Malignant Transformation and Associated Biomarkers of Ovarian Endometriosis: A Narrative Review

This review focuses on pathogenesis of endometriosis, its possible biomarkers and role in endometriosis-associated ovarian cancer. We analyzed various databases to obtain new insights, theories, and biomarkers associated with endometriosis. There are several theories of endometriosis development and biomarker changes including atypical forms. A number of studies have attempted to establish specific, reliable biomarkers to help diagnose endometriosis and endometriosis-associated diseases on the basis of different pathogenetic pathways. Nevertheless, despite intensive research extending even to the molecular level, the origin, natural history, malignant transformation, and laboratory management of endometriosis and related diseases are not yet clearly defined. Therefore, early laboratory diagnoses of endometriosis, its atypical form, and endometriosis-associated ovarian tumors are important problems that require further study in the context of advanced therapeutic strategies to provide maximal health benefits to patients.

Therapeutic Approaches of Resveratrol on Endometriosis via Anti-Inflammatory and Anti-Angiogenic Pathways

Endometriosis represents a severe gynecological pathology, defined by implantation of endometrial glands and stroma outside the uterine cavity. This pathology affects almost 15% of women during reproductive age and has a wide range of consequences. In affected women, infertility has a 30% rate of prevalence and endometriosis implants increase the risk of ovarian cancer. Despite long periods of studies and investigations, the etiology and pathogenesis of this disease still remain not fully understood. Initially, endometriosis was related to retrograde menstruation, but new theories have been launched, suggesting that chronic inflammation can influence the development of endometriosis because inflammatory mediators have been identified elevated in patients with endometriosis, specifically in the peritoneal fluid. The importance of dietary phytochemicals and their effect on different inflammatory diseases have been highlighted, and nowadays more and more studies are focused on the analysis of nutraceuticals. Resveratrol is a phytoestrogen, a natural polyphenolic compound with antiproliferative and anti-inflammatory actions, found in many dietary sources such as grapes, wine, peanuts, soy, berries, and stilbenes. Resveratrol possesses a significant anti-inflammatory effect via inhibition of prostaglandin synthesis and it has been proved that resveratrol can exhibit apoptosis-inducing activities. From the studies reviewed in this paper, it is clear that the anti-inflammatory effect of this natural compound can contribute to the prevention of endometriosis, this phenolic compound now being considered a new innovative drug in the prevention and treatment of this disease.

Macrophage and nerve interaction in endometriosis

Dysregulation of the immune system in endometriotic milieus has been considered to play a pivotal role in the pathogenesis of endometriosis. Macrophage recruitment and nerve fiber infiltration are the two major characteristics of this aberrant immune environment. First, the recruitment of macrophages and their polarization phenotype within the endometriotic lesion have been demonstrated to facilitate the development and maintenance of endometriosis. M1 phenotype of macrophages has the capacity to secrete multiple cytokines for inflammatory response, while M2 macrophage possesses an opposite property that can mediate the process of immunosuppression and neuroangiogenesis. Upon secretion of multiple abnormal signal molecules by the endometriotic lesion, macrophages could alter their location and phenotype. These changes facilitate the accommodation of the aberrant microenvironment and the exacerbation of disease progression. Second, the infiltration of nerve fibers and their abnormal distribution are proved to be involved in the generation of endometriosis-associated pain and inflammatory response. An imbalance in sensory and sympathetic innervation and the abnormal secretion of different cytokines could mediate neurogenesis and subsequent peripheral neuroinflammation in endometriosis. Although endometriosis creates an inflammatory milieu promoting macrophage infiltration and an imbalanced innervation, interaction between macrophages and nerve fibers in this process remains unknown. The aim of this review is to highlight the role of macrophage and nerve interaction in endometriosis, where macrophage recruitment and neurogenesis can be the underlying mechanism of neuroinflammation and pathogenesis of endometriosis.

Soluble ST2 and IL-33: Potential markers of endometriosis in the Tunisian population

Interleukin-33 is an IL-1 family cytokine which signals via its T1/ST2 receptor, and acts as a key regulator of inflammation. This study aims to measure the expression of soluble ST2 (sST2) and IL-33 in endometriosis. We investigated thirty women with laparoscopic and histopathological confirmed endometriosis and 20 control women without pelvic pathology. Peripheral blood mononuclear cells and peritoneal fluid (PF) were assessed for sST2 and IL-33 levels that are measured by sandwich enzyme-linked immunosorbent assay. Peritoneal fluid IL-33 mRNA expression was quantified by real-time reverse transcription polymerase chain reaction assays. We found that IL-33 levels in PF and in serum were significantly higher in patients with endometriosis compared to women without endometriosis (P < 0.05). IL-33 increased levels were significantly more important in PF [10.45 ± 14.33 ng/mL] than in serum [2.68 ± 1.54 ng/mL] from endometriosis patients. Higher levels of IL-33 mRNA expression were detected in PF from patients with endometriosis. Soluble ST2 levels in PF were significantly different between patients [2.96 ± 0.98 ng/mL; P < 0.0001] and controls [0.88 ± 0.076 ng/mL]. Serum sST2 levels were similarly expressed in endometriosis patients and in controls (P > 0.05). Significant correlation was observed between IL-33 and sST2 levels in PF. In conclusion, IL-33 and sST2 values observed in PF were found to correlate with endometriosis severity. Elevated and correlated PF IL-33 and sST2 levels from patients with endometriosis suggested a potential role as surrogate markers of disease activity.

Rectosigmoid endometriosis: comparison between CT water enema and video laparoscopy

AIM

To evaluate the accuracy of water enema computed tomography (CT) for predicting the location of endometriosis in patients with contraindications to magnetic resonance imaging (MRI), focusing on rectosigmoid lesions and having laparoscopic and histological data as the reference standard.

MATERIALS AND METHODS

Thirty-three women (mean age 33.4 ± 3.1 years) suspected of having deep pelvic endometriosis underwent 64-row CT and video laparoscopy within 4 weeks. Two radiologists blinded to the clinical data evaluated the CT images obtained after colonic retrograde distension using water as the contrast medium, and a comparison with laparoscopic and histological findings was performed. CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated. The radiation dose to patients was estimated. Cohen's weighted kappa (κ) test was used to evaluate the interobserver agreement.

RESULTS

In 23 out of 33 patients (69%) intestinal implants were found at surgery and pathological examinations. CT confirmed the diagnosis of rectosigmoid endometriosis in 20 out of 23 implants. Three nodules located on the proximal sigmoid colon (two serosal lesions and one infiltrating the muscularis layer) with a diameter of less than 1 cm were not diagnosed. CT sensitivity, specificity, PPV, NPV, and accuracy values were 87, 100, 100, 77, and 91%, respectively. The mean effective dose estimate was 6.30 ± 1.7 mSv. Almost perfect agreement between the two readers was found (k = 0.84).

CONCLUSION

Water enema CT can play a role in the diagnosis of bowel endometriosis and represents another accurate potential tool for video laparoscopic approaches, especially in patients for whom MRI is contraindicated.