering and faint strands between the uterus and intestine showed a sensitivity of 73% and a specificity of 91%-100%, indicating the usefulness of these findings for detecting deep endometriosis lesions. However, finding a retroflexed uterus did not contribute to DIE lesion detection. The sensitivities of an elevated posterior fornix and fibrotic nodules covering the surface of the uterus were as low as 46%-59%, and their specificities were as high as 84%-91%.

Conclusion

Preoperative preparation is essential for patients with intestinal tethering or faint strands between the uterus and intestine on preoperative MRI after obtaining appropriate informed consent.

Impact of deep resection of endometriosis in the pelvis on urodynamic parameters

PURPOSE

To evaluate the effects of deep resection of endometriosis in the posterior pelvic region on urodynamic parameters.

METHODS

A prospective observational study conducted with female patients diagnosed with deep pelvic endometriosis before and after endometriosis resection surgery. Clinical history, image exams, the Female Lower Urinary Tract Symptoms questionnaire, urodynamic examination, cystometry, and voiding study were evaluated.

RESULTS

Patients aged 30-39 years old, operative duration of 132.5 minutes, and 2.7 days of hospital stay. Uroflowmetry and cystometry showed tendency for an increase after the surgery in the flow duration, time to maximum flow, and first voiding desire and decreased residual volume and maximum cystometric capacity. Opening, maximum urinary flow, and maximum flow pressure decreased at T1, and the closing parameters increased, although statistically non significant. The variables decreased at T1 in the urodynamic, except for detrusor overactivity. Although we observed a reasonable number of low bladder compliance and abnormal bladder sensation, the results were maintained at T1. General scores for filling and incontinence showed a significant decrease after surgery.

CONCLUSIONS

A significant response in the patient's perception of urinary function was demonstrated after surgery. It is observed that the surgical procedure did not affect the uroflowmetric and cystometric characteristics of the evaluated patients.

Exosomal microRNAs and long noncoding RNAs: as novel biomarkers for endometriosis

Endometriosis is a gynecological inflammatory disorder characterized by the development of endometrial-like cells outside the uterine cavity. This disease is associated with a wide range of clinical presentations, such as debilitating pelvic pain and infertility issues. Endometriosis diagnosis is not easily discovered by ultrasound or clinical examination. Indeed, difficulties in noninvasive endometriosis diagnosis delay the confirmation and management of the disorder, increase symptoms, and place a significant medical and financial burden on patients. So, identifying specific and sensitive biomarkers for this disease should therefore be a top goal. Exosomes are extracellular vesicles secreted by most cell types. They transport between cells' bioactive molecules such as noncoding RNAs and proteins. MicroRNAs and long noncoding RNAs which are key molecules transferred by exosomes have recently been identified to have a significant role in endometriosis by modulating different proteins and their related genes. As a result, the current review focuses on exosomal micro-and-long noncoding RNAs that are involved in endometriosis disease. Furthermore, major molecular mechanisms linking corresponding RNA molecules to endometriosis development will be briefly discussed to better clarify the potential functions of exosomal noncoding RNAs in the therapy and diagnosis of endometriosis.

Thoracic Endometriosis Syndrome (TES) in Martinique, a French West Indies Island

INTRODUCTION

Endometriosis is a female disease that affects 5-10% of women of childbearing age, with predominantly pelvic manifestations. It is currently declared as a public health priority in France. Thoracic endometriosis syndrome (TES) is the most common extra-pelvic manifestation.

OBJECTIVE

The objective of this study was to describe the epidemiological and clinical characteristics, and outcomes of patients with TES in Martinique.

PATIENTS AND METHODS

We performed a descriptive, retrospective study including all patients managed at the University Hospital of Martinique for TES between 1 January 2004 and 31 December 2020.

RESULTS

During the study period, we identified 479 cases of pneumothorax, of which 212 were women (44%). Sixty-three patients (30% of all female pneumothorax) were catamenial pneumothorax (CP) including 49 pneumothoraxes alone (78% of catamenial pneumothorax) and 14 hemopneumothorax (22% of catamenial pneumothorax). There were 71 cases of TES, including 49 pneumothoraxes (69%), 14 hemopneumothoraxes (20%) and 8 hemothorax (11%). The annual incidence of TES was 1.1 cases/100,000 inhabitants. The prevalence of TES was 1.2/1000 women aged from 15 to 45 years and the annual incidence of TES for this group was 6.9/100,000. The annual incidence of CP was 1 case/100,000 inhabitants. The average age at diagnosis was 36 ± 6 years. Eight patients (11%) had no prior diagnosis of pelvic endometriosis (PE). The mean age at pelvic endometriosis diagnosis was 29 ± 6 years. The mean time from symptom onset to diagnosis was 24 ± 50 weeks, and 53 ± 123 days from diagnosis to surgery. Thirty-two patients (47%) had prior abdominopelvic surgery. Seventeen patients (24%) presented other extra-pelvic localizations. When it came to management, 69/71 patients (97%) underwent surgery. Diaphragmatic nodules or perforations were found in 68/69 patients (98.5%). Histological confirmation was obtained in 55/65 patients who underwent resection (84.6%). Forty-four patients (62%) experienced recurrence. The mean time from the initial treatment to recurrence was 20 ± 33 months. The recurrence rate was 16/19 (84.2%) in patients who received medical therapy only, 11/17 (64.7%) in patients treated by surgery alone, and 17/31 (51.8%) in patients treated with surgery and medical therapy (p = 0.03).

CONCLUSIONS

We observed a very high incidence of TES in Martinique. The factors associated with this high incidence in this specific geographical area remain to be elucidated. The frequency of recurrence was lower in patients who received both hormone therapy and surgery.

MicroRNA-92a-3p Inhibits Cell Proliferation and Invasion by Regulating the Transcription Factor 21/Steroidogenic Factor 1 Axis in Endometriosis

Endometriosis (EMS) is an estrogen-dependent disease. However, little is known about the regulation of estrogen, a potential therapeutic target, in EMS, which remains very poorly managed in the clinic. We hypothesized that microRNAs (miRNAs) can be exploited therapeutically to regulate transcription factor 21 (TCF21) and steroidogenic factor-1 (SF-1) gene expression. In our study, paired eutopic and ectopic endometrial samples were obtained from women with EMS and processed by a standard protocol to obtain human endometrial stromal cells (EMs) for in vitro studies. We found that miR-92a-3p levels were decreased in ectopic endometrium and ectopic stromal cells (ESCs) compared with paired eutopic lesions. miR-92a-3p overexpression significantly suppressed the proliferation and migration of ESCs, whereas a decreased level of miR-92a-3p generated the opposite results. Next, we identified TCF21 as a candidate target gene of miR-92a-3p. In vitro cell experiments showed that miR-92a-3p negatively regulated the expression of TCF21 and its downstream target gene SF-1. Moreover, cell proliferation and invasion ability decreased after the silencing of SF-1 and increased after SF-1 overexpression. We also observed that silencing SF-1 while inhibiting miR-92a-3p partially blocked the increase in cell proliferation and invasion ability caused by miR-92a-3p knockdown while overexpressing both SF-1 and miR-92a-3p mitigated the impairment in cell proliferation and invasion ability caused by miR-92a-3p overexpression. Our results may provide a novel potential therapeutic target for the treatment of EMS.

Current treatments for endometriosis in South Korea: an analysis of nationwide data from 2010 to 2019

While a wide range of treatments, including medical therapies and surgery, are used to manage endometriosis, the characteristics and treatment status of patients who received these treatments have not been investigated in Korea. This study analyzed the Korean Health Insurance Review & Assessment Service-National Patient Sample (HIRA-NPS) data from 2010 to 2019 with 7530 patients diagnosed with endometriosis. Annual trends in the types of visit and surgery, medication prescriptions and associated costs were investigated. The analysis showed that surgery slightly decreased among the types of utilized healthcare services (2010: 16.3, 2019: 12.7), dienogest prescription rapidly increased due to national health insurance coverage from 2013 (2013: 12.1, 2019: 36.0), and the use of gonadotrophin-releasing hormone analogues decreased (2010: 33.6, 2019: 16.4). There was no significant change in total and outpatient costs per person over time. Regarding endometriosis treatment, conservative treatment mainly based on prescribed medications has been gradually replacing surgery. Particularly, the listing of dienogest for national health insurance coverage might have affected the trend. However, there were no significant changes in terms of total and medication costs per person.

Extrapelvic Endometriosis Mimicking Peritoneal Surface Malignancy: Case Report and a Review of Literature

Extrapelvic endometriosis is a rare presentation of endometriosis with atypical clinical symptoms. It can mimic peritoneal surface malignancy, as well as some abdominal infectious diseases. A 29-year-old Moroccan woman presented with abdominal pain, progressive abdominal distention, and an intermittent inflammatory syndrome. Imaging revealed multiple, progressively growing abdominal cysts. She had elevated tumor markers CA125 and CA19.9. Despite thorough investigation, several differential diagnoses persisted for a long time. Definitive pathological diagnosis could only be established after debulking surgery. Literature review on malignant and benign conditions causing multicystic abdominal distention is provided. When definitive diagnosis is not established, but suspicion for peritoneal malignancy remains, a debulking procedure can be undertaken. Organ preservation can be pursued whenever benign disease is still considered. In case of malignancy, short-term (curative) debulking procedure with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed.

Endometriosis in an ectopic kidney: a rare case report and literature review

BACKGROUND

Endometriosis mainly occurs in female pelvic organs. Endometriosis in the kidney is extremely rare.

CASE PRESENTATION

We herein describe a case of a 19-year-old girl with occasional mild abdominal pain associated with an ectopic left kidney. SPECT-CT showed no abnormal radioactive distribution in the left pelvis, suggesting loss of function of the ectopic kidney. Laparoscopic left ectopic kidney resection was subsequently performed. Histopathology revealed endometriosis of the ectopic left kidney.

CONCLUSIONS

In female patients with clinical manifestations of abdominal pain and gross hematuria, the possibility of renal endometriosis should be considered.

Vorinostat decrease M2 macrophage polarization through ARID1A6488delG/HDAC6/IL-10 signaling pathway in endometriosis-associated ovarian carcinoma

Endometriosis is a common disease in women and may be one of the factors that induces malignant epithelial ovarian tumors. Previous studies suggested that endometriosis is related to ARID1A mutation mediating the expression of HDAC6, but the detailed pathogenic mechanism is still unclear. First, we collected endometriosis-associated ovarian carcinoma (EAOC) clinical samples and examined the expression of HDAC6. Our results found that the high HDAC6 expression group was positively correlated with EAOC histology (P = 0.015), stage (P < 0.000), and tumor size (P < 0.000) and inversely correlated with survival (P < 0.000). We also found that ARID1A^6488delG/HDAC6 induced M2 polarization of macrophages through IL-10. In addition, the HDAC inhibitor (HDACi) vorinostat inhibited cell growth and blocked the effect of HDAC6. Tomographic microscopy was used to monitor the live cell morphology of these treated cells, and we found that vorinostat treatment resulted in substantial cell apoptosis by 3 h 42 min. Next, we established a transgenic mouse model of EAOC and found that vorinostat significantly reduced the size of ovarian tumors by inhibiting M2 macrophage polarization in mice. Together, these data demonstrate that the signaling pathway of E4F1/ARID1A^6488delG/HDAC6/GATA3 mediates macrophage polarization and provides a novel immune cell-associated therapeutic strategy targeting IL-10 in EAOC.

Genital tract infection and pelvic surgery contribute to the development of endometriosis

Endometriosis is a multifactorial disease, and inflammation is considered a core pathology. Inflammation related to genital tract infection (GTI) and surgical injury may cause endometriosis. Therefore, we investigated the incidence of endometriosis in women with a recent history of GTI, pelvic surgery, or both. Using the Korean National Health Insurance Service-National Sample Cohort, 20- to 49-year-old women diagnosed with GTI or who underwent pelvic surgeries between 2002 and 2008 were collected and followed up for five years. After excluding women who had already been diagnosed with endometriosis or diseases that may affect endometriosis, a total of 30,336 women were diagnosed with GTI (Study 1), 2894 women who underwent pelvic surgery (Study 2), and 788 women who underwent GTI and pelvic surgery, both (Study 3) were enrolled for each study. The comparison groups in which sociodemographic factors matched for each group were collected. The incidence of endometriosis per 1000 person-year was 5.37, 5.17, and 20.81 in each case group and was significantly higher than each comparison group. A recent history of GTI increased an adjusted hazard ratio (aHR) of 2.29 (1.99-2.63, 95% confidence interval) for the development of endometriosis. The aHRs of pelvic surgery history and the history of both GTI and pelvic surgery were 2.10 and 7.82, respectively. In conclusion, the pelvic inflammation resulting from genital infection and pelvic surgical injury may play a role in developing endometriosis. Active treatment of genital infections and careful surgical procedures to minimize tissue injury may reduce the incidence of pelvic endometriosis.

Diagnosis of pelvic endometriosis: a preliminary study on the added value of R2*MFGRE sequence in magnetic resonance imaging

BACKGROUND

Identifying and locating endometriotic lesions is crucial for preoperative planning, so new magnetic resonance imaging (MRI) techniques are urgently needed to improve the diagnostic sensitivity for pelvic endometriosis.

PURPOSE

To evaluate the feasibility of R2* multiple fast gradient recalled echo (MFGRE) imaging in the diagnosis of pelvic endometriosis.

MATERIAL AND METHODS

A total of 46 patients with suspected endometriosis underwent routine pelvic MRI and R2*MFGRE imaging. Clinical diagnosis was pathologically confirmed one month after MRI examination. Three radiologists who were blinded to the pathological results evaluated the number of ovarian endometriomas (OMAs) and deep infiltrating endometriosis (DIE) lesions using routine MRI and its combination with R2*MFGRE. The diagnostic sensitivity for OMA or DIE using the two examination methods was determined. Two-correlation sample rank-sum tests were used to compare both methods. Additionally, for all lesions, the R2* values were measured and statistically analyzed.

RESULTS

Among 46 patients, 47 OMAs and 30 DIE lesions were found surgically and pathologically confirmed. The diagnostic sensitivity of the routine MRI was 87.2% for OMA and 46.7% for DIE. The diagnostic sensitivity of the routine imaging combined with R2*MFGRE was 100% for OMA and 90% for DIE. The two-correlation sample rank-sum test showed a significant difference between both methods (P<0.01, z = -4.26). The median R2* value was 25.20 (IQR=14) for the OMA group, and 45.21 (IQR=40) for the DIE group. The difference between both groups was statistically significant (P<0.01, z = -4.89).

CONCLUSION

R2*MFGRE imaging, as a supplement to the routine MRI, could improve the diagnostic sensitivity for pelvic endometriosis, especially for DIE.

The role of cytokeratin 19 levels in the determination of endometriosis stages

OBJECTIVE/AIM

Endometrisosis, one of the most common gynecological disease, is characterized by the presence of endometriotic tissue outside of uterine cavity. The development and the validation of a simple blood biomarker specific and sensitive for endometriosis may facilitate the rapid and the accurate diagnosis of the disease and thus early treatment. Cytokeratin expression changes during epithelial differentiation and this expression is important for the modulation and the control of cell cycle regulation, tumor cell motility and apoptosis. Cytokeratin 19 (CK-19) is expressed in most simple epithelial cells and their malignant counterparts. The aim of this study is to investigate serum CK-19 expression levels in patients with endometriosis and to determine the diagnostic role of CK-19 levels in differentiating various stage of endometriosis.

METHODS

Ctytokeratin-19 expression and level were studied in 70 endometriosis patients and 50 volunteers by ELISA and RT-PCR. ROC analysis was performed by comparing all stages with each other and with the control group.

RESULTS

The CK-19 levels were significantly higher in the endometriosis groups than that of the control group by ELISA and RT-PCR. A significant (p < .05) difference was observed in endometriosis patients according to the stages.

CONCLUSION

Based on our data, it suggests that Cytokeratin-19 may have a potential role in the development of endometriosis.

Site-Specific Regulation of Sulfatase and Aromatase Pathways for Estrogen Production in Endometriosis

Endometriosis is a highly prevalent gynecological disease characterized by lesions in different sites. Regulation of specific estrogen pathways may favor the formation of distinct microenvironments and the progression of endometriosis. However, no study has simultaneously evaluated the gene and protein regulation of the main estrogen-synthesizing enzymes in endometriosis. Thus, our goals were to study the relationship between gene and protein expression of aromatase (CYP19A1 or ARO), steroid sulfatase (STS), and hydroxysteroid 17-beta dehydrogenase (HSD17B1) in superficial (SUP), ovarian (OMA), and deep infiltrating (DIE) endometriotic lesion sites as well as in the eutopic endometrium of patients with (EE) and without (control) endometriosis in the same and large cohort of patients. The site-specific expression of these enzymes within different cells (glandular and stromal components) was also explored. The study included 108 patients surgically diagnosed with endometriosis who provided biopsies of EE and endometriotic lesions and 16 disease-free patients who collected normal endometrium tissue. Our results showed that CYP19A1 was detected in all endometriosis tissues and was in higher levels than in control. Unique patterns of the STS and HSD17B1 levels showed that they were most closely regulated in all tissues, with manifestation at greater levels in DIE compared to the other endometriotic lesion sites, OMA and SUP. Gene and protein expression of ARO, STS, and HSD17B1 occurred at different rates in endometriotic sites or EE. The distinctive levels of these estrogen-synthesizing enzymes in each endometriotic site support the hypothesis of a tissue microenvironment that can both influence and be influenced by the expression of different estrogenic pathways, locally affecting the availability of estrogen needed for maintenance and progression of endometriotic lesions.

Urinary Biomarkers for Detection of Clinical Endometriosis or Adenomyosis

Endometriosis or adenomyosis can be clinically diagnosed by ultrasound, symptoms, physical examination, and serum CA125. The urinary markers need to be investigated. The aim of our study was to investigate the urinary markers of clinical endometriosis/adenomyosis, and the correlation of serum CA125 was also studied. From the literature, alpha-1 antitrypsin (A1AT), enolase-1, vitamin D binding protein (VDBP), and CA125 in urine and serum were used in our study and measured by enzyme-linked immunosorbent assays (ELISA). Further clinical correlation and detection performance were evaluated. We enrolled 19 normal controls and 33 patients clinically diagnosed with endometriosis/adenomyosis. There were significant differences between studied patients and normal controls, as follows: serum CA125 (130.91 vs. 19.75 U/mL, p = 0.004); urinary CA125-creatinine ratio (5.591 vs. 0.254 ng/mg, p = 0.028); and urinary VDBP-creatinine ratio (28.028 vs. 7.301 ng/mg, p = 0.018). For diagnostic performances, serum CA125 provided the best results, with an area under curve (AUC) of 0.888 (p = 0.001) and accuracy of 86.5%. Other excellent results were also found using urinary VDBP (AUC 0.841, p = 0.001) and A1AT (AUC 0.722, p = 0.011) creatinine ratio. Using three combined biomarkers, serum CA125, urinary VDBP, and A1AT creatinine ratio, provided good detection power (AUC 0.913, p = 0.001, sensitivity 90.9%, specificity 76.5%). Double urine markers used in combination with VDBP and A1AT creatinine ratio also provided good diagnostic performance (AUC 0.809, p = 0.001, sensitivity 81.8%, specificity 76.5%, accuracy 80%). Further development of non-invasive point-of-care tests using these biomarkers could be a fruitful future endeavor.

Long Intergenic Non-Protein Coding RNA 02381 Promotes the Proliferation and Invasion of Ovarian Endometrial Stromal Cells through the miR-27b-3p/CTNNB1 Axis

Purpose: Catenin Beta 1 (CTNNB1) is a key regulator of cell proliferation and invasion in endometriosis; however, its upstream factor is not clear. Long noncoding RNAs may participate in endometriosis. The aim of this study was to investigate the mechanism of interaction between LINC02381 and CTNNB1 in endometriosis. Method: Screening and validation of RNAs were completed by whole transcriptional sequencing and qRT-PCR. The subcellular localization of LINC02381 was determined by RNA in situ hybridization and nucleo-cytoplasmic separation. Plasmids were transfected for functional experiments. Luciferase assay was used to verify the binding relationship. Results: The expression of LINC02381 and CTNNB1 was significantly increased in ovarian ectopic endometrial tissues (OSAs) and ectopic endometrial stromal cells (ESCs). When LINC02381 was downregulated in ESCs, the expression of CTNNB1, metallopeptidase 9 (MMP9) and cyclinD1, as well as ESCs invasion and proliferation, decreased. LINC02381 was mainly present in the cytoplasm of ESCs, indicating that it may act as a competitive endogenous RNA. Bioinformatic analysis revealed that microRNA-27b-3p (miR-27b-3p) is a downstream target of LINC02381. miR-27b-3p decreased in OSAs and ESCs. Moreover, when miR-27b-3p was upregulated in ESCs, the expression of CTNNB1, MMP9 and cyclinD1, as well as the invasion and proliferation ability of ESCs, were reduced. Additionally, rescue experiments demonstrated that the expression of CTNNB1, MMP9 and cyclinD1, as well as the invasion and proliferation ability, were significantly increased in the group transfected with both sh-LINC02381 and a miR-27b-3p inhibitor. Conclusion: LINC02381 upregulated CTNNB1 by adsorbing miR-27b-3p, causing increased proliferation and invasion of ESCs.

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background

Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning.

Objective

To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI).

Methods

Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors.

Results

Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis.

MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants.

Conclusion

The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

The efficiency of susceptibility-weighted MRI in the differentiation of endometriomas from haemorrhagic ovarian cysts

OBJECTIVES

The aim of the study was to investigate the efficiency of susceptibility-weighted magnetic resonance (MR) imaging (SWIs) in differentiating endometriomas from haemorrhagic ovarian cysts.

MATERIALS AND METHODS

Between July 2017 and January 2019, 89 ovarian cystic lesions (57 endometriomas and 32 haemorrhagic cysts) that were identified as complicated cystic lesions on ultrasonography (US) and underwent lower abdominal MRI with susceptibility weighting were retrospectively evaluated. Final diagnoses were obtained with surgical pathological correlation and radiological-clinical follow-up. Two radiologists blinded to the final diagnoses retrospectively reviewed the images in consensus. The signal intensity on T1- and T2-weighted images and curved linear or punctate signal void areas on SWI were noted for the presence of lesions.

RESULTS

Forty of the 57 endometriomas demonstrated the defined MRI criteria, including a cystic hyperintensity on T1-weighted images and hypointensity on T2-weighted images. The remaining 17 lesions did not demonstrate these criteria on conventional MR images. SWI showed punctate or curved linear signal void areas in 53 of 57 endometriomas (92.9%) and none of the haemorrhagic cysts. The sensitivity, specificity and accuracy of SWI in differentiating endometrioma from haemorrhagic cyst were 92.9%, 100.0%, and 95.5%, respectively.

CONCLUSIONS

The addition of the SWI sequence to conventional MRI can help distinguish endometriomas from haemorrhagic ovarian cysts.

Brief Review of Endometriosis and the Role of Trace Elements

Endometriosis is a chronic, estrogen-dependent, inflammatory condition that is defined as the presence of endometrial glands and stroma outside the uterine cavity. Despite the progress in research into the mechanisms leading to the development of endometriosis, its cause has not yet been established. It seems to be possible that the formation of oxidative stress may be one of the main causes of the development of endometriosis. There is much research that studies the potential role of trace elements in the appearance of endometrial-like lesions. Most studies focus on assessing the content of selected trace elements in the blood, urine, or peritoneal fluid in women with endometriosis. Meanwhile, little is known about the content of these elements in endometrial-like implants, which may be helpful in developing the theory of endometriosis. Investigations that are more comprehensive are needed to confirm a hypothesis that some trace elements play a role in the pathomechanism of endometriosis.

Rectal endometriosis presenting as toxic megacolon

Background

The bowel is the most common site of extragenital endometriosis, with involvement of the locoregional sigmoid colon and anterior rectum seen most often. The clinical presentation varies depending on how soon patients seek medical care, thus requiring changes in management strategies. Endometriosis can cause a life-threatening surgical emergency with progressive obliteration of the bowel lumen leading to obstruction and late complications including toxic megacolon and transmural necrosis.

Case presentation

We report the case of a 41-year-old woman presenting with an acute abdomen and complete large bowel obstruction complicated by sepsis and toxic megacolon. The patient underwent emergency total colectomy with ileostomy. Medical history was significant for chronic, vague, and episodic lower abdominal pain self-medicated with herbal tea and laxatives. Pathologic examination demonstrated colonic endometriosis within the bowel wall as the cause of obstruction, ischemia, and transmural necrosis.

Conclusions

Although a rare clinical entity, this case highlights two important points. First, it demonstrates the value of performing proper and complete clinical work up to rule out or in all possible causes of colonic obstruction, including intestinal endometriosis. Second, it suggests a potential benefit of a formalized multidisciplinary approach, including surgery, in the management of medically unresponsive endometriosis. In conclusion, this case shows that endometriosis can cause life-threatening colonic obstruction in women of childbearing age. Prompt early intervention is warranted, particularly when obstruction is only partial and ischemia has not supervened, to conceivably prevent the development of a toxic megacolon requiring colectomy and avoid late complications.

Thoracic endometriosis syndrome in Nigeria: a single-centre experience

OBJECTIVES

Thoracic endometriosis syndrome (TES) is the presence of functional endometrial tissue in or around the lung. There seem to be differences in the clinical presentation of this condition among Nigerian patients. We aim to study the clinical presentation and management outcome of TES in our centre.

METHODS

This is an analysis of consecutive patients with TES treated over a 5-year period and followed up for 6 months to 5 years. Information collected included the gynaecological history, clinical presentation, causes of misdiagnosis, modalities of treatment and outcome.

RESULTS

Twenty-three patients with TES aged between 24 and 45 years (median 32 years) were treated. Severe dysmenorrhoea was a prominent symptom in 91.3% of cases (median dysmenorrhoea score 8) and was uninfluenced by the marital status (P = 0.522). The patients usually presented with massive or recurrent haemothorax associated with massive ascites [16/23 (69.5%) of cases (P = 0.0006)]. The right side alone was involved in 21 cases and 1 patient had catamenial haemoptysis as a part of her symptoms, even though there was bronchial bleed at bronchoscopy in 6 patients. In 40%, tuberculosis was the misdiagnosis. Diagnosis was established histologically in 18/23 (78.3%) of the cases. Treatment was multimodal and multidisciplinary with notable macroscopic lesions in 77.8% of the patients that had surgery.

CONCLUSIONS

TES is not an uncommon lesion. Presentation with massive haemothorax is usually associated with massive ascites. A large percentage of such have pleural and diaphragmatic lesions that require surgical treatment. The ascites may be refractory to treatment requiring repeated paracentesis.

Thoracic Endometriosis: Still a Diagnostic Dilemma

We report a case of thoracic endometriosis syndrome (TES) presenting with a five-week history of progressive shortness of breath, cough, and wheezing. Investigations revealed a large, right-sided pleural effusion that was bloody on aspiration. A diagnosis of TES was one of the diagnoses entertained and eventually confirmed on finding evidence of pelvic endometriosis on laparotomy. The management of TES should include hormonal therapy, surgical management, or a combination of both.

Endometriosis of the Small Bowel: A Diagnostic Enigma

Endometriosis refers to the implantation and proliferation of endometrial tissue outside the uterus. Small bowel endometriosis is an uncommon location for endometrial deposits and when present, it can pose diagnostic difficulty. Here, we present a case of a 50-year-old female with small bowel endometriosis who suffered from recurrent attacks of colicky abdominal pain for few months. Her cross-sectional investigations remained largely inconclusive. Ultimately, she underwent diagnostic laparoscopy which was diagnostic and therapeutic.

Two Cases of Endometriosis in the Cecum Detected by Contrast-enhanced Computed Tomography with Air/Carbon Dioxide Insufflation

We herein report two patients with endometriosis in the cecum. Both patients presented with a protruding, subepithelial tumor on colonoscopy and were diagnosed with cecal endometriosis after surgical resection. It is notable that the cecal lesions were not initially identified on computed tomography (CT), while CT colonography with air/carbon dioxide insufflation resulted in the detection of the cecal tumor. These cases highlight the possibility of false-negative results on conventional CT in patients with cecal endometriosis. We consider CT colonography with air/carbon dioxide insufflation useful for detecting cecal tumors in such cases.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study

INTRODUCTION

Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed.

METHODS

We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE.

RESULTS

50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients.

CONCLUSION

The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Thoracic endometriosis presented as catamental hemoptysis: a case series of a rare disease

OBJECTIVE

Thoracic endometriosis syndrome (TES) is a rare disease in which a functioning endometrial tissue is observed in the pleura, lung, parenchyma, airways, and/or diaphragm. The optimal management of this disease remains a matter of debate. We aimed to report TES cases and their effective hormonal treatment and management.

METHODS

In this retrospective study, women presented as catamenial hemoptysis (CH) diagnosed with thoracic endometriosis were included. The main outcome of measure was cessation or recurrence of the clinical manifestations of thoracic endometriosis.

RESULTS

The mean onset age of the 14 patients was 30.21 ± 5.40 years. CH was characteristic symptom of these patients. All patients underwent chest computed tomography (CT) scan during menstruation and 2 or 3 weeks after menstruation, which showed the obvious shrinking or disappearance of the lesions. All of the patients were given Gonadotropin releasing hormone agonists (GnRHa) for 3 to 6 months, eleven of them were administered with combined oral contraceptives (COC) cyclically after GnRHa. The median follow-up duration was 24 months. Hemoptysis recurrence was observed in one patient.

CONCLUSIONS

CH is a rare clinical entity of thoracic endometriosis, the change of CT images during and after menstruation or the response to GnRHa were helpful for accurate diagnosis. Hormonal treatment with GnRHa followed by COCs cyclically could be employed for efficient management of thoracic endometriosis.

The impact of phthalate on reproductive function in women with endometriosis

BACKGROUND

Endometriosis is a common gynecological condition in which stromal or glandular epithelium is implanted in extrauterine locations. Endometriosis causes detrimental effects on the granulosa cells, and phthalate interferes with the biological and reproductive function of endometrial cells at a molecular level.

METHODS

This article retrospectively reviewed the studies on phthalate exposure and its relationship with endometriosis. A literature search was performed for scientific articles using the keywords "phthalate and endometriosis," "endometriosis and granulosa cells," "phthalate and granulosa cells," and "phthalates and endometrial cells."

RESULTS

Endometriosis can affect cytokine production, steroidogenesis, cell cycle progression, expression of estrogen receptor-α (ER-α)/progesterone receptor (PR), and cause endoplasmic reticulum stress, senescence, apoptosis, autophagy, and oxidative stress in the granulosa cells. Mono-n-butyl phthalate (MnBP) alters the expression of cytokines, cell cycle-associated genes, ovarian stimulation, steroidogenesis, and progesterone production. Several in vitro studies have demonstrated that phthalate caused inflammation, invasion, change in cytokines, increased oxidative stress, viability, resistance to hydrogen peroxide, and proliferation of endometrial cells.

CONCLUSION

This might provide new insights about the impact of phthalate on the pathogenesis of endometriosis and its consequences on the ovarian function.

S100A7 promotes the development of human endometriosis by activating NF-κB signaling pathway in endometrial stromal cells

Endometriosis (EM) is a chronic inflammatory disease affecting women aged between 23 and 42 years with a prevalence of 6%-10%. S100A7, a member of the S100 protein family, has been implicated in promoting inflammation. However, the role of S100A7 in EM and its underlying mechanism remain to be elucidated. S100A7 was silenced or overexpressed in primary endometrial stromal cells (ESCs). Cell proliferation was determined using a Cell Counting Kit-8. Cell cycle/apoptosis was monitored using a flow cytometer. Cell invasion was studied by a Transwell assay. Quantitative RT-PCR and Western blot analyses were used to evaluate gene expression. S100A7 and NF-κB expression is increased in both endometriotic tissue and ESCs from women with EM. The expression of S100A7 is correlated with the expression of NF-κB. S100A7 knockdown inhibits ESCs proliferation, cell cycle progression, cell invasion, and inflammation, but promotes cell apoptosis in an NF-κB dependent manner. In contrast, S100A7 overexpression demonstrated an inverse effect. S100A7 is increased in both endometriotic tissue and ESCs from women with EM. S100A7 overexpression contributes to EM through increasing ESCs proliferation, cell cycle progression, cell invasion, and inflammation, and inhibiting cell apoptosis in the NF-κB dependent manner. These findings highlight the importance of S100A7/NF-κB signaling in EM and provide new insights into therapeutic strategies for EM.

"There's a problem, now what's the solution?": suggestions for technologies to support the menopausal transition from individuals experiencing menopause and healthcare practitioners

OBJECTIVE

To elicit novel ideas for informatics solutions to support individuals through the menopausal transition. (Note: We use "individuals experiencing menopause" and "experiences" rather than "symptoms" when possible to counter typical framing of menopause as a cisgender women's medical problem.).

METHODS

A participatory design study was conducted 2015-2017 in the Western US. Two sessions were held with individuals experiencing menopause recruited from the general public; and 3 sessions with healthcare practitioners (HCPs) including nurses, physicians, and complementary and integrative health (CIH) practitioners were held. Participants designed technologies addressing informational needs and burdensome experiences. HCPs reflected on designs from participants experiencing menopause. Directed content analysis was used to analyze transcripts.

RESULTS

Eight individuals experiencing menopause (n = 4 each session) and 18 HCPs (n = 10 CIH, n = 3 nurses, n = 5 physicians) participated. All participants provided ideas for solution purpose, hardware, software, features and functions, and data types. Individuals experiencing menopause designed technologies to help understand and prevent burdensome menopause experiences. HCPs designed technologies for tracking and facilitating communication. Compared to nurses and physicians, CIH practitioners suggested designs reframing menopause as a positive experience and accounted for the complex lives of individuals experiencing menopause, including stigma; these ideas corresponded to comments made by participants experiencing menopause. Participants from both populations were concerned about data confidentiality and technology accessibility.

CONCLUSIONS

Participant generated design ideas included novel ideas and incorporated existing technologies. This study can inform the development of new technologies or repurposing of existing technologies to support individuals through the menopausal transition.

Thoracic Endometriosis: a Clinical Review and Update of Current and Evolving Diagnostic and Therapeutic Techniques

Purpose of Review

The goal of this review is to provide a comprehensive understanding of the pathophysiology, clinical presentation, diagnostic workup, and clinical management of thoracic endometriosis (TE), as well as highlight our personal experience with TE workup and management.

Recent Findings

TE can present in a wide range of clinical manifestations. Without high clinical suspicion, diagnosis can be delayed. Since no specific laboratory testing is available, diagnosis is often based on careful history taking, imaging, and direct visualization of endometrial lesions through video-assisted thoracoscopic surgery (VATS). Medical thoracoscopy (MT) may also be a useful tool in the diagnostic workup of TE.

Summary

The diagnosis and management of TE require a multidisciplinary approach and a high index of clinical suspicion. While VATS remains the gold standard for diagnosis, we share our experience using MT to diagnose and manage a case of TE-related hemothorax.

Determination of PD-1 expression in peripheral blood cells in patients with endometriosis

In patients with endometriosis, ectopic endometrial tissues can escape from immune system control and survive in other tissues. The pathophysiology of endometriosis is still not fully understood. In this study, we aimed to clarify the pathophysiology of endometriosis, which is thought to be a benign but infiltrative cancer type, which has many similarities with cancer biology by determining PD-1 expression in patients with endometriosis. In this study, n = 73 cases who underwent surgery or examination at the Obstetrics and Gynecology Clinic of Sivas Cumhuriyet University Faculty of Medicine and diagnosed as endometriosis in the biopsy material taken with the pre-diagnosis of endometriosis constituted the patient group. The control group consisted of n = 64 healthy subjects without concomitant malignancy or chronic inflammatory disease. Venous whole blood samples were obtained from the study groups. PD-1 and PD-L1 levels were determined by the ELISA method from serum and plasma samples. PD-1 gene expression level was determined by RT-PCR. The PD-1 level was found to be approximately 350 ± 150 ng/L and 45 ± 17 ng/L in endometriosis and control group, respectively. While the PD-L1 level was approximately 760 ± 108 ng/L in the patients, this level was 140 ± 14 ng/L in the controls. According to the RT-PCR results, the expression of the PD-1 gene 10 times higher compared to the controls. Conclusion: The identified increase of PD-1 levels and gene expression in endometriosis groups show that immunotherapy may be used in the treatment of endometriosis.

Markedly increased risk of malignancies in women with endometriosis

OBJECTIVE

To assess the cancer risk in a cohort of women with newly diagnosed endometriosis.

METHODS

This retrospective, nationwide, population-based cohort study utilized data from the 10-year claims database of the Korean National Health Insurance from January 2008 to December 2018. Patients diagnosed with endometriosis between 2010 and 2013 were included; those who underwent appendectomy but were not diagnosed with endometriosis during the study period served as controls. No participant was diagnosed with cancer before enrollment. Cancer diagnoses according to the International Classification of Diseases, 10th revision, were compared between the two groups. Cancer occurrence in both groups was identified according to the diagnostic codes for different organ sites.

RESULTS

Altogether, 179,865 patients with endometriosis and 87,408 controls were analyzed, and the incidence rates of cancer were 644.3 and 543.8 per 100,000 person-years, respectively. Patients with endometriosis had a significantly increased overall cancer risk (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.28-1.40; p < 0.001) than controls after adjusting for age, insurance type, and comorbidities. They had significantly increased uterine (HR, 4.59; 95% CI, 3.56-5.91; p < 0.001), ovarian (HR, 2.51; 95% CI, 1.99-3.16; p < 0.001), cervical (HR, 1.84; 95% CI, 1.49-2.28; p < 0.001), breast (HR, 1.44; 95% CI, 1.31-1.58; p < 0.001), and thyroid cancer (HR, 1.34; 95% CI, 1.24-1.45; p < 0.001) risk. Median age at diagnosis was <50 years for all cancer types.

CONCLUSIONS

Endometriosis was associated with an increased cancer risk, specifically uterine, ovarian, cervical, breast, and thyroid cancers, suggesting that effective cancer screening for early detection of malignancies in women should be implemented in those with endometriosis.

Renal endometriosis mimicking a renal tumor in a pregnant patient

Renal endometriosis, if progressed is a serious localization of disease burden that can lead to urinary tract obstruction, with subsequent hydronephrosis leading to potential kidney loss. Diagnosis is elusive and relies heavily on clinical suspicion as endometriosis can occur with both minimal and extensive disease. Management technique varies but the goal is to salvage renal function and disease burden.

Decidualization of an ovarian endometrioma complicated by a sigmoid fistula during pregnancy: a case report

BACKGROUND

During pregnancy, the discovery of adnexal masses remains frequent. Such masses are mostly benign. Ovarian endometrioma is a rare etiology. The diagnosis may be difficult in some situations, such as decidualization. It may be asymptomatic or result in complications for which magnetic resonance imaging is needed.

CASE PRESENTATION

We describe an unusual case of decidualization of an ovarian endometrioma complicated by a sigmoid fistula during a 7-week, 1-day pregnancy in a Arabic patient aged 38 years who developed acute pelvic pain with fever. She had a medical history of unexplored secondary dysmenorrhea. The diagnosis was suspected on the basis of magnetic resonance imaging findings. The management was based on surgery, during which exploration revealed a mass at the expense of the left ovary being very adherent and fistulized to the sigmoid. We performed adnexectomy followed by digestive ostomy. The result of pathological study with immunohistochemistry led to a diagnosis of decidualization of an ovarian endometrioma altered by infection.

CONCLUSION

Decidualization of an ovarian endometrioma can lead sometimes to unexpected complications. The decision to provide surgery must be made with caution without delaying treatment in the event of a deep suspicion of malignancy and/or complication. The particular and exceptional complication discovered in our patient is the fistulization to the sigmoid.

Genetic variants in the nucleotide excision repair genes are associated with the risk of developing endometriosis

Endometriosis is a major health issue among women of reproductive age. However, its etiology has not yet been completely understood. We investigated 10 single nucleotide polymorphisms from six novel nucleotide excision repair genes and the susceptibility to endometriosis. A total of 153 patients with endometriosis were recruited during 2000-2010 from central Taiwan. Pathological confirmation was necessary for all patients, and exclusion criteria included the presence of leiomyoma, adenomyosis, or cancer of the uterine, cervix, or ovary and a prescription of hormone therapy. Furthermore, a total of 636 age-matched individuals without endometriosis were recruited during the same time period from central Taiwan. The polymerase chain reaction coupled with restriction fragment length polymorphism methodology was applied for genotyping. The multivariate logistic regression analysis showed that subjects carrying the ERCC1 rs11615 TT (OR = 2.04, 95% CI = 1.36-3.41), ERCC2 rs1799793 AA (OR = 1.86, 95% CI = 1.14-3.11), and ERCC6 rs2228528 AA genotypes (OR = 1.79, 95% CI = 1.13-2.83) exhibited significantly increased risks of developing endometriosis compared with their counterparts carrying the wild-type genotypes. This study suggests that certain single nucleotide polymorphisms of nucleotide excision repair genes excision repair cross-complementation group 1 (ERCC1, ERCC2, and ERCC6) predispose women to the development of endometriosis.

Global, regional, and national endometriosis trends from 1990 to 2017

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus that causes pelvic pain and infertility. We used the Global Burden of Disease Study (GBD) 2017 to comprehensively analyze the burden of endometriosis between 1990 and 2017. DisMod-MR 2.1 was used to estimate the incidence and prevalence in some countries/territories with sparse or absent data. Annual percent changes were calculated to quantify endometriosis burden estimate trends. Furthermore, the sociodemographic index (SDI) was used to assess the relationship between endometriosis burden estimates and development level. Between 1990 and 2017, endometriosis age-standardized incidence and prevalence and years of life lived with disability (YLDs) decreased globally by 0.21% (95% confidence interval (CI): -0.23% to -0.20%), 0.29% (95% CI: -0.31% to -0.28%), and 0.28% (95% CI: -0.30% to -0.27%) per year, respectively. Apart from the high SDI quintiles with increasing trends of endometriosis incidence rate, prevalence rate, and YLDs, decreasing trends were observed in all SDI quintiles for all burden estimates. In conclusion, it appears that all endometriosis burden estimates have decreased globally between 1990 and 2017. However, these results are based on limited data and highlight the need for increased data collection on the incidence and prevalence of endometriosis.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Abdominal and perineal scar endometriosis: Retrospective study on 40 cases

OBJECTIVE(S)

Abdominal and perineal scar endometriosis usually develop in association with a prior surgical scar. The purpose of the study was to detect and review patients' characteristics of these women over a long period.

STUDY DESIGN

We retrospectively review the clinical records of 860 women with endometriosis between 1989 and 2019. Data were collected and analyzed from medical and pathological reports of 40 patients with abdominal and perineal scar endometriosis.

RESULTS

26 patients (3,0 %) were detected in the abdominal wall endometriosis group (AWE) (mean age 36,5 ± 3,4 years) and 14(1,6 %) cases in the perineal endometriosis (PE) group (32,5 ± 2,4 years), respectively. We observed that 92,3 % of women with AWE had undergone at least 1 cesarean section. Moreover, the majority of patients presented with abdominal pain (77, 0 %) and sensation of a mass (96,2 %). 15,4 % of cases had concurrent pelvic endometriosis and the recurrent rate of the disease was 15,4 %. All cases with perineal scar endometriosis were multiparous and delivered vaginally with episiotomy. 92,8 % of patients presented with cyclical pain and swelling. 3 cases suffered from perineal endometriosis combined with pelvic endometriosis. There was a recurrence of perineal endometriosis in 2 women (14,2 %). Surgical excision was the standard treatment of this condition and tissue biopsy confirmed the diagnosis.

CONCLUSIONS

Abdominal wall and perineal scar endometriosis are rare, multifactorial entities which are associated mainly with cesarean section and vaginal episiotomy. Clinicians should be aware of these conditions among all women of reproductive age presenting with cyclic or non-cyclic pain and swelling at the incision sites.

Endometriosis in pregnancy

Endometriosis constitutes the presence of ectopic endometrial glands and stroma outside the uterine endometrium, which is hormonally responsive and responds to pregnancy hormones as well. Decidualization is a physiologic process, where the normal endometrium readies itself for optimal accommodation of a pregnancy. A similar hormonal response can be seen with ectopic endometrium as well. As such, ovarian endometriomas and deep endometriosis implants can undergo decidualization. Overall, the progestational state of pregnancy favors an improvement in endometriosis, however, decidualization can lead to findings that can lead to increased size of endometriomas and deep infiltrative endometriosis implants, changes in imaging appearance and even complications, such as spontaneous hemoperitoneum in pregnancy. Awareness of this process can help prevent misdiagnosis of decidualized endometriomas as ovarian malignancy and recognize common imaging manifestations of hormonal effects of pregnancy on endometriosis.

Exposure to Mono-n-Butyl Phthalate in Women with Endometriosis and Its Association with the Biological Effects on Human Granulosa Cells

To study the association between urinary phthalate metabolite levels, endometriosis, and their effects on human granulosa cells, we recruited patients who underwent laparoscopy to confirm endometriosis (n = 123) and control patients (n = 78). Liquid chromatography–tandem mass spectrometry was used to measure the following five urinary phthalate metabolites: mono-n-butyl phthalate (MnBP), mono(2-ethylhexyl) phthalate, monobenzyl phthalate, mono(2-ethyl-5-oxo-hexyl) phthalate, and mono(2-ethyl-5-hydroxyhexyl) phthalate. Urinary MnBP levels were higher in patients with endometriosis than in controls after multivariable logistic regression including the number of deliveries, body mass index, and use of medicine as covariables. MnBP correlates with other phthalate metabolites. Previous studies found that endometriosis was a detrimental condition for granulosa cells. In our study, we observed whether MnBP affected granulosa cells. MnBP treatment altered the gene expression of BIRC5, BUB1B, CDC20, cyclin B1, IL-1β, TNF-α, inhibin-B, StAR, and P450ssc and attenuated the ratio of the mitochondrial membrane potential in human granulosa cells. Moreover, MnBP decreased the expression of the anti-Mullerian hormone. These findings suggest that MnBP concentration is associated with endometriosis and may affect the health and steroidogenesis of human granulosa cells.

Endometriosis-associated Ovarian Cancer is a Subset With a More Favorable Outcome and Distinct Clinical-pathologic Characteristics

There is a controversy about whether endometriosis-associated ovarian cancer (EAOC) might represent a different entity from the corresponding ovarian cancer occurring de novo, in the absence of endometriosis. This study investigated the clinical-pathologic characteristics and outcome of EAOC compared with other ovarian carcinomas that are not associated with endometriosis (non-EAOC) in a large cohort. Seven hundred two patients meeting the inclusion criteria were further subclassified as group I when patients had ovarian carcinoma associated with or arising within endometriosis (EAOC) and group II when patients had non-EAOC. Age, gross features, histologic type, International Federation of Gynecology and Obstetrics stage, and disease-free survival (DFS) were compared between the groups. One hundred sixty-eight (23.9%) patients had EAOC, whereas 534 (76.1%) patients had non-EAOC. EAOCs were mostly endometrioid and clear cell type. Patients with EAOC were younger, present early, and had a lower rate of recurrence when compared with patients with non-EAOC, P<0.001. Patients with EAOC had longer DFS time, 51.9 mo (95% confidence interval, 44.9-58.8) versus 30.5 mo (95% confidence interval, 27.7-33.3) in non-EAOC patients. The 5 yr Kaplan-Meier estimate of DFS rate was 70% in 166 patients of group I and was 39.3% in 532 patients of group II, P<0.001. On multivariate analysis, International Federation of Gynecology and Obstetrics staging, histologic type, and treatment were the only significant factors affecting the hazards of recurrence. Patients with tumors associated with endometriosis are usually, younger, present early, have lower rate of recurrence, longer DFS, and their tumors are of lower grade and are more likely endometrioid or clear cell carcinoma.

Epigenetic control of embryo-uterine crosstalk at peri-implantation

Embryo implantation is one of the pivotal steps during mammalian pregnancy, since the quality of embryo implantation determines the outcome of ongoing pregnancy and fetal development. A large number of factors, including transcription factors, signalling transduction components, and lipids, have been shown to be indispensable for embryo implantation. Increasing evidence also suggests the important roles of epigenetic factors in this critical event. This review focuses on recent findings about the involvement of epigenetic regulators during embryo implantation.

Multiplex analysis of 40 cytokines do not allow separation between endometriosis patients and controls

Endometriosis is a common gynaecological condition characterized by severe pelvic pain and/or infertility. The combination of nonspecific symptoms and invasive laparoscopic diagnostics have prompted researchers to evaluate potential biomarkers that would enable a non-invasive diagnosis of endometriosis. Endometriosis is an inflammatory disease thus different cytokines represent potential diagnostic biomarkers. As panels of biomarkers are expected to enable better separation between patients and controls we evaluated 40 different cytokines in plasma samples of 210 patients (116 patients with endometriosis; 94 controls) from two medical centres (Slovenian, Austrian). Results of the univariate statistical analysis showed no differences in concentrations of the measured cytokines between patients and controls, confirmed by principal component analysis showing no clear separation amongst these two groups. In order to validate the hypothesis of a more profound (non-linear) differentiating dependency between features, machine learning methods were used. We trained four common machine learning algorithms (decision tree, linear model, k-nearest neighbour, random forest) on data from plasma levels of proteins and patients’ clinical data. The constructed models, however, did not separate patients with endometriosis from the controls with sufficient sensitivity and specificity. This study thus indicates that plasma levels of the selected cytokines have limited potential for diagnosis of endometriosis.

Endometriosis, the great imitator - a successful case of fertility preservation in a woman receiving sterilizing treatment due to a diagnosis of rectosigmoid carcinoma

Bowels are the most common site of extrapelvic endometriosis. Still, colonic endometriosis often presents a diagnostic challenge, mimicking a broad spectrum of diseases including primary colonic malignancy. For women of fertile age, the consequences of endometriosis being misdiagnosed as colorectal cancer may include loss of fertility. We hereby present a case of endometriosis mimicking rectosigmoid adenocarcinoma in a young woman, where fertility preservation prior to the start of antineoplastic treatments turned out to be of crucial importance for the woman's future attempts to achieve a pregnancy and livebirth.

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.

Validation of Laser Capture Microdissection Protocol in Endometriosis Studies

Background and Objectives: The presence of endometrial-like tissue outside the uterine cavity is a key feature of endometriosis. Although endometriotic lesions appear to be histologically quite similar to the eutopic endometrium, detailed studies comparing both tissues are required because their inner and surrounding cellular arrangement is distinct. Thus, comparison between tissues might require methods, such as laser capture microdissection (LCM), that allow for precise selection of an area and its specific cell populations. However, it is known that the efficient use of LCM depends on the type of studied tissue and on the choice of an adequate protocol. Recent studies have reported the use of LCM in endometriosis studies. The main objective of the present study is to establish a standardized protocol to obtain good-quality microdissected material from eutopic or ectopic endometrium. Materials and Methods: The main methodological steps involved in the processing of the lesion samples for LCM were standardized to yield material of good quality to be further used in molecular techniques. Results: We obtained satisfactory results regarding the yields and integrity of RNA and protein obtained from LCM-processed endometriosis tissues. Conclusion: LCM can provide more precise analysis of endometriosis biopsies, provided that key steps of the methodology are followed.

Recurrent pleural effusion and pain in the shoulder in women of reproductive age could have a gynecological cause: case series

Background

Endometriosis is a benign disorder defined as the presence of endometrial glands and stroma outside of the uterine cavity. It has been estimated that approximately 10% of the women of reproductive age and 30–50% of the women with infertility are affected.

Case presentation

We report two nulliparous patients with recurrent pleural effusion and pain in the right shoulder highly suspicious for thoracic endometriosis syndrome (TES).

Conclusion

The objective of this study was to present patients with unusual symptoms related to gynecological disease. The second aim was to show our single institution experience as a second level hospital in terms of treatment and diagnosis of TES and diaphragmatic endometriosis.