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Nezhat FR, Cathcart AM, Nezhat CH, Nezhat CR. Pathophysiology and Clinical Implications of Ovarian Endometriomas. Obstet Gynecol 2024; 143:759-766. [PMID: 38626453 PMCID: PMC11090516 DOI: 10.1097/aog.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Abstract
Ovarian endometriomas affect many patients with endometriosis and have significant effects on quality of life, fertility, and risk of malignancy. Endometriomas range from small (1-3 cm), densely fibrotic cysts to large (20 cm or greater) cysts with varying degrees of fibrosis. Endometriomas are hypothesized to form from endometriotic invasion or metaplasia of functional cysts or alternatively from ovarian surface endometriosis that bleeds into the ovarian cortex. Different mechanisms of endometrioma formation may help explain the phenotypic variability observed among endometriomas. Laparoscopic surgery is the preferred first-line modality of diagnosis and treatment of endometriomas. Ovarian cystectomy is preferred over cyst ablation or sclerotherapy for enabling pathologic diagnosis, improving symptoms, preventing recurrence, and optimizing fertility outcomes. Cystectomy for small, densely adherent endometriomas is made challenging by dense fibrosis of the cyst capsule obliterating the plane with normal ovarian cortex, whereas cystectomy for large endometriomas can carry unique challenges as a result of adhesions between the cyst and pelvic structures. Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. Whether the optimal management, fertility consequences, and malignant potential of endometriomas vary on the basis of size and phenotype remains to be fully explored.
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Affiliation(s)
- Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, and NYU Long Island School of Medicine, Mineola, New York; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia; and the Center for Special Minimally Invasive and Robotic Surgery, and Stanford University Medical Center, Palo Alto, and the University of California, San Francisco, San Francisco, California
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Centini G, Schettini G, Pieri E, Giorgi M, Lazzeri L, Martire FG, Mancini V, Raimondo D, Seracchioli R, Habib N, Fedele F, Zupi E. Endometriosis-Related Ovarian Cancer: Where Are We Now? A Narrative Review towards a Pragmatic Approach. J Clin Med 2024; 13:1933. [PMID: 38610698 PMCID: PMC11012952 DOI: 10.3390/jcm13071933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Endometriosis affects more than 10% of reproductive-aged women, causing pelvic pain and infertility. Despite the benign nature of endometriosis, ovarian endometriomas carry a higher risk of developing endometrioid carcinomas (EnOCs) and clear cell ovarian carcinomas (CCCs). Atypical endometriosis, defined as cytological atypia resembling intraepithelial cancer, is considered the precursor of endometriosis-associated ovarian cancer (EAOC). This narrative review aims to provide an overview of EAOC, proposing a practical approach to clinical and therapeutic decision making. METHODS An electronic literature search was conducted from inception up to January 2023, using the MEDLINE database via PubMed to evaluate the existing literature on EAOC, including its pathogenesis, the diagnostic process, and the therapeutic possibilities, with articles not relevant to the topic or lacking scientific merit being excluded. RESULTS Eighty-one articles were included in the review to present the current state of the art regarding EAOC. A pragmatic clinical flowchart is proposed to guide therapeutic decisions and improve patient outcomes. CONCLUSIONS Endometriosis patients may have an increased risk of developing EAOC (either EnOC or CCC). Despite not being fully accepted, the concept of AE may reshape the endometriosis-ovarian cancer relationship. Further research is needed to understand the unaddressed issues.
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Affiliation(s)
- Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Giorgia Schettini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Emilio Pieri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Matteo Giorgi
- Department of Surgical Sciences, Gynecological Unit, Valdarno Hospital, 52025 Montevarchi, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Francesco Giuseppe Martire
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
- Department of Surgical Sciences, Gynecological Unit, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Virginia Mancini
- Department of Medical Biotechnology, Section of Pathology, University of Siena, 53100 Siena, Italy;
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (D.R.); (R.S.)
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (D.R.); (R.S.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Nassir Habib
- Department of Obstetrics and Gynecology, Francois Quesnay Hospital, 78201 Mantes-la-Jolie, France;
| | - Francesco Fedele
- Department of Obstetrics and Gynecology, Fondazione “Policlinico-Mangiagalli-Regina Elena” University of Milan, 20122 Milan, Italy;
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
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Sellers TA, Peres LC, Hathaway CA, Tworoger SS. Prevention of Epithelial Ovarian Cancer. Cold Spring Harb Perspect Med 2023; 13:a038216. [PMID: 37137500 PMCID: PMC10411689 DOI: 10.1101/cshperspect.a038216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Given the challenges with achieving effective and durable treatment for epithelial ovarian cancer, primary prevention is highly desirable. Fortunately, decades of research have provided evidence for several strategies that can be deployed to optimize risk reduction. These include surgery, chemoprevention, and lifestyle factor modifications. These broad categories vary in terms of the magnitude of risk reduction possible, the possible short-term and long-term side effects, the degree of difficulty, and acceptability. Thus, the concept of a risk-based model to personalize preventive interventions is advocated to guide discussion between care providers and women at risk. For women with inherited major gene mutations that greatly increase risk of ovarian cancer, surgical approaches have favorable risk to benefit ratios. Chemoprevention and lifestyle factor modifications portend a lower degree of risk reduction but confer lower risk of undesirable side effects. Since complete prevention is not currently possible, better methods for early detection remain a high priority.
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Affiliation(s)
- Thomas A Sellers
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon 97239, USA
| | - Lauren C Peres
- Department of Cancer Epidemiology, Moffitt Cancer Center & Research Institute, Tampa, Florida 33612, USA
| | - Cassandra A Hathaway
- Department of Cancer Epidemiology, Moffitt Cancer Center & Research Institute, Tampa, Florida 33612, USA
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, Moffitt Cancer Center & Research Institute, Tampa, Florida 33612, USA
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Canis M, Guo SW. In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain. Hum Reprod 2023; 38:1245-1252. [PMID: 37023473 DOI: 10.1093/humrep/dead061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
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Affiliation(s)
- Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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Orlando MS, Cadish LA, Shepherd JP, Falcone T, Chang OH, Kho RM. Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis. Am J Obstet Gynecol 2022; 227:311.e1-311.e7. [PMID: 35490792 DOI: 10.1016/j.ajog.2022.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. OBJECTIVE We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. STUDY DESIGN We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. RESULTS Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. CONCLUSION Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.
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Hernández A, Sanz A, Spagnolo E, Carbonell M, Rodríguez E, López A, Raganato R, Del Forno S, Ramiro-Cortijo D. Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer. J Clin Med 2022; 11:jcm11092414. [PMID: 35566541 PMCID: PMC9100079 DOI: 10.3390/jcm11092414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/24/2022] [Indexed: 12/15/2022] Open
Abstract
Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women’s age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women’s age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.
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Affiliation(s)
- Alicia Hernández
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 2, 28029 Madrid, Spain
| | - Angela Sanz
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
| | - Emanuela Spagnolo
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
- Correspondence:
| | - María Carbonell
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
| | - Elena Rodríguez
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
| | - Ana López
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; (A.H.); (A.S.); (M.C.); (E.R.); (A.L.)
| | - Riccardo Raganato
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain;
| | - Simona Del Forno
- Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero, S. Orsola Hospital, University of Bologna, Via Masserenti 13, 40138 Bologna, Italy;
| | - David Ramiro-Cortijo
- Department of Physiology, Faculty of Medicine, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 2, 28029 Madrid, Spain;
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Hermens M, van Altena AM, Bulten J, van Vliet HAAM, Siebers AG, Bekkers RLM. Incidence of ovarian cancer after bilateral salpingo-oophorectomy in women with histologically proven endometriosis. Fertil Steril 2022; 117:938-945. [PMID: 35300832 DOI: 10.1016/j.fertnstert.2022.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/16/2022] [Accepted: 01/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the incidence of ovarian cancer in women with histologically proven endometriosis after bilateral salpingo-oophorectomy (BSO). DESIGN Retrospective nationwide cohort study. SETTING Dutch pathology database. PATIENT(S) Women with histologically proven endometriosis who had undergone BSO between 1990 and 2015 (n = 7,984). This study consists of 2 control cohorts: women with histologically proven endometriosis without BSO (n = 42,633) and women with a benign dermal nevus (n = 132,535). INTERVENTION(S) Observational study. MAIN OUTCOME MEASURE(S) Number of histologic diagnoses of (extra-)ovarian cancers. Incidence rate ratios (IRR) were estimated for (extra-)ovarian cancer. The number needed to treat was calculated. RESULT(S) We identified 9 (0.1%) (extra-)ovarian cancers in the BSO cohort and 170 (0.4%) and 444 (0.3%) ovarian cancers in the endometriosis and nevus control cohorts, respectively. We found an age-adjusted IRR of 0.34 (95% confidence interval [CI], 0.15-0.76) when the BSO cohort was compared with the endometriosis cohort. Comparing the BSO cohort with the nevus control cohort resulted in an age-adjusted IRR of 0.38 (95% CI, 0.17-0.85). The number needed to treat when the BSO cohort was compared with the endometriosis control cohort was 351 (95% CI, 272-591). CONCLUSION(S) In this nationwide study, we found that the (extra-)ovarian cancer incidence in women with histologically proven endometriosis decreased to less than the background population risk after BSO. Additionally, we found a significant reduction of the incidence of ovarian cancer when compared with women with histologically proven endometriosis without BSO. Endometriosis surgery could in the future be a preventive strategy in women with endometriosis and a high-risk profile for ovarian cancer.
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Affiliation(s)
- Marjolein Hermens
- Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, the Netherlands; Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Anne M van Altena
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johan Bulten
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Huib A A M van Vliet
- Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, the Netherlands; Department of Obstetrics and Gynecology, University Hospital Ghent, Ghent, Belgium
| | - Albert G Siebers
- Dutch Nationwide Registry of Histopathology and Cytopathology-Pathologisch Anatomisch Landelijk Geautomatiseerd Archief (PALGA), Houten, the Netherlands
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
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Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N. ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:hoac009. [PMID: 35350465 PMCID: PMC8951218 DOI: 10.1093/hropen/hoac009] [Citation(s) in RCA: 409] [Impact Index Per Article: 204.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION How should endometriosis be diagnosed and managed based on the best available evidence from published literature? SUMMARY ANSWER The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected. LIMITATIONS REASONS FOR CAUTION The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s and Reproductive Health, Endometriosis CaRe
Centre, University of Oxford, Oxford, UK
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Semmelweis University,
Budapest, Hungary
| | - Oskari Heikinheimo
- Department of Obstetrics & Gynecology, University of Helsinki and Helsinki
University Hospital, Helsinki, Finland
| | - Andrew Horne
- EXPPECT Centre for Endometriosis and Pelvic Pain, MRC Centre for Reproductive
Health, University of Edinburgh, Edinburgh, UK
| | - Femke Jansen
- EndoHome—Endometriosis Association Belgium, Belgium
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital
Muenster, Muenster, Germany
| | | | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy,
“Exposome and Heredity” Team, CESP, Villejuif, France
| | - Annemiek Nap
- Department of Gynaecology and Obstetrics, Radboudumc, Nijmegen,
The Netherlands
| | | | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College London
Hospital, London, UK
- Elizabeth Garrett Anderson Institute for Women’s Health, University College
London, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center,
University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine, Department of Development and Regeneration, LEERM (Lab of
Endometrium, Endometriosis and Reproductive Medicine), KU Leuven, Leuven,
Belgium
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center
Utrecht, Utrecht, The Netherlands
| | - Nicolas Vulliemoz
- Department of Woman Mother Child, Fertility Medicine and Gynaecological
Endocrinology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology,
Strombeek-Bever, Belgium
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9
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Khoja L, Weber RP, Webb PM, Jordan SJ, Muthukumar A, Chang-Claude J, Fortner RT, Jensen A, Kjaer SK, Risch H, Doherty JA, Harris HR, Goodman MT, Modugno F, Moysich K, Berchuck A, Schildkraut JM, Cramer D, Terry KL, Anton-Culver H, Ziogas A, Phung MT, Hanley GE, Wu AH, Mukherjee B, McLean K, Cho K, Pike MC, Pearce CL, Lee AW. Endometriosis and menopausal hormone therapy impact the hysterectomy-ovarian cancer association. Gynecol Oncol 2022; 164:195-201. [PMID: 34776242 PMCID: PMC9444325 DOI: 10.1016/j.ygyno.2021.10.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/17/2021] [Accepted: 10/26/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the association between hysterectomy and ovarian cancer, and to understand how hormone therapy (HT) use and endometriosis affect this association. METHODS We conducted a pooled analysis of self-reported data from 11 case-control studies in the Ovarian Cancer Association Consortium (OCAC). Women with (n = 5350) and without ovarian cancer (n = 7544) who never used HT or exclusively used either estrogen-only therapy (ET) or estrogen+progestin therapy (EPT) were included. Risk of invasive epithelial ovarian cancer adjusted for duration of ET and EPT use and stratified on history of endometriosis was determined using odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Overall and among women without endometriosis, there was a positive association between ovarian cancer risk and hysterectomy (OR = 1.19, 95% CI 1.09-1.31 and OR = 1.20, 95% CI 1.09-1.32, respectively), but no association upon adjusting for duration of ET and EPT use (OR = 1.04, 95% CI 0.94-1.16 and OR = 1.06, 95% CI 0.95-1.18, respectively). Among women with a history of endometriosis, there was a slight inverse association between hysterectomy and ovarian cancer risk (OR = 0.93, 95% CI 0.69-1.26), but this association became stronger and statistically significant after adjusting for duration of ET and EPT use (OR = 0.69, 95% CI 0.48-0.99). CONCLUSIONS The hysterectomy-ovarian cancer association is complex and cannot be understood without considering duration of ET and EPT use and history of endometriosis. Failure to take these exposures into account in prior studies casts doubt on their conclusions. Overall, hysterectomy is not risk-reducing for ovarian cancer, however the inverse association among women with endometriosis warrants further investigation.
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Affiliation(s)
- Lilah Khoja
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA.
| | - Rachel Palmieri Weber
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27705, USA.
| | - Penelope M Webb
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia.
| | - Susan J Jordan
- School of Public Health, The University of Queensland, Brisbane, Queensland 4006, Australia.
| | - Aruna Muthukumar
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA.
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Renée T Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Allan Jensen
- Department of Lifestyle, Reproduction and Cancer, Danish Cancer Society Research Center, Copenhagen, DK-2100, Denmark.
| | - Susanne K Kjaer
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, DK-2100, Denmark; Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, DK-2100, Denmark.
| | - Harvey Risch
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT 06510, USA.
| | - Jennifer Anne Doherty
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA.
| | - Holly R Harris
- Department of Epidemiology, University of Washington, Seattle, WA 98195, USA; Program in Epidemiology, Department of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
| | - Marc T Goodman
- Cancer Prevention and Genetics Program, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
| | - Francesmary Modugno
- Women's Cancer Research Center, Magee-Women's Research Institute and Hillman Cancer Center, Pittsburgh, PA 15213, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
| | - Kirsten Moysich
- Division of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA.
| | - Andrew Berchuck
- Department of Gynecologic Oncology, Duke University Medical Center, Durham, NC 277170, USA.
| | | | - Daniel Cramer
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA 02115, USA; Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
| | - Kathryn L Terry
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA 02115, USA; Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
| | - Hoda Anton-Culver
- Department of Epidemiology, Genetic Epidemiology Research Institute, University of California Irvine, Irvine, CA 92617, USA.
| | - Argyrios Ziogas
- Department of Epidemiology, Genetic Epidemiology Research Institute, University of California Irvine, Irvine, CA 92617, USA.
| | - Minh Tung Phung
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA.
| | - Gillian E Hanley
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Anna H Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA.
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Karen McLean
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
| | - Kathleen Cho
- Department of Pathology, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
| | - Malcolm C Pike
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA.
| | - Alice W Lee
- Department of Public Health, California State University, Fullerton, CA 92831, USA.
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10
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Sun Y, Liu G. Endometriosis-associated Ovarian Clear Cell Carcinoma: A Special Entity? J Cancer 2021; 12:6773-6786. [PMID: 34659566 PMCID: PMC8518018 DOI: 10.7150/jca.61107] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/12/2021] [Indexed: 02/06/2023] Open
Abstract
Endometriosis is an estrogen-dependent disease, which serves as a precursor of ovarian cancer, especially clear cell carcinoma (OCCC) and endometrial carcinoma. Although micro-environmental factors such as oxidative stress, immune cell dysfunction, inflammation, steroid hormones, and stem cells required for malignant transformation have been found in endometriosis, the exact carcinogenic mechanism remains unclear. Recent research suggest that many putative driver genes and aberrant pathways including ARID1A mutations, PIK3CA mutations, MET activation, HNF-1β activation, and miRNAs dysfunction, play crucial roles in the malignant transformation of endometriosis to OCCC. The clinical features of OCCC are different from other histological types. Patients usually present with a large, unilateral pelvic mass, and occasionally have thromboembolic vascular complications. OCCC patients are easier to be resistant to chemotherapy, have a worse prognosis, and are usually difficult to treat. To improve the survival of OCCC patients, it is necessary to better understand its specific carcinogenic mechanism and explore new treatment strategy, including molecular target.
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Affiliation(s)
- Yue Sun
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, 300052, China.,Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, 300052, China
| | - Guoyan Liu
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, 300052, China.,Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, 300052, China
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11
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Abstract
Endometriosis will affect about 10% of the female population and not only can it significantly impact adversely on quality of life and result in infertility, but data are accumulating that malignant transformation is an important consideration. Endometriosis can be histologically typical or atypical, ovarian, superficial peritoneal or deep infiltrating. The precursor for malignant transformation appears to be the ovarian atypical endometriosis component. Ovarian cancer is the most important associated cancer, primarily endometrioid and clear cell cancer. These are the only subtypes wherein a direct clonal relationship between endometriosis, as a direct precursor, and cancer has been made. There is no substantive evidence to support an altered association of borderline cancers of the ovary, serous ovarian cancers and breast, endometrial or cervical cancers. This review provides an overview of the prevailing data pertaining to the molecular and genetic aberrations that accompany the transformation of atypical endometriosis to malignancy and the accumulated epidemiologic evidence which supports the association.
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Affiliation(s)
- F Guidozzi
- Parklane Clinic, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
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12
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Antioxidants and Therapeutic Targets in Ovarian Clear Cell Carcinoma. Antioxidants (Basel) 2021; 10:antiox10020187. [PMID: 33525614 PMCID: PMC7911626 DOI: 10.3390/antiox10020187] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 01/04/2023] Open
Abstract
Ovarian clear cell carcinomas (OCCCs) are resistant to conventional anti-cancer drugs; moreover, the prognoses of advanced or recurrent patients are extremely poor. OCCCs often arise from endometriosis associated with strong oxidative stress. Of note, the stress involved in OCCCs can be divided into the following two categories: (a) carcinogenesis from endometriosis to OCCC and (b) factors related to treatment after carcinogenesis. Antioxidants can reduce the risk of OCCC formation by quenching reactive oxygen species (ROS); however, the oxidant stress-tolerant properties assist in the survival of OCCC cells when the malignant transformation has already occurred. Moreover, the acquisition of oxidative stress resistance is also involved in the cancer stemness of OCCC. This review summarizes the recent advances in the process and prevention of carcinogenesis, the characteristic nature of tumors, and the treatment of post-refractory OCCCs, which are highly linked to oxidative stress. Although therapeutic approaches should still be improved against OCCCs, multi-combinatorial treatments including nucleic acid-based drugs directed to the transcriptional profile of each OCCC are expected to improve the outcomes of patients.
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13
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Amano T, Chano T. Linking oxidative stress and ovarian cancers. Cancer 2021. [DOI: 10.1016/b978-0-12-819547-5.00008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Guo SW. Cancer-associated mutations in endometriosis: shedding light on the pathogenesis and pathophysiology. Hum Reprod Update 2020; 26:423-449. [PMID: 32154564 DOI: 10.1093/humupd/dmz047] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/22/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endometriosis is a benign gynaecological disease. Thus, it came as a complete surprise when it was reported recently that the majority of deep endometriosis lesions harbour somatic mutations and a sizeable portion of them contain known cancer-associated mutations (CAMs). Four more studies have since been published, all demonstrating the existence of CAMs in different subtypes of endometriosis. While the field is still evolving, the confirmation of CAMs has raised many questions that were previously overlooked. OBJECTIVE AND RATIONALE A comprehensive overview of CAMs in endometriosis has been produced. In addition, with the recently emerged understanding of the natural history of endometriotic lesions as well as CAMs in normal and apparently healthy tissues, this review attempts to address the following questions: Why has there been such a wild discrepancy in reported mutation frequencies? Why does ectopic endometrium have a higher mutation rate than that of eutopic endometrium? Would the presence of CAMs in endometriotic lesions increase the risk of cancer to the bearers? Why do endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart? What clinical implications, if any, do the CAMs have for the bearers? Do these CAMs tell us anything about the pathogenesis and/or pathophysiology of endometriosis? SEARCH METHODS The PubMed database was searched, from its inception to September 2019, for all papers in English using the term 'endometriosis and CAM', 'endometriosis and cancer-driver mutation', 'somatic mutations', 'fibrosis', 'fibrosis and epigenetic', 'CAMs and tumorigenesis', 'somatic mutation and normal tissues', 'oestrogen receptor and fibrosis', 'oxidative stress and fibrosis', 'ARID1A mutation', and 'Kirsten rat sarcoma mutation and therapeutics'. All retrieved papers were read and, when relevant, incorporated into the review results. OUTCOMES Seven papers that identified CAMs in endometriosis using various sequencing methods were retrieved, and their results were somewhat different. Yet, it is apparent that those using microdissection techniques and more accurate sequencing methods found more CAMs, echoing recent discoveries that apparently healthy tissues also harbour CAMs as a result of the replicative aging process. Hence endometriotic lesions, irrespective of subtype, if left intact, would generate CAMs as part of replicative aging, oxidative stress and perhaps other factors yet to be identified and, in some rare cases, develop cancer. The published data still are unable to paint a clear picture on pathogenesis of endometriosis. However, since endometriotic epithelial cells have a higher turnover than their stromal counterpart due to cyclic bleeding, and since the endometriotic stromal component can be formed by refresh influx of mesenchymal cells through epithelial-mesenchymal transition, endothelial-mesenchymal transition, mesothelial-mesenchymal transition and other processes as well as recruitment of bone-marrow-derived stem cells and outflow due to smooth muscle metaplasia, endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart. The epithelial and stromal cellular components develop in a dependent and co-evolving manner. Genes involved in CAMs are likely to be active players in lesional fibrogenesis, and hyperestrogenism and oxidative stress are likely drivers of both CAMs and fibrogenesis. Finally, endometriotic lesions harbouring CAMs would conceivably be more refractory to medical treatment, due, in no small part, to their high fibrotic content and reduced vascularity and cellularity. WIDER IMPLICATIONS The accumulating data on CAMs in endometriosis have shed new light on the pathogenesis and pathophysiology of endometriosis. They also suggest new challenges in management. The distinct yet co-evolving developmental trajectories of endometriotic stroma and epithelium underscore the importance of the lesional microenvironment and ever-changing cellular identity. Mutational profiling of normal endometrium from women of different ages and reproductive history is needed in order to gain a deeper understanding of the pathogenesis. Moreover, one area that has conspicuously received scant attention is the epigenetic landscape of ectopic, eutopic and normal endometrium.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai 200011, China
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15
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Kvaskoff M, Mahamat-Saleh Y, Farland LV, Shigesi N, Terry KL, Harris HR, Roman H, Becker CM, As-Sanie S, Zondervan KT, Horne AW, Missmer SA. Endometriosis and cancer: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:393-420. [PMID: 33202017 DOI: 10.1093/humupd/dmaa045] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/16/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Marina Kvaskoff
- CESP, Fac. de médecine - Univ. Paris-Sud, Fac. de médecine - UVSQ, INSERM, Université Paris-Saclay, Villejuif 94805, France.,Gustave Roussy, Villejuif F-94805, France
| | - Yahya Mahamat-Saleh
- CESP, Fac. de médecine - Univ. Paris-Sud, Fac. de médecine - UVSQ, INSERM, Université Paris-Saclay, Villejuif 94805, France.,Gustave Roussy, Villejuif F-94805, France
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Nina Shigesi
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Kathryn L Terry
- Obstetrics and Gynecology Epidemiology Center, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Horace Roman
- Endometriosis Centre, Tivoli-Ducos Clinic, Bordeaux, France.,Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian M Becker
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Krina T Zondervan
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.,Wellcome Centre for Human Genetics, University of Oxford, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Stacey A Missmer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
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16
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Huang CY, Chang WH, Huang HY, Guo CY, Chou YJ, Huang N, Lee WL, Wang PH. Subsequent Development of Epithelial Ovarian Cancer After Ovarian Surgery for Benign Ovarian Tumor: A Population-Based Cohort Study. Clin Epidemiol 2020; 12:637-649. [PMID: 32606989 PMCID: PMC7308129 DOI: 10.2147/clep.s199349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 05/24/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Chen-Yu Huang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Hsun Chang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Yi Huang
- Biostatics Task Force, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Yu Guo
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Yiing-Jenq Chou
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Ling Lee
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan.,Department of Nursing, Oriental Institute of Technology, New Taipei City, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Female Cancer Foundation, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
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17
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Farland LV, Harris HR. Long-term Health Consequences of Endometriosis - Pathways and Mediation by Treatment. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020; 9:79-88. [PMID: 33552675 DOI: 10.1007/s13669-020-00287-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review The purpose of this review is to discuss the most up to date research on endometriosis and chronic disease risk, highlighting the role treatments for endometriosis may play in these associations. Recent findings Previous studies have shown a consistent association between endometriosis and risk for epithelial ovarian cancer but the association with other cancers is less clear. Current research indicates that endometriosis may in be associated with risk of systemic lupus erythematosus, and potentially other autoimmune diseases. Limited evidence is also present for the association between endometriosis and cardiovascular disease and related conditions (e.g,. hypertension, hypercholesterolemia). A potential explanation for a portion of the increased risk of chronic diseases among women with endometriosis may relate to treatments for endometriosis impacting these outcomes. Summary Given the prevalence of endometriosis, understanding the relation between endometriosis and other chronic diseases has the potential to impact the health of many women. However, few high-quality studies with limited biases and adequate follow-up currently exist. Future multi-disciplinary research in prospective cohorts, with ample follow-up time, and detailed information on endometriosis characteristics and treatment is critical to advancing our understanding of this disease and its consequences.
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Affiliation(s)
- Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
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Pejovic T, Thisted S, White M, Nezhat FR. Endometriosis and Endometriosis-Associated Ovarian Cancer (EAOC). ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1242:73-87. [DOI: 10.1007/978-3-030-38474-6_5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Králíčková M, Laganà AS, Ghezzi F, Vetvicka V. Endometriosis and risk of ovarian cancer: what do we know? Arch Gynecol Obstet 2019; 301:1-10. [DOI: 10.1007/s00404-019-05358-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/25/2019] [Indexed: 12/15/2022]
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Dixon-Suen SC, Webb PM, Wilson LF, Tuesley K, Stewart LM, Jordan SJ. The Association Between Hysterectomy and Ovarian Cancer Risk: A Population-Based Record-Linkage Study. J Natl Cancer Inst 2019; 111:1097-1103. [PMID: 30753695 PMCID: PMC6792101 DOI: 10.1093/jnci/djz015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/19/2018] [Accepted: 01/08/2019] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Suzanne C Dixon-Suen
- Correspondence to: Suzanne C. Dixon-Suen, MEpi, Population Health Department, QIMR Berghofer Medical Research Institute, Locked Bag 2000, Royal Brisbane Hospital, Herston Qld 4029, Australia (e-mail: )
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21
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Huang CC, Lin CH. Response to comment on: prior uterine myoma and risk of ovarian cancer: a population-based case-control study. J Gynecol Oncol 2019; 30:e109. [PMID: 31328471 PMCID: PMC6658595 DOI: 10.3802/jgo.2019.30.e109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 07/07/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Chun Che Huang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Ching Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Public Health, Fu-Jen Catholic University, New Taipei, Taiwan.,Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Tamhane N, Imudia AN, Mikhail E. Contemporary management of adnexa at the time of benign hysterectomy: a review of the literature. J OBSTET GYNAECOL 2019; 39:896-902. [PMID: 31303119 DOI: 10.1080/01443615.2019.1581747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.
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Affiliation(s)
- Nupur Tamhane
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
| | - Anthony N Imudia
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
| | - Emad Mikhail
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
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Salvador S, Scott S, Francis JA, Agrawal A, Giede C. No. 344-Opportunistic Salpingectomy and Other Methods of Risk Reduction for Ovarian/Fallopian Tube/Peritoneal Cancer in the General Population. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:480-493. [PMID: 28527613 DOI: 10.1016/j.jogc.2016.12.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This guideline reviews the potential benefits of opportunistic salpingectomy to prevent the development of high grade serous cancers (HGSC) of the ovary/fallopian tube/peritoneum based on current evidence supporting the fallopian tube origin of disease. INTENDED USERS Gynaecologists, obstetricians, family doctors, registered nurses, nurse practitioners, residents, and health care providers. TARGET POPULATION Adult women (18 and older): OPTIONS: Women considering hysterectomy who wish to retain their ovaries in situ have traditionally also retained their fallopian tubes. In addition, women undergoing permanent surgical sterilization have usually undergone tubal ligation using various methods rather than undergoing surgical removal of the entire fallopian tube. EVIDENCE For the sections "Evidence Supporting the Hypothesis That HGSC Originates in the Fallopian Tube" and "Current Literature on the Effects and Safety of Opportunistic Salpingectomy," relevant studies were searched in PubMed, Medline, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials: "high grade serous cancers ovary," "fallopian tube," "peritoneum," "opportunistic salpingectomy," "epithelial ovarian cancers," "origin," "tubal carcinoma in situ," "BRCA mutation," "prophylactic salpingectomy," "inflammation," "clear cell," and "endometrioid." The initial search was performed in March 2015 with a final literature search in March 2016. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. The total number of studies identified was 458, and 56 studies were included in this review. For the section "Other Factors Influencing the Risk of Developing "Ovarian" Cancers" a general Medline search was carried out using the terms "ovarian neoplasm" and "prevention." The search included papers published from December 2005 to March 2016. Meta-analyses were preferentially selected except where no such review was found. Additional searches for each subheading were also conducted (e.g., "ovarian neoplasm" and "tubal ligation.") Additional significant articles were identified through cross-referencing the identified reviews. For the search for "ovarian neoplasm" and "prevention," 10 meta-analyses were identified. For the search for "ovarian neoplasm" and "tubal ligation," an additional 4 meta-analyses were identified. VALIDATION METHODS The content and recommendations were drafted and agreed on by the principal authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (Table 1). The interpretation of strong and weak recommendations is described in Table 2. The summary of findings is available on request. BENEFITS, HARMS, AND/OR COSTS The addition of opportunistic salpingectomy to a planned hysterectomy or permanent sterilization did not increase rates of hospital readmission (OR 0.91, 95% CI 0.75 to 1.10 and OR 0.8, 95% CI 0.56 to 1.21, respectively) or blood transfusions (OR 0.86, 95% CI 0.67 to 1.10 and OR 0.75, 95% CI 0.32 to 1.73, respectively) but did increase the overall operating time (by 16 minutes and 10 minutes, respectively) in a retrospective review of 43 931 women. The risk of repeat surgery for tubal pathology among women with retained fallopian tubes after hysterectomy was at least doubled (OR 2.13, 95% CI 1.88 to 2.42 in a population-based study of 170 000 women). If general gynaecologists were to consider removal of fallopian tubes at the time of every hysterectomy and sterilization procedure with referral of all patients with HGSC for hereditary cancer counselling and genetic testing, experts project a potential reduction in the rate of HGSC by 40% over the next 20 years. GUIDELINE UPDATE Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SPONSORS This guideline was developed with resources funded by the Society of Gynecologic Oncology of Canada and SOGC. SUMMARY STATEMENTS RECOMMENDATIONS.
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Hidari T, Hirata T, Arakawa T, Koga K, Neriishi K, Fukuda S, Nakazawa A, Nagashima N, Ma S, Sun H, Takamura M, Harada M, Hirota Y, Wada-Hiraike O, Fujii T, Osuga Y. Contralateral ovarian endometrioma recurrence after unilateral salpingo-oophorectomy. BMC WOMENS HEALTH 2019; 19:59. [PMID: 31046768 PMCID: PMC6498560 DOI: 10.1186/s12905-019-0760-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/22/2019] [Indexed: 11/17/2022]
Abstract
Background The recurrence rate after unilateral salpingo-oophorectomy (USO) for unilateral endometrioma has not been reported. We evaluated the rate of and risk factors for endometrioma recurrence after USO. Methods In this retrospective observational study, we enrolled 110 women (age, 35–45 years) who underwent laparoscopic USO (n = 50) or cystectomy (n = 60) for unilateral ovarian endometrioma from January 2010 through December 2012. We compared patients’ characteristics between patients who underwent USO and those who underwent cystectomy. We also compared patients with and without an endometrioma recurrence after USO using univariate and multivariate stepwise logistic regression models to identify recurrence risk factors. Endometrioma recurrence was defined as an ovarian cyst (> 2 cm) with features typical of an endometrioma identified by postoperative transvaginal sonography. Results Endometrioma recurred in 8 (16%) patients after USO (mean follow-up, 46.0 ± 12.9 months [range, 15–73]). The post-USO cumulative recurrence rates at 12, 24, 36, and 60 months were 8.0, 10.2, 12.7, and 24.7%, respectively (Kaplan-Meier analysis). In logistic regression analysis, a contralateral side adhesion score ≥ 4 was an independent risk factor for endometrioma recurrence after USO (odds ratio, 19.48, 95% confidence interval, 1.59–237.72). The post-USO cumulative recurrence rates at 12, 24, 36, and 57 months were 19.5, 24.1, 31.0, and 54.0%, respectively, in cases with contralateral side adhesion scores ≥4, and 0.0, 0.0, 0.0, and 5.9%, respectively, in cases with scores < 4 (log-rank test, P = 0.0023). Conclusions To our knowledge, this is the first report on the recurrence rate and risk factors associated with recurrence after USO. Endometrioma recurrence rates were 24.7% during the first 5 years after USO. The post-USO recurrence rate increased significantly in cases with contralateral side adhesions. Our findings could improve the planning of USO and patient selection for postoperative hormonal therapy.
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Affiliation(s)
- Tokie Hidari
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tetsuya Hirata
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tomoko Arakawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuaki Neriishi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shinya Fukuda
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Akari Nakazawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Natsuki Nagashima
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Suke Ma
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hui Sun
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masashi Takamura
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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25
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Clinicopathologic characteristics of ovarian clear cell carcinoma in the background of endometrioma: a surveillance strategy for an early detection of malignant transformation in patients with asymptomatic endometrioma. Obstet Gynecol Sci 2018; 62:27-34. [PMID: 30671391 PMCID: PMC6333765 DOI: 10.5468/ogs.2019.62.1.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 12/28/2022] Open
Abstract
Objective This study aimed to analyze the clinical features of clear cell carcinoma in relation to endometriosis and to determine an appropriate surveillance strategy for the early detection of malignant transformation of endometrioma in asymptomatic patients. Methods We retrospectively reviewed the clinicopathologic data of 50 patients with ovarian clear cell carcinoma. Clinicopathologic characteristics, treatment outcomes, and the association between endometriosis and the risk of malignant transformation were analyzed. Results Ten (20%) patients had been diagnosed with endometrioma before the diagnosis of clear cell carcinoma. The median period from the diagnosis of endometrioma to clear cell carcinoma diagnosis was 50 months (range, 12–213 months). After complete staging surgery, histological confirmation of endometriosis was possible in 35 (70%) patients. Of the 50 patients, 39 (78%) had not undergone any gynecologic surveillance until the onset of symptoms, at which time many of them presented with a rapidly growing pelvic mass (median 10 cm, range 4.6–25 cm). With the exception of 2 patients, all cancer diagnoses were made when the patients were in their late thirties, and median tumor size was found to increase along with age. Asymptomatic patients (n=11) who had regular gynecologic examinations were found to have a relatively smaller tumor size, lesser extent of tumor spread, and lower recurrence rate (P=0.011, 0.283, and 0.064, respectively). The presence of endometriosis was not related to the prognosis. Conclusion Considering the duration of malignant transformation and the timing of cancer diagnosis, active surveillance might be considered from the age of the mid-thirties, with at least a 1-year interval, in patients with asymptomatic endometrioma.
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Mallen A, Soong TR, Townsend MK, Wenham RM, Crum CP, Tworoger SS. Surgical prevention strategies in ovarian cancer. Gynecol Oncol 2018; 151:166-175. [PMID: 30087058 DOI: 10.1016/j.ygyno.2018.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022]
Abstract
Given the current lack of effective screening for ovarian cancer, surgical removal of at-risk tissue is the most successful strategy to decrease risk of cancer development. However, the optimal timing of surgery and tissues to remove, as well as the appropriate patients to undergo preventive procedures are poorly understood. In this review, we first discuss the origin and precursors of ovarian epithelial carcinomas, focusing on high-grade serous carcinomas and endometriosis-associated carcinomas, which cause the majority of the mortality and incidence of ovarian cancer. In addition, we summarize the implications of current understanding of specific pathogenic origins for surgical prevention and remaining gaps in knowledge. Secondly, we review evidence from the epidemiologic literature on the associations of various surgical prevention strategies, including endometriosis excision, tubal procedures, and bilateral salpingo-oophorectomy, with risk of future ovarian cancer development, as well as the short- and long-term consequences of these strategies on women's health and quality and life. We conclude with recommendations for surgical prevention in women with high-risk genetic mutations and average-risk women, and a brief discussion of ongoing research that will help clarify optimal surgical approaches that balance risk-reduction with maintenance of women's quality of life.
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Affiliation(s)
- Adrianne Mallen
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
| | - T Rinda Soong
- Department of Pathology, University of Washington, Seattle, WA, United States of America
| | - Mary K Townsend
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, United States of America
| | - Robert M Wenham
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
| | - Christopher P Crum
- Department of Pathology, Division of Women's and Perinatal Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, United States of America; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
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27
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Perimenopausal management of ovarian endometriosis and associated cancer risk: When is medical or surgical treatment indicated? Best Pract Res Clin Obstet Gynaecol 2018; 51:151-168. [DOI: 10.1016/j.bpobgyn.2018.01.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
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Abstract
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.
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Taylor HS, Adamson GD, Diamond MP, Goldstein SR, Horne AW, Missmer SA, Snabes MC, Surrey E, Taylor RN. An evidence-based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis. Int J Gynaecol Obstet 2018; 142:131-142. [DOI: 10.1002/ijgo.12521] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/19/2018] [Accepted: 05/03/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Hugh S. Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale School of Medicine; New Haven; CT USA
| | | | - Michael P. Diamond
- Department of Obstetrics and Gynecology; Augusta University; Augusta GA USA
| | - Steven R. Goldstein
- Department of Obstetrics and Gynecology; New York University Langone Medical Center; New York NY USA
| | - Andrew W. Horne
- Medical Research Council Centre for Reproductive Health; University of Edinburgh; Edinburgh UK
| | - Stacey A. Missmer
- Department of Epidemiology; Harvard TH Chan School of Public Health; Boston MA USA
- Department of Obstetrics, Gynecology and Reproductive Biology; Michigan State University; Grand Rapids MI USA
| | | | - Eric Surrey
- Colorado Center for Reproductive Medicine; Lone Tree; CO USA
| | - Robert N. Taylor
- Department of Obstetrics and Gynecology; Wake Forest School of Medicine; Winston-Salem NC USA
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Taniguchi F. New knowledge and insights about the malignant transformation of endometriosis. J Obstet Gynaecol Res 2018; 43:1093-1100. [PMID: 28718209 DOI: 10.1111/jog.13372] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/13/2017] [Accepted: 04/02/2017] [Indexed: 12/25/2022]
Abstract
Endometriosis may be a definitive risk factor for ovarian cancer, the most fatal gynecological cancer. The ability of endometriosis to transform into malignancy, first described by Dr. Sampson in 1925, is considered a rare occurrence, affecting approximately 1% of ovarian endometriomas. Recently we conducted a retrospective study regarding the malignant transformation of endometriosis in Japanese women. Many studies have reported a consistent correlation between endometriosis and ovarian cancer according to histological subtypes. However, the existing epidemiological evidence linking this association is insufficient to define the role of endometriosis as a cause of ovarian cancer and to influence changes to current clinical practice. Prospective cohort studies are therefore needed to clarify this issue. Additionally, the results of many molecular studies are conflicting, and earlier studies showing the molecular aberrations involved in genomic instability and mutation that enable malignant transformation have not been replicated in later studies. Careful long-term observation of a patient with endometrioma is required to detect possible subsequent incidence of malignant transformation. More importantly, a precise strategy should be set up for better prevention, early detection, specific diagnosis and treatment targeting molecular pathogenesis to understand the mechanisms of endometriosis-associated ovarian cancer. Clinicians need to be aware of the increased ovarian cancer risk in women with endometriosis.
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Affiliation(s)
- Fuminori Taniguchi
- Department of Obstetrics and Gynecology, Tottori University Faculty of Medicine, Yonago, Japan
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31
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Borghese B, Santulli P, Marcellin L, Chapron C. [Definition, description, clinicopathological features, pathogenesis and natural history of endometriosis: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29540335 DOI: 10.1016/j.gofs.2018.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endometriosis and adenomyosis are histologically defined. The frequency of endometriosis cannot be precisely estimated in the general population. Endometriosis is considered a disease when it causes pain and/or infertility. Endometriosis is a heterogeneous disease with three well-recognized subtypes that are often associated with each other: superficial endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). DIE is frequently multifocal and mainly affects the following structures: the uterosacral ligaments, the posterior vaginal cul-de-sac, the bladder, the ureters, and the digestive tract (rectum, recto-sigmoid junction, appendix). The role of menstrual reflux in the pathophysiology of endometriosis is major and explains the asymmetric distribution of lesions, which predominate in the posterior compartment of the pelvis and on the left (NP3). All factors favoring menstrual reflux increase the risk of endometriosis (early menarche, short cycles, AUB, etc.). Inflammation and biosteroid hormones synthesis are the main mechanisms favoring the implantation and the growth of the lesions. Pain associated with endometriosis can be explained by nociception, hyperalgia, and central sensitization, associated to varying degrees in a single patient. Typology of pain (dysmenorrhea, deep dyspareunia, digestive or urinary symptoms) is correlated with the location of the lesions. Infertility associated with endometriosis can be explained by several non-exclusive mechanisms: a pelvic factor (inflammation), disrupting natural fertilization; an ovarian factor, related to oocyte quality and/or quantity; a uterine factor disrupting implantation. The pelvic factor can be fixed by surgical excision of the lesions that improves the chance of natural conception (NP2). The uterine factor can be corrected by an ovulation-blocking treatment that improves the chances of getting pregnant by in vitro fertilization (NP2). The impact of endometrioma exeresis on the ovarian reserve (NP2) should be considered when a surgery is scheduled. Endometriosis is a multifactorial disease, resulting from combined action of genetic and environmental factors. The risk of developing endometriosis for a first-degree relative is five times higher than in the general population (NP2). Identification of genetic variants involved in the disease has no implication for clinical practice for the moment. The role of environmental factors, particularly endocrine disrupters, is plausible but not demonstrated. Literature review does not support the progression of endometriosis over time, either in terms of the volume or the number of the lesions (NP3). The risk of acute digestive occlusion or functional loss of a kidney in patients followed for endometriosis seems exceptional. These complications were revealing the disease in the majority of cases. IVF does not increase the intensity of pain associated with endometriosis (NP2). There is few data on the influence of pregnancy on the lesions, except the possibility of a decidualization of the lesions that may give them a suspicious aspect on imaging. The impact of endometriosis on pregnancy is debated. There is an epidemiological association between endometriosis and rare subtypes of ovarian cancer (endometrioid and clear cell carcinomas) (NP2). However, the relative risk is moderate (around 1.3) (NP2) and the causal relationship between endometriosis and ovarian cancer is not demonstrated so far. Considering the low incidence of endometriosis-associated ovarian cancer, there is no argument to propose a screening or a risk reducing strategy for the patients.
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Affiliation(s)
- B Borghese
- Service de chirurgie gynécologie obstétrique 2 et médecine de la reproduction, CHU Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Équipe génomique, épigénétique et physiopathologie de la reproduction, Inserm U1016, département développement, reproduction, cancer, université Paris Descartes, Sorbonne Paris cité, 12, rue de l'École-de-médecine, 75270 Paris cedex 06, France.
| | - P Santulli
- Service de chirurgie gynécologie obstétrique 2 et médecine de la reproduction, CHU Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Équipe génomique, épigénétique et physiopathologie de la reproduction, Inserm U1016, département développement, reproduction, cancer, université Paris Descartes, Sorbonne Paris cité, 12, rue de l'École-de-médecine, 75270 Paris cedex 06, France
| | - L Marcellin
- Service de chirurgie gynécologie obstétrique 2 et médecine de la reproduction, CHU Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Équipe stress oxydant, prolifération cellulaire et inflammation, Inserm U1016, département développement, reproduction, cancer, université Paris Descartes, Sorbonne Paris cité, 12, rue de l'École-de-médecine, 75270 Paris cedex 06, France
| | - C Chapron
- Service de chirurgie gynécologie obstétrique 2 et médecine de la reproduction, CHU Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Équipe génomique, épigénétique et physiopathologie de la reproduction, Inserm U1016, département développement, reproduction, cancer, université Paris Descartes, Sorbonne Paris cité, 12, rue de l'École-de-médecine, 75270 Paris cedex 06, France
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Wu B, Yang Z, Tobe RG, Wang Y. Medical therapy for preventing recurrent endometriosis after conservative surgery: a cost-effectiveness analysis. BJOG 2017; 125:469-477. [PMID: 28613432 DOI: 10.1111/1471-0528.14786] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- B Wu
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Z Yang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - R G Tobe
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Y Wang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Salvador S, Scott S, Francis JA, Agrawal A, Giede C. N o 344-Salpingectomie opportuniste et autres méthodes pour réduire le risque de cancer de l'ovaire, de la trompe de Fallope et du péritoine dans la population générale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:494-508. [PMID: 28527614 DOI: 10.1016/j.jogc.2017.03.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIF La présente directive clinique examine les avantages potentiels de la salpingectomie opportuniste pour prévenir le développement du cancer séreux de grade élevé de l'ovaire, de la trompe de Fallope et du péritoine à la lumière de données probantes actuelles selon lesquelles ce type de cancer prendrait naissance dans la trompe de Fallope. UTILISATEURS CIBLES Gynécologues, obstétriciens, médecins de famille, infirmières autorisées, infirmières praticiennes, résidents et fournisseurs de soins de santé. POPULATION CIBLE Femmes adultes (18 ans et plus) : OPTIONS: Les femmes envisageant une hystérectomie et souhaitant conserver leurs ovaires conservent généralement aussi leurs trompes de Fallope. De plus, celles qui subissent une chirurgie de stérilisation permanente subissent habituellement aussi une ligature des trompes selon des méthodes variées plutôt qu'un retrait chirurgical complet des trompes. RéSULTATS: Les sections « Données probantes appuyant l'hypothèse selon laquelle les CSGE prendraient naissance dans la trompe de Fallope » et « Articles récents sur les répercussions et la sûreté de la salpingectomie opportuniste » reposent sur des études pertinentes rédigées en anglais, qui ont été repérées dans PubMed, Medline et la Cochrane Database of Systematic Reviews à l'aide des termes suivants, seuls ou combinés : high grade serous cancers ovary, fallopian tube, peritoneum, opportunistic salpingectomy, epithelial ovarian cancers, origin, tubal carcinoma in situ, BRCA mutation, prophylactic salpingectomy, inflammation, clear cell et endometrioid. La recherche initiale a été menée en mars 2015, et une dernière recherche a été effectuée en mars 2016. Dans l'ordre, les données probantes pertinentes ont été tirées de méta-analyses, de revues de la littérature, de directives, d'essais cliniques randomisés, d'études de cohorte prospectives, d'études d'observation, de revues non systématiques, d'études de série de cas ainsi que de rapports. Au total, 458 études ont été repérées, et 56 ont été retenues pour la présente directive. Pour la section « Autres facteurs influant sur le risque de développer un cancer de ″l'ovaire″ », une recherche générale a été effectuée dans Medline à partir des termes ovarian neoplasm et prevention. Ont été inclus dans cette recherche des articles rédigés entre décembre 2005 et mars 2016. Les méta-analyses ont été privilégiées lorsque possible. Des recherches supplémentaires ont également été menées pour chaque sous-descripteurs (p. ex., ovarian neoplasm et tubal ligation). D'autres articles pertinents ont été ciblés au moyen d'une vérification des références des revues de la littérature retenues. Les termes ovarian neoplasm et prevention ont permis de repérer 10 méta-analyses; les termes ovarian neoplasm et tubal ligation, 4 méta-analyses. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux. La direction et le conseil de la Société de gynéco-oncologie du Canada ont examiné le contenu et soumis des commentaires, puis le Conseil d'administration de la SOGC a approuvé la version finale avant publication. La qualité des données probantes a été évaluée à partir des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) (tableau 1). L'interprétation des recommandations solides et conditionnelles est décrite dans le tableau 2. Le résumé des conclusions peut être fourni sur demande. AVANTAGES, INCONVéNIENTS ET COûTS: L'ajout d'une salpingectomie opportuniste à une hystérectomie ou à une procédure de stérilisation permanente prévue n'a pas entraîné une augmentation des taux de réadmission à l'hôpital (RC : 0,91; IC à 95 % : 0,75-1, 10 et RC : 0,8; IC à 95 % : 0,56-1,21, respectivement) ou de transfusion sanguine (RC : 0,86; IC à 95 % : 0,67-1,10 et RC : 0,75; IC à 95 % : 0,32-1,73, respectivement), mais il a entraîné une hausse de la durée des opérations (de 16 minutes et de 10 minutes, respectivement) selon une étude rétrospective portant sur 43 931 femmes. Le risque de subir des interventions répétées pour une pathologie tubaire chez les femmes ayant conservé leurs trompes de Fallope après une hystérectomie était au moins deux fois plus élevé (RC : 2,13; IC à 95 % : 1,88-2,42, selon une étude fondée sur une population de 170 000 femmes). Selon des experts, si les gynécologues généralistes envisageaient systématiquement de retirer les trompes de Fallope lors d'une hystérectomie ou d'une procédure de stérilisation et d'aiguiller toutes les patientes aux prises avec un CSGE vers une consultation en oncologie génétique et un dépistage génétique, le taux de CSGE pourrait diminuer de 40 % au cours des 20 prochaines années. MISE à JOUR DE DIRECTIVES CLINIQUES: Une revue des données probantes sera menée cinq ans après la publication de la présente directive clinique afin de déterminer si une mise à jour complète ou partielle s'impose. Cependant, si de nouvelles données probantes importantes sont publiées avant la fin du cycle de cinq ans, le processus pourrait être accéléré afin que certaines recommandations soient mises à jour rapidement. PARRAINS La présente directive clinique a été élaborée à l'aide de ressources financées par la Société de gynéco-oncologie du Canada et la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Validity of self-reported endometriosis and endometriosis-related questions in a Swedish female twin cohort. Fertil Steril 2017; 107:174-178.e2. [DOI: 10.1016/j.fertnstert.2016.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 09/20/2016] [Indexed: 11/30/2022]
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Development of ovarian cancer after excision of endometrioma. Fertil Steril 2016; 106:1432-1437.e2. [DOI: 10.1016/j.fertnstert.2016.07.1077] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/07/2016] [Accepted: 07/14/2016] [Indexed: 11/19/2022]
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Thomsen LH, Schnack TH, Buchardi K, Hummelshoj L, Missmer SA, Forman A, Blaakaer J. Risk factors of epithelial ovarian carcinomas among women with endometriosis: a systematic review. Acta Obstet Gynecol Scand 2016; 96:761-778. [DOI: 10.1111/aogs.13010] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/23/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Line H. Thomsen
- Department of Gynecology and Obstetrics; Aarhus University Hospital; Aarhus Denmark
| | - Tine H. Schnack
- Gynecologic and Obstetric Department; Rigshospitalet University Hospital of Copenhagen; Copenhagen Denmark
| | | | | | - Stacey A. Missmer
- Department of Obstetrics; Gynecology and Reproductive Biology College of Human Medicine; Michigan State University; Boston MA USA
- Department of Epidemiology; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Axel Forman
- Department of Gynecology and Obstetrics; Aarhus University Hospital; Aarhus Denmark
| | - Jan Blaakaer
- Department of Gynecology and Obstetrics; Aarhus University Hospital; Aarhus Denmark
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Promotion of angiogenesis and proliferation cytokines patterns in peritoneal fluid from women with endometriosis. J Reprod Immunol 2016; 116:1-6. [DOI: 10.1016/j.jri.2016.01.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/20/2016] [Accepted: 01/27/2016] [Indexed: 11/19/2022]
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Nezhat FR, Apostol R, Nezhat C, Pejovic T. New insights in the pathophysiology of ovarian cancer and implications for screening and prevention. Am J Obstet Gynecol 2015; 213:262-7. [PMID: 25818671 DOI: 10.1016/j.ajog.2015.03.044] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/31/2015] [Accepted: 03/20/2015] [Indexed: 11/30/2022]
Abstract
Despite advances in medicine, ovarian cancer remains the deadliest of the gynecological malignancies. Herein we present the latest information on the pathophysiology of ovarian cancer and its significance for ovarian cancer screening and prevention. A new paradigm for ovarian cancer pathogenesis presupposes 2 distinct types of ovarian epithelial carcinoma with distinct molecular profiles: type I and type II carcinomas. Type I tumors include endometrioid, clear-cell carcinoma, and low-grade serous carcinoma and mostly arise via defined sequence either from endometriosis or from borderline serous tumors, mostly presenting in an early stage. More frequent type II carcinomas are usually high-grade serous tumors, and recent evidence suggests that the majority arise from the fimbriated end of the fallopian tube. Subsequently, high-grade serous carcinomas usually present at advanced stages, likely as a consequence of the rapid peritoneal seeding from the open ends of the fallopian tubes. On the other hand, careful clinical evaluation should be performed along with risk stratification and targeted treatment of women with premalignant conditions leading to type I cancers, most notably endometriosis and endometriomas. Although the chance of malignant transformation is low, an understanding of this link offers a possibility of prevention and early intervention. This new evidence explains difficulties in ovarian cancer screening and helps in forming new recommendations for ovarian cancer risk evaluation and prophylactic treatments.
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MESH Headings
- Adenocarcinoma, Clear Cell/classification
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/prevention & control
- Carcinoma, Endometrioid/classification
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/prevention & control
- Early Detection of Cancer
- Endometriosis/surgery
- Fallopian Tubes
- Female
- Humans
- Neoplasm Grading
- Neoplasms, Cystic, Mucinous, and Serous/classification
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/prevention & control
- Ovarian Diseases/surgery
- Ovarian Neoplasms/classification
- Ovarian Neoplasms/pathology
- Ovarian Neoplasms/prevention & control
- Ovariectomy
- Precancerous Conditions/surgery
- Salpingectomy
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Affiliation(s)
- Farr R Nezhat
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mount Sinai Roosevelt, Division of Minimally Invasive Gynecologic Surgery, Winthrop University Hospital, State University of New York at Stony Brook, College of Medicine, New York, NY.
| | - Radu Apostol
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Mount Sinai-St. Luke's and Roosevelt Hospital System, New York, NY
| | - Camran Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Tanja Pejovic
- Division of Gynecologic Oncology, Oregon Health and Science University, Portland, OR
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Lee WL, Chang WH, Wang KC, Guo CY, Chou YJ, Huang N, Huang HY, Yen MS, Wang PH. 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. Medicine (Baltimore) 2015; 94:e1633. [PMID: 26426652 PMCID: PMC4616839 DOI: 10.1097/md.0000000000001633] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
This article aims to test the hypothesis that the risk of epithelial ovarian cancer (EOC) in women with endometriosis might be changed by enrolling different population. A nationwide 14-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 239,385 women aged between 20 and 51 years, with at least 1 gynecologic visit after 2000, were analyzed. Cases included women with a diagnosed endometriosis, which was established along a spectrum from at least 1 medical record of endometriosis (recalled endometriosis) to tissue-proved ovarian endometriosis (n = X). Controls included women without any diagnosis of endometriosis (n = 239,385 - X). We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CI) to determine the risk of EOC in patients. The EOC incidence rates (IRs, per 10,000 person-years) of women with endometriosis ranged from 1.90 in women with recalled endometriosis to 18.70 in women with tissue-proved ovarian endometrioma, compared with those women without any diagnosis of endometriosis (0.77-0.89), contributing to crude HRs ranging from 2.59 (95% CI, 2.09-3.21; P < 0.001) to 24.04 (95% CI, 17.48-33.05; P < 0.001). After adjustment for pelvic inflammatory disease, infertility, Charlson co-morbidity index, and age, adjusted HRs were ranged from the lowest of 1.90 (95% CI, 1.51-2.37; P < 0.001) in recalled endometriosis to the highest of 18.57 (95% CI, 13.37-25.79; P < 0.001) in tissue-proved ovarian endometrioma, which was inversely related to the prevalence rate of endometriosis (from the highest of 30.80% in recalled endometriosis to the lowest of 1.54% in tissue-proved ovarian endometrioma). The risk of EOC in women with endometriosis varied greatly by different criteria used. Women with endometriosis might have a more apparently higher risk than those reported by systematic review and meta-analysis.
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Affiliation(s)
- Wen-Ling Lee
- From the Department of Nursing, Oriental Institute of Technology, New Taipei City (W-LL, K-CW); Department of Medicine, Cheng-Hsin General Hospital (W-LL); Department of Obstetrics and Gynecology (W-LL, M-SY, P-HW); Department of Nursing (W-LL, W-HC, P-HW); Institute of Hospital and Health Care Administration and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (C-YG, Y-JC, NH); Department of Nursing (W-HC); Department of Obstetrics and Gynecology (W-HC, M-SY, P-HW); Biostatics Task Force, Taipei Veterans General Hospital, Taipei, Taiwan (H-YH); Department of Medical Research (P-HW); and China Medical University Hospital, Taichung, Taiwan
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Guo SW. Endometriosis and ovarian cancer: potential benefits and harms of screening and risk-reducing surgery. Fertil Steril 2015; 104:813-830. [PMID: 26335131 DOI: 10.1016/j.fertnstert.2015.08.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/03/2015] [Accepted: 08/05/2015] [Indexed: 12/23/2022]
Abstract
Although endometriosis is well recognized as a benign gynecologic condition, its association with ovarian cancer (OVCA) has frequently been reported. Review articles on this topic are voluminous, yet there seems to be no consensus as to whether endometriosis is truly a precursor of OVCA and whether any screening or risk-reducing surgery should be instituted, on the basis of our current knowledge. In this review, published data are compiled and critically appraised. Through this critical appraisal, it seems clear that the strongest evidence seems to come from prevalence data. This type of data also suggests a reduced risk of certain histotypes (mainly type II) of OVCA in women with endometriosis. This may explain the rather moderate increase in risk as shown in epidemiologic studies. Even with this moderate increase in OVCA risk, caution should be exercised because of apparent bias in favor of publication of positive results, extensive heterogeneities among prevalence estimates, and inverse relationship between estimates and sizes of the studies. Many molecular studies are conflicting, and earlier studies showing molecular aberrations involved in genomic instability and mutation that enable malignant transformation are not replicated in later studies. Given the low incidence of OVCA and the rather moderate increase in risk of mostly type I tumors, screening seems to be ill-advised, and risk-reducing surgery such as salpingectomy with or without oophorectomy does not seem to yield any substantial benefit to women with endometriosis.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, People's Republic of China; Department of Biochemistry and Molecular Biology, Shanghai College of Medicine, Fudan University, Shanghai, People's Republic of China.
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Kok VC, Tsai HJ, Su CF, Lee CK. The Risks for Ovarian, Endometrial, Breast, Colorectal, and Other Cancers in Women With Newly Diagnosed Endometriosis or Adenomyosis: A Population-Based Study. Int J Gynecol Cancer 2015; 25:968-76. [PMID: 25893280 DOI: 10.1097/igc.0000000000000454] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Recent studies report a link between endometriosis and ovarian cancer (OC). Using a population-based cohort study to confirm the association between endometriosis and cancer is desirable. We thus examined the magnitude of the risks of OC, endometrial cancer (EC), breast cancer, colorectal cancer (CRC), and other cancers in women with newly diagnosed endometriosis or adenomyosis (internal endometriosis). METHODS/MATERIALS Women older than 20 years with claims data between 2003 and 2005 were identified from the Longitudinal Health Insurance Dataset containing 1 million individuals randomly sampled from the National Health Insurance Research Database. Those with preexisting malignancies, hysterectomy, or oophorectomy were excluded. The endometriosis cohort (n = 2266, including 768 cases of pure adenomyosis) and comparison cohort (n = 9064), formed by 1:4 matching, were followed up until incidence cancer, dropout, or December 31, 2008. Outcome measures included cancer incidence and adjusted hazard ratio by Cox model adjusted for age group, comorbidities, and endometriosis medication use. RESULTS With 9842 person-years of follow-up in endometriosis cohort and 36,274 person-years of follow-up in comparison cohort, there were increased risks of all cancers (adjusted hazard ratio, 1.8; 95% confidence interval, 1.4-2.4), OC (4.56, 1.72-12.11), and EC (4.05, 1.20-13.66). The ovarian endometriosis group was associated with increased risk of subsequent OC (4.37, 1.07-17.83). The adenomyosis group was strongly associated with both OC (5.50, 1.95-15.50) and EC (5.13, 1.36-19.40). Increased risk of subsequent CRC was observed in women with adenomyosis with coexistent endometriosis at other sites (13.04, 2.21-77.04). However, no statistically significant increased risk of breast or other cancers was observed. CONCLUSIONS Having limitations such as lacking of parity information which may affect the magnitude of risk estimates, this study demonstrates that ovarian endometriosis has a 4-fold increased risk of OC. Adenomyosis may associate with a 4- to 5-fold increased risk of OC and EC, and unexpectedly, a 13-fold increased risk of CRC.
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Affiliation(s)
- Victor C Kok
- *Division of Medical Oncology, Kuang Tien General Hospital Cancer Center, Shalu, Taichung, Taiwan; †Department of Biomedical Informatics, Asia University, Wufeng, Taichung, Taiwan; and Departments of ‡Obstetrics & Gynecology and §Pathology, Kuang Tien General Hospital, Shalu, Taichung, Taiwan
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Rozenberg S, Antoine C, Vandromme J, Fastrez M. Should we abstain from treating women with endometriosis using menopausal hormone therapy, for fear of an increased ovarian cancer risk? Climacteric 2015; 18:448-52. [PMID: 25958744 DOI: 10.3109/13697137.2015.1041905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Women suffering from endometriosis often have an early menopause, resulting in severe menopausal symptoms and an increased risk of osteoporosis. They are therefore candidates for menopausal hormone therapy (MHT). Unfortunately, MHT may increase the risk of endometriosis recurrence. Moreover, endometriosis patients are at increased risk of ovarian cancer, which may be further enhanced by MHT use. It is unknown, however, whether MHT more frequently increases type I (low-grade serous tumors), which seem to be increased when endometriosis is present, or type II (the more aggressive high-grade serous) tumors. We propose the following decision-making algorithm for endometriosis patients considering MHT. Those who have been treated with bilateral salpingo-oophorectomy, and in whom there is no residual endometriotic disease, can probably be treated using MHT without risk of endometriosis recurrence or fear of ovarian cancer. For women with significant, residual endometriosis lesions, the benefit may outweigh the risks, when menopause is reached before the age of 45 years or when severe symptoms are present.
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Affiliation(s)
- S Rozenberg
- Department of Obstetrics and Gynecology, CHU Saint-Pierre, Université Libre de Bruxelles, Vrije Universiteit Brussel , Brussels , Belgium
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Aci�n P, Velasco I, Aci�n M, Capello C, Vela P. Epithelial Ovarian Cancers and Endometriosis. Gynecol Obstet Invest 2015; 79:126-35. [DOI: 10.1159/000367597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 08/14/2014] [Indexed: 11/19/2022]
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Králíčková M, Vetvicka V. Endometriosis and ovarian cancer. World J Clin Oncol 2014; 5:800-805. [PMID: 25493219 PMCID: PMC4259943 DOI: 10.5306/wjco.v5.i5.800] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 09/18/2014] [Accepted: 11/10/2014] [Indexed: 02/06/2023] Open
Abstract
Endometriosis is the leading cause of morbidity among premenopausal women and the complex pathogenesis of this disease remains controversial despite extensive research. This disease represents one of the most common gynecological problems. It is generally believed that this disease is due primarily to retrograde menstruation or transplantation of shed endometrium. Based on overwhelming data, ovarian endometrioma is considered a neoplastic process, since most endometriosis-associated ovarian carcinoma occur in the presence of atypical ovarian endometriosis. A study comparing patients with typical epithelial ovarian cancer with endometriosis-associated ovarian cancer demonstrated that the patients with the latter disease strongly differ in both biological and histological characteristics. The prevelance of this disease is not completely established, but approximately 15 percent of women suffer from this disease. In addition, we know about the possible links between endometriosis and cancer for almost 100 years. Despite clear evidence revealing that endometriosis increases ovarian cancer risks, it is possible that it may not affect disease progression after the appearance of ovarian cancer. However, despite clear evidence revealing that endometriosis increases ovarian cancer risk, our knowledge of the risk factors is far from established. In our review, we focused on the most recent approaches including possible biomarkers and genetic approaches.
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45
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Tamaresis JS, Irwin JC, Goldfien GA, Rabban JT, Burney RO, Nezhat C, DePaolo LV, Giudice LC. Molecular classification of endometriosis and disease stage using high-dimensional genomic data. Endocrinology 2014; 155:4986-99. [PMID: 25243856 PMCID: PMC4239429 DOI: 10.1210/en.2014-1490] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Endometriosis (E), an estrogen-dependent, progesterone-resistant, inflammatory disorder, affects 10% of reproductive-age women. It is diagnosed and staged at surgery, resulting in an 11-year latency from symptom onset to diagnosis, underscoring the need for less invasive, less expensive approaches. Because the uterine lining (endometrium) in women with E has altered molecular profiles, we tested whether molecular classification of this tissue can distinguish and stage disease. We developed classifiers using genomic data from n = 148 archived endometrial samples from women with E or without E (normal controls or with other common uterine/pelvic pathologies) across the menstrual cycle and evaluated their performance on independent sample sets. Classifiers were trained separately on samples in specific hormonal milieu, using margin tree classification, and accuracies were scored on independent validation samples. Classification of samples from women with E or no E involved 2 binary decisions, each based on expression of specific genes. These first distinguished presence or absence of uterine/pelvic pathology and then no E from E, with the latter further classified according to severity (minimal/mild or moderate/severe). Best performing classifiers identified E with 90%-100% accuracy, were cycle phase-specific or independent, and used relatively few genes to determine disease and severity. Differential gene expression and pathway analyses revealed immune activation, altered steroid and thyroid hormone signaling/metabolism, and growth factor signaling in endometrium of women with E. Similar findings were observed with other disorders vs controls. Thus, classifier analysis of genomic data from endometrium can detect and stage pelvic E with high accuracy, dependent or independent of hormonal milieu. We propose that limited classifier candidate genes are of high value in developing diagnostics and identifying therapeutic targets. Discovery of endometrial molecular differences in the presence of E and other uterine/pelvic pathologies raises the broader biological question of their impact on the steroid hormone response and normal functions of this tissue.
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Affiliation(s)
- John S Tamaresis
- Center for Reproductive Sciences (J.S.T., J.C.I., G.A.G., L.C.G.), Department of Obstetrics, Gynecology and Reproductive Sciences, and Department of Pathology (J.T.R.), University of California, San Francisco, California 94143; Department of Obstetrics and Gynecology and Clinical Investigation (R.O.B.), Madigan Healthcare System, Tacoma, Washington 98431; Department of Obstetrics and Gynecology (C.N.), Stanford University, Stanford, California 94024; and Fertility and Infertility Branch (L.V.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892
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Endometriosis and the subsequent risk of epithelial ovarian cancer. Taiwan J Obstet Gynecol 2014; 53:530-5. [DOI: 10.1016/j.tjog.2014.04.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 11/17/2022] Open
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Wang KC, Chang WH, Lee WL, Huang N, Huang HY, Yen MS, Guo CY, Wang PH. An increased risk of epithelial ovarian cancer in Taiwanese women with a new surgico-pathological diagnosis of endometriosis. BMC Cancer 2014; 14:831. [PMID: 25403543 PMCID: PMC4240825 DOI: 10.1186/1471-2407-14-831] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023] Open
Abstract
Background Epidemiological evidence of relationships between endometriosis and epithelial ovarian cancer (EOC) has been obtained mainly from Western countries. Our goal was to determine the risk of EOC due to endometriosis in Taiwanese women. Methods A retrospective cohort study was performed by linking to the National Health Insurance Research Database (NHIRD) of Taiwan. A total of 5,945 women with a new surgico-pathological diagnosis of endometriosis from 2000 to 2010 and 23,780 multivariable-matched controls (1:4) were selected. The Cox regression model adjusted for potential confounders was used to assess the risk of EOC due to endometriosis. Results The EOC incidence rate (IR) of the women with and without endometriosis was 11.64 and 2.66 per 10,000 person-years, contributing to a crude hazard ratio (HR) of 4.48 (95% confidence interval [CI] 2.84-7.06), and HR after adjustment for all confounders (adjusted HR) of 5.62 (95% CI 3.46-9.14); the risk was higher in clear-cell carcinoma subtypes (adjusted HR 7.36, 95% CI 1.91-28.33). The EOC IR of women with endometriosis consistently increased with increasing age, ranging from 4.99 (<30 years) to 35.81 (≥50 years) per 10,000 person-years, contributing to a progressively increased risk of EOC (crude HRs ranging from 2.80 to 6.74 and adjusted HRs ranging from 3.34 to 9.63) compared to age-matched women without endometriosis, whose EOC IR also increased with age. The older women (≥50 years) with endometriosis had a risk of EOC that was higher than both the age-matched women without endometriosis (adjusted HR 9.63, 95% CI 3.27-28.37) and the youngest women (<30 years) with endometriosis (adjusted HR 4.97, 95% CI 1.03-24.09). Conclusions These significant findings corroborate the previously reported association between endometriosis and increased risk of EOC. Since the risk of EOC in women with a new surgico-pathological diagnosis of endometriosis constantly increased with age and this increased risk of EOC was more significant in women aged ≥50 years, active and intensive surgical intervention should be taken into consideration for older women with endometriosis.
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Affiliation(s)
| | | | | | | | | | | | - Chao-Yu Guo
- Department of Nursing, National Yang-Ming University School of Nursing, Taipei, Taiwan.
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Ovarian Endometrioma: What the Patient Needs. J Minim Invasive Gynecol 2014; 21:505-16. [DOI: 10.1016/j.jmig.2014.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 12/16/2022]
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Abstract
Epithelial ovarian cancer is the fifth commonest cancer among women and the leading cause of gynecological cancer death in the UK. Most women present with advanced disease, mainly because the nonspecific nature of the symptoms lead to diagnostic delays. Recent data have shown a fall in ovarian cancer mortality rates in the UK, but rates are still higher when compared to other European countries or the USA. In addition, surgeons in the UK achieve on average lower optimal surgical cytoreduction rates in patients with advanced ovarian cancer. Despite a wealth of information on epidemiological risk factors, the pathogenesis of epithelial ovarian cancer remains largely unknown. This review presents the most recent data on incidence, mortality, and survival for epithelial ovarian cancer in the UK. Time trends, trends by age, international comparisons, and regional variation in incidence, survival, and mortality are presented within the context of a major reorganization of cancer services that took place in the UK over 10 years ago. Centralization of cancer services has meant that women with ovarian cancer receive treatment in specialist Cancer Centers.
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Affiliation(s)
- Konstantinos Doufekas
- Department of Gynaecological Oncology, University College London Hospitals, London, UK
| | - Adeola Olaitan
- Department of Gynaecological Oncology, University College London Hospitals, London, UK
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Abstract
Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.
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Affiliation(s)
- Paolo Vercellini
- Department of Obstetrics and Gynecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milan, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Via Olgettina 60, 20136 Milan, Italy
| | - Edgardo Somigliana
- Department of Obstetrics and Gynecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milan, Italy
| | - Luigi Fedele
- Department of Obstetrics and Gynecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milan, Italy
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