The Risk of Epithelial Ovarian Cancer of Women With Endometriosis May be Varied Greatly if Diagnostic Criteria Are Different: A Nationwide Population-Based Cohort Study

Ovarian remnant syndrome with paraintestinal ovarian serous cystadenofibroma arose 30 years after bilateral salpingo-oophorectomy: A case report

RATIONALE

Ovarian cystadenofibroma is a relatively rare benign ovarian tumor. Ovarian remnant syndrome (ORS) is a rare complication of bilateral salpingo-oophorectomy (BSO). We report a rare case of ORS with paraintestinal ovarian serous cystadenofibroma that developed 30 years after total abdominal hysterectomy and BSO in a 73-year-old woman.

PATIENT CONCERNS

A 73-year-old woman complained of long-term lower abdominal discomfort.

DIAGNOSIS

She was diagnosed with a cystic lesion in the lower abdomen on transabdominal ultrasonography. Further diagnostic imaging and laboratory tests could not exclude a diagnosis of malignancy.

INTERVENTIONS

The patient underwent laparoendoscopic single-site surgery. We found one cystic lesion 5 cm in size with multiple septa that was adhered to the small bowel. We consulted a general surgeon for tumor resection. Dissection was performed and the specimen was then removed from the umbilical wound.

OUTCOMES

Histopathological examination revealed an ovarian serous cystadenofibroma. The postoperative recovery was uneventful.

LESSONS

Patients with lower abdominal pain after a previous hysterectomy and BSO should be examined with transabdominal sonography for ORS.

Repurposing gestrinone for tumor suppressor through P21 reduction regulated by JNK in gynecological cancer

Endometriosis has been shown to increase the risk of gynecological cancers. However, the effect of gestrinone, a clinical endometriosis drug, on gynecological cancers remains unclear. This study aimed to understand the effect of gestrinone on gynecological cancers. A retrospective study was conducted using the Longitudinal Health Insurance Database 2000 of the Taiwan National Health Insurance Research Database (NHIRD) to observe the risk of gynecological cancers. Medication records from the Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital CSMUH and cancer records from the Taiwan Cancer Registry were collected to analyze the correlation between gestrinone use and gynecological cancers. Subsequently, human cell lines were used to investigate the effect of gestrinone on gynecological cancers. A total of 8330 endometriosis patients were enrolled, and analyses revealed that endometriosis patients had a higher risk of developing ovarian and endometrial cancer. However, the rate of cervical cancer was not statistically different (P = 0.249). Analyses of both the NHIRD and CSMUH databases revealed that gestrinone may reduce the risk of gynecological cancer. Cellular experiments verified the anticancer effects of gestrinone, which effectively and specifically inhibited the growth of HeLa cervical cancer cells, decreased P21 expression via JNK phosphorylation, and induced apoptosis. Combining the results of clinical database analysis and cell experiments, our findings prove that gestrinone has the potential to protect against cancer through regulation of the JNK-P21 axis. Repurposing the anticancer efficacy of gestrinone may be a strategy for targeted therapy in the future.

Association Between Endometriosis and Prognosis of Ovarian Cancer: An Updated Meta-Analysis

Objective

Increased risk of ovarian cancer (OC) among endometriosis patients has been proposed. However, the association between endometriosis and prognosis of OC remains controversial. This study evaluated whether endometriosis had influence on the survival outcomes of OC through a meta-analysis.

Methods

Relevant studies were retrieved from PubMed, Embase, and Web of Science databases and were evaluated using the Newcastle-Ottawa Quality Assessment Scale. Effect size was presented as hazard ratio (HR) and 95% confidence interval (CI). Heterogeneity test evaluation was performed using Cochran’s Q test and I2 statistics. Publication bias was determined using Egger’s test. Statistical analysis was performed using Stata 12.0 software.

Results

Twenty-one studies involving 38641 patients were included. For the total OC, there were significant differences in overall survival (OS) [HR (95% CI)=0.67 (0.55, 0.80), P<0.001] and progression-free survival (PFS) [HR (95% CI)=0.58 (0.42, 0.81), P=0.001] between endometriosis-associated ovarian cancer (EAOC) and non-EAOC patients in the random-effects models (P<0.05). For ovarian clear cell cancer, there were significant differences in terms of OS [HR (95% CI)=0.63 (0.48, 0.83), P=0.001] and PFS [HR (95% CI)=0.67 (0.52, 0.87), P=0.002] between EAOC and non-EAOC patients in the fixed-effects models (P>0.05). Subgroup analysis suggested no significant differences between EAOC and non-EAOC in OS and PFS in the univariate analysis per subgroup, and PFS in the American subgroup (P>0.05).

Conclusion

EAOC patients tended to have better OS and PFS than non-EAOC patients. Conducting higher quality prospective cohort studies with large sample sizes is recommended to confirm the authenticity of the current study’s results.

Systematic Review Registration

https://inplasy.com/inplasy-2022-3-0109/.

Fibroblast growth factor receptor 2 promotes the proliferation, migration, and invasion of ectopic stromal cells via activation of extracellular-signal-regulated kinase signaling pathway in endometriosis

Endometriosis is defined as the presence of endometrial tissues with cancer-like features in extrauterine locations. Fibroblast growth factor receptor 2 (FGFR2) is a tyrosine kinase that is involved in cancer pathogenesis. This study aimed to determine the role of FGFR2 in endometriosis. A total of 29 pairs of ectopic and eutopic endometrial tissues were collected from women with endometriosis. Endometrial tissues from women with hysteromyomas were considered as normal controls. Primary ectopic stromal cells (ESCs) were isolated from the ectopic endometrium. The role of FGFR2 in ESCs was assessed using immunohistochemistry, polymerase chain reaction, cell counting kit-8 assay, EdU staining, flow cytometry, transwell assay, and western blotting. The following signaling pathways were detected using bioinformatic analysis and confirmed in vitro. By searching the GSE171154, GSE86543, and GSE77182 datasets, FGFR2 was identified as an upregulated overlapping gene in endometriosis. Compared to eutopic and normal endometria, FGFR2 was highly expressed in ectopic tissues. Transfection of primary ESCs with FGFR2 small interfering RNA (siRNA) repressed the viability and proliferation of cells and induced apoptosis. FGFR2 siRNA inhibited the migration, invasion, and transforming growth factor-β1-triggered epithelial-mesenchymal transition (EMT). Extracellular signal-regulated kinase (ERK) signaling was found to be a downstream signaling pathway for FGFR2. The ERK1/2 inhibitor PD98059 was found to reverse the promoting effects of FGFR2 on ESC proliferation and invasion. FGFR2 silencing effectively inhibited the growth, migration, invasion, and EMT of ESCs. The effects of FGFR2 on endometriosis might be mediated via the activation of ERK signaling.

To Investigate the Risk of Herpes Zoster in Women With Endometriosis: A Taiwan National Population-Based Cohort Study

Background: The objective of this study is to investigate the occurrence of herpes zoster (HZ) in patients with endometriosis.

Methods: This retrospective population-based cohort study was conducted using the Taiwan National Health Insurance Research Database. Between 2000 and 2012, women aged ≥20 years with newly diagnosed endometriosis were enrolled into the endometriosis group. Each patient with endometriosis was randomly matched to 4 controls according to age and index year. All the patients were traced from the index date to HZ diagnosis, loss to follow-up, death, or the end of December 2013.

Results: In total, 19,147 patients with newly diagnosed endometriosis and 76,588 participants without endometriosis were enrolled. The incidence of HZ was higher in endometriosis persons (5.36 per 1,000 person-years) than in matched controls (4.43 per 1,000 person-years) (p < 0.001). After adjustment for age and comorbidities, patients with endometriosis age ≤ 49 years (adjusted hazard ratio [aHR] = 1.17) (p < 0.001) and 50–64 years (aHR = 1.27) (p < 0.05) showed significantly higher risk of HZ than the corresponding controls. Among women without any comorbidities, patients with endometriosis were 1.22 times (p < 0.001) more likely to have HZ than those without endometriosis.

Conclusion: Taiwanese women with endometriosis may have a higher rate of HZ occurrence. Endometriosis seems to be a high burden for affected women. Therefore, we suggest that clinicians should be aware of HZ among women with endometriosis, although there may be ethnic differences.

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 cancer: a systematic review and meta-analysis

BACKGROUND

Endometriosis is an often chronic, inflammatory gynaecologic condition affecting 190 million women worldwide. Studies have reported an elevated cancer risk among patients with endometriosis. However, prior research has included methodologic issues that impede valid and robust interpretation.

OBJECTIVE AND RATIONALE

We conducted a meta-analysis of studies investigating the association between endometriosis and cancer risk and analysed the results by methodologic characteristics. We discuss the implications of cancer screening in patients and management challenges faced by clinicians.

SEARCH METHODS

We searched PubMed and Embase databases for eligible studies from inception through 24 October 2019. We included cohort and case-control studies examining the association between endometriosis and cancer risk; cross-sectional studies and case reports were excluded. Publications had to present risk/rate/odds estimates with 95% CI. Random effects meta-analysis was used to estimate summary relative risks (SRR) and CIs. Heterogeneity across studies was assessed by the Q test and I2 statistics, and publication bias using Egger's and Begg's tests. Risk of bias and quality of the included studies were assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool.

OUTCOMES

Forty-nine population-based case-control and cohort studies were included. Twenty-six studies were scored as having a 'serious'/'critical' risk of bias, and the remaining 23 'low'/'moderate'. Cancer-specific analyses showed a positive association between endometriosis and ovarian cancer risk (SRR = 1.93, 95% CI = 1.68-2.22; n = 24 studies) that was strongest for clear cell (SRR = 3.44, 95% CI = 2.82-4.42; n = 5 studies) and endometrioid (SRR = 2.33, 95% CI = 1.82-2.98; n = 5 studies) histotypes (Pheterogeneity < 0.0001), although with significant evidence of both heterogeneity across studies and publication bias (Egger's and Begg's P-values < 0.01). A robust association was observed between endometriosis and thyroid cancer (SRR = 1.39, 95% CI =1.24-1.57; n = 5 studies), a very small association with breast cancer (SRR = 1.04, 95% CI =1.00-1.09; n = 20 studies) and no association with colorectal cancer (SRR = 1.00, 95% CI =0.87-1.16; n = 5 studies). The association with endometrial cancer was not statistically significant (SRR = 1.23, 95% CI =0.97-1.57; n = 17 studies) overall and wholly null when restricted to prospective cohort studies (SRR = 0.99, 95% CI =0.72-1.37; n = 5 studies). The association with cutaneous melanoma was also non-significant (SRR = 1.17, 95% CI =0.97-1.41; n = 7 studies) but increased in magnitude and was statistically significant when restricted to studies with low/moderate risk of bias (SRR = 1.71, 95% CI = 1.24-2.36, n = 2 studies). The most robust finding both in terms of statistical significance and magnitude of effect was an inverse association with cervical cancer (SRR = 0.68, 95% CI =0.56-0.82; n = 4 studies); however, this result has a high potential to reflect heightened access to detection of dysplasia for women who reached an endometriosis diagnosis and is thus likely not causal. Several additional cancer types were explored based on <4 studies.

WIDER IMPLICATIONS

Endometriosis was associated with a higher risk of ovarian and thyroid, and minimally (only 4% greater risk) with breast cancer, and with a lower risk of cervical cancer. However, this meta-analysis confirms that: a majority of studies had severe/critical risk of bias; there is impactful heterogeneity across studies-and for ovarian cancer, publication bias; and causal inference requires temporality, which in many studies was not considered. We discuss the implications of these potential associations from the perspectives of patients with endometriosis, clinicians involved in their care, and scientists investigating their long-term health risks.

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.

Subsequent Development of Epithelial Ovarian Cancer After Ovarian Surgery for Benign Ovarian Tumor: A Population-Based Cohort Study

Purpose

The goal of the current study is to determine the risk of subsequent development of epithelial ovarian cancer (EOC) in women after ovarian surgery for benign ovarian tumors.

Patients and Methods

We conducted the nationwide population-based historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan. Eleven thousand six hundred twenty women who underwent ovarian surgery for ovarian benign diseases were analyzed. The collected data included age, types of ovarian surgery, medical history by Charlson comorbidity index (CCI), infertility (yes/no), pelvic inflammatory disease (PID) (yes/no), tubal ligation (yes/no), total/subtotal hysterectomy (TH/STH) (yes/no), and endometrioma (yes/no). We used the Kaplan-Meier method and the Log-rank test to evaluate the risk factors. Cox proportional hazard methods were used to evaluate risk factors for the subsequent development of EOC. Multivariate analysis using Cox stepwise forward regression was conducted for the covariate selected in univariate analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Wald test.

Results

Subsequent EOC incidence rate (IR, incidence per 10,000 person-years) of women after ovarian surgery for benign ovarian tumors was 2.98. Separating into four groups based on different age, IR of EOC was 1.57 (<30 years), 4.71 (30-39 years), 3.59 (40-49 years) and 0.94 (≥50 years), respectively. Univariate and multivariate analyses identified only high level of CCI (≥2 or more) as an independent risk factor for subsequent development of EOC in women after ovarian surgery for benign ovarian tumors (HR 59.17, 95% CI 7.50-466.80 in women with CCI level of 2 and HR 190.68, 95% CI 24.33-2494.19, in women with CCI level ≥3, respectively).

Conclusion

Our results, if confirmed, suggest that women with other comorbidities (CCI) should be well informed that they may have a higher risk of subsequent development of EOC when ovarian surgery is planned even though the final pathology showed a benign ovarian tumor.

Immunology and ovarian cancers

The current standard therapy of epithelial ovarian cancer (EOC) is the combination of surgery and multiagent chemotherapy with/without adding targeted therapy. After treatment, response rate is high and nearly all patients can achieve complete remission, even though they are advanced diseases; however, the majority of patients will relapse and subsequently die of diseases within several years after initial treatment. When treatment options are limited, there is the urgent need for new novel therapeutic approaches for precise cancer control. The development of chemoresistance and evading of the anticancer immune response may be one of the important causes contributing to the therapeutic failure, and therefore, it represents a paradigm shift in cancer research. An individual's immune response and interaction with EOC cells might be one of the key factors for cancer treatment. There are many interventions, including targeting certain type immunogenic EOC-associated antigens, immune checkpoint blockade, and adoptive cellular therapy, which present a profound opportunity to revolutionize EOC treatment. This review will encompass the interaction between EOC and immune system and highlight recent data regarding the research of immunotherapy in EOC.

Aberrant sialylation in ovarian cancers

Sialylation (the covalent addition of sialic acid to the terminal end of glycoproteins or glycans), tightly regulated cell- and microenvironment-specific process and orchestrated by sialyltransferases and sialidases (neuraminidases) family, is one of the posttranslational modifications, which plays an important biological role in the maintenance of normal physiology and involves many pathological dysfunctions. Glycans have roles in all the cancer hallmarks, referring to capabilities acquired during all steps of cancer development to initiate malignant transformation (a driver of a malignant genotype), enable cancer cells to survive, proliferate, and metastasize (a consequence of a malignant phenotype), which includes sustaining proliferative signaling, evading growth suppressor, resisting cell apoptosis, enabling replicative immortality, inducing angiogenesis, reprogramming of energy metabolism, evading tumor destruction, accumulating inflammatory microenvironment, and activating invasion and accelerating metastases. Regarding the important role of altered sialylation of cancers, further knowledge about the initiation and the consequences of altered sialylation pattern in tumor cells is needed, because all may offer a better chance for developing novel therapeutic strategy. In this review, we would like to update alteration of sialylation in ovarian cancers.

Disseminated Endometriosis and Low-Grade Endometrioid Stromal Sarcoma in a Patient with a History of Uterine Morcellation for Adenomyosis

Morcellation of benign uterine tumors allows for removal of the tumors via minimally invasive laparoscopic procedures. However, in rare cases, morcellation has been associated with upstaging of unexpected malignancies. Morcellation has also been associated with dissemination of benign pathologic processes such as endometriosis and leiomyomas. Endometrial stromal sarcoma typically arises in the uterine cavity, although cases of extrauterine endometrioid stromal sarcoma arising out of foci of endometriosis have been reported. Dissemination of endometrial stromal sarcomas can be an unintended consequence of morcellation procedures, as can dissemination of endometriosis, from which endometrioid stromal sarcomas can arise. Herein, we report a case of a 55-year-old woman who was found to have disseminated endometriosis and low-grade endometrioid stromal sarcoma, with bowel and liver parenchymal metastasis, 7 years after undergoing supracervical hysterectomy with unconfined uterine morcellation for adenomyosis. Our case highlights the potential for malignant transformation of disseminated adenomyosis/endometriosis and the importance of patient counseling and shared decision-making prior to morcellation procedures.

Hysterectomy and unilateral salpingectomy associate with a higher risk of subsequent ovarian cancer: A population-based cohort study in Taiwan

Studies on the relationship between gynecologic surgery and subsequent ovarian cancer have been carried out in limited Western ethnic groups. We aim to evaluate whether receiving hysterectomy and/or salpingectomy associated with ovarian cancer risk in Taiwan.From the Taiwan National Health Insurance Research Database, we identified a gynecologic surgery cohort consisting of women who had newly received hysterectomy (N = 181,151), salpingectomy (N = 45,410) or both hysterectomy and salpingectomy (N = 11,875) in 2000 to 2013. A comparison cohort of 953,744 women was randomly selected from women without the surgeries, frequency-matched by age and index date of the surgery case. They were followed up to identify subsequent ovarian cancer by the end of 2013.The overall ovarian cancer incidence was 4.4-fold greater in the gynecologic surgery cohort than in the comparison cohort (41.5 vs 9.43 per 10 person-years) with an adjusted hazard ratio of 3.86 (95% confidence interval = 2.56-5.84). Women with both hysterectomy and salpingectomy had the highest incidence and followed by women with hysterectomy or salpingectomy (52.5, 45.5, or 23.3 per 10 person-years, respectively). No ovarian cancer was noted in the subgroup with bilateral salpingectomies.We conclude that women with gynecologic surgery of hysterectomy and/or salpingectomy are at an increased risk of developing ovarian cancer, particularly among women who have had other gynecologic comorbidity. Women with gynecologic surgery and comorbidity deserve greater attention to prevent and screen for ovarian cancer.

The Association Between Hysterectomy and Ovarian Cancer Risk: A Population-Based Record-Linkage Study

BACKGROUND

Recent studies have called into question the long-held belief that hysterectomy without oophorectomy protects against ovarian cancer. This population-based longitudinal record-linkage study aimed to explore this relationship, overall and by age at hysterectomy, time period, surgery type, and indication for hysterectomy.

METHODS

We followed the female adult Western Australian population (837 942 women) across a 27-year period using linked electoral, hospital, births, deaths, and cancer records. Surgery dates were determined from hospital records, and ovarian cancer diagnoses (n = 1640) were ascertained from cancer registry records. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between hysterectomy and ovarian cancer incidence.

RESULTS

Hysterectomy without oophorectomy (n = 78 594) was not associated with risk of invasive ovarian cancer overall (HR = 0.98, 95% CI = 0.85 to 1.11) or with the most common serous subtype (HR = 1.05, 95% CI = 0.89 to 1.23). Estimates did not vary statistically significantly by age at procedure, time period, or surgical approach. However, among women with endometriosis (5.8%) or with fibroids (5.7%), hysterectomy was associated with substantially decreased ovarian cancer risk overall (HR = 0.17, 95% CI = 0.12 to 0.24, and HR = 0.27, 95% CI = 0.20 to 0.36, respectively) and across all subtypes.

CONCLUSIONS

Our results suggest that for most women, having a hysterectomy with ovarian conservation is not likely to substantially alter their risk of developing ovarian cancer. However, our results, if confirmed, suggest that ovarian cancer risk reduction could be considered as a possible benefit of hysterectomy when making decisions about surgical management of endometriosis or fibroids.

Risk of Endometriosis and Subsequent Ovary and Breast Cancers in Nurses: A Population-Based Cohort Study in Taiwan

Background: Endometriosis has been associated with the subsequent development of ovarian and breast cancers. This study evaluated whether nurses were at increased risks of developing endometriosis and subsequent ovarian and breast cancers. Methods: From Taiwan National Health Insurance Research Database during 2000 to 2011, we established 3 study cohorts, consisting of 23,801 nurses, 11,973 other hospital employees, and 143,096 general women free of endometriosis and cancer. Women in all cohorts were followed to the end of 2011 to measure the occurrences of endometriosis and subsequent ovarian and breast cancers. The incident endometriosis cases and related hazard ratio (HR) and 95% confidence interval (CI) were calculated. The incident cases of ovarian cancer and breast cancer and related odds ratio were calculated. Results: The incidence of endometriosis was the highest in the nurse cohort (4.23 per 100, n = 966) followed by other health professionals (3.74 per 100, n = 427) and control cohort (3.06 per 100, n = 4193), with adjusted hazard ratios of 1.28 (95% CI = 1.20–1.38) and 1.13 (95% CI = 1.02–1.25), respectively, comparing to controls. Among those who developed endometriosis, nurses had higher subsequent ovarian cancer and lower breast cancer, but not significant. Conclusions: Nurses are at a higher risk of developing endometriosis. However, the link between endometriosis and subsequent cancers is weak.

Increased levels of proapoptotic markers in normal ovarian cortex surrounding small endometriotic cysts

Endometriosis can impair fertility by reducing ovarian reserve and the production of good-quality oocytes. The surgical removal of endometriotic lesions is generally recommended for women who wish to conceive. In this paper we studied whether ovarian cortex adjacent to excised small (diameter ≤ 4 cm) endometriotic cyst (here referred as Cortex Surrounding Endometriotic Cyst, CSEC) showed signs of tissue damages by evaluating the expression of proteins involved in DNA repair and apoptosis. To this end, phosphorylated H2A.X, Chk1 and 2, ATM and ATR, Bcl-2, Bid, phosphorylated and total p53, caspases (9, 8 and 3), XIAP, phosphorylated and total NFκB were analyzed by western blot. Results showed that caspase 8, XIAP, p53/p-p53 and NFκB were more abundantly expressed in all samples of CSEC group in comparison with ovarian cortex of controls. Conversely, the levels of the other proteins were comparable between the two groups. In conclusion, these results suggest that NFκB, caspase 8 and p53/p-p53 elevated expressions in samples of CSEC can be considered as an early sign of tissue injury, indicating that ovarian cortex is already sensitized to apoptosis and inflammation. Therefore, excision of EC should occur very early, to avoid further ovarian damages.

Endometriosis and cancer

Endometriosis, characterized by the presence of extra-uterine endometrium, is a common gynecologic disorder in reproductive-age women. Although the detailed molecular mechanism of etiology remains unelucidated, recent studies have gradually revealed both genetic and epigenetic backgrounds of the development of endometriosis. In clinical practice, endometriosis has been recognized as a precursor lesion of several types of malignancies and endometriosis-associated carcinoma. An imbalance between reactive oxygen species and local antioxidants has been reported to contribute to the development of endometriosis-associated carcinoma as well as the pathophysiology of this disease through a systemic inflammatory response in the peritoneal cavity. This review mainly presents an epidemiology, possible etiology of endometriosis, precursor lesions, molecular features, and the association between the microenvironmental accumulations of oxidative stress in endometriosis-associated ovarian cancer progression.

Endometriosis-associated ovarian cancer: What have we learned so far?

Endometriosis is defined as the presence of ectopic endometrial tissue outside of the uterine cavity, most commonly in the ovaries and peritoneum. It is a complex disease that is influenced by multiple factors. It is also a common gynecological disorder and affects approximately 10-15% of all women of reproductive age. Recent molecular and pathological studies indicate that endometriosis may serve as a precursor of ovarian cancer (endometriosis-associated ovarian cancer, EAOC), particularly endometrioid and clear cell ovarian cancers. Although histological and epidemiological studies have demonstrated that endometriosis has a malignant potential, the molecular mechanism that underlies the malignant transformation of endometriosis is still controversial, and the precise mechanism of carcinogenesis must be fully elucidated. Currently, the development and improvement of a new sequencing technology, next-generation sequencing (NGS), has been increasingly relevant in cancer genomics research. Recently, NGS has also been utilized in clinical oncology to advance the personalized treatment of cancer. In addition, the sensitivity, speed, and cost make NGS a highly attractive platform compared to other sequencing modalities. For this reason, NGS may lead to the identification of driver mutations and underlying pathways associated with EAOC. Here, we present an overview of the molecular pathways that have led to the current opinions on the relationship between endometriosis and ovarian cancer.

Maternal pregnancy-induced hypertension increases the subsequent risk of transient tachypnea of the newborn: A nationwide population-based cohort study

OBJECTIVE

To determine the association between pregnancy-induced hypertension (PIH) and transient tachypnea of the newborn (TTN) and to identify the predictive risk factors.

MATERIALS AND METHODS

Pregnant women with a newly diagnosed PIH (between 2000 and 2013) from the Taiwan National Health Insurance Research Database (NHIRD) were compared with a matched (with respect to age and year of delivery) cohort of pregnant women without PIH. The occurrence of TTN was evaluated in both cohorts.

RESULTS

Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. According to a multivariate analysis, PIH (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.69-2.03, p < 0.0001), age ≥ 30 years (OR = 1.38, 95% CI = 1.26-1.51, p < 0.0001), primiparity (OR = 1.37, 95% CI = 1.24-1.5, p < 0.0001), preterm birth (OR = 3.4, 95% CI = 3.09-3.75, p < 0.0001), multiple births (OR = 2.54, 95% CI = 2.24-2.89, p < 0.0001), and cesarean section (OR = 1.71, 95% CI = 1.56-1.88, p < 0.0001) were independent risk factors for the development of TTN.

CONCLUSION

Women with PIH have an increased risk of having infants who develop TTN compared with those without PIH. Additionally, age ≥30 years, primiparity, preterm birth, multiple births, and cesarean section were independent risk factors for the development of TTN.

Benign gynecologic conditions are associated with ovarian cancer risk in African-American women: a case-control study

BACKGROUND

The association between common benign gynecologic conditions and ovarian cancer remains under-studied in African Americans. Therefore, we examine the association between self-reported history of benign gynecologic conditions and epithelial ovarian cancer risk in African-American women.

METHODS

Data from a large population-based, multi-center case-control study of epithelial ovarian cancer in African-American women were analyzed to estimate the association between self-reported history of endometriosis, pelvic inflammatory disease (PID), fibroid, and ovarian cyst with epithelial ovarian cancer. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the associations between individual and composite gynecologic conditions and ovarian cancer.

RESULTS

600 cases and 752 controls enrolled in the African American Cancer Epidemiology Study between 1 December 2010 and 31 December 2015 comprised the study population. After adjusting for potential confounders, a history of endometriosis was associated with ovarian cancer (OR 1.78; 95% CI 1.09-2.90). A non-significant association of similar magnitude was observed with PID (OR 1.33; 95% CI 0.82-2.16), while no association was observed in women with a history of fibroid or ovarian cyst. A positive trend was observed for an increasing number of reported gynecologic conditions (p = 0.006) with consistency across histologic subtypes and among both oral contraceptive users and non-users.

CONCLUSION

A self-reported history of endometriosis among African-American women was associated with increased risk of ovarian cancer. Having multiple benign gynecologic conditions also increased ovarian cancer risk.

The role of α2,3-linked sialylation on clear cell type epithelial ovarian cancer

OBJECTIVE

Our previous study has shown that high expression of α2,3-sialytransferase type I was associated with advanced stage serous type epithelial ovarian cancer (EOC). The aim of the current study further attempts to evaluate the altered α 2,3-sialylation on the behavior of clear cell type EOC (C-EOC).

MATERIALS AND METHODS

Immunohistochemistry staining, bioinformatics analysis and tissue array were used to disclose the clinical significance of over α2,3-sialylation in C-EOC. An α2,3 sialylation inhibitor, soyasaponin I (SsaI) was used to investigate the behavior change of the C-EOC cell line.

RESULTS

We reconfirmed that α2,3-sialylation, instead of α2,6- sialylation, was associated with late-stage C-EOC. Soyasaponin I could inhibit α2,3-sialylation of C-EOC cell lines and increase E-cadherin expression with subsequently suppressing migration of C-EOC cells.

CONCLUSIONS

The current study demonstrated the important role of α2,3-linked sialylation in C-EOC and targeting of α2,3-linked sialylation might offer as a potential therapeutic strategy in the future.

Endometriosis-associated Ovarian Cancers

Endometriosis-associated cancers include clear cell and endometrioid ovarian carcinoma. A history of endometriosis has long been considered to be a risk factor for later development of these malignancies; however, recent molecular genetic evidence has provided unequivocal evidence that these lesions are in fact the precursors for endometriosis-associated cancers. Herein, we will explore the relationship between endometriosis and ovarian carcinomas, similarities between the premalignant lesions and their cancerous counterparts, and the potential role of mutations and the ovarian microenvironment that may contribute to malignant transformation.

Women with adenomyosis are at higher risks of endometrial and thyroid cancers: A population-based historical cohort study

Objective

Both adenomyosis and endometriosis are characterized by the presence of ectopic endometrial glands and stroma and have been suggested to share some characteristics with malignant tumors. Although accumulating evidence indicates that endometriosis is associated with some cancer types, the cancer risks in patients with adenomyosis have been rarely examined. In this study, we investigated the relationship between adenomyosis and risks of common cancers.

Methods

This study included a cohort of 12,447 women with adenomyosis but not endometriosis, born in 1951–1984, and a cohort of 124,470 adenomyosis-free women matched by birth year. Their medical records (collected between 1996 and 2011) were obtained from the National Health Insurance Research Database of Taiwan. We first compared the distribution of cancer-free survival (CFS) between cohorts with and without adenomyosis. Subsequently, within the adenomyosis cohort, we examined whether time-to-onset of the identified cancer type was correlated with time-to-onset of adenomyosis. The Cox proportional hazards model was used to compare the distribution of CFS between the adenomyosis and adenomyosis-free cohorts and between the early- and late-diagnosed adenomyosis groups. For comparison, we further evaluated the cancer risks for a cohort of 10,962 women with endometriosis but not adenomyosis and a birth-year matched cohort of 109,620 endometriosis-free women.

Results

Compared with adenomyosis-free women, patients with adenomyosis had higher risks of endometrial and thyroid cancers, with estimated hazard ratios (HRs) (95% confidence interval) of 2.19 (1.51–3.16) and 1.70 (1.29–2.24), respectively. For both cancers, distributions of CFS were not significantly different between the early- and late-diagnosed adenomyosis groups. Furthermore, compared with endometriosis-free women, patients with endometriosis had higher risks of endometrial and ovarian cancers, with HRs of 1.89 (1.07–3.35) and 2.01 (1.27–3.16), respectively.

Conclusions

Women with adenomyosis are at higher risks of endometrial and thyroid cancers, while women with endometriosis are at higher risks of endometrial and ovarian cancers.

α2,3-sialyltransferase type I regulates migration and peritoneal dissemination of ovarian cancer cells

Epithelial ovarian cancer (EOC) has the highest mortality rate among gynecologic cancers due to advanced stage presentation, peritoneal dissemination, and refractory ascites at diagnosis. We investigated the role of α2,3-sialyltransferase type I (ST3GalI) by analyzing human ovarian cancer datasets and human EOC tissue arrays. We found that high expression of ST3GalI was associated with advanced stage EOC. Transwell migration and cell invasion assays showed that high ST3GalI expression enhanced migration of EOC cells. We also observed that there was a linear relation between ST3GalI expression and epidermal growth factor receptor (EGFR) signaling in EOC patients, and that high ST3GalI expression blocked the effect of EGFR inhibitors. Co-Immunoprecipitation experiments demonstrated that ST3GalI and EGFR were present in the same protein complex. Inhibition of ST3GalI using a competitive inhibitor, Soyasaponin I (SsaI), inhibited tumor cell migration and dissemination in the in vivo mouse model with transplanted MOSEC cells. Further, SsaI synergistically enhanced the anti-tumor effects of EGFR inhibitor on EOC cells. Our study demonstrates that ST3GalI regulates ovarian cancer cell migration and peritoneal dissemination via EGFR signaling. This suggests α2,3-linked sialylation inhibitors in combination with EGFR inhibitors could be effective agents for the treatment of EOC.

Risks of female genital tract related cancers (gynecological cancers) or breast cancer in women with and without chronic kidney disease: A population-based cohort study in Taiwan

This article aims to test the hypothesis that the risk of female genital tract related cancer (gynecological cancer: GC) or breast cancer (BC) of women with chronic kidney disease (CKD) might be different from that of those women without CKD.A nationwide 17-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 3045 women with a diagnosis of CKD from 1996 to 2013 and 3045 multivariable-matched controls (1:1) were selected. We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CIs) to determine the risk of GC or BC in women.The GC incidence rates (IRs, per 10,000 person-years) of the CKD and non-CKD women were 11.02 and 19.09, respectively, contributing to a significantly decreased risk of GCs (crude HR 0.57, 95% CI 0.39-0.81; adjusted HR 0.44, 95% CI 0.30-0.65) in the CKD women. The GC IR was relatively constant in the CKD women among the different age categories (IR ranged from 8.10 to 12.29). On contrast, the non-CKD women had a progressive and continuous increase of GC IR in the advanced age, which was more apparent at age ≥50 years (IR 17.16 for 50-59; IR 23.05 for 60-69; and IR 31.62 for ≥70, respectively), contributing to the lower risk of GC in the CKD women than that in the non-CKD women. There was no difference of BC incidence between women with and without CKD.The findings of the lower risk of GCs in the CKD women in Taiwan are worthy of further evaluation.

Avoiding excessive pregnancy weight gain to obtain better pregnancy outcomes in Taiwan

Pregnancy weight gain may be associated with adverse pregnancy outcomes. The article aims to explore the relationship between weight change and pregnancy outcome in the Taiwanese pregnant women.The retrospective cohort study enrolled women with vertex singleton pregnancy at University-associated Hospital between 2011 and 2014. Pregnancy weight change was separated into 3 groups, based on the Institute of Medicine (IOM) guidelines: below (n = 221); within (n = 544); and above (n = 382). Analysis of variance, χ tests, generalized linear models, and logistic regression models were used for statistical comparisons.Pregnant women with weight change above IOM guidelines had a significant increase in both maternal and perinatal complications compared with normal controls (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.03-1.98; P = .043; OR 1.45, 95% CI 1.01-1.87; P = .049, respectively). This finding was not found in pregnant women with weight gain below IOM guidelines. Moreover, age (OR 1.08, 95% CI 1.02-1.15; P = .0011), pre-pregnancy weight (OR 1.04, 95% CI 1.01-1.09; P = .0008), pre-pregnancy body mass index (BMI; OR 1.15, 95% CI 1.06-1.30; P < .0001), weight at the time of delivery (OR 1.05, 95% CI 1.02-1.13; P < .0001) and BMI at the time of delivery (OR 1.15, 95% CI 1.06-1.39; P < .0001), all contributed to increased maternal complications but not perinatal complications, whereas parity (OR 0.23, 95% CI 0.12-0.41; P < .0001) and gestational age (OR 0.50, 95% CI 0.35-0.62; P < .001) were associated with fewer maternal complications.Our study reconfirmed that for Taiwanese pregnant women, the approximate pregnancy weight gain recommended by IOM in 2009 was associated with the fewest maternal and perinatal complications. If approximate pregnancy weight gain cannot be attained, even less weight gain during pregnancy is still reasonable without significantly and adversely affecting maternal and perinatal outcomes in Taiwan.

Gene set-based analysis of mucinous ovarian carcinoma

OBJECTIVE

Mucinous ovarian carcinoma (MOC) is an uncommon subtype of epithelial ovarian cancers, and the pathogenesis is still poorly understood because of its rarity. We conducted a gene set-based analysis to investigate the pathogenesis of MOC by integrating microarray gene expression datasets based on the regularity of functions defined by gene ontology or canonical pathway databases.

MATERIALS AND METHODS

Forty-five pairs of MOC and normal ovarian tissue sample gene expression profiles were downloaded from the National Center for Biotechnology Information Gene Expression Omnibus database. The gene expression profiles were converted to the gene set regularity indexes by measuring the change of gene expression ordering in a gene set. Then the pathogenesis of MOC was investigated with the differences of function regularity with the gene set regularity indexes between the MOC and normal control samples.

RESULTS

The informativeness of the gene set regularity indexes was sufficient for machine learning to accurately recognize and classify the functional regulation patterns with an accuracy of 99.44%. The statistical analysis revealed that the GTPase regulators and receptor tyrosine kinase erbB-2 (ERBB2) were the most important aberrations; the exploratory factor analysis revealed phosphoinositide 3-kinase-activating kinase, G-protein coupled receptor pathway, oxidoreductase activity, immune response, peptidase activity, regulation of translation, and transport and channel activity were also involved in the pathogenesis of MOC.

CONCLUSION

Investigating the pathogenesis of MOC with the functionome provided a comprehensive view of the deregulated functions of this disease. In addition to GTPase regulators and ERBB2, a plenty of deregulated functions such as phosphoinositide 3-kinase, G-protein coupled receptor pathway, and immune response also participated in the interaction network of MOC pathogenesis.

Malignant changes in adenomyosis in patients with endometrial adenocarcinoma: A case series

The aim of the study is to describe the clinical characteristics and prognosis of malignant transformation of adenomyosis in patients with endometrial cancer.In this retrospective descriptive study, the clinical data of patients with endometrial cancer (n = 127) who were admitted at our hospital between January 2006 and December 2013 were evaluated.Among the 127 patients with endometrial cancer, 24 patients had endometrial cancer concurrently with adenomyosis. Among these 24 patients, 3 were diagnosed with malignant transformation of adenomyosis. Postoperative pathological investigations in the cancer+adenomyosis group revealed endometrial adenocarcinoma of Grade I (n = 21) and II (n = 3). The patients with malignant transformation of adenomyosis were relatively younger than the other patients. In those 3 patients, both the estrogen and progesterone receptors were strongly expressed in eutopic endometrium and were weakly positive in ectopic endometrium.Although adenomyosis is usually benign, it might also be a precursor of malignant disease. As the incidence of adenomyosis malignant transformation is low, and its clinical manifestations are nonspecific, it may only be confirmed by postoperative pathological examination. Further investigations on larger sample size may provide additional data about prognosis of adenomyosis malignant transformation.

Clinical implication for endometriosis associated with ovarian cancer

We reviewed current literature regarding the association of endometriosis and epithelial ovarian cancer based on epidemiology studies, molecular researches and clinical observations. Our methods include a review of literature research of MEDLINE, PubMed, Cochrane Library of Systematic Reviews and reference search in selected papers. The life time risk of epithelial ovarian cancer in women with endometriosis is low, yet there might be a cluster of individuals who have higher risk of developing epithelial ovarian cancer from endometriosis. Endometriosis associated ovarian cancer (EAOC) is predominant in particular histological subtypes of epithelial ovarian carcinoma and are related to some specific molecular aberrations. Clinical observations showed age as an important variable to the development of EAOC. Rapid growth of tumor and solid components in sonography are key features to detect malignant transformation of endometriosis. Evidence is not clear about prophylactic oophorectomy in preventing EAOC in patients with endometriosis. This review provided rationale data for identifying, monitoring, counseling and management of women with endometriosis who are potentially high risk for malignant transformation.

Medical therapy for preventing recurrent endometriosis after conservative surgery: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of different strategies, including gonadotropin-releasing hormone agonist (GnRH-a) and oral contraceptive therapy, for the prevention of endometriosis recurrence after conservative surgery.

DESIGN

Cost-effectiveness analysis from a health care perspective.

SETTING

A health-resource-limited setting in China.

POPULATION

Patients who underwent conservative laparoscopic or laparotomic surgery for endometriosis.

METHODS

A Markov model was developed for the endometriosis disease course. Clinical data were obtained from published studies. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. The health and economic outcomes were evaluated over a period from treatment initiation to menopause onset. Sensitivity analyses were carried out to test the impact of various parameters and assumptions on the model output.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) gained and costs from a health care perspective.

RESULTS

The incremental cost-effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with peritoneal endometriosis. A one-way sensitivity analysis showed considerable influential factors, such as remission rates and utility values. Probabilistic sensitivity analysis indicated that 6-month GnRH-a therapy is cost-effective in most cases at a threshold of $7,400/QALY, regardless of the type of endometriosis.

CONCLUSION

Six months of therapy with GnRH-a can be a highly cost-effective option for the prevention of endometriosis recurrence.

TWEETABLE ABSTRACT

Gonadotropin-releasing hormone agonist is cost effective for the prevention of endometriosis recurrence.

Predictive factors of ovarian carcinoma for women with ovarian endometrioma aged 45 years and older in China

BACKGROUND

To explore the risk factors of endometriosis-associated ovarian cancer (EAOC) in women with ovarian endometriosis (OEM) aged 45 years and above in China.

METHODS

This study reviewed the medical records of 1038 women in total who were aged 45 years and above, surgical-pathologically diagnosed with ovarian endometriosis, and were treated at Peking Union Medical College Hospital between December 1996 and December 2016. Histology evaluation was used to determine whether the ovarian endometriosis specimen was with (n = 30) or without (n = 1008) ovarian cancer.

RESULTS

2.9% (30/1038) of women with the surgical-pathological diagnosis of ovarian endometriosis were found to have EAOC. Those patients with EAOC were prone to be in the postmenopausal status at the time of the diagnosis (OR 5.50, 95%CI 2.54-11.90, P < .001) and larger size of tumor (≥8 cm, OR 7.19, 95% CI 3.34-15.50, P < .001), and higher prevalence of coexisting with endometrial disorders (OR 4.11, 95%CI 1.73-9.73, P = .003). This study showed that patients of an older age when diagnosed with OEM, were at a higher risk of developing EAOC, respectively measuring of 1.7% (13/751) at 45-49 years, 5.6% (12/215) at 50-54 years, and 10.0%(5/50) at 55-59 years (P < 0.001).

CONCLUSIONS

This study showed that for women aged 45 years and above who were diagnosed with OEM, the independent risk factors of EAOC were menopausal status, tumor size of 8 cm or greater in diameter, and coexisting endometrial disorders. Therefore, intensive follow-ups or active interventions should be considered for them.

Uterine sarcoma part III-Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Endometriosis and risk of ovarian and endometrial cancers in a large prospective cohort of U.S. nurses

PURPOSE

Endometriosis is associated with ovarian cancer, but the relation with endometrial cancer is unclear. Prior studies generally were retrospective and had potential limitations, including use of self-reported endometriosis, failure to account for delays between symptom onset and endometriosis diagnosis, and changes in risk factors post-endometriosis diagnosis. We evaluated whether these limitations obscured a weak association with endometrial cancer and the extent to which these limitations impacted associations with ovarian cancer.

METHODS

Cox proportional hazards regression models were used to assess associations between endometriosis and cancer risk, evaluating the impacts of self-reported vs. laparoscopically confirmed endometriosis, delayed diagnosis, and post-endometriosis diagnosis changes in risk factor exposures on relative risk estimates.

RESULTS

Over 18 years of follow-up, we identified 228 ovarian and 166 endometrial cancers among 102,025 and 97,109 eligible women, respectively. Self-reported endometriosis was associated with ovarian cancer [relative risk (RR): 1.81; 95% confidence interval (CI): 1.26-2.58]; this association was stronger for laparoscopically confirmed endometriosis (HR: 2.14; 95% CI 1.45-3.15). No association was observed with endometrial cancer (self-report RR: 0.78; 95% CI 0.42-1.44; laparoscopic-confirmation RR: 0.76; 95% CI 0.35-1.64). Accounting for diagnosis delays or post-endometriosis diagnosis changes in risk factors had a little impact.

CONCLUSIONS

This study adds to the evidence that endometriosis is not strongly linked to endometrial cancer risk and that the association with ovarian cancer is robust to misclassification, diagnostic delay, and changes in exposures post-endometriosis diagnosis. Our analysis suggests that confounding and misclassification do not obscure a weak association for endometrial cancer risk, although our results should be replicated.

Endometriosis and Ovarian Cancer: an Integrative Review (Endometriosis and Ovarian Cancer)

Despite being initially considered a benign disease, it is widely thought nowadays that endometriosis and especially ovarian endometriomas are neoplastic conditions with the potential to become malignant. This review was conducted to summarize, in a concise and systematic manner, the available scientific data relating endometriosis to ovarian cancer, published in the past five years. After reading abstracts and applying our predefined inclusion and exclusion criteria, a final list of 11 scientific papers was obtained and subjected to review. Endometriosis is associated with an increased risk of developing epithelial ovarian cancer (EOC), mainly of endometrioid and clear cell subtypes. This might be by virtue of the high estrogen concentration with the disease, which leads to malignant proliferation of endometriotic cysts, or be due to mutations in the ARID1A gene and consequent loss of BAF250a expression. The iron produced in the fluid of endometriotic cysts promotes oxidative stress, which in turn may cause genetic mutations and malignant progression of ovarian cysts.

Endometriosis Might Be Inversely Associated with Developing Chronic Kidney Disease: A Population-Based Cohort Study in Taiwan

This study was conducted to determine the risk of chronic kidney disease (CKD) among women with endometriosis in Taiwan. We conducted a retrospective cohort study using the National Health Insurance Research Database of Taiwan. A total of 27,973 women with a diagnosis of endometriosis and 27,973 multivariable-matched controls (1:1) from 2000 to 2010 were selected. Cox regression and computed hazard ratios (HR) with 95% confidence intervals (95% CI) were used to determine the risk of CKD among women with endometriosis. The incidence rates (IR, per 10,000 person-years) of CKD among women with and without endometriosis were 4.64 and 7.01, respectively, with a significantly decreased risk of CKD (crude HR 0.65, 95% CI 0.53–0.81; adjusted HR 0.69, 95% CI 0.56–0.86) among women with endometriosis. The IR of CKD progressively increased with age, but the trend of lower CKD risk among women with endometriosis was consistent. However, the lower risk of CKD in women with endometriosis was no longer statistically significant after adjusting for menopausal status (adjusted HR 0.85, 95% CI 0.65–1.10). The results suggest that endometriosis is inversely associated with CKD, but this effect was mediated by menopause. The possible mechanism of this association is worthy of further evaluation.

Chronic lymphocytic leukemia-associated refractory immune thrombocytopenia successfully treated with eltrombopag

Chronic lymphocytic leukemia (CLL) may be associated with immune thrombocytopenia (ITP). The standard treatment for CLL-associated ITP is steroids. For refractory cases, various treatment strategies such as rituximab, splenectomy, and thrombopoietic mimetics are available. We report a patient with CLL who developed recurrent ITP and life-threatening pulmonary hemorrhage. Platelet counts remained extremely low despite massive platelet transfusion and treatment including steroids, immunoglobulin, and single-dose rituximab infusion. The bleeding stopped and platelet counts were increased to normal range 13 days after treatment with eltrombopag 25 mg per day. Our experience suggests that eltrombopag is an effective treatment option in CLL-associated, refractory ITP, especially during major bleeding, which requires relatively rapid improvement of thrombocytopenia.