Indian J Pathol Microbiol. 2010 Jan-Mar;53(1):197-8.

Xanthogranulomatous oophoritis associated with primary infertility and endometriosis.

Shukla S, Pujani M, Singh SK, Pujani M.

Hum Reprod. 2010 Mar;25(3):633-41. Epub 2010 Jan 19.

Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial.

Strowitzki T, Marr J, Gerlinger C, Faustmann T, Seitz C.

Department of Gynecological Endocrinology and Reproductive Medicine, University of Heidelberg, Vossstrasse 9, 69115 Heidelberg, Germany. thomas_strowitzki@med.uni-heidelberg.de

BACKGROUND: Dienogest is a selective progestin that has been investigated in a clinical trial programme for the treatment of endometriosis. The current non-inferiority trial compared the efficacy and safety of dienogest against leuprolide acetate (LA) for treating the pain associated with endometriosis. METHODS: Patients with confirmed endometriosis were randomized to treatment with dienogest (2 mg/day, orally) or LA (3.75 mg, depot i.m. injection, every 4 weeks) for 24 weeks. The primary efficacy variable was absolute change in pelvic pain from baseline to end of treatment, assessed by visual analogue scale (VAS). Safety variables included adverse event profile, laboratory parameters, bone mineral density (BMD), bone markers and bleeding patterns. RESULTS: A total of 252 women were randomized to treatment with dienogest (n = 124) or LA (n = 128); 87.9 and 93.8% of the respective groups completed the trial. Absolute reductions in VAS score from baseline to Week 24 were 47.5 mm with dienogest and 46.0 mm with LA, demonstrating the equivalence of dienogest relative to LA. Hypoestrogenic effects (e.g. hot flushes) were reported less frequently in the dienogest group. As expected, bleeding episodes were suppressed less with dienogest than with LA. Changes in mean lumbar BMD between screening and final visit were +0.25% with dienogest and -4.04% with LA subgroups (P = 0.0003). Markers of bone resorption increased with LA but not dienogest. CONCLUSIONS: Dienogest 2 mg/day orally demonstrated equivalent efficacy to depot LA at standard dose in relieving the pain associated with endometriosis, although offering advantages in safety and tolerability.

Fam Cancer. 2010 Jan 20. [Epub ahead of print]

High risk for neoplastic transformation of endometriosis in a carrier of lynch syndrome.

Nyiraneza C, Marbaix E, Smets M, Galant C, Sempoux C, Dahan K.

Center for Human Genetics, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.

Lynch syndrome is an autosomal dominant cancer-susceptibility disorder caused by mutations in DNA mismatch repair genes. Women with Lynch syndrome have an increased lifetime risk for endometrial and ovarian cancers. While there is evidence of efficacy for prophylactic surgery, no standard recommendations have been developed to support screening for premalignant endometrial and ovarian epithelial lesions in high-risk women. Here, we report a case of a healthy woman carrying a germline mutation in MLH1 gene with endometrial intra-epithelial neoplasia and ovarian endometriotic lesions exhibiting a loss of MLH1 protein expression. This case report illustrates the malignant potential of endometriosis, and highlights the need for a meticulous management of gynecologic premalignant precursor lesions in reducing cancer risk among related Lynch syndrome women.

Surg Radiol Anat. 2010 Jan 20. [Epub ahead of print]

Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique.

Ceccaroni M, Clarizia R, Alboni C, Ruffo G, Bruni F, Roviglione G, Scioscia M, Peters I, De Placido G, Minelli L.

Gynecologic Oncology Division, Department of Obstetrics and Gynecology, European Gynaecology Endoscopy School, Sacred Heart Hospital “Ospedale Sacro Cuore-Don Calabria”, Via Don A. Sempreboni no. 5, 37024, Negrar, Verona, Italy, roberto.clarizia@gmail.com.

PURPOSE: Endometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique. METHODS: Confidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves. RESULTS: We describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves. CONCLUSIONS: Laparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

Cancer Epidemiol Biomarkers Prev. 2010 Feb;19(2):398-404. Epub 2010 Jan 19.

Clinical presentation of endometrioid epithelial ovarian cancer with concurrent endometriosis: a multicenter retrospective study.

Lim MC, Chun KC, Shin SJ, Lee IH, Lim KT, Cho CH, Park SY, Nam JH.

Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Korea.

BACKGROUND: Endometrioid epithelial ovarian cancer (EEOC) is frequently diagnosed in conjunction with endometriosis and is suggested to arise during the process of endometriosis. This study evaluates the clinical manifestations, including endometriosis-related symptoms and their relationships according to the coexistence of endometriosis. METHODS: Using medical records, a retrospective analysis was conducted on 221 patients treated for EEOC at four tertiary educational hospitals between 2000 and 2008. The initial presenting symptoms, particularly those related to endometriosis, were examined in relation to the coexistence of endometriosis or other clinical variables. RESULTS: Endometriosis was identified in 82 (37.1%) of the 221 patients with EEOC. The most common symptoms were pelvic pain followed by gastrointestinal symptoms, palpable mass, abdominal distension, vaginal bleeding, and newly developed or exacerbated dysmenorrhea (18.1%) and dyspareunia (13.6%). Notably, dysmenorrhea and dyspareunia were frequently observed in patients with endometriosis. Among 210 patients identified with pretreatment serum CA-125, 54 (25.7%) displayed normal CA-125 levels (<35 units/mL) and 23.3% and 29.9% of patients without and with endometriosis had normal CA-125 levels, respectively (P = 0.381). Additionally, 32.6% of the patients with early-stage EEOC displayed normal CA-125 levels. CONCLUSIONS: In this large series of patients with EEOC, the main presenting symptoms were pelvic pain followed by gastrointestinal symptoms, palpable mass, abdominal distension, vaginal bleeding, and newly developed or exacerbated dysmenorrhea and dyspareunia. Dyspareunia and dysmenorrhea were more frequently detected in patients with endometriosis. Normal CA-125 levels cannot be applied as a marker to exclude EEOC, particularly at the early stages.

Hum Reprod. 2010 Mar;25(3):569-74. Epub 2010 Jan 18.

The enigmatic uterine junctional zone: the missing link between reproductive disorders and major obstetrical disorders?

Brosens I, Derwig I, Brosens J, Fusi L, Benagiano G, Pijnenborg R.

Leuven Institute for Fertility and Embryology, Leuven, Belgium. ivo.brosens@med.kuleuven.be

While there is a growing realization that the origins of major obstetrical complications associated with defective deep placentation, such as pre-term labour, fetal growth restriction and pre-eclampsia, may lie in the very early pregnancy events, the underlying mechanisms are not understood. Impaired deep placentation is foremost a vascular pathology, characterized by a lack of endovascular trophoblast invasion and remodelling of a segment of the spiral arteries embedded within the inner myometrium of the uterus. Outside pregnancy, the inner myometrium represents a highly specialized, hormone-dependent structure, termed the junctional zone (JZ), which plays an integral part in the implantation process. The JZ changes with age and is disrupted in several reproductive disorders, such as endometriosis and adenomyosis, which in turn may account for the increased risk of adverse pregnancy outcome. Unlike the endometrium, the myometrial JZ is not readily accessible to biochemical or molecular studies, yet its structure and function can be assessed using imaging techniques, such as high-resolution ultrasound and magnetic resonance imaging. Thus, non-invasive assessment of the JZ prior to conception may turn out to be useful in identifying those women at risk of major obstetrical complications.

J Obstet Gynaecol Can. 2009 Dec;31(12):1159-71.

Abdominal bloating: an under-recognized endometriosis symptom.

Luscombe GM, Markham R, Judio M, Grigoriu A, Fraser IS.

Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants, The University of Sydney, Australia.

OBJECTIVE: To explore the association between the symptom of abdominal bloating and the diagnosis of endometriosis. METHODS: Twenty-six patients with endometriosis diagnosed by laparoscopy and 25 women without endometriosis were recruited to a case-control study. Subjects completed detailed questionnaires regarding perception of abdominal bloating, bloating-related symptoms, and effect on lifestyle. Abdominal girth was measured three times daily for one whole menstrual cycle, as were ratings of perceived abdominal bloating severity and discomfort. Experiences of abdominal and gastrointestinal symptoms were compared. RESULTS: A significantly larger proportion of women with endometriosis than control subjects experienced abdominal bloating (96% vs. 64%). In women with abdominal bloating, the following were more common in those who had endometriosis: associated severe discomfort (30% vs. 0%), wearing loose clothes during bloating (87% vs. 38%), and simultaneous hand swelling (30% vs. 6%). The experiences of cyclically related diarrhea and constipation were more frequent with endometriosis. While there were significant changes in bloating and discomfort ratings across the menstrual cycle, there was a trend towards a difference between the control subjects and unmedicated endometriosis groups only in how the pattern of bloating severity fluctuated across the cycle. Lower abdominal girth measurements changed significantly across menstrual cycle phases. Control and unmedicated endometriosis groups differed significantly in girth changes across the menstrual cycle, controls experiencing much less variation. Compared with the unmedicated endometriosis group, women receiving hormonal treatment had higher bloating severity ratings and discomfort scores, but there was no objective difference in abdominal girth. CONCLUSION: Painful abdominal bloating appears to be common in women with endometriosis and causes considerable symptomatic distress.

J Exp Clin Cancer Res. 2010 Jan 19;29:4.

Higher expression of vascular endothelial growth factor (VEGF) and its receptor VEGFR-2 (Flk-1) and metalloproteinase-9 (MMP-9) in a rat model of peritoneal endometriosis is similar to cancer diseases.

Machado DE, Berardo PT, Palmero CY, Nasciutti LE.

Programa de Pesquisa em Biologia Celular e do Desenvolvimento, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Cidade Universitária-Ilha do Fundão, 21941-590 Rio de Janeiro, RJ Brazil. luiz.nasciutti@histo.ufrj.br.

ABSTRACT: BACKGROUND: Endometriosis is a common disease characterized by the presence of a functional endometrium outside the uterine cavity, causing pelvic pain, dysmenorrheal, and infertility. This disease has been associated to development of different types of malignancies; therefore new blood vessels are essential for the survival of the endometrial implant. Our previous observations on humans showed that angiogenesis is predominantly found in rectosigmoid endometriosis, a deeply infiltrating disease. In this study, we have established the experimental model of rat peritoneal endometriosis to evaluate the process of angiogenesis and to compare with eutopic endometrium. METHODS: We have investigated the morphological characteristics of these lesions and the vascular density, VEGF and its receptor Flk-1 and MMP-9 expression, and activated macrophage distribution, using immunohistochemistry and RT-PCR. RESULTS: As expected, the auto-transplantation of endometrium pieces into the peritoneal cavity is a well-established method for endometriosis induction in rats. The lesions were cystic and vascularized, and demonstrated histological hallmarks of human pathology, such as endometrial glands and stroma. The vascular density and the presence of VEGF and Flk-1 and MMP-9 were significantly higher in endometriotic lesions than in eutopic endometrium, and confirmed the angiogenic potential of these lesions. We also observed an increase in the number of activated macrophages (ED-1 positive cells) in the endometriotic lesions, showing a positive correlation with VEGF. CONCLUSION: The present endometriosis model would be useful for investigation of the mechanisms of angiogenesis process involved in the peritoneal attachment of endometrial cells, as well as of the effects of therapeutic drugs, particularly with antiangiogenic activity.

Ginecol Obstet Mex. 2009 Nov;77(11):518-22.

Deep cervical endometriosis causing profuse vaginal bleeding. Case report and literature review.

[Article in Spanish]

Mendoza GO, Castañón FJ, Hernández M, Maguregui SC, Orozco VM.

Clínica Maternidad Conchita, Delicias, Chih. México. olivasmg@prodigy.net.mx

It is reported the case of a patient with cervical endometriosis deep in the fourth decade of life, with regular menstruation, dysmenorrhea secondary progressive, disabling, dyspareunia, and chronic pelvic pain, disquesia in the last three years. Was presented in the emergency on the twentieth day of the menstrual cycle due to an abrupt and substantial transvaginal bleeding, and led to acute anemia. In gynecological exploration was observed in the posterior lip of the cervix and glandular eversion had a solitary lesion in a punch, with active bleeding from the interior of the lesion, independent of the external cervical os and the endocervical canal. The rest of the colposcopy was normal. Total hysterectomy was performed and the histopathologic report was of deep cervical endometriosis, adenomyosis and hemorrhagic salpingitis left.

Hum Reprod. 2010 Mar;25(3):728-33. Epub 2010 Jan 17.

‘Here comes the sun’: pigmentary traits and sun habits in women with endometriosis.

Somigliana E, Viganò P, Abbiati A, Gentilini D, Parazzini F, Benaglia L, Vercellini P, Fedele L.

Department of Obstetrics, Gynecology and Neonatology, Fondazione Ospedale Maggiore Policlinico, Mangiagalli and Regina Elena, Milan, Italy.

BACKGROUND: There is limited but interesting evidence suggesting that endometriosis may be associated with specific pigmentary traits and sun habits. In this case-control study, we aimed to further clarify this point. MATERIALS AND METHODS: Consecutive patients with a first laparoscopic diagnosis of endometriosis according to Holt and Weiss criteria were selected as cases. Controls were women who underwent laparoscopy during the same study period, but who were found to be free of the disease. Selected women were interviewed and examined by two trained physicians. An unconditional logistic regression model that included age and baseline variables significantly differing between the two groups was used to estimate the adjusted odds ratios (OR). RESULTS: There were 98 women with endometriosis and 94 controls selected. Overall, women with the disease had a more photo-sensitive phenotype and were exposed less to sun or ultraviolet radiation. A statistically significant difference was documented for eye color, skin reaction to first sun exposure, freckles score and the use of tanning creams. The adjusted OR (95% CI) for the disease was 1.95 (1.02-3.72) for women with green/blue eyes, 2.19 (1.12-4.28) for those who frequently/always had skin burn reaction to first sun exposure, 5.67 (1.98-16.24) for those with a higher number of freckles and 0.35 (0.15-0.85) for the use of tanning creams. CONCLUSIONS: Women with endometriosis have a specific photo-sensitive phenotype and protect themselves more from the sun. This latter habit may be consequent to the former. We speculate that there is a shared genetic background between pigmentation and endometriosis.

Surg Neurol. 2009 Dec;72(6):573-6.

Neuromodulation of the superior hypogastric plexus: a new option to treat bladder atonia secondary to radical pelvic surgery?

Possover M, Chiantera V.

Department of Surgical Gynecology & Neuro-Pelveology, Hirslanden Clinic, CH-8032 Zürich, Switzerland. marcpossover@aol.com

BACKGROUND: The aim of this study is to report on the impact of neuromodulation to the superior hypogastric plexus in patients with bladder atonia secondary to pelvic surgery. METHODS: In 4 consecutive patients with bladder atonia secondary to pelvic surgery, we performed a laparoscopic implantation of a neurostimulator–LION procedure–to the entire superior hypogastric plexus. RESULTS: Of the 4 reported patients, 3 are able to partially void or empty their bladder. CONCLUSIONS: If the presented results could be obtained in further patients and maintained in long-term follow-up, the LION procedure to the superior hypogastric plexus could change the management of bladder function in patients with bladder atonia. Copyright 2009. Published by Elsevier Inc.

Rev Esp Enferm Dig. 2009 Dec;101(12):872-4.

Small bowel obstruction secondary to ileal endometriosis: multisection computer tomography evaluation.

[Article in English, Spanish]

Fernández-Rey CL, Alvarez-González SA, Díaz-Solís P, Blanco-González A, Costilla-García S.

Services of Radiodiagnosis and General Surgery, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.

Cell Mol Immunol. 2010 Jan;7(1):51-60.

Abnormal regulation of chemokine TECK and its receptor CCR9 in the endometriotic milieu is involved in pathogenesis of endometriosis by way of enhancing invasiveness of endometrial stromal cells.

Wang Y, Yu J, Luo X, Wang X, Li M, Wang L, Li D.

Laboratory for Reproductive Immunology, Hospital and Institute of Obstetrics and Gynecology, Shanghai Medical College of Fudan University, Shanghai 200011, China.

The chemokine thymus-expressed chemokine (TECK), which regulates T-cell development and tissue-specific homing, has been identified as a potential contributor to the pathogenesis and progression of endometriosis. Dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin, TCDD), an air pollutant, and estrogen also appear to be involved in endometriosis. Both endometrial stromal cells (ESCs) and the combination of 17beta-estradiol and TCDD increase the secretion of TECK in the endometriosis-associated cells and promote the invasiveness of ESCs by increasing expression of matrix metalloproteinase (MMP)-2 and MMP-9. Anti-TECK neutralizing antibodies can effectively inhibit the invasiveness of ESCs and the expression of MMP-2 and MMP-9 in the cells. Interestingly, the expression of chemokine C receptor 9 (CCR9) and its ligand TECK increases significantly in the endometriotic milieu of patients with endometriosis. Therefore, the over-expressed TECK interacts with CCR9 on the ESCs in the endometriotic milieu, which may contribute to the onset and progression of endometriosis.

Fertil Steril. 2010 Jan 14. [Epub ahead of print]

Increased expression of p21-activated kinase in adenomyosis.

Kim SR, Kim SH, Lee HW, Chae HD, Kim CH, Kang BM.

Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.

The present study was designed to evaluate whether the expression of p21-activated kinase 1 (Pak1), which recently has been shown to be increased in the eutopic endometrium of women with endometriosis, is also increased in adenomyotic nodules as well as in the eutopic endometrium in women with adenomyosis. Comparative immunohistochemical study using a monoclonal antihuman Pak1 antibody revealed that the expression of Pak1 is increased in the eutopic endometrium of women with adenomyosis during the secretory phase, along with its increased expression in adenomyotic nodules, suggesting a possible role of Pak1 in the establishment of adenomyosis. Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Fertil Steril. 2010 Jan 14. [Epub ahead of print]

Papillary serous carcinoma arising in abdominal wall endometriosis treated with neoadjuvant chemotherapy and surgery.

Omranipour R, Najafi M.

Cancer Institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.

OBJECTIVE: To report a case of malignant transformation of abdominal wall endometriosis. DESIGN: Case report. SETTING: Private practice. PATIENT(S): A 59-year-old woman with a rapidly growing abdominal wall mass. INTERVENTION(S): Neoadjuvant chemotherapy and surgical resection of the mass. MAIN OUTCOME MEASURE(S): Shrinkage of the tumor after neoadjuvant chemotherapy and wide excision and reconstruction of abdominal wall. RESULT(S): A 59-year-old woman had a history of laparotomy performed for uterine perforation due to dilatation and curettage 20 years ago. She noticed a mass in her abdominal wall shortly after the operation, which changed in size with menstrual cycles. The mass showed a rapid growth in the last 6 months before presentation. Incisional biopsy revealed papillary serous carcinoma. Owing to the large size of the mass, the patient received neoadjuvant chemotherapy and underwent surgery after shrinkage of the mass. CONCLUSION(S): Malignant transformation of endometriosis is a rare event. In case of huge tumors, neoadjuvant chemotherapy might facilitate surgery by shrinking the tumor. Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Zhonghua Fu Chan Ke Za Zhi. 2009 Nov;44(11):832-6.

Clinicopathological features of 67 cases of endometriosis-associated epithelial ovarian carcinoma.

[Article in Chinese]

Lu Y, Liu MH, Zheng Y, Guo SW, Liu XS.

Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200032, China.

OBJECTIVE: To investigate clinicopathological features of endometriosis-associated epithelial ovarian carcinoma. METHODS: Retrospective follow-up study, clinicopathological data from patients with ovarian epithelial carcinoma were retrieved, analyzed and compared. Among the 727 cases, 34 were found to originate from endometriosis (group A), 33 were found to have co-existing ovarian endometriosis (group B), and the remaining 660 had no ovarian endometriosis at all (group C). RESULT: Seven hundred and twenty-seven epithelial ovarian carcinoma patients were identified and their clinicopathological data retrieved. Sixty-seven (9.2%) of these cases were found to have coexisting endometriosis. The frequency of malignant tumors arising from ovarian endometriosis in this case series was estimated to be 0.87% (34/3890). The mean (standard deviation) age in groups A, B, and C were (47.2 +/- 1.3), (47.8 +/- 1.2), (51.2 +/- 0.4) years, respectively, with patients in group C being significantly older (P = 0.013). Patients with coexisting ovarian endometriosis were mostly diagnosed at stage I (P = 0.000) and having subtype of clear-cell (P = 0.000), while other patients were mostly diagnosed at stage III (P = 0.001), and having subtype of serous carcinoma (P = 0.000). The estrogen receptor (ER) positivity was significantly lower in groups A and B than that in group C (22.2%, 31.6% vs 43.9%; P = 0.018), but the difference in positivity of progestogen receptor among the three groups did not reach statistical significance (22.2%, 15.8% vs 35.5%; P = 0.082). While the five-year overall survival rate for all patients was 55.6%, significant difference in overall survival among the three groups was found 78.9%, 92.8%, 51.9%, respectively, for groups A, B and C (P = 0.000). CONCLUSION: Patients of endometriosis-associated epithelial ovarian carcinoma, especially patients with tumors arising from endometriosis, were found to be younger, having a significant lower stage and a better survival, and were mostly diagnosed with the subtype of clear-cell.

Zhonghua Fu Chan Ke Za Zhi. 2009 Nov;44(11):812-5.

Study on transvaginal hydrolaparoscopic pelvic adhesiolysis in the infertile women.

[Article in Chinese]

Hu XL, Xu LM.

Department of Obstetrics and Gynecology, Affiliated Second Hospital, Jinan University Medical College, Shenzhen 518020, China. Email: hu6622@163.com.

OBJECTIVE: To investigate the safety and efficacy of transvaginal hydrolaparoscopic pelvic adhesiolysis (THLPA) treatment in the infertile women. METHODS: From May 2007 to Sep. 2008, 30 infertile patients underwent THLPA. The dye-test, hysteroscopy, and dye-test using catheterization of tubal ostium by hysteroscopy were performed at the same time. Pelvic adhesions were scored according to the revised American Fertility Society classification of endometriosis (1985). The adhesions were graded as mild (score 1-9), moderate (10-19), and severe (>/= 20). Twenty-four cases were in mild adhesions, 5 moderate adhesions, and 1 severe adhesion. The duration of the operation and discharge, pelvic adhesions score, tubal patency, complications, and pregnancy rate were investigated. RESULTS: (1) THPLA: the majority of pelvic adhesions in all patients were successfully performed adhesiolysis. Only a little filmy adhesions of proximal peritube of 7 tubes and proper ligament of 5 ovaries and cohesive adhesions of 4 ovaries did not underwent surgical lysis. (2) Tubal patency: 35 tubes were of proximal occlusion by dye-test, of which 21 (60%, 21/35) were unobstructed and 4 (11%, 4/35) were partly unobstructed after the dye-test using catheterization of the tubal ostium by hysteroscopy. (3) The duration of operation: the overall operative time were (32 +/- 6) minutes in mild adhesion, (52 +/- 6) minutes in moderate adhesion, and 83 minutes in severe adhesion. Of which the time of THLPA were (11 +/- 5) minutes in mild adhesion, (35 +/- 7) minutes in moderate adhesion, and 62 minutes in severe adhesion, respectively. (4) The duration of discharge: the postoperative discharge time was 120 – 175 minutes. No complications occurred. (5) The rate of pregnancy: in the (15.8 +/- 4.3) months’ follow-up, the rate of pregnancy was 45% (13/29), which one patient lost follow-up. CONCLUSIONS: THLPA is safe, efficacious and not being hospitalized management. When compared with laparoscopy, it is simpler, more economic, and less minimally invasive approach. The appropriate indication of THLPA is to treat filmy, especially mild pelvic adhesions. It could partly avoid transabdominal operative laparoscopy for the infertile women.

Dig Endosc. 2010 Jan;22(1):59-63.

Endometrioid adenocarcinoma arising from endometriosis of the rectosigmoid.

Kobayashi S, Sasaki M, Goto T, Asakage N, Sekine M, Suzuki T, Tsukada K, Yamasaki S, Ukawa S.

Department of Surgery, Tokyo Rinkai Hospital, Tokyo, Japan. kshigrinkai@yahoo.co.jp

A case of endometrioid adenocarcinoma supposedly arising from endometriosis of the rectum is reported. Malignant transformation is uncommon but a well-known complication of endometriosis. In the present case, it was proved by histopathological findings and immunophenotype such as cytokeratin7+/cytokeratin20-/estrogen receptor+. The cause of rectal endometriosis in this case might have been related with previously received hormone replacement therapy for ovarian endometriosis. Following surgical removal of the lesion, this patient underwent adjuvant chemotherapy with paclitaxel and carboplatin, although this kind of therapy is still controversial as to its effectiveness.

Nippon Rinsho. 2010 Jan;68(1):163-7.

Maintenance therapy of endometriosis.

[Article in Japanese]

Kitawaki J.

Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine.

Endometriosis is one of the most common gynecological diseases and is frequently associated with pelvic pain and infertility. Surgical and endocrine therapies successfully suppress pelvic pain, but it often recurs after completion of treatment. To maintain relief from pelvic pain while minimizing hypoestrogenic side effects, several regimens are proposed. Oral contraceptives plus dienogest, a novel progestogen, or a gonadotropin-releasing hormone agonist with estrogen supplementation (add-back therapy) can be used in long-term administration. The relief from pelvic pain achieved with a gonadotropin-releasing hormone agonist can be sustained by long-term administration of a tapered dose of danazol or medium-to-low doses of oral contraceptives. Local treatment with the levonorgestrel-releasing intrauterine system is an option for long-term suppression of pelvic pain.

Rev Col Bras Cir. 2009 Jul;36(3):250-5.

Development of an experimental model of endometriosis in rats.

[Article in English, Portuguese]

do Amaral VF, Dal Lago EA, Kondo W, Souza LC, Francisco JC.

Graduate Program in Health Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.

OBJECTIVES: To develop an experimental model of endometriosis in rats. METHODS: Thirty adult female Wistar rats were used. The surgical technique consisted of median laparotomy with identification of the bicornuate uterus and resection of a 2-cm segment of the right uterine horn. A 0.25 cm(2) flap was removed from that structure and sutured to the abdominal wall with the endometrial side facing the peritoneal cavity. The rats were randomly divided into two groups according to the reoperation date: group 1 (n=15) was reoperated in 30 days, and group 2 (n=15), in 60 days. On the occasion of the second laparotomy, the implants were evaluated macroscopically, resected and referred for microscopic analysis with hematoxylin-eosin and immunohistochemical staining (HEMA, AE1 and AE2). RESULTS: The implants developed in 83.3 % of group 1 and 71.4% of group 2. There was no statistically significant difference between the weights of the animals in the two groups. No statistically significant difference was found in the surface area of the induced lesions: in group 1, the mean was 0.37 cm(2) and in group 2, 0.25 cm(2). According to Keenan’s semiquantitative histological classification (based on the preservation status of the epithelial layer of the endometrium), the mean for group 1 was 1.9 and for group 2, 2.4. CONCLUSION: The technique used for inducing the development of endometriosis in rats was satisfactory.

Eur J Obstet Gynecol Reprod Biol. 2010 Jan 12. [Epub ahead of print]

Topical non-barrier agents for postoperative adhesion prevention in animal models.

Imai A, Suzuki N.

Institute of Endocrine-Related Cancer, Matsunami General Hospital, Kasamatsu Gifu 501-6062, Japan.

Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. Most surgical procedures performed by obstetrician-gynecologists are associated with pelvic adhesions that may cause subsequent serious sequelae, including small bowel obstruction, infertility, chronic pelvic pain, and difficulty in postoperative treatment, including complexity during subsequent surgical procedures. An increasing number of adhesion reduction agents, in the form of site-specific and broad-coverage barriers and solutions, are becoming available to surgical teams. The most widely studied strategies include placing synthetic barrier agents between the pelvic structures. Most of the adhesions in the barrier-treated patients develop in uncovered areas in the abdomen. This fact suggests that the application of liquid or gel anti-adhesive agents to cover all potential peritoneal lesions, together with the use of barrier agents, may reduce the formation of postoperative adhesions. This article introduces the topical choices available for adhesion prevention mentioned in preliminary clinical applications and animal models. To date there is no substantial evidence that their use reduces the incidence of postoperative adhesions. In combination with good surgical techniques, these non-barrier agents may play an important role in adhesion reduction. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

J Reprod Immunol. 2010 Mar;84(2):199-205. Epub 2010 Jan 13.

Interleukin-6 and other soluble factors in peritoneal fluid and endometriomas and their relation to pain and aromatase expression.

Velasco I, Acién P, Campos A, Acién MI, Ruiz-Maciá E.

Division of Gynecology, School of Medicine, Miguel Hernández University, 03550 Alicante, Spain; Service of Obstetrics and Gynecology, San Juan University Hospital, 03550 Alicante, Spain.

Immunological changes and gene expression anomalies are involved in the etiopathophysiology of endometriosis, although how these alterations are connected is not well established. The aim of this study was to determine the relationship between levels of immune cell populations, cytokines and CA-125 in peritoneal fluid (PF) and ‘chocolate’ cyst fluid (CF), and aromatase expression in endometriotic tissue, as well as to investigate any association with symptoms or recurrence of the disease. Eutopic and ectopic endometrium, CF and PF were collected from 84 women with endometriomas and 24 with benign non-functioning ovarian tumors undergoing radical or conservative surgery. Immunohistochemistry was performed to determine aromatase expression. PF cell populations were assessed by flow cytometry, and CF and PF levels of interleukin (IL)-6, IL-8, IL-13, IL-17 and CA-125 were quantified by ELISA. These parameters were compared with aromatase expression, symptoms and recurrence of the disease. IL-6 levels in PF were higher in patients with endometriosis than in patients with benign non-functioning ovarian cysts, and correlated positively to dysmenorrhea and pelvic pain in the first group. An association between PF IL-8 and CA-125 was also observed in endometriosis. Aromatase positive patients showed higher levels of PF CA-125 and CF IL-17. Recurrence of symptoms or endometrioma occurred sooner in patients having higher IL-6 or IL-8 levels in CF, respectively. These findings suggest an association of IL-6 with pain in endometriosis, as well as a relationship between cytokine expression and recurrence of the disease. However no clear relationship between aromatase expression and other parameters was found. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

Fertil Steril. 2010 Jan 12. [Epub ahead of print]

A case of hematometra following laparoscopic resection of retrocervical and rectovaginal endometriosis.

Kovoor E, Nassif J, Miranda-Mendoza I, Baulon E, Wattiez A.

Institut de Recherche Contre les Cancers de l’Appareil Digestif (IRCAD) and University Hospitals Strasbourg, Strasbourg, France.

OBJECTIVE: To report a case of hematometra following laparoscopic resection of rectovaginal endometriosis extending to the cervix. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 31-year-old woman with endometriosis and infertility. INTERVENTION(S): Combined laparoscopic and vaginal surgery. RESULT(S): The cervix had retracted into the vaginal scar after surgery, preventing the escape of menstrual blood. The hematometra was drained, and the cervix was repositioned into the vagina with use of a combined vaginal and laparoscopic approach. CONCLUSION(S): Retraction of the cervix into the cul-de-sac can occur as a complication of excision of rectovaginal nodules that extend onto the posterior surface of the cervix. Excision of the posterior cervix should avoid deep excision of the posterior lip and should be limited only to the ectocervical margin to avoid such complications. Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Arch Gynecol Obstet. 2010 Jan 14. [Epub ahead of print]

Diagnostic laparoscopy in chronic pelvic pain.

Sharma D, Dahiya K, Duhan N, Bansal R.

Department of Obstetrics and Gynecology, Pt. BDS, PGIMS, Rohtak, Haryana, India.

INTRODUCTION: Laparoscopy, because of its availability and safety, provides a valuable tool in the evaluation of undiagnosed chronic pelvic pain. It is a simple and definitive means of establishing the presence or absence of pelvic pathology without resorting to major abdominal surgery. OBJECTIVE: To evaluate the causes of chronic pelvic pain using laparoscopy and to correlate between clinical examination, ultrasonography, and laparoscopy. MATERIAL AND METHODS: The present prospective study was done in the Department of Obstetrics and Gynecology of Pt. BD Sharma, PGIMS Rohtak. Fifty cases of chronic pelvic pain attending gynae OPD were included in the study. After detailed history, examination, investigations, and ultrasonography, the patients were subjected to laparoscopy. RESULTS: The mean age and parity of the patients with CPP was 30.88 +/- 7.71 years and 1.74 +/- 1.38, respectively. The mean duration of pain was 2.8 years (6 months-8 years). The commonest finding on laparoscopy was adhesions in 40%, endometriosis in 18%, and pelvic congestion syndrome in 20%, while 10% of the patients had normal pelvis. Laparoscopic findings were taken as gold standard and pelvic examination and ultrasonographic findings were compared with it. CONCLUSION: Clinical examination and ultrasonography has a sensitivity of 8.1 and 2%, respectively. Laparoscopy helps in detecting many causes of CPP which clinical methods and ultrasonography fail to identify. This enforces the position of laparoscopy as a gold standard in evaluation of this condition.

Int J Impot Res. 2010 Jan 14. [Epub ahead of print]

Impact of gynecological surgery on female sexual function.

Pauls RN.

Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA.

Sexual function is complex and involves interaction of many factors, including emotional connection, body image, intact physical response and partner sexual function. Disease processes such as abnormal uterine bleeding, endometriosis, urinary incontinence and pelvic organ prolapse may have a negative impact on various parameters of sexual health. Gynecological surgery to address these common complaints may correct the pathological process. However, despite improvements in symptoms related to the disease, improvements in sexuality are not guaranteed and occasionally there may be deteriorations. This review will summarize the current literature assessing sexual symptoms following benign gynecological surgery, including hysterectomy, and bilateral salpingo-oophorectomy, tubal ligation, anti-incontinence surgery and pelvic organ prolapse reconstruction with and without mesh. In the majority of cases, sexual function and quality of life benefit from these surgical interventions. However, it is critical that physicians remain aware of the potential for negative outcomes. Subjects who experience worsening should undergo thorough evaluation early in the postoperative period in order to mitigate symptoms. Treatment modalities for sexual dysfunction following surgery should be the focus of future research.International Journal of Impotence Research advance online publication, 14 January 2010; doi:10.1038/ijir.2009.63.

Colorectal Dis. 2010 Jan 12. [Epub ahead of print]

Appendiceal Intussusception and Endometriosis mimicking Colorectal cancer.

Hanly A, Ryan EM, McNamara DA.

Department of Colorectal Surgery, Beaumont Hospital, Beaumont Road, Dublin 9.

Am J Reprod Immunol. 2010 Mar 1;63(3):227-32. Epub 2010 Jan 12.

PTPN22 C1858T polymorphism in women with endometriosis.

Gomes FM, Bianco B, Teles JS, Christofolini DM, de Souza AM, Guedes AD, Barbosa CP.

Division of Pathological Gynecology and Human Reproduction, Department of Gynecology and Obstetrics, ABC School of Medicine, Avenida Príncipe de Gales 821, Santo André, Brazil.

PROBLEM: Endometriosis has been suggested to be an autoimmune disease and recently, an allelic variation of the PTPN22 (C1858T) gene was revealed to be associated with the development of autoimmunity. The aim of the study was to determine the frequency of the PTPN22 (C1858T) polymorphism in Brazilian women with endometriosis as compared with controls. METHOD OF STUDY: Case-control study included 140 women with endometriosis and a control group consisting of 180 healthy fertile women without a history of endometriosis and/or autoimmune diseases from the ABC School of Medicine. The PTPN22 (C1858T) polymorphism was studied by restriction fragment length polymorphism polymerase chain reaction (RFLP-PCR). RESULTS: Genotypes CC, CT and TT of PTPN22 polymorphism presented frequencies of 67.9, 30.0 and 2.1% in the women with endometriosis (P = 0.008); 76.2, 19.0 and 4.8% in women with minimal/mild endometriosis (P = 0.173); 61.0, 39.0 and 0.0% in women with moderate/severe endometriosis (P < or = 0.001) and 82.8, 16.1 and 1.1% in control group. Allele C and T were present in 82.9 and 17.1%; 85.7 and 14.3%; 80.5 and 19.5%; and 90.8 and 9.2% respectively, in women with endometriosis (P = 0.004), women with minimal/mild endometriosis (P = 0.148), women with moderate/severe endometriosis (P = 0.002) and control group. CONCLUSION: The data suggest that in Brazilian women polymorphism PTPN22 (C1858T) may be an important genetic predisposing factor for endometriosis, especially, in advanced disease.

Gynecol Obstet Invest. 2009 Nov 25;69(2):93-100. [Epub ahead of print]

Expression of Cyclooxygenase-2 in Eutopic Endometrium and Ovarian Endometriotic Tissue in Women with Severe Endometriosis.

Cho S, Park SH, Choi YS, Seo SK, Kim HY, Park KH, Cho DJ, Lee BS.

Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

Background/Aims: The purpose of this study is to evaluate the level and pattern of cyclooxygenase-2 (Cox-2) expression in endometriosis and to investigate the correlation between the expression of Cox-2 and several clinicosurgical parameters. Methods: Twenty-six patients with endometriosis and 21 patients with other benign gynecological conditions were enrolled. The eutopic endometrium was sampled by pipelle, and fragments of ovarian endometrioma and non-endometriotic ovarian cysts were sampled during surgery. Total RNA isolation and semiquantitative reverse transcriptase polymerase chain reaction was performed. Results: The expression of Cox-2 mRNA (mean +/- SEM) in eutopic endometrium and ovarian endometriotic tissue significantly increased in patients with endometriosis compared with the controls. The expression of Cox-2 increased significantly in the proliferative phase in eutopic endometrium and in the secretory phase in ovarian endometriotic tissue of patients with endometriosis compared with the controls. Cox-2 mRNA expression in the endometrium and ovarian lesions significantly correlated with serum CA-125 and the diameter of the endometrioma. Conclusions: Cox-2 expression increased in the eutopic endometrium and ovarian endometriotic tissue of the patients with endometriosis. These findings indicate that Cox-2 may be involved in the pathogenesis and progression of endometriosis. Copyright © 2009 S. Karger AG, Basel.

Endocrinology. 2010 Mar;151(3):1341-55. Epub 2010 Jan 12.

The protein kinase a pathway-regulated transcriptome of endometrial stromal fibroblasts reveals compromised differentiation and persistent proliferative potential in endometriosis.

Aghajanova L, Horcajadas JA, Weeks JL, Esteban FJ, Nezhat CN, Conti M, Giudice LC.

M.Sc., Professor and Chair, Department of Obstetrics, Gynecology, and Reproductive Sciences, The Robert B. Jaffe, MD, Endowed Professor in the Reproductive Sciences, University of California, San Francisco, 505 Parnassus Avenue, M1496, Box 0132, San Francisco, California 94143-0132. giudice@obgyn.ucsf.edu.

Intrinsic abnormalities in transplanted eutopic endometrium are believed to contribute to the pathogenesis of pelvic endometriosis. Herein we investigated transcriptomic differences in human endometrial stromal fibroblasts (hESFs) from women with (hESF(endo)) vs. without (hESF(nonendo)) endometriosis, in response to activation of the protein kinase A (PKA) pathway with 8-bromoadenosine-cAMP (8-Br-cAMP). hESF(nonendo) (n = 4) and hESF(endo) (n = 4) were isolated from eutopic endometrium and treated +/- 0.5 mm 8-Br-cAMP for 96 h. Purified total RNA was subjected to microarray analysis using the whole-genome Gene 1.0 ST Affymetrix platform. A total of 691 genes were regulated in cAMP-treated hESF(nonendo) vs. 158 genes in hESF(endo), suggesting a blunted response to cAMP/PKA pathway activation in women with disease. Real-time PCR and ELISA validated the decreased expression of decidualization markers in hESF(endo) compared with hESF(nonendo). In the absence of disease, 8-Br-cAMP down-regulated progression through the cell cycle via a decrease in cyclin D1, cyclin-dependent kinase 6, and cell division cycle 2 and an increase in cyclin-dependent kinase inhibitor 1A. However, cell cycle components in hESF(endo) were not responsive to 8-Br-cAMP, resulting in persistence of a proliferative phenotype. hESF(endo) treated with 8-Br-cAMP exhibited altered expression of immune response, extracellular matrix, cytoskeleton, and apoptosis genes. Changes in phosphodiesterase expression and activity were not different among experimental groups. These data support that eutopic hESF(endo) with increased proliferative potential can seed the pelvic cavity via retrograde menstruation and promote establishment, survival, and proliferation of endometriosis lesions, independent of hydrolysis of cAMP and likely due to an inherent abnormality in the PKA pathway.

Obstet Gynecol Int. 2009;2009:465180. Epub 2009 Dec 29.

Pneumothorax and pneumomediastinum in pregnancy: a case report.

Sathiyathasan S, Jeyanthan K, Furtado G, Hamid R.

Mayday University Hospital, Croydon, Surrey CR77YE, UK.

Case Report. A 37 years old patient at 40 weeks gestation presented with acute severe hypoxia with a seizure followed by fetal bradycardia. Caesarean section was performed under GA and she was intubated and ventilated. History revealed longstanding right pleural endometriosis with multiple pneumothoraces and hydrothoraces. A CT chest showed extensive bilateral pnenumothoraces. Her clinical condition improved with a left-sided chest drain. Discussion. Severe hypoxia and seizures in a patient with previous history of pnenumothorax are highly suggestive of tension pneumothorax. Radiological investigations are vital for diagnosis. The traditional treatment approach to recurrent pneumothorax has been thorocotomy with bleb or bulla resection and pleurodeisis. The advantages of thorocoscopic surgical treatment over thorocotomy are decreased time of exposure to anaesthetic drugs, rapid lung expansion, decreased post operative pain, and a potentially shorter post operative recovery. In any future pregnancy due to the high risk of recurrence of pneumothorax Contemporary obstetric management should determine the method of delivery and continuous lumbar/epidural anesthesia should be used if at all feasible. Preconceptual counseling about this risk is vital, and women must be advised about potential serious adverse outcomes.

J Zoo Wildl Med. 2009 Dec;40(4):791-5.

Intrapartum uterine rupture with coincidental uterine adenomyosis in an African wild dog (Lycaon pictus).

Newell-Fugate A, Lane E.

Department of Production Animal Studies, Faculty of Veterinary Science, Onderstepoort 0110, South Africa. newellf1@uiuc.edu

A 7-yr-old African wild dog (Lycaon pictus) multiparous bitch experienced severe dystocia and death one day after the onset of parturition. Necropsy revealed three placental attachments in the right uterine horn and one in the left. A full-thickness rupture of the right horn at the middle placental attachment and an autolysed fetus free in the abdomen were present. Death was attributed to hypovolemic and endotoxemic shock after uterine rupture. Myometrium adjacent to the rupture and in the left uterine horn was subdivided into irregular pseudolobules by fibrous connective tissue tracts containing small endometrial glandular acini suggestive of adenomyosis, which may have facilitated uterine rupture. This is the first reported case of dystocia-induced uterine rupture and of adenomyosis in a wild dog.

Hematol Oncol Stem Cell Ther. 2009;2(1):289-93.

Polymorphic (CAG)n repeats in the androgen receptor gene: a risk marker for endometriosis and uterine leiomyomas.

Shaik NA, Govindan S, Kodati V, Rao KP, Hasan Q.

Department of Genetics, Vasavi Medical and Research Centre, Khairtabad, Hyderabad 500 004, Andhra Pradesh, India.

BACKGROUND: Endometriosis and uterine leiomyomas are leading hormone responsive, benign uterine disorders responsible for high morbidity in women of reproductive age group. A polymorphic (CAG)n repeat length located in exon 1 of the androgen receptor (AR) gene has been proposed as a risk marker for both endometriosis and leiomyomas in some ethnic groups. The present study was carried out to assess the frequency of AR (CAG)n repeat polymorphism as a risk marker for endometriosis and uterine leiomyomas in Asian Indian women. METHODS: DNA was isolated from peripheral blood samples of 331 subjects, which include 90 endometriosis cases, 140 cases of leiomyomas and 101 healthy age- and sex-matched controls. PCR was carried out to amplify exon 1 of the AR gene. All the PCR amplicons were analysed initially on 2% agarose gel electrophoresis, followed by bidirectional sequencing to calculate the number CAG repeats in individuals. RESULTS: The CAG repeat ranges detected in endometriosis cases were 4-33 (Mode-19) and in leiomyomas cases 5-34 (Mode-20), whereas in controls it was 5-34 (Mode-22). A distinct variation was observed in the three groups at 14, 18, 19, 20 and 22 (CAG)n repeats, which were statistically analyzed using chi-square and odds ratio tests. 19 CAG repeats were found to be higher in endometriosis cases (19.09%) when compared with controls (9.04%), while 20 CAG repeats were higher in leiomyomas cases (14.02%) compared to controls (6.14%). A statistically significant (P < 0.05) association was observed in 19 and 20 CAG repeats in endometriosis and leiomyomas, respectively. CONCLUSION: This is the first report from an Asian Indian population proposing that 19 and 20 CAG repeats of the AR gene are associated with endometriosis and leiomyoma and can be regarded as high-risk markers.

J Med Case Reports. 2009 Nov 18;3:135.

Endometriosis in a postmenopausal woman without previous hormonal therapy: a case report.

Manero MG, Royo P, Olartecoechea B, Alcázar JL.

Department of Obstetrics and Gynecology, Clínica Universitaria de Navarra, Avenida Pío XII, 36, 31008 Pamplona, Spain.

INTRODUCTION: The prevalence of pelvic endometriosis is high, affecting approximately 6% to 10% of women of reproductive age. Although endometriosis has been associated with the occurrence of menstrual cycles, it can affect between 2% to 5% of postmenopausal women. CASE PRESENTATION: We present a case of ovarian endometriosis in a 62-year-old Spanish Caucasian woman with no previous use of hormonal therapy and no history of endometriosis or infertility. CONCLUSION: ALTHOUGH THE REPORTED SITUATION IS RARE, IT IS IMPORTANT TO BE AWARE OF ENDOMETRIOSIS AFTER THE MENOPAUSE: post-menopausal endometriosis confers a risk of recurrence and malignant transformation.

J Med Case Reports. 2009 Dec 10;3:9326.

Menstruating from the umbilicus as a rare case of primary umbilical endometriosis: a case report.

Bagade PV, Guirguis MM.

Department of Obstetrics and Gynaecology, Wansbeck General Hospital, Woodhorn Lane, Ashington NE63 9JJ, Northumberland, UK.

INTRODUCTION: Endometriosis is a common gynecological condition and presents mainly with involvement of the pelvic organs. Extrapelvic presentations in almost all parts of the body have been reported in the literature. However, umbilical endometriosis that is spontaneous or secondary to surgery is uncommon and accounts for only 0.5% to 1% of all endometriosis cases. CASE PRESENTATION: A 35-year-old Caucasian woman presented with umbilical bleeding during periods of menstruation. Her umbilicus had a small nodule with bloody discharge. An ultrasound was performed and a diagnosis of possible umbilical endometriosis was thus made. The nodule shrunk in response to gonadotropin-releasing hormone analogues but continued to persist. The patient underwent a wide local excision of the nodule with a corresponding umbilical reconstruction. Histopathology confirmed the diagnosis of umbilical endometriosis. The patient was asymptomatic at follow-up, but nevertheless warned of the risk of recurrence. CONCLUSIONS: Pelvic endometriosis is a common condition, but the diagnosis of primary umbilical endometriosis is difficult and differentials should be considered. This case strongly suggests that a differential diagnosis of endometriosis should be considered when an umbilical swelling presents in a woman of reproductive age.

Oncogene. 2010 Jan 11. [Epub ahead of print]

Identification of an ovarian clear cell carcinoma gene signature that reflects inherent disease biology and the carcinogenic processes.

Yamaguchi K, Mandai M, Oura T, Matsumura N, Hamanishi J, Baba T, Matsui S, Murphy SK, Konishi I.

[1] Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan [2] Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.

Ovarian clear cell carcinoma (OCCC) shows unique clinical features including an association with endometriosis and poor prognosis. We previously reported that the contents of endometriotic cysts, especially high concentrations of free iron, are a possible cause of OCCC carcinogenesis through iron-induced persistent oxidative stress. In this study, we conducted gene expression microarray analysis using 38 ovarian cancer cell lines and identified genes commonly expressed in both OCCC cell lines and clinical samples, which comprise an OCCC gene signature. The OCCC signature reproducibly predicts OCCC specimens in other microarray data sets, suggesting that this gene profile reflects the inherent biological characteristics of OCCC. The OCCC signature contains known markers of OCCC, such as hepatocyte nuclear factor-1beta (HNF-1beta) and versican (VCAN), and other genes that reflect oxidative stress. Expression of OCCC signature genes was induced by treatment of immortalized ovarian surface epithelial cells with the contents of endometriotic cysts, indicating that the OCCC signature is largely dependent on the tumor microenvironment. Induction of OCCC signature genes is at least in part epigenetically regulated, as we found hypomethylation of HNF-1beta and VCAN in OCCC cell lines. This genome-wide study indicates that the tumor microenvironment induces specific gene expression profiles that contribute to the development of distinct cancer subtypes.Oncogene advance online publication, 11 January 2010; doi:10.1038/onc.2009.470.

Am J Surg Pathol. 2010 Feb;34(2):137-46.

PAX2 distinguishes benign mesonephric and mullerian glandular lesions of the cervix from endocervical adenocarcinoma, including minimal deviation adenocarcinoma.

Rabban JT, McAlhany S, Lerwill MF, Grenert JP, Zaloudek CJ.

Department of Pathology, University of California San Francisco, 505 Parnassus Avenue, M-551, San Francisco, CA 94143, USA. joseph.rabban@ucsf.edu

Mesonephric remnants of the cervix are vestiges of the embryonic mesonephric system which typically regresses during female development. Uncommonly, hyperplasia of the mesonephric remnants may occur. The differential diagnosis of exuberant mesonephric hyperplasia includes minimal deviation adenocarcinoma of the cervix, a tumor with deceptively bland morphology for which no reliable diagnostic biomarkers currently exist. PAX2 encodes a transcription factor necessary in the development of the Wolffian duct system, and the protein is expressed in several tumors of mesonephric origin, including renal cell carcinoma, Wilm tumor, and nephrogenic adenoma. We hypothesized that PAX2 may also be expressed in mesonephric lesions of the cervix and may distinguish mesonephric hyperplasia from minimal deviation adenocarcinoma of the cervix. We demonstrated that PAX2 was strongly and diffusely expressed in mesonephric remnants (6 of 6) and in mesonephric hyperplasia (18 of 18); however, no expression was noted in mesonephric adenocarcinoma (0 of 1). PAX2 was expressed in normal endocervical glands (including tunnel clusters and Nabothian cysts) (86 of 86), lobular endocervical glandular hyperplasia (5 of 5), tubal/tuboendometrioid metaplasia (8 of 8), and cervical endometriosis (13 of 14). In contrast, only 2 cases of endocervical adenocarcinoma were positive for PAX2 [invasive adenocarcinoma of the minimal deviation type (0 of 5), usual type (1 of 22), and endometrioid type (1 of 1)]. Adjacent adenocarcinoma in situ, as well as cases of pure adenocarcinoma in situ (0 of 6), were also PAX2 negative. PAX2 expression in the 2 positive endocervical adenocarcinomas was patchy and weak. Most (11 of 15) stage II endometrial endometrioid adenocarcinomas lacked PAX2 expression but 1 of 10 grade 1 tumors and 3 of 5 grade 2 tumors did express PAX2. These results suggest that PAX2 immunoreactivity may be useful to (1) distinguish mesonephric hyperplasia from minimal deviation adenocarcinoma, (2) to distinguish lobular endocervical glandular hyperplasia from minimal deviation adenocarcinoma, and (3) to distinguish endocervical tubal metaplasia or cervical endometriosis from endocervical adenocarcinoma in situ. Overall, a strong, diffuse nuclear PAX2 expression pattern in a cervical glandular proliferation predicts a benign diagnosis (positive predictive value 90%, negative predictive value 98%; P<0.001); however, PAX2 should not be interpreted in isolation from the architectural and cytologic features of the lesion as it may be expressed in some stage II endometrial adenocarcinomas involving the cervix.

Hum Pathol. 2010 Jan 6. [Epub ahead of print]

Clear cell adenocarcinoma of the bladder and urethra: cases diffusely mimicking nephrogenic adenoma.

Herawi M, Drew PA, Pan CC, Epstein JI.

Department of Pathology, Harper University Hospital, Wayne State University School of Medicine, and Karmanos Cancer Institute, Detroit, MI 48201, USA.

Although clear cell adenocarcinoma have been described focally mimicking nephrogenic adenoma, we have identified a subset of clear cell adenocarcinoma that diffusely resembles nephrogenic adenoma (nephrogenic adenoma-like clear cell adenocarcinoma). Twelve classic clear cell adenocarcinomas of the bladder and urethra and 7 nephrogenic adenoma-like clear cell adenocarcinomas were compared to 10 nephrogenic adenomas. Classic clear cell adenocarcinomas and nephrogenic adenoma-like clear cell adenocarcinomas comprised 4 men and 15 women. The following features were seen in classic clear cell adenocarcinomas: nephrogenic adenoma-like clear cell adenocarcinomas: predominantly solid pattern (7/12:0/7), marked nuclear pleomorphism (7/12:1/7), prominent nucleoli (5/12:1/7), clear cytoplasm in 50% or greater of tumor (7/12:0/7), and necrosis (8/12:3/7), although the necrosis in nephrogenic adenoma-like clear cell adenocarcinomas was often focal and intraluminal. Both patterns of clear cell adenocarcinomas showed prominent hobnail features, although more pronounced in nephrogenic adenoma-like clear cell adenocarcinomas. Muscularis propria invasion was seen in 5 of 9 classic clear cell adenocarcinomas and 6 of 6 nephrogenic adenoma-like clear cell adenocarcinomas, where evaluable. Classic clear cell adenocarcinoma was associated with urothelial carcinoma (n = 2) and endometriosis (n = 1). The Ki-67 rate in clear cell adenocarcinomas ranged from 10% to 80% compared with 0% to 5% in nephrogenic adenoma. The following antibodies were not helpful in distinguishing nephrogenic adenoma-like clear cell adenocarcinoma from nephrogenic adenoma: CD10, estrogen receptor, p63, high-molecular-weight cytokeratin, and alpha-methylacyl coenzyme-A racemase. PAX2 expression was more frequent in nephrogenic adenoma (89%) compared to both patterns of clear cell adenocarcinoma (29%-32%). The key features discriminating between nephrogenic adenoma-like clear cell adenocarcinoma and nephrogenic adenoma include occasional clear cells, more prominent pleomorphism especially hyperchromatic enlarged nuclei, and extensive muscular invasion. Presence of mitoses and a high rate of Ki-67 expression in lesions resembling nephrogenic adenoma require clinical correlation, close follow-up, and repeat biopsy with more extensive sampling. Copyright © 2010. Published by Elsevier Inc.

Diagn Cytopathol. 2010 Jan 7. [Epub ahead of print]

Fine-needle aspiration cytology of scar endometriosis: Study of seven cases and literature review.

Medeiros FD, Cavalcante DI, Medeiros MA, Eleutério J Jr.

Faculty of Medicine, Maternal and Child Department, Federal University of Ceará (UFC), Brazil.

Endometriosis is defined as the presence of endometrial-like glands and stroma outside the uterine endometrial lining. Endometrial tissue has also been identified in numerous surgical or procedure scars, including cesarean section and laparoscopic trocar tract.A prospective study was conducted at Maternidade-Escola Assis Chateaubriand, Faculty of Medicine, Federal University of Ceara, Brazil in seven patients with abdominal wall mass pathologically proven as scar endometriosis from January 2004 to December 2008. All cases were submitted to fine-needle aspiration cytology (FNAC).Age ranged from 21 to 42 years old (mean: 30) with parity ranging from 0 to 3 (mean: 1.4). The preceding history of pelvic procedures was miomectomy (1 of 7), cesarean section (3 of 7), and diagnostic laparoscopy (3 of 7). The complaints occurred about 18 months after the surgical proceeding. The FNAC findings were endometrial-like epithelial cells (6 of 7) and stromal cells (6 of 7); decidualization occurred in 2 of 7 cases. Hemosiderin-laden macrophages were present in all cases. FNAC is a fast and accurate method to make the diagnosis before the surgery, avoiding errors in the approach of the abdominal wall endometriosis’ scars. Diagn. Cytopathol. 2010. (c) 2010 Wiley-Liss, Inc.

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