The coagulation status in women of endometriosis with stage IV

BACKGROUND

Endometriosis is considered as a systemic disease with the presence of proinflammatory cytokines in the circulation, which drives hypercoagulable state of endometriosis. Currently, endometriosis is classified into four stages: I (minimal), II (mild), III (moderate) and IV (severe). The aim of this study is to investigate the correlations between inflammatory markers and coagulation factors in patients diagnosed of endometriosis with stage IV.

METHODS

This retrospective case-control study included 171 endometriosis patients with stage IV and 184 controls. Continuous data were expressed by mean ± standard deviation. Mann-Whitney U and χ2 tests were used to compare the medians and frequencies among the groups. Spearman analysis was conducted to determine the correlation among the measured parameters. The diagnostic values of the parameters differentiating endometriomas were tested by receiver operating characteristic (ROC) curve.

RESULTS

The time of activated partial thromboplastin time (APTT) was decreased and the concentration of fibrinogen (FIB) and neutrophil-to-lymphocyte ratio (NLR) were increased in women of endometriosis with stage IV. The APTT were negatively correlated with NLR while the concentrations of FIB were positively correlated with NLR. The ROC analysis showed that the Area under the curve (AUC) of FIB was 0.766 (95% confidence interval:0.717-0.814) with sensitivity and specificity reaching 86.5 and 60.9%, respectively. The AUC of CA125 and CA199 was 0.638 (95% confidence interval: 0.578-0.697), 0.71 (95% confidence interval: 0.656-0.763) with sensitivity and specificity reaching 40.9 and 91.8%, 80.7 and 56.5% respectively. The combination of these factors showed the highest AUC of 0.895 (0.862-0.927) with sensitivity of 88.9% and specificity of 77.7%.

CONCLUSION

In the present study, we found that inflammatory factors showed significant correlation with APTT or FIB in endometriosis with stage IV. Moreover, the coagulation factors combined with CA125 and CA199 were more reliable for identifying the endometriosis with stage IV.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Diagnostic significance of neutrophil to lymphocyte ratio in endometriosis: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to compile existing evidence on the significance of the NLR in predicting endometriosis in order to aid clinical decision-making and outcomes.

METHODS

We searched ProQuest, Web of Science, and PubMed for related studies published before January 2, 2023. Standardized mean difference (SMD) with a 95% confidence interval (CI) was reported for each outcome. Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used Newcastle-Ottawa Scale (NOS) for quality assessment.

RESULTS

Overall, 18 article with were included in the analysis. A random-effect model revealed that patients with endometriosis had elevated levels of NLR compared to healthy controls (SMD = 0.79, 95% CI = 0.33 to 1.25, P < 0.001). Patients with endometriosis had elevated levels of NLR compared to those with other benign tumors (SMD = 0.85, 95% CI = 0.17 to 1.53, P = 0.014). In addition, NLR level of patients with stage III and IV endometriosis was not different from that of patients with stage I and II endometrioma (SMD = 0.30, 95% CI = -0.14 to 0.74, P = 0.18). However, NLR level was not different between endometriosis patients with and without peritoneal lesions (SMD = -0.12, 95% CI = -0.34to 0.10, P = 0.28), between patients with and without endometrioma (SMD = 0.20, 95% CI = -0.15 to 0.55, P = 0.26) and between endometriosis patients with and without deep lesions (SMD = 0.04, 95% CI = -0.20 to 0.28, P = 0.72). The pooled sensitivity of NLR was 0.67 (95% CI = 0.60-0.73), and the pooled specificity was 0.68 (95% CI, 0.62-0.73).

CONCLUSIONS

NLR might be utilized in clinics as a possible predictor to help clinicians diagnose endometriosis in affected women.

The Abundance and Function of Neutrophils in the Endometriosis Systemic and Pelvic Microenvironment

Endometriosis is a common inflammatory illness in which endometrial tissue grows outside the uterine cavity. Immune dysfunction is now widely acknowledged as the primary cause of endometriosis. The immune cell population represented by neutrophils is thought to play an essential role in the etiology, pathophysiology, and associated clinical outcome. There is growing evidence that neutrophils have a role in chronic and aseptic inflammatory diseases, and endometriosis patients have increased levels of neutrophils in plasma, peritoneal fluid, and ectopic endometrium. Here, we sought to review the function of neutrophils in the pathogenesis of endometriosis, with an emphasis on the role of neutrophils in regulating endometrial angiogenesis and the local inflammatory microenvironment.

Red blood cell indices as an effective marker for the existence and severity of endometriosis (STROBE)

To evaluate the association between red blood cell (RBC) indices (mean corpuscular volume [MCV], mean corpuscular hemoglobin [MCH], MCH concentration [MCHC], red cell distribution width [RDW], hemoglobin [Hb], hematocrit [Hct], and neutrophil-to-lymphocyte ratio [NLR]) and the severity of endometriosis. Data were obtained from the medical records of 200 patients with endometriosis (stage I/II and stage III/IV groups), and 100 patients with benign ovarian tumors (control group), treated between September 2011 and April 2021. The mean Hb and Hct were significantly lower in the stage III/IV group compared to those in the control and stage I/II group (P = .015 and P = .004, respectively). The mean MCV, MCH, and Hb at postoperative day (POD)#1 were significantly lower in the stage III/IV group compared to those in the control and stage I/II group (P = .007, P = .032, and P < .0001, respectively). In addition, NLR at POD#1 was significantly higher in stage III/IV group compared to that in the control and stage I/II group. Multivariate analysis revealed that younger age (≤38 years old), lower preoperative MCV (≤88.5 fL), lower POD#1 Hb (<11.6g/dL), and higher POD#1 NLR (>2.5) were independent risk factors of stage III/IV endometriosis. Lower levels of RBC indices, including preoperative MCV and postoperative Hb, and higher postoperative NLR were significantly associated with the severity of endometriosis, which is potentially derived from a dysregulation in iron metabolism and inflammation.

In vitro modeling of endometriosis and endometriotic microenvironment - Challenges and recent advances

Endometriosis is a chronic condition with high prevalence in reproductive age women, defined as the growth of endometrial tissue outside the uterine cavity, most commonly on the pelvic peritoneum. The ectopic endometrial lesions exist in a unique microenvironment created by the interaction of epithelial, stromal, endothelial, glandular, and immune cell components, dominated by inflammatory, angiogenic, and endocrine signals. Current research is directed at understanding the complex microenvironment of the lesions and its relationship with different endometriosis stages, phenotypes, and disease symptoms and at the development of novel diagnostic and therapeutic concepts that minimalize the undesirable side effects of current medical management. Recreating pathophysiological cellular and molecular mechanisms and identifying clinically relevant metrics to assess drug efficacy is a great challenge for the experimental disease models. This review summarizes the complete range of available in vitro experimental systems used in endometriotic studies, which reflect the multifactorial nature of the endometriotic lesion. The article discusses the simplistic in vitro models such as primary endometrial cells and endometriotic cell lines to heterogeneous 2D co-cultures, and recently more common, 3D systems based on self-organization and controlled assembly, both in microfluidic or bioprinting methodologies. Basic research models allow studying fundamental pathological mechanisms by which menstrual endometrium adheres, invades, and establishes lesions in ectopic sites. The advanced endometriosis experimental models address the critical challenges and unsolved problems and provide an approach to drug screening and medicine discovery by mimicking the complicated behaviors of the endometriotic lesion.

Blood tests for prediction of deep endometriosis: A case-control study

BACKGROUND

Deep endometriosis (DE) is the most aggressive subtype of endometriosis. The diagnosis may be challenging, and no biomarkers that can discriminate women with DE from those without DE have been developed.

AIM

To evaluate the role of blood hemostatic parameters and inflammatory indices in the prediction of DE.

METHODS

This case-control study was performed at the Women’s Hospital, Zhejiang University School of Medicine between January 2015 and December 2016. Women with DE and women with benign gynecologic disease (control group) eligible for gynecological surgery were enrolled. Routine plasma hemostatic parameters and inflammatory indices were obtained before surgery. Univariate and multivariate analysis were performed. Receiver operating characteristic (ROC) curves were generated, and areas under the curve (AUC) were calculated to assess the predictive values of the selected parameters.

RESULTS

A total of 126 women were enrolled, including 31 with DE and 95 controls. Plasma fibrinogen (Fg, P < 0.01), international normalized ratio (P < 0.05), and C-reactive protein levels (P < 0.01) were significantly higher in women with DE compared with controls. Plasma hemoglobin (HB) levels (P < 0.05) and shortened thrombin time (P < 0.05) were significantly lower in women with DE than in controls. Plasma Fg levels [adjusted OR (aOR) 2.12, 95%confidence interval (CI): 1.31-3.75] and plasma HB levels (aOR 0.48, 95%CI: 0.29-0.78) were significantly associated with DE (both P < 0.05). ROC analysis showed that the diagnostic value of Fg or HB alone for DE was limited. The AUC of the combination of both markers as a dual marker index was 0.773 with improved sensitivity (67.7%) and specificity (78.9%) at cutoffs of 3.09 g/L and 126 g/L, respectively.

CONCLUSION

The combination of Fg and HB was a reliable predictor of DE. A larger study is needed to confirm the findings.

Preoperative Neutrophil-to-Lymphocyte Ratio Level is a Predictor of Postoperative Fertility in Infertile Patients with Ovarian Endometrioma

To investigate the predictive efficacy of the preoperative neutrophil-lymphocyte ratio (NLR) for natural pregnancy outcome after laparoscopic cystectomy in infertile patients with ovarian endometrioma (OMA). Current evidence suggests that endometriosis likely induces local and systemic inflammatory processes. The NLR has been demonstrated to be of great utility in the diagnosis of endometriosis. However, the association between NLR and natural pregnancy outcome after laparoscopic surgery for endometriosis remains unknown. Data on infertile OMA patients undergoing laparoscopic surgery from January 2014 to October 2019 were retrospectively analyzed. Cox regression analysis was used to identify predictors of natural pregnancy outcome. A predictive model was then established using the nomogram. Among 217 patients, 115 patients (53.0%) experienced natural pregnancy after surgery. Compared with patients with pregnancy failure, those with pregnancy success had a significantly higher NLR (P < 0.05). Multivariate analysis revealed that age, least function (LF) score, and NLR were independent predictors of postoperative pregnancy (all P < 0.05). The NLA (NLR, LF score and age) scoring was then established and had a high predictive ability (AUC = 0.725). Patients were divided into three groups (low-, intermediate- and high-risk) based on the scoring, and the 1-year pregnancy rates were 43.5%, 34.4%, and 21.0%, respectively (P < 0.05). The preoperative NLR level was significantly associated with natural pregnancy outcome in infertile OMA patients after surgery. A predictive model combining NLR, LF score, and age could assist in the clinical decision-making process.

Evaluating hematological parameters in women with endometriosis

In the present study, we aimed to evaluate the relationship between the level of hematological parameters and the presence and stage of endometriosis. We included medical records of patients diagnosed with endometriosis (endometriosis group) and patients diagnosed with benign non-endometriotic ovarian masses (control group), who were eligible based on inclusion and exclusion criteria and compared the preoperative level of hematological parameters between the two groups. According to our findings, neutrophil and WBC counts, mean platelet volume, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were significantly higher, and the haemoglobin concentration, platelet count, and absolute lymphocyte count were lower in women diagnosed with endometriosis compared to the control group. There was no significant difference in hematological parameters of patients with endometriosis stages III and IV. Finally, we found that the preoperative level of hematological parameters lacked sufficient power for the diagnosis of endometriosis. Also, our results indicate that endometriosis is associated with an inflammatory processes.IMPACT STATEMENTWhat is already known on this subject? Inflammatory factors are believed to be involved in the pathogenesis of endometriosis; however, there are inconsistent reports on the association between blood inflammatory markers and endometriosis.What do the results of this study add? The results of this study indicate that endometriosis is associated with inflammatory processes that lead to changes in hematological parameters; however, preoperative measurement of these parameters has not sufficient power for the diagnosis of endometriosis.What are the implications of these findings for clinical practice and/or further research? The preoperative level of hematological parameters lacks sufficient power for the diagnosis of endometriosis, but they may help doctors make a diagnosis in the clinical setting as auxiliary findings.

Assessment of Coagulation Parameters in Women Affected by Endometriosis: Validation Study and Systematic Review of the Literature

The presence of endometriosis determines an inflammatory response locally. The objective of this validation study and systematic review was to assess systemic levels of coagulation and inflammatory parameters in women with or without the disease. We conducted a retrospective analysis of a database prospectively collected from January 2017 to February 2020 including n = 572 women who underwent laparoscopic surgery for endometriosis (cases, n = 324) or other benign gynecologic diseases (controls, n = 248). Inflammatory markers and coagulation parameters were determined. An advanced systematic search of the literature on the same parameters was conducted up to April 2020. A significantly higher neutrophil count was found in endometriosis patients. Patients with endometriomas and stage III–IV disease had a significantly lower absolute lymphocyte count and shortened activated partial thromboplastin time (aPTT) values. In the final regression model, aPTT retained significant predictive value for stage III–IV endometriosis (odds ratio (OR) = 0.002, 95% confidence interval (CI) = 0.00–0.445; p = 0.024). Results from the n = 14 included studies in the systematic review are characterized by a high variability, but some consistency has been found for alterations in thrombin time, platelet-to-lymphocyte ratio, and neutrophil count associated with endometriosis. Modest systemic changes of some inflammatory and coagulation parameters are associated with endometriosis. Indeed, all the modifications detected are still within the normal reference intervals, explaining the high heterogeneity among studies.

[The influence of endometrioid heterotopias on the red blood parameters.]

Endometrioid heterotopia can have an adverse systemic effect on the organism through erythropoietin synthesis, which can affect erythropoiesis and reflect in blood analysis. The aim of the study was to investigate the effect of endometrioid heterotopia on parameters of red blood. The investigated group included patients with endometrioid heterotopias of various localisations (115 cases), functional ovarian cysts made up the control group (28 cases). Retrospectively, the number of red blood cells, the amount of hemoglobin, and the level of (CA-125) were recorded in the medical histories. The parameters were taken into account both before and after radical surgery. The highest values of the number of red blood cells and hemoglobin are observed in endometrioid ovarian cysts, followed by adenomyosis, endometriosis of the pelvic peritoneum and skin scar, respectively. After surgery, these differences have disappeared. Comparison of the number of red blood cells and hemoglobin before and after surgery revealed significant changes for both parameters in the group of patients with endometriosis, while in the control group the number of red blood cells and the level of hemoglobin did not change significantly. The number of cases with endometrioid ovarian cysts, where the red blood cell count was higher than normal, significantly differed from the control group; on the contrary, with non-endometrioid ovarian cysts, a significantly more frequent decreased number of red blood cells was observed. In addition, red blood counts in patients with endometriosis before surgery had a moderate negative correlation with the level of CA-125 protein.The possible systemic influence of endometrioid heterotopias on erythropoiesis in the form of its stimulation is demonstrated. In non-endometrioid ovarian cysts a significantly more frequent decrease in the number of red blood cells is observed. The reveales pecularities can be used for complex differential diagnostics of ovarian cysts at the preoperative stage due to their easy accessibility and minimally invasive nature.

Systemic Inflammatory Response Markers Associated with Infertility and Endometrioma or Uterine Leiomyoma in Endometriosis

Purpose

The aim of this study was to find the most useful marker of endometriosis-related infertility and evaluate predictive and diagnostic values of systemic inflammatory response markers (preoperative white blood–cell subtypes, neutrophil:lymphocyte ratio [NLR], platelet:lymphocyte ratio [PLR], and monocyte:lymphocyte ratio [MLR]) and CA125 levels in endometriosis patients.

Methods

This study comprised 662 women who had undergone laparoscopic surgery and been pathologically confirmed as having endometriosis and 83 patients pathologically confirmed with benign ovarian tumors. Related inflammatory factors in endometriosis complicated by infertility were analyzed via logistic regression analysis. Diagnostic values of the inflammatory response markers were obtained by receiver operating–characteristic analysis.

Results

We firstly identified that lower NLR level was an independent risk factor of infertility. Serum lymphocytes were significantly higher in endometriosis patients, while serum CA125, NLR, MLR, and PLR were elevated. For differentiating endometriosis from other benign ovarian tumors, the combination of NLR and CA125 achieved greater sensitivity than CA125 alone. In addition, both CA125 and NLR were positively correlated with stage, oviduct adhesion, and diameter of ovarian ectopic cysts.

Conclusion

NLR may be used as a simple and easily obtained predictive marker for endometriosis with infertility. Moreover, NLR can be a neoadjuvant biomarker for serum CA125 to diagnose endometriosis.

Is there a correlation between inflammatory markers and coagulation parameters in women with advanced ovarian endometriosis?

Background

Endometriosis is defined as a chronic inflammatory disease. Recent studies have shown that increased coagulation parameters including fibrinogen and platelets are associated with endometriosis. The objective of this study was to determine the levels of inflammatory markers and coagulation parameters and their correlations in women with endometriomas compared to those with benign ovarian cysts or normal pelvic anatomy.

Methods

Between June 2015 and June 2017, a total of 548 women who underwent laparoscopic/laparotomic surgery for ovarian endometriomas (OMA group, n = 226), non-endometriosis benign ovarian cysts (Cyst group, n = 210) and tubal reanastomosis (Control group, n = 112) were recruited in this study. Inflammatory markers including c-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and coagulation parameters including platelet count, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time, and plasma fibrinogen as well as CA-125 were determined.

Results

Compared with Cyst group and Control group, TT and PT in OMA group were significantly shorter and plasma fibrinogen levels were significantly higher (P < 0.05). Moreover, the levels of plasma fibrinogen were positively correlated with CRP, NLR and PLR (P < 0.05). In addition, the confidence intervals for the area under the curve (AUC) for CA-125 × fibrinogen were significantly higher than those for CA-125 (0.904–0.952 vs. 0.899–0.949) in the diagnosis of endometrioma.

Conclusions

These results indicate that women with endometriomas demonstrate a hypercoagulable status due to the inflammatory nature of endometriosis. The combined determination for CA-125 and fibrinogen demonstrate a higher area under the curve than the single detection of CA-125 in those with endometriomas compared to these with benign ovarian cysts.

Trial registration

This study was approved by the Human Ethics Committee of the Women’s Hospital, School of Medicine, Zhejiang University (No.20170174) and all women provided written informed consent.

Diagnostic value of serum D-dimer, CA125, and neutrophil-to-lymphocyte ratio in differentiating ovarian cancer and endometriosis

OBJECTIVE

To assess the utility of hematologic, inflammatory, and immunologic biomarkers for differentiating between ovarian cancer and endometriosis.

METHODS

Data were retrospectively reviewed from women diagnosed with ovarian cancer and endometriosis after ovarian cyst surgery in Zhejiang, China, 2014-2016. Serologic and hematologic biomarkers, including white blood cell count, lymphocyte count, neutrophil count, red blood cell count, hemoglobin, platelets, and D-dimer, albumin, globulin, cancer antigen 125 (CA125) and CA199 serum levels recorded pre-operatively were assessed by ROC curve and logistic regression analysis.

RESULTS

Overall, 49 women were diagnosed with ovarian cancer and 192 with endometriosis. For predicting ovarian cancer, the area under the curve (AUC) was 0.96 (95% confidence interval [CI], 0.94-0.99); sensitivity, 93.2%; specificity, 87.5%) for log(D-dimer), 0.95 (95% CI, 0.91-0.98; sensitivity, 81.3%; specificity, 96.3%) for log(CA125), and 0.92 (95% CI, 0.86-0.98; sensitivity, 92.6%; specificity, 79.2%) for neutrophil-to-lymphocyte ratio (NLR). The AUC for the combination of D-dimer, NLR, and CA125 was 0.96 (95% CI, 0.94-0.99; sensitivity, 91.6%; specificity, 89.6%).

CONCLUSION

Serum D-dimer, NLR, and CA125 were found to be potential diagnostic factors for ovarian cancer. Combined measurement of D-dimer, NLR, and CA125 might offer a convenient screening method.

Correlation of preoperative biomarkers with severity of adhesion in endometriosis

This study was undertaken to evaluate the correlation between preoperative Serum markers and pelvic adhesions in endometriosis patients and to explore the markers' clinical value for outcome prediction. Preoperative blood Serum and CA 125 results were obtained and pelvic adhesion scores were calculated. The patient group with adhesion scores less than 28 points was defined as the mild adhesion group, and those with a score of 28 or more were members of the severe adhesion group. The CA 125 level was significantly higher in the severe adhesion group than in the mild adhesion group. The CA 125 level, size of the largest cyst, and WBC count were associated with the level of pelvic adhesion. Adhesion scores were significantly higher in the CA 125 ≥ 35 U/mL group than in the CA 125 < 35 U/mL group. Patients with a preoperative CA 125 level higher than 35 U/mL are at high risk for pelvic adhesion.

CCR5/CCR5 ligand-induced myeloid-derived suppressor cells are related to the progression of endometriosis

RESEARCH QUESTION

Immunological disorders have been reported to promote the progression of endometriosis. Several recent studies have shown that myeloid-derived suppressor cells (MDSC) drive the progression of endometriosis. The aim of this case-control study was to test whether CCR5 and its ligands drive MDSC accumulation and play a role in the progression of endometriosis.

DESIGN

Thirty-six endometriosis patients and 20 controls were recruited. All subjects underwent laparoscopy. An ELISA kit was used to define CCR5 ligands in plasma and peritoneal fluid from endometriosis patients; flow cytometry was then used to characterize CCR5⁺MDSC in peripheral blood and peritoneal fluid.

RESULTS

Data showed that endometriosis patients displayed a significantly higher production of plasma CCL3 (P = 0.046) and peritoneal fluid CCL3/5 (P = 0.042/0.036) compared with those from the uterine leiomyoma group. Furthermore, the concentrations of peritoneal fluid CCL5 were elevated in late stage patients compared with those from the uterine leiomyoma group. Accumulation of blood CCR5⁺Mo-MDSC was detected in endometriosis patients compared with those from both the ovarian dermoid cysts and uterine leiomyoma groups. Endometriosis patients also showed an elevation of CCR5⁺MDSC and CCR5⁺Mo-MDSC in peritoneal fluid samples compared with uterine leiomyoma samples. It was also found that enrichment of CCR5⁺MDSC (r = 0.6807; P < 0.0001) and CCR5⁺Mo-MDSC (r = 0.6893; P < 0.0001) were correlated with enhanced production of CCL5 in peritoneal fluid from endometriosis patients.

CONCLUSIONS

This study showed that CCR5 and its ligands could drive the progression of endometriosis by enhancing the accumulation of MDSC. These findings might produce a promising treatment that targets CCR5⁺MDSC for endometriosis patients.

Usefulness of hematological parameters for differential diagnosis of endometriomas in adolescents/young adults and older women

BACKGROUND

Inflammatory processes have been considered to be involved in the pathogenesis of endometriosis. However, the predictive role of inflammatory hematological parameters in endometriosis is not clear. The aim of this study was to analyze the clinical value of hematologic markers in the differential diagnosis of endometriomas in younger and older reproductive age women.

MATERIALS AND METHODS

A retrospective chart review was done for 502 patients who underwent surgery: 267 with endometriomas (endometrioma group) and 235 with other benign adnexal cysts (control group). Patients were placed into subgroups as younger (adolescents/young adults, aged <25 years) and older (aged ≥25 years) women. Total and differential white blood cell count, neutrophil-to-lymphocyte ratio, platelet indices and platelet-to-lymphocyte ratio (PLR) were evaluated with receiver operating characteristic curve analysis for differential diagnosis of endometriomas.

RESULTS

The mean serum levels of PLR, plateletcrit (PCT), platelet count and CA-125 (reference range below 35 IU/mL) were significantly higher in the endometrioma group (p < 0.001). The area under the curve (AUC) for CA-125 was 0.85 [95% confidence interval (CI), 0.82-0.88] (p < 0.001) for the entire group. However, platelet count, PLR, and PCT showed poor discriminative ability for detecting endometriomas with AUC values of 0.59 (95% CI, 0.55-0.65, p < 0.001), 0.58 (95% CI, 0.53-0.63, p = 0.002) and 0.61 (95% CI, 0.56-0.66, p < 0.001), respectively. In age-stratified analysis, these platelet indices had also low diagnostic performance in both age groups.

CONCLUSIONS

Hematologic markers do not adequately differentiate ovarian endometriomas from other benign cysts in neither adolescents/young adults nor older women.

Involvement of immune cells in the pathogenesis of endometriosis

Endometriosis is characterized by the implantation and growth of endometriotic tissues outside the uterus. It is widely accepted the theory that endometriosis is caused by the implantation of endometrial tissue from retrograde menstruation; however, retrograde menstruation occurs in almost all women and other factors are required for the establishment of endometriosis, such as cell survival, cell invasion, angiogenesis, and cell growth. Immune factors in the local environment may, therefore, contribute to the formation and progression of endometriosis. Current evidence supports the involvement of immune cells in the pathogenesis of endometriosis. Peritoneal neutrophils and macrophages secrete biochemical factors that help endometriotic cell growth and invasion, and angiogenesis. Peritoneal macrophages and NK cells in endometriosis have limited capability of eliminating endometrial cells in the peritoneal cavity. An imbalance of T cell subsets leads to aberrant cytokine secretions and inflammation that results in the growth of endometriosis lesions. It is still uncertain whether these immune cells have a role in the initial cause and/or stimulate actions that enhance disease; however, in either case, modulating the actions of these cells may prevent initiation or disease progression. Further studies are needed to deepen the understanding of the pathology of endometriosis and to develop novel management approaches of benefit to women suffering from this disease.

Coagulation Status in Women With Endometriosis

Subtle alterations in coagulation and fibrinolysis have been recently reported in patients with endometriosis supporting a potential hypercoagulable status associated with the disease. This cross-sectional study aimed at evaluating some variables of coagulation status and inflammatory markers in women with endometriosis. A total of 314 women who underwent surgery were considered. The case group (n = 169) included patients with a surgical diagnosis of endometriosis, at any stage of disease. The control group (n = 145) included women with a surgical diagnosis of benign gynecologic pathology. No difference was found for thrombin time, International Normalized Ratio (INR), platelet count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio (PLR) between women with endometriosis and controls. Conversely, patients with endometriosis had significantly shortened activated partial thromboplastin time (APTT) when compared to controls (1.08 ± 0.06 and 1.12 ± 0.19, respectively; P < .01). In the subgroup analysis, women with ovarian endometriosis had significantly shortened APTT values in comparison to women without this form and women with stage I to II endometriosis had significantly shorter APTT values and higher PLR than those with stage III to IV disease. In multivariate logistic regression analysis, after controlling for potential confounders, a shortened APTT remained associated with the disease. Activated partial thromboplastin time is shorter in women with endometriosis but still in the normal range. The evidence is insufficient to foresee a possible use of APTT as a diagnostic marker and to claim a crucial role of a systemic hypercoagulable state in the origin of the disease. A role of the local coagulation system in the pathogenesis of the disease cannot be excluded.

CA125 modified by PLT and NLR improves the predictive accuracy of adenomyosis-derived pelvic dense adhesion

To explore the value of serum levels of CA125, platelet count (PLT), neutrophil-lymphocyte ratio (NLR), and modified CA125 markers CA125a and CA125b in predicting pelvic dense adhesion (PDA) associated with adenomyosis, CA125a = lg(CA125 × PLT × 10), CA125b = lg(CA125 × NLR).This retrospective study included 304 patients who underwent surgery for adenomyosis. Correlations of serum levels of CA125, PLT, NLR, and modified CA125 markers with adenomyosis-derived PDA were analyzed by Logistic regression. Receiver operating characteristic curve was applied to assess the utility of these parameters for predicting PDA.All the parameters including CA125, PLT, NLR, and modified CA125 markers were positively correlated with PDA (P < .05 or P < .01). More importantly, CA125a was more specific (85.03% vs. 83.00%) and more sensitive (47.56% vs. 47.47%) than CA125 alone for the prediction of PDA, and CA125b could also improve the predictive specificity of PDA (53.13% vs. 47.47%).Serum CA125, PLT, and NLR were all closely correlated with PDA in adenomyosis patients. CA125 modified by PLT and NLR could further improve the predictive accuracy of adenomyosis-derived PDA, thus providing more meaningful references for better-informed decisions about the mode of surgical access for the clinical treatment of adenomyosis.