Prevalence of endometriosis in ovarian cancer

How Progesterone Receptor Expression Impacts Platinum Sensitivity in Ovarian Clear Cell Carcinoma: Insights from Clinical and Experimental Perspectives

Ovarian clear cell carcinoma (OCCC) is often considered a relatively platinum-resistant malignancy. The aim of this study was to explore the influence of progesterone receptor (PR) expression levels on platinum sensitivity and survival outcomes in people with OCCC. A retrospective analysis was conducted with 80 people with OCCC who underwent surgery followed by adjuvant chemotherapy. PR expression was assessed via immunohistochemical (IHC) staining and quantified using the H score. The platinum sensitivity and survival outcomes of patients with weak and strong PR expression were compared. Additionally, cisplatin viability and migration experiments were conducted with OCCC cell lines (ES-2 and TOV-21G) with varying PR isoform expressions. Among the 80 patients, 62 were classified as having platinum-sensitive disease, while 18 had platinum-resistant disease. The mean total PR H- score of platinum-sensitive tumors was significantly higher than that of platinum-resistant tumors (p = 0.002). Although no significant differences in progression-free and overall survival were observed between patients with high and low PR expression, those with high PR expression tended to have longer survival. While PR protein was only weakly detectable in ES-2 and TOV-21G cells, a transfection of the PR-A or PR-B gene resulted in a strong expression of PR-A or PR-B, which led to significantly reduced proliferation and migration in ES-2 and TOV-21G cells. Furthermore, overexpression of PR-A or PR-B enhanced cisplatin cytotoxicity in these cell lines. In conclusion, strong PR expression was associated with improved platinum sensitivity and survival outcomes, consistent with our experimental findings. The potential of PR as a tumor sensitizer to cisplatin in OCCC warrants further investigation.

Mucinous carcinoma originating from uterine adenomyosis: a case report

BACKGROUND

Uterine adenomyosis is rarely a precursor of malignant tumors, but the most frequent histological subtype is endometrioid carcinoma. We observed a rare case of mucinous carcinoma originating from uterine adenomyosis.

CASE PRESENTATION

A 63-year-old Japanese woman presented to our hospital with lower abdominal pain. She had no atypical genital bleeding. Ultrasound demonstrated thickening of the entire uterine wall, but the endometrium was not thick. Magnetic resonance imaging demonstrated an enlarged uterus with thickening of the entire uterine wall, suggesting adenomyosis. On the basis of the specimen of endocervical curettage, adenocarcinoma originating from the endometrium was suspected. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed to confirm the diagnosis. Macroscopically, the resected enlarged uterus had no nodules and exudation of mucin was observed from the cut surface of the thickened myometrium. The surface of the endometrium was smooth. On histological examination, mucinous carcinoma invaded almost the entire myometrium. Adenomyotic lesions were distributed focally in the uterine wall, and transition from adenomyotic glandular epithelium to mucinous carcinoma was detected within several foci. Although adenocarcinoma cells proliferated adjacent to the endometrium, the primary endometrial epithelium was atrophic without atypia. Throughout the myometrium, the mucinous carcinoma cells proliferated and floated in dilated lymph vessels with abundant mucin pools. We diagnosed this case as mucinous carcinoma originating from adenomyosis. Although the patient received 11 courses of intravenous adjuvant chemotherapy, she died of disease 18 months after the first operation.

CONCLUSION

As only one case of mucinous carcinoma originating from adenomyosis has been reported to date, this is the second case report of mucinous carcinoma. Moreover, an abnormal manner of proliferation with marked lymphatic permeation of the tumor cells throughout the myometrium was observed.

Whole-tumor ADC histogram analysis for differentiating endometriosis-related tumors: seromucinous borderline tumor, clear cell carcinoma and endometrioid carcinoma

PURPOSE

To investigate the feasibility of whole-tumor apparent diffusion coefficient (ADC) histogram analysis for improving the differentiation of endometriosis-related tumors: seromucinous borderline tumor (SMBT), clear cell carcinoma (CCC) and endometrioid carcinoma (EC).

METHODS

Clinical features, solid component ADC (ADC_SC) and whole-tumor ADC histogram-derived parameters (volume, the ADC_mean, 10th, 50th and 90th percentile ADCs, inhomogeneity, skewness, kurtosis and entropy) were compared among 22 SMBTs, 42 CCCs and 21 ECs. Statistical analyses were performed using chi-square test, one-way ANOVA or Kruskal-Wallis test, and receiver operating characteristic curves.

RESULTS

A significantly higher ADC_SC and smaller volume were associated with SMBT than with CCC/EC. The ADC_mean was significantly higher in CCC than in EC. The 10th percentile ADC was significantly lower in EC than in SMBT/CCC. The 50th and 90th percentile ADCs were significantly higher in CCC than in SMBT/EC. For differentiating SMBT from CCC, AUCs of the ADC_SC, volume, and 50th and 90th percentile ADCs were 0.97, 0.86, 0.72 and 0.81, respectively. For differentiating SMBT from EC, AUCs of the ADC_SC, volume and 10th percentile ADC were 0.97, 0.71 and 0.72, respectively. For differentiating CCC from EC, AUCs of the ADC_mean and 10th, 50th and 90th percentile ADCs were 0.79, 0.72, 0.81 and 0.85, respectively.

CONCLUSION

Whole-tumor ADC histogram analysis was valuable for differentiating endometriosis-related tumors, and the 90th percentile ADC was optimal in differentiating CCC from EC.

Nanotechnology-Based Nucleic Acid Vaccines for Treatment of Ovarian Cancer

Anticancer vaccines represent a promising approach for effective treatment of cancer and along with recent advantages of nucleic acid-based vaccines for other diseases form a prospective and potentially efficacious direction of the research, development and clinical applications. Despite the ongoing several clinical trials of mRNA vaccines for the treatment of various types of cancer, to-date no cancer vaccines were approved by the US Food and Drug Administration. The present review analyzes and summarizes major approaches for treating of different forms of ovarian cancer including mRNA-based vaccines as well as nanotechnology-based approaches for their delivery.

Predicting Long-Term Prognoses and Grading Platinum Sensitivity Using a Novel Progression-Free Interval Criterion in Ovarian Clear Cell Carcinoma: A Multi-Institutional Cohort Study

This large-scale study aimed to determine the long-term influences of potential prognostic predictors and progression-free interval (PFI) criteria for grading platinum-sensitivity in ovarian clear cell carcinoma (OCCC). We retrospectively reviewed the medical records of OCCC patients presenting at nine tertiary centres (1995−2015), and evaluated patient characteristics, therapeutic factors, clinical outcomes, and hazard ratios for disease progression and death. We enrolled 536 patients (median follow-up, 36.6 months) and developed newly defined distributions of PFIs (seven and 14 months) for grading platinum sensitivity. In the multivariate model, preoperative CA125 levels and chemo-response independently predicted early-stage progression-free survival (PFS) risk. Post-progression cytoreduction correlated with reduced mortality risk. No unfavourable outcomes were observed with respect to coexisting endometriosis, fertility-sparing strategies, or platinum-based regimens. A PFI of <7 months, the strongest predictor of both post-progression mortality and second relapse risks, correlated with chemo-resistance, advanced tumour stage, and shortened post-progression survival. Chemotherapy regimens commonly used in front-line or relapse settings were limited in improving prognoses, especially in the advanced-stage cohort. Clinical trials of novel targeted agents and/or innovative biomarkers for chemoresistance should be comprehensively investigated and offered early to advanced-stage patients or those with OCCC progression occurring within seven months after receiving chemotherapy.

Comparison of surgical and oncologic outcomes in patients with clear cell ovarian carcinoma associated with and without endometriosis

PURPOSE

To compare clinical characteristics, surgical and oncologic outcomes of clear cell ovarian cancer among patients with cancer arising from endometriosis, cancer coexisting with endometriosis, and cancer without endometriosis.

METHODS

A retrospective chart review of patients diagnosed with clear cell ovarian cancer during January 1998-March 2013 was performed. All histopathology specimens were reviewed by a gynecologic pathologist and classified into one of the three following endometriosis status groups: arising group, coexisting group, or without group. The primary outcome was disease-specific survival (DSS). The secondary outcomes were progression-free survival, surgical morbidities, response rate, recurrence rate, and cancer-specific death.

RESULTS

Finally, 249 patients were included. There were 82, 96, and 71 patients in the arising, coexisting, and without groups, respectively. Regarding baseline characteristics among groups, the without group was significantly older and had more advanced diseases. There was a significant difference in progression-free survival between the arising group and the without group (p = 0.003). Five-year progression-free survival rates were 62.8% in the arising group, 50.2% in the coexisting group, and 38.3% in the without group. DSS was not significantly different among groups. Multivariate analysis revealed ovarian surface invasion (HR = 2.76) and pelvic lymphadenectomy (HR = 0.39) to be independent prognostic factors for progression-free survival, whereas no remission after primary treatment (HR = 8.03) and pelvic lymphadenectomy (HR = 0.21) were prognostic factors for DSS. Intraoperative blood loss and residual tumor were significantly higher in the without group.

CONCLUSIONS

Endometriosis status was found not to significantly influence surgical and oncologic outcomes in patients with clear cell ovarian cancer.

Ovarian endometrioid carcinoma and clear cell carcinoma: A 21-year retrospective study

Objective

This study aimed to identify the clinical characteristics of Chinese patients with ovarian endometrioid carcinoma (EC) and clear cell carcinoma (CCC) and to assess the impact of concurrent endometriosis on this group.

Methods

The present study reviewed the medical records of patients who received initial treatment and a postoperative pathological diagnosis of EC or CCC at our center in China between 1998 and 2018.

Results

Of 211 patients, 73 had pure EC, and 91 had pure CCC, and the remaining 47 had mixed cancer. The proportion of EC and CCC remained stable over past 21 years. The proportion of EC declined with aging and the age of EC onset to incline to the young. And the age of CCC onset had two peaks, namely, 36 and 77 years. After review by the pathologist, the number of endometriosis cases found in the pathological section of the analysis increased to 114, accounting for 54% of patients. As the stage progressed, the appearance of endometriosis became increasingly scarce in pathological sections(p = 0.001).

Compared with CCC, EC had a higher frequency of concurrent endometrial cancer (independent endometrial lesions) and estrogen and progesterone receptor expression(p = 0.000). And more patients were in premenopausal state in EC group(p = 0.040).

In the pure group, multivariate analysis showed that correlation existed between relevance to endometriosis and worse outcomes(p = 0.041). In patients with mixed cancer, mixed endometrioid histology was associated with better survival than other subtypes, even with stage III or poorly differentiated tumors(p = 0.001).

Conclusions

CCC and EC which are common in ovarian cancer patients who have associated with endometriosis have distinct clinicopathological characteristics. Attention should be paid to ovarian cancer patients with a history of endometriosis and those with concurrent endometriosis in pathological sections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-021-00804-1.

Tetraspanin 1 promotes endometriosis leading to ovarian clear cell carcinoma

Ovarian clear cell carcinoma (OCCC) reportedly develops from endometriosis. However, the molecular mechanism underlying its malignant progression to OCCC remains elusive. This study aimed to identify an essential gene in the malignant transformation of endometriosis to OCCC. We performed RNA sequencing in formalin‐fixed, paraffin‐embedded (FFPE) tissues of endometriosis (n = 9), atypical endometriosis (AtyEm) (n = 18), adjacent endometriosis to OCCC (AdjEm) (n = 7), and OCCC (n = 17). We found that tetraspanin 1 (TSPAN1) mRNA level was significantly increased by 2.4‐ (DESeq2) and 3.4‐fold (edgeR) in AtyEm and by 80.7‐ (DESeq2) and 101‐fold (edgeR) in OCCC relative to endometriosis. We confirmed that TSPAN1 protein level was similarly overexpressed in OCCC tissues and cell lines. In immortalized endometriosis cell lines, TSPAN1 overexpression enhanced cell growth and invasion. Mechanistically, TSPAN1 triggered AMP‐activated protein kinase (AMPK) activity, promoting endometriosis and cell growth. Upregulated levels of TSPAN1 are considered an early event in the development of high‐risk endometriosis that could progress to ovarian cancer. Our study suggests the potential of TSPAN1 as a screening candidate for high‐risk endometriosis.

Pathology of Endometrioid and Clear Cell Carcinoma of the Ovary

This review is an appraisal of the current state of knowledge of 2 enigmatic histotypes of ovarian carcinoma: endometrioid and clear cell carcinoma. Both show an association endometriosis and the hereditary nonpolyposis colorectal cancer (Lynch) syndrome, and both typically present at an early stage. Pathologic and immunohistochemical features that distinguish these tumors from high-grade serous carcinomas, each other, and other potential mimics are discussed, as are staging, grading, and molecular pathogenesis.

Poorly differentiated mucinous carcinoma with signet ring cells in an ovarian endometriotic cyst: a case report

Background

Ovarian signet ring cell carcinomas are predominantly metastatic. Cases coexisting with endometriotic cysts are extremely rare, and are supposed to be primary. However, such cases have not been well-documented to date.

Case presentation

A 46-year-old Chinese woman had an incidental small nodule in the right ovarian endometriotic cyst. She underwent a staging surgery due to an unexpected ovarian carcinoma from her frozen section. Laparotomy exploration, MRI and gastrointestinal endoscopy revealed no other abnormalities in the abdominal organs. She had a pelvic recurrence at 7 months and was alive with disease for 13 months at present. Gross examination showed a small mural nodule (l.0 × 0.5 × 0.2 cm) in the wall of the right ovarian cyst (18x15x14 cm). Microscopically, the neoplastic cells arranged in solid nests, crowded small irregular glands and scattered single cells. They had abundant cytoplasmic mucin and contained a significant component of signet ring cells. The stroma was desmoplastic and occasionally contained extracellular mucin deposits. The surrounding endometriotic cyst had several foci of atypical surface epithelium (atypical endometriotic cyst) that was continuous with the mucinous carcinoma. Immunohistochemistry demonstrated that the tumor cells were diffusely positive for CK7 and negative for CK20 and CDX2.

Conclusions

Primary ovarian poorly differentiated mucinous carcinoma with signet ring cells can occur in an atypical endometriotic cyst. This rare case addresses the necessity of careful and extensive pathological examination on large ovarian endometriotic cysts.

Algorithms Used in Ovarian Cancer Detection: A Minireview on Current and Future Applications

BACKGROUND

Ovarian cancer is the 5th most common cause of cancer death among women in the US. Currently, there is no screening algorithm for asymptomatic women that has been shown to lower mortality rates. Screening is currently not recommended and has been shown to increase harm. Epithelial ovarian cancer (EOC) detection is reviewed, with a focus on high-grade serous, clear-cell, and endometrioid histotypes.

CONTENT

A review of current literature surrounding tools used in detection of ovarian cancer will be presented. CA 125, HE4, risk of ovarian cancer algorithm (ROCA), risk of malignancy algorithm (ROMA), risk of malignancy (RMI), OVA1, and future potential biomarkers are reviewed.

SUMMARY

Screening and early identification of EOC is currently managed as a single disease entity. However, recent evidence has shown ovarian cancer varies with relation to cellular origin, pathogenesis, molecular alterations, and prognosis, depending on histotype. There is a clear need for future studies identifying histotype-specific preclinical tumor markers to aid in detection and improvement of survival rates.

Endometriosis does not confer improved prognosis in ovarian clear cell carcinoma: a retrospective study at a single institute

BACKGROUND

Considered as the precursor lesion of a subset of ovarian clear cell carcinoma (OCCC), the prognostic role of endometriosis in OCCC patients remains controversial. This study aimed to investigate the prognostic role of coexisting endometriosis in the survival of patients with OCCC, and also sought to identify other prognostic factors.

RESULTS

A total of 125 patients were diagnosed with OCCC during the study period. Of these, 55 (44.0%) patients had coexisting endometriosis. Patients with endometriosis were younger (p = 0.030), had smaller tumor diameter (p = 0.005) and lower preoperative CA125 levels (p = 0.005). More patients with endometriosis had International Federation of Gynecology and Obstetrics (FIGO) stage I disease (83.6% vs. 51.4%, p = 0.000) and exhibited sensitivity to platinum-based regimen (89.6% vs. 66.7%, p = 0.003). Univariate and multivariate analysis revealed that coexisting endometriosis was not a predictor of 5-year overall survival (OS) or progression-free survival (PFS) of OCCC patients. For OS, chemosensitivity was the only useful prognostic factor (Hazards ratio (HR) 109.33, 95% Confidence Interval (CI) 23.46-511.51; p = 0.000). For PFS, the useful prognostic factors were ascites (HR 2.78, 95% CI 1.21-6.47; p = 0.016), FIGO stage (HR 1.61, 95% CI 1.04-2.49; p = 0.033), and chemosensitivity (HR 101.60, 95% CI 29.45-350.49; p = 0.000). Moreover, higher FIGO stage was the only risk factor for resistance to platinum-based chemotherapy (Exp (B) = 0.292, 95% CI 0.123-0.693; p = 0.005).

CONCLUSIONS

In this study, coexisting endometriosis was not a prognostic factor for the survival of OCCC patients. The most important predictor of both 5-year OS and PFS was chemosensitivity to platinum-based regimen, which decreased significantly with increase in FIGO stage.

Recent Advances in Molecular Genetics of Endometriosis

Endometriosis (MIM 131200) is a prevalent and complex gynecological disease polygenically inherited with multifactorial pathogenesis. It is increasingly recognized as a major women's health issue. Endometriosis is characterized by the presence of endometrial-like tissue in sites outside the uterus, mainly the pelvic peritoneum, ovaries and rectovaginal septum causing severe dysmenorrhoea, dyspareunia, chronic pelvic pain and subfertility. Recent advances in molecular technologies have provided many evidences about the underlying biological events that are likely to be involved in the development of endometriosis. Different chromosomal regions, genes and other molecules, such as microRNAs, have been identified as potentially involved in endometriosis pathogenesis. Moreover, genome-wide analyses of endometriosis have showed novel molecular signatures or individual genes that had not been previously associated with the disease. The goal of these studies is to provide information that might, in turn, lead to new therapies. In this review, some previous studies were updated supporting the polygenic/multifactorial inheritance and the association with malignant neoplasias. We have also emphasized the importance of identifying the causative genes and determining novel diagnostic and predictive biomarkers.

Morphological and immunohistochemical characterization of spontaneous endometriosis in rhesus macaques (Macaca mulatta)

Several cases of spontaneous endometriosis in middle-aged to old rhesus macaques (Macaca mulatta) from the breeding colony of the German Primate Center were thoroughly characterized with regards to anatomical distribution and macroscopic appearance, histological differentiation and immunohistochemical profile including somatic markers, hormonal receptors, and proliferation indices. More than half of the examined animals (five of nine) were directly related to one breeding male, supporting a strong genetic predisposition. Histologically, four different types of endometriotic lesions, depending on the degree of ectopic endometrial gland and stromal differentiation (well differentiated, purely stromal, mixed differentiation, poorly differentiated), could be constantly identified within all animals. Immunohistochemistry (IHC) of cytokeratin (CK), vimentin, smooth muscle actin (SMA), desmin, estrogen (ER), and progesterone (PR) receptors as well as of the nuclear proteins Ki67 and p53 revealed varying staining patterns in the four different types of endometriosis differentiation and compared to normal endometrium. Purely stromal, mixed, or poorly differentiated lesions, especially, showed additional cytokeratin-positive stromal cells, whereas epithelial cells of endometriosis with mixed or poor differentiation increasingly expressed mesenchymal markers (vimentin, SMA). Hormonal receptor and Ki67 expression in well-differentiated endometriotic lesions mostly reflected that of normal endometrial tissue according to the cyclic phase of the animal, while the expression gradually diminished with decreasing grade of differentiation. However, increased nuclear accumulations of p53 antigen could only be continuously detected in epithelial cells of mixed or poorly differentiated endometriosis. Altogether, these findings support the pathogenetic theory of coelomic metaplasia, since the expression profiles of somatic markers in less differentiated forms closely resembled that of mesothelial cells. Thus, the four different histological types of endometriosis might display subsequent grades of differentiation in the course of time, with poorly differentiated types representing newly formed, immature lesions and well-differentiated types being older, fully differentiated forms, rather than being the outcome of dedifferentiation processes.

Mature cystic teratoma coexisting with clear-cell carcinoma in the ovary

Mature cystic teratoma (MCT) is the most common benign ovarian tumor; clear-cell carcinoma (CCC) is a relatively common malignant ovarian tumor in Japan, but there are few reports on the coexistence of MCT and CCC. Here we report a case of simultaneous MCT and CCC in the ovary and review the relevant literature. The patient was a 49-year-old woman. A 5-cm MCT was found in the left ovary on initial gynecological examination, and she was referred to hospital for treatment because it was expanding. Magnetic resonance imaging showed a multilocular cystic tumor 16 × 10 × 9.5 cm in the left ovary, and surgery was performed. The final pathological diagnosis was MCT, endometriotic cyst, clear-cell adenofibroma, clear-cell borderline tumor, and CCC in the left ovary.

Diagnostic performance of MR imaging findings and quantitative values in the differentiation of seromucinous borderline tumour from endometriosis-related malignant ovarian tumour

OBJECTIVES

To evaluate the diagnostic performance of quantitative values and MRI findings for differentiating seromucinous borderline tumours (SMBTs) from endometriosis-related malignant ovarian tumours (MT).

METHODS

This retrospective study examined 19 lesions from SMBT and 84 lesions from MT. The following quantitative values were evaluated using receiver-operating characteristic analysis: overall and solid portion sizes, fluid signal intensity (SI), degree of contrast-enhancement, and mean and minimum apparent diffusion coefficient (ADC) values of the solid portion. Two radiologists independently evaluated four MRI findings characteristic of SMBT, fluid SI on the T1-weighted image and SI of the solid portion on diffusion-weighted image. The diagnostic values of these findings and interobserver agreement were assessed.

RESULTS

For diagnosing SMBT, the mean ADC value of the solid portion showed the greatest area under the curve (0.860) (cut-off value: 1.31 × 10^-3 mm²/s, sensitivity: 1.00, specificity: 0.61). The T2-weighted image (T2WI) high SI solid portion was the most useful finding, with high specificity and interobserver agreement (sensitivity, 0.58; specificity, 0.95-0.96, kappa = 0.96), followed by T2WI low SI core (sensitivity, 0.48-0.63; specificity, 0.98, kappa = 0.68).

CONCLUSION

Mean ADC values of the solid portion, T2WI high SI solid portion, and T2WI low SI core were useful for differentiating SMBT from MT.

KEY POINTS

• SMBT is a newly categorised ovarian tumour often associated with endometriosis. • Differentiation of SMBT from endometriosis-related malignant ovarian tumour is clinically important. • Diagnostic performances of quantitative values and MRI findings were evaluated. • Mean ADC value of the solid portion was the most useful value. • "T2WI high SI solid portion" was the most useful MRI finding.

Does the Presence of Endometriosis Affect Prognosis of Ovarian Cancer?

Ovarian cancers diagnosed between 2000 and 2013 were examined and cases with and without endometriosis compared. Among 139 epithelial ovarian, there were 49 (35%) with endometriosis and 90 (65%) without endometriosis. Endometriosis associated ovarian cancers were more likely to be confined to the pelvis (54% vs. 9%, p < 0.0001) and lower grade (51% vs. 29%, p = 0.014). Younger age and earlier stage independently predicted the presence of endometriosis (p = 0.0011 and p < 0.0001, respectively). Ovarian cancer patients with endometriosis had improved PFS and OS [(HR = 0.20; 95% CI, 0.09-0.43), (HR = 0.18; 95% CI, 0.04-0.81)], compared to patients without endometriosis; however, endometriosis had no independent prognostic significance.

Evidence for the Relationship Between Endometriosis and Epithelial Ovarian Cancer

Endometriosis may be a precursor lesion for some epithelial ovarian cancers (EOCs), especially those of clear cell and endometrioid histologies. The causality of this relationship remains controversial and in need of further investigation because the high prevalence of endometriosis and high mortality of EOC carry significant public health implications if the association is real. Endometriosis-associated ovarian cancer (EAOC) often presents at an earlier stage and with lower-grade lesions than non-EAOC. After surgical resection, these patients also tend to have less residual disease than do patients with non-EAOC. Survival has been reported to be better for women with EAOC. The tumor suppression gene, ARID1A, is frequently disrupted in EAOC. The ARID1A mutation has been reported in preneoplastic lesions and may be an early marker in the transformation of endometriosis into cancer. The current evidence in respect to critical molecular pathways underscores the need to investigate possible role of targeted therapies in the treatment of EAOC.

Endometriosis and ovarian cancer: potential benefits and harms of screening and risk-reducing surgery

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.

Ovarian cancer: new developments in clear cell carcinoma and hopes for targeted therapy

Until recently, ovarian clear cell carcinoma was recognized by its unique morphology and unfavorable patient outcome primarily due to tumor chemoresistance. Recently, specific molecular characteristics of ovarian clear cell carcinoma, such as PI3CA mutation, ARID1a mutation and MET amplification, have been elucidated. In addition, an association between endometriosis and the tumor has also been a focus of research in recent years. The aim of this review is to discuss the specificity and importance of molecular changes and various intriguing points that are not solved until today. Finally, future aspects, including hopes for the development of novel therapies, are discussed.

RUNX3 is inactivated by promoter hypermethylation in malignant transformation of ovarian endometriosis

The aim of the present study was to investigate the role of epigenetic inactivation of the runt-related transcription factor 3 gene (RUNX3) in the malignant transformation of ovarian endometriosis. Samples obtained by microdissection and scraping included 30 malignant ovarian endometriotic cyst tissues and 30 corresponding eutopic endometrium tissues from the endometriosis-associated ovarian carcinoma (EAOC) group, 19 benign ovarian endometriotic cyst tissues and 22 corresponding eutopic endometrium tissues from the endometriosis (EM) group and 22 normal eutopic endometrium tissues from the control endometrium (CE) group. RUNX3 methylation status was determined by methylation-specific PCR and bisulfite sequencing, while levels of RUNX3 and ERα protein expression were evaluated using immunohistochemistry. The percentage of RUNX3 methylation and negative RUNX3 protein expression in the malignant ovarian endometriotic cysts from the EAOC group was significantly higher than that in the benign ovarian endometriotic cysts from the EM group. The percentage of RUNX3 methylation and negative RUNX3 protein expression in the eutopic endometrium from the EAOC group was significantly higher than that in the EM and CE groups. An inverse correlation between positive RUNX3 protein expression and methylation was observed and a positive correlation was shown between RUNX3 methylation and ERα protein expression. In the malignant ovarian endometriotic cysts from the EAOC group, there was no significant correlation between methylation frequency of the RUNX3 gene and histological type. However, the percentage of RUNX3 gene methylation was significantly higher in the tissue samples from patients with surgical stage IC EAOC than the percentage in patients with stage IA and IB disease. These results suggest that RUNX3 inactivation by promoter hypermethylation plays a role in the progression of malignant transformation of ovarian EM and is closely related to estrogen metabolism. Negative protein expression and abnormal RUNX3 methylation in the eutopic endometrium could be used as diagnostic markers in patients with ovarian EM who may be at an increased risk of developing EAOC.

The Link Between Endometriosis and Ovarian Cancer: Clinical Implications

Objectives

The objectives of this study were to evaluate the current evidence of the association of endometriosis and subsequent carcinoma of the ovary and to contextualize this evidence into daily practice issues.

Methods

This study is a critical review of observational and in vitro studies.

Results

Although the lifetime risk for ovarian cancer is low in general population and remains low in the broad spectrum of endometriosis, there may be clusters of individuals at higher risk of oncogenesis, whose identification would allow individualized surveillance and prophylactic interventions. Prevalence studies show that specific subtypes of ovarian cancer predominate in women with endometriosis. This has been validated in pathogenetic, genomic, immunobiologic, and hormonal studies.

Conclusions

Taken together, these data provide a strong rationale for identifying, monitoring, counseling, and treating women with endometriosis who are at highest risk for cancer conversion.

Comparison of clinical outcomes of patients with clear cell and endometrioid ovarian cancer associated with endometriosis to papillary serous carcinoma of the ovary

OBJECTIVE

The aim of this investigation was to compare outcomes of patients with clear cell carcinoma (CCC) and endometrioid carcinoma (EC) of the ovary associated with endometriosis to patients with ovarian papillary serous carcinoma (PSC).

METHODS

Patients with CCC and EC of the ovary associated with endometriosis were identified and matched by age and stage to PSC controls. Student's t test and chi square test were used to analyze continuous and categorical data. The Kaplan-Meier method was used for survival analysis.

RESULTS

67 cases associated with endometriosis were identified, of which 45 were arising in endometriosis. Cases were matched to 134 PSC controls. 27 patients with tumors associated with endometriosis presented at stage I (40.3%), 27 at stage II (40.3%), ten at stage III (14.9%) and three at stage IV (4.5%). There was no difference in rate of optimal cytoreduction or response to chemotherapy in cases vs. PSC controls. There was a significant increase in synchronous endometrial cancer in tumors associated with endometriosis compared to PSC (25.4% vs. 3.7%; P<0.001). 18 cases (26.9%) had recurrent disease vs. 55 (41%) controls (P=0.03). The 5-year disease-free survival (DFS) and overall survival (OS) of patients with tumors associated with endometriosis compared to PSC controls were 75% vs. 55% (P=0.03) and 85% vs. 77% (P=0.2), respectively.

CONCLUSIONS

Patients with tumors associated with endometriosis had a higher rate of synchronous endometrial cancer. Cases also demonstrated a lower rate of recurrence and improved 5 year DFS; however, this did not translate into a difference in OS.

Hormonal and surgical treatments for endometriosis and risk of epithelial ovarian cancer

OBJECTIVE

Whether hormonal or surgical treatment of endometriosis is associated with risk of epithelial ovarian cancer.

DESIGN

Nested case-control study.

SETTING

Sweden.

POPULATION

All women with a first-time discharge diagnosis of endometriosis in 1969-2007 were identified using the National Swedish Patient Register and constituted our study base.

METHODS

By linkage to the National Swedish Cancer Register we identified all women diagnosed with epithelial ovarian cancer at least one year after the endometriosis diagnosis (cases). Two controls per case with no ovarian cancer before the date of cancer diagnosis of the case were randomly selected from the study base and matched for year of birth. Two-hundred-and-twenty cases and 416 controls entered the study. Information on hormonal and surgical treatments and other reproductive factors was extracted from medical records according to pre-specified protocols. Conditional logistic regression was used for all calculations.

MAIN OUTCOME MEASURES

Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for all hormonal as well as surgical treatments.

RESULTS

There was a significant association between one-sided oophorectomy, as well as for radical extirpation of all visible endometriosis, and ovarian cancer risk in both univariate analyses (crude OR 0.42, 95% CI 0.28-0.62 and OR 0.37, 95% CI 0.25-0.55, respectively) and multivariate analyses (adjusted OR 0.19, 95% CI 0.08-0.46 and OR 0.30, 95% CI 0.12-0.74, respectively).

CONCLUSIONS

One-sided oophorectomy as well as radical extirpation of all visible endometriosis is protective against later development of ovarian cancer.

CDC42-positive macrophages may prevent malignant transformation of ovarian endometriosis

It is currently thought that most clear cell and endometrioid carcinomas arise from ovarian endometriosis. We recently suggested that, besides their origin in the ovary, reduction of CDC42 messenger RNA (a member of the RHO GTPase family) may contribute to explain why clear cell carcinomas are not uncommonly found limited to the ovary (stage I). On the other hand, little is known about the expression of CDC42 in ovarian endometriosis with and without carcinoma. Twenty-two endometriotic cysts not associated with carcinoma, 19 endometriotic cysts associated with carcinoma (contiguous endometriosis), as well as the 19 corresponding tumors (11 clear cell, 4 endometrioid, and 4 mixed-clear cell and endometrioid-carcinomas) were investigated. We analyzed CDC42 expression both by real-time polymerase chain reaction and immunohistochemistry. Endometriotic cysts not associated with carcinoma showed higher expression of CDC42 messenger RNA than cysts associated with carcinoma (P = .002). Immunohistochemically, CDC42 was exclusively expressed by macrophages. CDC42-positive macrophages were present in most of the endometriotic cysts not associated with carcinoma (11/19, or 58%). In contrast, only 5 endometriotic cysts containing carcinoma (contiguous endometriosis) (5/18, or 28%) and 1 ovarian carcinoma arising from endometriosis (1/18, or 5%) had CDC42-positive macrophages (58% versus 28%, P = .065; 28% versus 5%, P = .046). Our results raise the possibility that CDC42-positive macrophages may prevent the development of endometrioid and clear cell carcinomas.

Expression of oct-4 and c-kit antigens in endometriosis

The objective of this study was to test the expression of the oct-4 and c-kit, both markers of stem cells, in the ectopic endometrial tissue of endometriotic lesions of women with severe endometriosis. Our findings show that ectopic epithelial cells express oct-4 and c-kit and this suggests that the ectopic endometrium in endometriosis has a stem cell origin and could explain the possible progression to ovarian cancer.

The ovarian dysgenesis syndrome

New thinking has arisen about the origin of adult onset diseases stemming from a collective body of evidence commonly referred to as the developmental origins of health and disease. This conceptual paradigm posits that certain adult onset diseases arise during critical or sensitive windows of human development or even transgenerationally. The testicular dysgenesis hypothesis (TDS) postulates an in utero origin for adverse male reproductive outcomes, and is an excellent example of the early origins of the paradigm. Despite similarities in the development of the male and female reproductive tracks, noticeably absent is a collective body of evidence focusing on the plausibility of an early origin for gynecologic outcomes and later onset of adult diseases. Using the TDS paradigm, we synthesized the available literature relative to the ovarian dysgenesis syndrome (ODS), which we define as alterations in ovarian structure or function that may manifest as fecundity impairments, gynecologic disorders, gravid diseases or later onset adult diseases. We evaluated environmental exposures, particularly the role of endocrine disrupting chemicals, in relation to these outcomes, and found evidence (although fragmented) consistent with an in utero origin of gynecologic outcomes, which in turn is associated with later onset of adult diseases. The findings are interpreted within the ODS paradigm while delineating methodological challenges and future research opportunities designed to answer critical data gaps regarding the origin of fecundity, gravid health and chronic diseases affecting the female population.

Endometriosis as a prognostic factor for cancer survival

Studies have shown an increased risk of malignancies in women with endometriosis. Little is known about the impact of endometriosis on cancer survival. We investigated whether the survival after a diagnosis of a malignancy differs in women with a previously diagnosed endometriosis compared to other women. Women with a first time diagnosis of a malignancy in 1969-2005, were identified using the National Swedish Cancer Register (NSCR). By use of the National Swedish Patient Register (NSPR) we identified all women with a diagnosis of endometriosis during the same period and linked these patients with the data from the NSCR. The cohort comprised 4,278 women with endometriosis and a malignancy, and 41,831 randomly selected matched women without endometriosis. Cox regression was used for all calculations to obtain crude and adjusted cause specific mortality rates, measured as hazard ratios (HR) with 95% confidence intervals (CI). A total of 46,109 women entered the study. There was a statistically significant better survival for women with endometriosis for all malignancies combined (HR=0.92) and for breast cancer (HR=0.86) and ovarian cancer (HR=0.81) specifically. For breast cancer the survival enhancing effect in women with endometriosis decreased with increasing parity. There was poorer survival in malignant melanoma for women with endometriosis (HR=1.52). The survival in a malignancy is better in women with a previously diagnosed endometriosis compared to women without endometriosis especially for breast and ovarian cancers. The prognosis of malignant melanoma is poorer in women with endometriosis.

Endometriosis-associated ovarian cancer: A ten-year cohort study of women living in the Estrie Region of Quebec, Canada

Objectives

Endometriosis has been believed to increase the risk of developing ovarian cancer, but recent data supporting this hypothesis are lacking. The aim of this study was to verify whether the incidence of endometriosis, ovarian cancer and the both increased during the last 10 years among women living in the Estrie region of Quebec.

Methods

We collected data of women diagnosed with endometriosis, ovarian cancer or both, between 1997 and 2006, from a population living in the Estrie region of Quebec. We performed this retrospective cross-sectional study from the CIRESSS (Centre Informatisé de Recherche Évaluative en Services et Soins de Santé) system, the database of the CHUS (Centre Hospitalier Universitaire of Sherbrooke), Sherbrooke, Canada.

Results

Among the 2854 identified patients, 2521 had endometriosis, 292 patients had ovarian cancer and 41 patients had both ovarian cancer and endometriosis. We showed a constant increase in the number of ovarian cancer (OC) between 1997 and 2006 (r² = 0.557, P = 0.013), which is not the case for endometriosis (ENDO) or endometriosis-associated ovarian cancer (EAOC). The mean age ± SD was 40.0 ± 9.9 and 53.9 ± 11.4 for patients having ENDO and OC, respectively. Mean age of women with EAOC was 48.3 ± 10.8, suggesting an early onset of ovarian cancer in women having endometriosis of about 5.5 years average, P = 0.003. Women with ENDO were at increased risk for developing OC (Rate Ratio [RR] = 1.6; 95% Confidence Interval [CI] = 1.12-2.09). Pathological analyses showed the predominance of endometrioid type (24.4%) and clear-cell type (21.9%) types in EAOC compared to OC, P = 0.0070 and 0.0029, respectively. However, the serous type is the most widespread in OC (44.5%) in comparison to EAOC (19.51%), P = 0.0023.

Conclusion

Our findings highlight that the number of cases of ovarian cancer is constantly increasing in the last ten years and that endometriosis represents a serious risk factor which accelerates its apparition by about 5.5 years.

[Surgical management of urinary tract endometriosis: 12 cases]

OBJECTIVES

Our study aimed at evaluating, retrospectively, the outcome of the surgical management of urinary tract endometriosis.

PATIENTS AND METHODS

Twelve women with a mean age of 36,4 were recruited between 1994 and 2007. They all had a histologically-proven and surgically-treated endometriosis of the urinary tract.

RESULTS

Seven of them had a unilateral ureteric localization, two had a bilateral ureteric localization and three had a vesical localization. One patient with bladder nodules underwent a partial cystectomy and the two other patients with bladder localization underwent a transurethral resection. Out of the nine patients who had a ureteric localization of endometriosis, seven had a ureterectomy and re-implantation with bladder psoas hitching and had no recurrence.

CONCLUSIONS

Our experience showed that ureterectomy and re-implantation with bladder psoas hitching is probably the best way of preventing recurrences in the case of urethral endometriosis. In the case of bladder endometriosis, transurethral resection did not appear as the most effective treatment although it remains an acceptable alternative, especially as far as premenopausal women or young women wishing to conceive are concerned.

Ovarian cancer in endometriosis: epidemiology, natural history, and clinical diagnosis

We review whether endometriosis-associated ovarian cancer is a specific entity compared with ovarian cancer not associated with endometriosis, with respect to epidemiology, natural history, and clinical diagnosis; we present a review of the English-language literature for ovarian cancer in endometriosis with respect to these three features. A recent prospective study in Japan directly showed that, during a follow-up of up to 17 years of an ovarian endometrioma cohort (n = 6398), 46 incident ovarian cancers were identified, showing that the ovarian cancer risk was significantly elevated in patients with ovarian endometrioma (standardized incidence ratio [SIR], 8.95; 95% confidence interval [CI], 4.12 to 15.3). Advancing age (>40 years) and the size of the endometriomas (>9 cm) were independent predictors of the development of ovarian cancer among the women with ovarian endometrioma. Although some endometriosis lesions may predispose to clear cell carcinoma (CCC) and endometrioid adenocarcinoma (EAC) of the ovary, both of these cancers differ from the other histological types with respect to their clinical characteristics and carcinogenesis. In patients with endometriosis-associated ovarian cancer, benign-appearing ovarian masses are typically present several years before the diagnosis of the cancer. A slightly elevated carbohydrate antigen [CA] 125 level is also typically present many years before the diagnosis in these patients. However, serous-type ovarian cancer may exhibit a rapid progression possibly through de-novo carcinogenesis. Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women. Understanding the mechanisms of the development of endometriosis and elucidating its pathogenesis and pathophysiology are intrinsic to the prevention of endometriosis-associated ovarian cancer and the search for effective therapies.

A conditional mouse model for human MUC1-positive endometriosis shows the presence of anti-MUC1 antibodies and Foxp3+ regulatory T cells

Endometriosis is defined by the presence of tissue implants resembling endometrial glands outside of the uterus, at ectopic sites, frequently on the ovarian surface. The ectopic lesions are often invasive, resistant to therapy, and may predispose to endometrioid and clear cell ovarian tumors. The complex mechanisms leading to chronic endometriosis are mediated partly by impaired immune surveillance in the host. Although innate immunity has been addressed previously, the response of adaptive immune effectors to specific antigens has not been characterized, mostly because very few endometriosis antigens have been defined to date. We postulated that the mucin 1 (MUC1) glycoprotein, which is normally present on eutopic human endometrial glands and overexpressed in endometrioid and clear cell ovarian tumors, is also present in ectopic lesions of ovarian endometriosis. Furthermore, changes in MUC1 expression in endometriosis could promote adaptive anti-MUC1 immunity that might play a role in the malignant progression. To test our hypothesis, we crossed MUC1 transgenic mice, which express human MUC1 under the endogenous promoter, with the loxP-Stop-loxP-Kras(G12D/+) (Kras) mice, in which endometriosis can be induced through Cre-loxP recombination. The double transgenic MUC1Kras mice develop benign, MUC1-positive ovarian lesions, closely resembling human endometriosis. Subsequent to disease induction, the mice generate high titers of IgM and IgG antibodies that are specific for MUC1. Antibodies appear early in disease and the predominance of the IgG1 subclass suggests Th2-driven immunity. Immune phenotyping revealed an accumulation of Foxp3+ CD4 regulatory T cells (Tregs) in the draining lymph nodes at late-stage disease. Furthermore, our observations in human endometriosis showed a similar recruitment of FOXP3+ CD4 T cells. Overall, our results reveal a Th2/Treg-dominant natural immunity in endometriosis with potential implications for cancer progression.

Screening, epidemiology, molecular biology, and treatment strategies for endometriosis-associated ovarian cancer

Objectives

This article reviews recent data on the biology, pathogenesis and pathophysiology of the different entity of epithelial ovarian cancer (EOC).

Study design

The present article reviews the English language literature for screening, epidemiology, clinical diagnosis, natural history, preclinical and clinical trials, and promising molecular targets on EOC, particularly for clear cell EOC (cEOC) based on the gene expression profiling studies.

Results

Prospective ovarian cancer screening trials in Japan showed that (1) serous-type EOC (sEOC) may exhibit a rapid progression possibly through de novo carcinogenesis, (2) the EOC risk was elevated significantly among patients with ovarian endometrioma (SIR = 8.95), (3) advancing age (>40 years) and the diameter of endometriomas (>9 cm) were independent predictors of development of EOC, (4) the benign-appearing ovarian masses are present several years before the EOC diagnosis in patients with endometriosis-associated EOC, and (5) the slightly elevated CA125 level is also typically present many years (>3 years) before the diagnosis in these patients. Upregulation of HNF-1beta and PLK-Emi1 genes were specifically detected in cEOC. In addition, the therapy currently used in renal cell carcinoma (RCC) should be considered as an attractive therapeutic option for cEOC.

Conclusions

Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women. Understanding the mechanisms of endometriosis development and elucidating its pathogenesis and pathophysiology are intrinsic to prevention and the search for effective therapies of endometriosis-associated EOC.

Ovarian cancer pathogenesis: a model in evolution

Ovarian cancer is a deadly disease for which there is no effective means of early detection. Ovarian carcinomas comprise a diverse group of neoplasms, exhibiting a wide range of morphological characteristics, clinical manifestations, genetic alterations, and tumor behaviors. This high degree of heterogeneity presents a major clinical challenge in both diagnosing and treating ovarian cancer. Furthermore, the early events leading to ovarian carcinoma development are poorly understood, thus complicating efforts to develop screening modalities for this disease. Here, we provide an overview of the current models of ovarian cancer pathogenesis, highlighting recent findings implicating the fallopian tube fimbria as a possible site of origin of ovarian carcinomas. The ovarian cancer model will continue to evolve as we learn more about the genetics and etiology of this disease.

Adenosquamous carcinoma of the ovary arising from endometriosis: two case reports

The author reports two cases of adenosquamous carcinoma arising from endometriosis of ovaries. The tumor patients were 38-year-old and 53-year-old women. Both patients underwent hysterectomy and bilateral salpingo-oophorectomy for ovarian carcinomas. Grossly, both ovarian tumors were located in the left ovaries, and were cystic tumors with mural tumors. Histologically, the cystic areas consisted of endometrial glandular epithelium. Both mural tumors were composed of grade I endometroid adenocarcinoma and squamous cell carcinoma. These two elements were admixed in some areas. A differentiation of endometrioid adenocarcinoma from the endometriosis were present in a few areas. Likewise, a differentiation of squamous cell carcinoma from the endometriosis were recognized in several areas. The pathologic diagnosis was adenosquamous carcinoma arising from endometriosis of the ovary in both cases, rather than endometrioid adenocarcinoma with malignant squamous differentiation. No tumors were present in other organs.

Adenosquamous carcinoma of the ovary arising from endometriosis: two case reports

The author reports two cases of adenosquamous carcinoma arising from endometriosis of ovaries. The tumor patients were 38-year-old and 53-year-old women. Both patients underwent hysterectomy and bilateral salpingo-oophorectomy for ovarian carcinomas. Grossly, both ovarian tumors were located in the left ovaries, and were cystic tumors with mural tumors. Histologically, the cystic areas consisted of endometrial glandular epithelium. Both mural tumors were composed of grade I endometroid adenocarcinoma and squamous cell carcinoma. These two elements were admixed in some areas. A differentiation of endometrioid adenocarcinoma from the endometriosis were present in a few areas. Likewise, a differentiation of squamous cell carcinoma from the endometriosis were recognized in several areas. The pathologic diagnosis was adenosquamous carcinoma arising from endometriosis of the ovary in both cases, rather than endometrioid adenocarcinoma with malignant squamous differentiation. No tumors were present in other organs.

Ovarian cancer

Ovarian carcinomas are a heterogeneous group of neoplasms and are traditionally subclassified based on type and degree of differentiation. Although current clinical management of ovarian carcinoma largely fails to take this heterogeneity into account, it is becoming evident that each major histological type has characteristic genetic defects that deregulate specific signaling pathways in the tumor cells. Moreover, within the most common histological types, the molecular pathogenesis of low-grade versus high-grade tumors appears to be largely distinct. Mouse models of ovarian carcinoma have been developed that recapitulate many of the morphological features, biological behavior, and gene-expression patterns of selected subtypes of ovarian cancer. Such models will likely prove useful for studying ovarian cancer biology and for preclinical testing of molecularly targeted therapeutics, which may ultimately lead to better clinical outcomes for women with ovarian cancer.

Clinicopathologic features of ovarian cancer in patients with ovarian endometrioma

OBJECTIVE

The purpose of this study was to describe the clinicopathologic features of malignant transformation in patients with ovarian endometrioma, their treatment and outcome in the Kinki region, Japan.

PATIENTS AND METHODS

Patients meeting Sampson and Scott's criteria for cancer associated with endometriosis were identified by chart review and pathology reports. This retrospective survey describes 18 women with a history of ovarian endometrioma. These cases were followed as benign ovarian endometrioma before malignant transformation on the basis of imaging findings by gynecologic oncologists or radiologists.

RESULTS

Mean age at presentation of malignant transformation was 45.2 years (range, 36-66 years), and 78% (n=14) were premenopausal women. The pattern of spread was local in 16 (89%), regional in 2 (11%) and distant in 0 (0%). There was a common left-sided predominance. Characteristic histologic findings were 61% clear cell carcinoma. Endometriosis-associated malignancies have a favorable prognosis. The patients showed long latency intervals before developing ovarian cancer (mean, 4.5 years; range, 1-16 years). Among them, subjects (n=10) whose ages are more than 45 years old had shorter latency intervals (mean, 1 year; range, 1-3 years), compared with those (n=8) aged less than 45 years old (mean, 8.4 years; range, 3-16 years).

CONCLUSION

Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women.

Two cases of pregnant women with ovarian endometrioma mimicking a malignant ovarian tumor

The detection of an ovarian mass during pregnancy is often a diagnostic challenge. We describe 2 cases of ovarian endometrioma during pregnancy with marked mural nodules on the cyst wall. The sonographic and MR imaging findings mimicked ovarian cancer. Surgical intervention may still be inevitable to exclude the possibility of malignancy.

Ovarian cancer hormonal and environmental risk effect

To understand the influence of hormonal and environmental factors on the risk of ovarian cancer, it is important to remember the established risk factors and postulated mechanisms that lead to the development of ovarian cancer. Several risk factors have been identified as increasing the risk of epithelial ovarian cancer, including low pariety, infertility, early age of menarche, and late age of menopause. This article discusses the different hypotheses and focuses on hormonal and environmental risk factors, as well the chemoprevention of epithelial ovarian cancer.

Ovarian endometrioma--risks factors of ovarian cancer development

OBJECTIVE

Our prospective studies in Japan have found an increased ovarian cancer incidence in women with ovarian endometrioma (standardized incidence ratio, 8.95; 95% confidence intervals, 4.12-5.3). The risk increased with increasing age at ovarian endometrioma diagnosis. The goal of this study was to define the risk factor(s) of ovarian cancer development in a Japanese population with ovarian endometrioma. We also analyzed whether the predisposition toward ovarian cancer is limited to endometrioid and clear cell carcinoma.

STUDY DESIGN

A total of 6398 participants at 212 participating hospitals in Shizuoka, Japan, were enrolled in the Shizuoka Cohort Study on Endometriosis and Ovarian Cancer (SCSEOC) Trial, which had prospective and retrospective components. The follow-up period was up to 17 years (median, 12.8 years). The risks of development of ovarian cancer were assessed in 6398 women with ultrasonographically diagnosed ovarian endometriomas. Cox proportional-hazards regression function was used to estimate impact in terms of risk factors and possible development of ovarian cancer.

RESULTS

The prospective study demonstrated that 46 (0.72%) of 6398 women developed histologically proven ovarian cancer and were operated upon during follow-up. Clear cell carcinoma (39%) and endometrioid adenocarcinoma (35%) were commonly observed among women with ovarian cancer. By multivariate analysis, tumor size > or =9 cm in diameter and postmenopausal women were independent predictive factors of patients with development of ovarian cancer.

CONCLUSIONS

Some endometriosis lesions may predispose to clear cell and endometrioid ovarian cancers. Advancing age and the size of endometriomas were independent predictors of development of ovarian cancer among women with ovarian endometrioma.