Hum Reprod. 2010 Aug;25(8):1949-58. Epub 2010 Jun 13.

Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.

Donnez J, Squifflet J.

Department of Gynecology, Université Catholique de Louvain, Cliniques Universitaires St Luc, 1200 Brussels, Belgium. jacques.donnez@uclouvain.be

BACKGROUND: The debate continues between advocates of the shaving technique and supporters of bowel resection in case of deep endometriosis with rectal muscularis involvement, despite little evidence for better improvement with bowel resection. METHODS: We analyzed complication, pregnancy and recurrence rates after deep endometriotic nodule excision by shaving surgery. This is a prospective analysis of 500 cases (<40 years old) of deep endometriotic nodules. RESULTS: Laparoscopic nodule resection was performed successfully in all cases. Major complications included: (i) rectal perforation in seven cases (1.4%); (ii) ureteral injury in four cases (0.8%); (iii) blood loss >300 ml in one case (0.2%); and (iv) urinary retention in four cases (0.8%). The median follow-up duration was 3.1 years (range 2-6 years). In our prospective series of 500 women, 388 wished to conceive. Of this number, 221 (57%) became pregnant naturally and 107 by means of IVF. In total, 328 women (84%) conceived. The recurrence rate was 8% among these 500 women, and it was significantly lower (P < 0.05) in women who became pregnant (3.6%) than in those who did not (15%). In women who failed to conceive, or were not interested in conceiving, severe pelvic pain recurred in 16-20% of patients. CONCLUSION: In young women, conservative surgery using the shaving technique preserves organs, nerves and the vascular blood supply, yielding a high pregnancy rate and low complication and recurrence rates. There is a need, however, for further strong and energetic debate to weigh up the benefits of shaving (debulking surgery) versus rectal resection (radical surgery).

Int J Gynaecol Obstet. 2010 Sep;110(3):203-207. Epub 2010 May 23.

Prevalence of newly diagnosed endometriosis in women attending the general practitioner.

Ferrero S, Arena E, Morando A, Remorgida V.

Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa, Italy; Cairosalute, Cairo Montenotte, Italy.

OBJECTIVE: To investigate the prevalence of newly diagnosed endometriosis in premenopausal women who requested a consultation with their general practitioner because of non-gynecological problems. METHOD: Participants in the study were invited to complete a questionnaire investigating the presence of pain symptoms and infertility. On the basis of the characteristics of these symptoms, some patients underwent gynecological examination and transvaginal ultrasound. Radiological examinations were performed when bowel or bladder endometriosis were suspected. RESULTS: A total of 1291 women without a previous diagnosis of endometriosis were included in the study. On the basis of the symptoms, 108 women were referred to a gynecologist. After gynecological examination and transvaginal ultrasound, endometriosis was suspected in 51 women (47.2%). The diagnosis of endometriosis was confirmed by radiological investigations and/or surgery in 46 patients; the diagnosis of endometriosis was presumed in 2 other women but it was not confirmed by radiological investigations and/or surgery. The prevalence of endometriosis diagnosed by magnetic resonance imaging and/or surgery was 3.6% (46/1291). CONCLUSION: The prevalence of newly diagnosed symptomatic endometriosis in this study was at least 3.6%. A simple evaluation of symptoms (pain and infertility) that can be performed by a general practitioner facilitates the diagnosis of endometriosis. Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Histopathology. 2010 May;56(6):740-9.

Cumulative alterations of p27-related cell-cycle regulators in the development of endometriosis-associated ovarian clear cell adenocarcinoma.

Yamamoto S, Tsuda H, Miyai K, Takano M, Tamai S, Matsubara O.

Department of Basic Pathology, National Defence Medical College, Tokorozawa, Saitama, Japan.

AIMS: To identify the key cell-cycle dysregulations in the development of endometriosis-associated ovarian clear cell adenocarcinoma (CCA). METHODS AND RESULTS: Expression of p27(Kip1)-interacting cell-cycle regulators, such as p27(Kip1) itself, Skp2, cyclin-dependent kinase subunit 1 (Cks1), cyclin A and cyclin E, and Ki67 labelling index (LI), were analysed by immunohistochemistry in 23 CCAs with 36 endometriotic or atypical endometriotic lesions adjacent to CCA from a cohort of 23 patients, and in 31 cases of solitary endometriosis. The cell-cycle regulators examined were overexpressed (Skp2, Cks1, cyclin A and cyclin E; P < 0.01, each) or down-regulated (p27(Kip1), P = 0.044) significantly more frequently in the CCAs than in the adjacent endometriosis. The frequency of Skp2 overexpression was significantly higher in atypical endometriosis than in endometriosis, and the frequency of Skp2 and cyclin A overexpression was significantly higher in CCA than in atypical endometriosis (P < 0.01, each). Mean Ki67 LI increased from endometriosis (8.4%) through atypical endometriosis (21.4%) to CCA (46.9%), with statistical significance between each component (P < 0.01, each). The frequency of cell-cycle regulator expression and mean Ki67 LIs were not significantly different between solitary endometriosis and endometriosis adjacent to CCA. CONCLUSIONS: Alteration of the p27(Kip1)-interacting cell-cycle regulators appeared strongly involved in the progression of endometriosis-associated ovarian clear cell carcinogenesis through increasing cell proliferative activity.

Arch Gynecol Obstet. 2010 Jun 12. [Epub ahead of print]

Etanercept causes regression of endometriotic implants in a rat model.

Yildirim G, Attar R, Ficicioglu C, Karateke A, Ozkan F, Yesildaglar N.

Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Yeditepe University Hospital, Devlet Yolu, Ankara Cad. No:102-104, Kozyatagi, 34752, Istanbul, Turkey, gaziyildirim@gmail.com.

OBJECTIVE: To determine the effects of etanercept (anti-TNF-alpha) on surgically induced endometriosis in a rat model. MATERIALS AND METHODS: This is a prospective, randomized, controlled, experimental study that was carried out at the Experimental Research Center of Yeditepe University (YUDETAM). Thirty female nonpregnant, nulligravid Wistar-Hannover albino rats were used. The summary of the technique: surgical induction of endometriosis, administration of estrogen for 2 weeks, and laparotomy; administration of etanercept for 2 weeks following the induction of endometriosis and laparotomy; administration of estrogen for 2 weeks and necropsy. The volume and histopathological scores of the endometriotic foci were evaluated. RESULTS: One-hundred twenty uterine horns were implanted in 30 rats. Endometriosis was completely formatted in 112 lesions (93.3%). No rats were lost. In the etanercept group, the lesions’ volumes were 83.9 +/- 13.1, 47.2 +/- 8.4, and 96.7 +/- 34.8 mm(3) at the end of the second week (pretreatment stage), at the end of the fourth week (post-treatment stage), and at the end of the sixth week, respectively (P = 0.007). Histopathologic scores were 2.3 +/- 0.2, 1.7 +/- 0.2, and 1.9 +/- 0.1, respectively (P = 0.08). The changes in the other groups were not statistically significant. CONCLUSIONS: Etanercept, a fusion protein consisting of human recombinant soluble TNF receptor-2, neutralizes TNF activity. Anti-TNF therapy could be a new non-hormonal therapeutic option for the treatment of endometriosis in humans.

PLoS One. 2010 Jun 8;5(6):e10969.

Species used for drug testing reveal different inhibition susceptibility for 17beta-hydroxysteroid dehydrogenase type 1.

Möller G, Husen B, Kowalik D, Hirvelä L, Plewczynski D, Rychlewski L, Messinger J, Thole H, Adamski J.

Helmholtz Zentrum München, Institute of Experimental Genetics, Genome Analysis Center, Neuherberg, Germany.

Steroid-related cancers can be treated by inhibitors of steroid metabolism. In searching for new inhibitors of human 17beta-hydroxysteroid dehydrogenase type 1 (17beta-HSD 1) for the treatment of breast cancer or endometriosis, novel substances based on 15-substituted estrone were validated. We checked the specificity for different 17beta-HSD types and species. Compounds were tested for specificity in vitro not only towards recombinant human 17beta-HSD types 1, 2, 4, 5 and 7 but also against 17beta-HSD 1 of several other species including marmoset, pig, mouse, and rat. The latter are used in the processes of pharmacophore screening. We present the quantification of inhibitor preferences between human and animal models. Profound differences in the susceptibility to inhibition of steroid conversion among all 17beta-HSDs analyzed were observed. Especially, the rodent 17beta-HSDs 1 were significantly less sensitive to inhibition compared to the human ortholog, while the most similar inhibition pattern to the human 17beta-HSD 1 was obtained with the marmoset enzyme. Molecular docking experiments predicted estrone as the most potent inhibitor. The best performing compound in enzymatic assays was also highly ranked by docking scoring for the human enzyme. However, species-specific prediction of inhibitor performance by molecular docking was not possible. We show that experiments with good candidate compounds would out-select them in the rodent model during preclinical optimization steps. Potentially active human-relevant drugs, therefore, would no longer be further developed. Activity and efficacy screens in heterologous species systems must be evaluated with caution.

Curr Opin Obstet Gynecol. 2010 Aug;22(4):320-5.

The outcomes of repeat surgery for recurrent symptomatic endometriosis.

Berlanda N, Vercellini P, Fedele L.

Luigi Mangiagalli Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda Ospedale Maggiore Policlinico, Universita di Milano, Via della Commenda, 12-20122 Milano, Italy. nicola.berlanda@policlinico.mi.it

PURPOSE OF REVIEW: To evaluate the efficacy of second-line surgery in the management of recurrent endometriosis. RECENT FINDINGS: Long-term probability of pain recurrence after repeat conservative surgery for recurrent endometriosis varies between 20 and 40%. The association of presacral neurectomy to the treatment of endometriosis might be effective in reducing midline pain; however, no studies have evaluated this procedure among patients with recurrent disease. The medium-term outcome of hysterectomy for endometriosis-associated pain is quite satisfactory; nevertheless, probability of pain persistence after hysterectomy is 15% and risk of pain worsening 3-5%, with a six times higher risk of further surgery in patients with ovarian preservation as compared to ovarian removal. The conception rate among women undergoing repetitive surgery for recurrent endometriosis associated with infertility is 26%, whereas the overall crude pregnancy rate after a primary procedure is 41%. SUMMARY: Repeat conservative surgery for pelvic pain associated with recurrent endometriosis has the same efficacy and limitations as primary surgery. Conversely, after repeat conservative surgery for infertility, the pregnancy rate is almost half the rate obtained after primary surgery. More data are needed to define the best therapeutic option in women with recurrent endometriosis, in terms of pain relief, pregnancy rate and patient compliance.

Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2010 May;35(5):409-18.

Effect of GnRH II and GnRH I on secretion of VEGF by eutopic and ectopic endometrial stromal cells of endometriosis patients.

Huang F, Liu Q, Wang H, Zou Y.

Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha 410011,China HFY6697@163.com.

Objective To determine the effect of GnRH I and GnRH II on the secretion of VEGF by eutopic and ectopic endometrial stromal cells cultured in vitro, and to provide theoretical basis for exploring new treatments for endometriosis (EMs).Methods Eutopic and ectopic endometrium stromal cells cultured in vitro were treated with different concentrations of GnRH II and a GnRH I(goserelin), and a control group was not treated by GnRH II and GnRH I. Enzyme linked immunosorbent assay (ELISA) was used to measure the content of vascular endothelial growth factor (VEGF) protein in the medium of the above 2 groups.Results (1)There was no difference in the VEGF protein secreted by eutopic and ectopic stromal cells in the medium after being cultured in vitro for 48 h (P>0.05).(2)10(-10), 10(-8), and 10(-6)mol/L GnRH II dose-dependently reduced VEGF protein secreted by endometrial stromal cells (P<0.05),and the inhibition effect was stronger than that of GnRH I (P<0.05).(3)The inhibition effect of GnRH II on VEGF in ectopic stromal cells was stronger than that of eutopic stromal cells (P<0.05).Conclusion (1)Ectopic stromal cells cultured in vitro can secrete VEGF,which has no difference from the eutopic stromal cells, and which may play an important role in the formation and development of EMs.(2)GnRH II can dose-dependently reduce VEGF protein secreted by ectopic and eutopic endometrial stromal cells cultured in vitro,and the inhibition effect is stronger than that of GnRH I, providing theoretical basis for exploring new treatments for EMs.

Reprod Biomed Online. 2010 Aug;21(2):179-185. Epub 2010 Apr 27.

Endometriosis-associated infertility: surgery and IVF, a comprehensive therapeutic approach.

Barri PN, Coroleu B, Tur R, Barri-Soldevila PN, Rodríguez I.

Service of Reproductive Medicine, Department of Obstetrics, Gynecology and Reproduction, Institut Universitari Dexeus, Gran Via Carles III 71-75, 08028 Barcelona, Spain.

Infertility is a common problem presented by patients with endometriosis. At present, whichever treatment is chosen, half of patients with advanced stages of the disease will remain infertile afterwards. This observational study looked at the reproductive outcome achieved after treating a group of 825 patients aged between 20 and 40years with endometriosis-associated infertility during the period 2001-2008. Of the 483 patients who had surgery as the primary option, 262 became pregnant (54.2%). Among the patients who did not become pregnant, 144 underwent 184 IVF cycles and 56 additional pregnancies were obtained (30.4% clinical pregnancy rate per retrieval). It is notable that, before any treatment, patients with endometriosis had a poorer ovarian reserve than the control group. The combined strategy of endoscopic surgery and subsequent IVF led to a total of 318 pregnancies, which represents a combined clinical pregnancy rate of 65.8%. This percentage is significantly higher than that obtained with surgery alone (P<0.0001), with 173 patients who were not operated on and who went to IVF as the primary option (P<0.0001) and with 169 patients who had no treatment and achieved 20 spontaneous pregnancies (P<0.0001). Copyright © 2010 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Reprod Biomed Online. 2010 Aug;21(2):259-265. Epub 2010 Apr 24.

Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence.

Vercellini P, Somigliana E, Viganò P, De Matteis S, Barbara G, Fedele L.

Department of Obstetrics and Gynaecology, University of Milan and Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy; Centre for Research in Obstetrics and Gynaecology (C.R.O.G.), Milan, Italy.

Prevention of the recurrence of post-operative endometriosis is crucial for future fertility. The incidence of disease relapse can be influenced by major demographic changes and by the use of long-term adjuvant medical treatment. Decrease in age at menarche, number of pregnancies and duration of breastfeeding and increase in age at first birth all lead to an increase in the overall number of ovulations and menstruations a woman has within a reproductive lifespan. These changes impact during the decade at highest risk for endometriosis, i.e. between 25 and 35 years of age, and may substantially expand the hiatus between first-line surgical treatment and conception attempt. Several lines of evidence suggest that ovulation inhibition reduces the risk of endometriosis recurrence. After pooling the results of a cohort and a randomized controlled trial on long-term post-operative oral contraceptive use, a recurrent endometrioma developed in 26/250 regular users (10%; 95% CI 7-15%) compared with 46/115 never users (40%; 95% CI 31-50%), with a common OR of 0.16 (95% CI 0.04-0.65). After first-line surgery for endometriosis, women should be invited to seek conception as soon as possible. Alternatively, oral contraceptive use until pregnancy is desired should be considered. Copyright © 2010 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

BMJ. 2010 Jun 10;340:c2661. doi: 10.1136/bmj.c2661.

Endometriosis.

Harvey J, Warwick I.

julesharvey@yahoo.co.uk

Fertil Steril. 2010 May 25. [Epub ahead of print]

Robotic versus standard laparoscopy for the treatment of endometriosis.

Nezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B, Nezhat C.

Center for Minimally Invasive and Robotic Surgery, Stanford University Medical Center, Palo Alto, California.

OBJECTIVE: To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis. DESIGN: A retrospective cohort controlled study. SETTING: Tertiary referral center. PATIENT(S): Seventy-eight reproductive aged women. INTERVENTION(S): Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009. MAIN OUTCOME MEASURE(S): Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications. RESULT(S): Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy. CONCLUSION(S): Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars. Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Fertil Steril. 2010 May 25. [Epub ahead of print]

Florid endometriosis in a postmenopausal woman.

Bailey AP, Schutt AK, Modesitt SC.

Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia.

OBJECTIVE: To report a case of florid endometriosis. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 53-year-old postmenopausal woman with a 10-cm retroperitoneal mass comprised of endometriosis causing hydroureteronephrosis and loss of ipsilateral kidney function. INTERVENTION(S): The patient underwent exploratory laparotomy with extensive lysis of adhesions, right nephrectomy, radical resection of the retroperitoneal mass including partial resection of the psoas muscle, dissection from the inferior vena cava, and resection of distal ileum, cecum, and appendix with a primary ileoascending colon reanastomosis. MAIN OUTCOME MEASURE(S): Postoperative symptom resolution. RESULT(S): The patient had widespread adhesive disease with a primary retroperitoneal endometriotic mass and a secondary mass involving the small bowel mesentery. Endometriomas were found in the right kidney and right distal ureter. Additional endometriotic implants were found at the right common iliac bifurcation, appendix, and in multiple mesenteric nodules. No residual ovarian tissue was identified, and preoperative FSH and estrogen (E) levels indicated no evidence of an ovarian remnant. CONCLUSION(S): Severe endometriosis caused ipsilateral renal failure despite postmenopausal levels of E and FSH, supporting the theory that endometriotic implants may have an autocrine function involving E biosynthesis or may respond to hormone production in adipose tissue. Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Int J Gynaecol Obstet. 2010 Sep;110(3):199-202.

Implication of the RAGE-EN-RAGE axis in endometriosis.

Sharma I, Dhawan V, Saha SC, Rashmi B, Dhaliwal LK.

Department of Experimental Medicine & Biotechnology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

OBJECTIVE: To investigate the involvement of the receptor gene for advanced glycation (RAGE), its ligand EN-RAGE, and COX-2 in endometriosis. METHODS: The mRNA and protein expression of the corresponding genes were determined from endometriotic cells from 28 study patients and healthy endometrial stromal cells from 20 controls by semiquantitative RT-PCR and Western blot analysis, respectively, using beta-actin as an invariant control. RESULTS: The expression of COX-2, RAGE, and EN-RAGE was significantly increased, as evidenced by the significantly greater mRNA and protein expression in the cells of the study patients (P<0.001). Previous treatment for endometriosis did not lessen mRNA and protein expression (P<0.001). CONCLUSION: Our findings strengthen the hypothesis of an underlying inflammation in the pathophysiology of endometriosis and suggest exploring anti-inflammatory therapies as adjunct treatment. Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

J Dermatol. 2010 Jun;37(6):545-9.

Cutaneous endometriosis in the umbilical region: the usefulness of CD10 in identifying the interstitium of ectopic endometriosis.

Fukuda H, Mukai H.

Department of Dermatology, Toho University Ohashi Medical Center, Meguro-ku, Tokyo, Japan. h-fukuda@med.toho-u.ac.jp

Endometriosis is a condition in which endometrium or endometrium-like tissue grows in areas other than the endometrium and is often found within the pelvis such as in the uterus or ovary, but occasionally develops ectopically in the skin. In this paper, we report a case of cutaneous endometriosis in the umbilical region found in a 37-year-old woman with no history of pregnancy. The lesion was a brown, firm and elastic nodule, 9 mm x 7 mm in size, and caused bleeding as well as pain which increased during menstruation. Histopathological findings revealed that there were small and large glandular cavity structures in the dermis and the edematous interstitium around it. On immunohistochemical staining for estrogen and progesterone receptors, the cellular nuclei of glandular cavity walls were mainly found to be positive for both, and cells in the edematous interstitium around the glandular cavity were positive for CD10. Consequently, we diagnosed this case as cutaneous endometriosis in the umbilical region. CD10 was initially described as a tumor-specific antigen found in acute lymphoblastic leukemia. Recently, the usefulness of CD10 in diagnosing endometriosis in addition to various types of lymphoma or blood cancer has been confirmed, and in our case it also proved to be as useful as estrogen receptor or progesterone receptor in the definitive diagnosis of endometriosis.

Surg Endosc. 2010 Jun 8. [Epub ahead of print]

Laparoscopic versus laparotomic radical en bloc hysterectomy and colorectal resection for endometriosis.

Daraï E, Ballester M, Chereau E, Coutant C, Rouzier R, Wafo E.

Department of Gynecology and Obstetrics, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, CancerEst, Université Pierre et Marie Curie, Paris 6, France, emile.darai@tnn.aphp.fr.

BACKGROUND: Radical en bloc hysterectomy and colorectal resection (REHCR) is the ultimate and radical surgery for extensive pelvic endometriosis. Our aims were to evaluate feasibility, quality of life, and urinary function after REHCR by laparoscopy compared with laparotomy. METHODS: Single-center, retrospective study of 29 endometriosis patients having undergone REHCR (16 by laparoscopy, 13 by laparotomy). Gynecologic and digestive symptoms, quality of life [Short-Form (SF)-36 health status], and urinary function [International Prostate Score Symptoms (IPSS) and Bristol Female Lower Urinary Tract Symptoms (BFLUTS)] were evaluated using validated questionnaires. RESULTS: Except for mean age, no difference in epidemiologic characteristics was found between groups. Mean follow-up was 14 months (range 1-78 months). Four of the 16 patients (25%) of the laparoscopic group required laparoconversion. Consumption of analgesic drugs was lower in the laparoscopic group, and diarrhea (P < 0.001) and lower back pain (P < 0.001) improved. Improvement in dysmenorrhea (P < 0.001), dyspareunia (P < 0.001), asthenia (P < 0.001), and quality of life was observed without difference between groups. Urinary function was not altered and did not differ between groups. CONCLUSION: Our data support the feasibility of REHCR by laparoscopy with less analgesic consumption. Efficacy in terms of symptoms and improvement in quality of life were similar between groups, suggesting that laparoscopy should be offered to patients requiring REHCR.

Folia Histochem Cytobiol. 2010 Jan 1;48(1):148-52.

Trichrome Mallory’s stain may indicate differential rates of RNA synthesis in eutopic and ectopic endometrium.

Wołuń-Cholewa M, Szymanowski K, Andrusiewicz M, Szczerba A, Warchoł JB.

Department of Cell Biology, K. Marcinkowski University of Medical Sciences, Poznań, Poland. doskon@amp.edu.pl

Mallory’s triple staining is a histochemical technique used mainly for analysing connective tissues and glands and other tissues. We have described the differences in the nuclear staining between eutopic and ectopic endometrium as well as endometrial hyperplasia and adenocarcinoma using the Mallory’s method. The ultrastructural differences between eutopic and ectopic endometrium have been detected. In normal and hyperplastic endometrium the presence of stromal cell nuclei with an increased affinity to aniline blue has been observed. The affinity has disappeared after digestion of tissues with RNase. In cases of endometriosis, independently of cell types, the nuclei have shown affinity to orange G. Similar effects in adenocarcinoma have been noted. The ultrastructural studies have shown that in normal endometrium the stroma contained cells with euchromatic and low electron density cell nuclei. In endometriosis heterochromatic cell nuclei present both in the stroma and within glands have been detected. The results indicate that the Mallory’s technique may be a useful tool for recognizing the differences between eutopic and ectopic endometrium. The affinity for aniline blue in normal and hyperplastic endometrium occurs most likely due to increased RNA synthesis. Based on Mallory’s staining a similarity between hyperplasia and unchanged endometrium in contrast to similar results of the staining obtained in cases of adenocarcinoma and endometriosis may be suggested.

JSLS. 2010 Jan-Mar;14(1):140-2.

Cecal endometriosis as a cause of ileocolic intussusception.

Indraccolo U, Trevisan P, Gasparin P, Barbieri F.

Operative Unit of Obstetrics and Gynecology, ULSS 17, Veneto, Italy. ugo.indraccolo@libero.it

Endometriosis is a disease that can affect various organs, has an unclear symptomatology, and in extreme cases, can result in intestinal obstruction. This particular case illustrates the synchronous localization of endometriosis, both genital and intestinal, resulting in ileo-colic and colonic intussusception. The relative diagnostic and therapeutic approach for such a rare occurrence is discussed.

JSLS. 2010 Jan-Mar;14(1):70-9.

The role of hand assist laparoscopic surgery (HALS) in pelvic surgery for nonmalignant disease.

Brotherton J, McCarus S, Jones KY, Redan J, Kim JC.

Celebration Women’s Center for Pelvic Health, Celebration, Florida, USA. jbrotherton@obgyn.humc.edu

OBJECTIVE: Hand assist laparoscopic surgery (HALS) is a surgical modality rarely used in benign gynecology. We analyzed nonmalignant pelvic disorders that utilized HALS to see whether there is any benefit over standard laparotomy. METHODS: A case control chart review identified patients who underwent HALS for a variety of benign gynecological conditions from 2004 through 2007. Cases were then compared with a control group of all the patients who underwent similar procedures for the same diagnosis via laparotomy (ELAP) in our center within the same time period. The groups were comparable with respect to age, BMI, and surgical indication. RESULTS: Twenty-nine patients were analyzed: 12 cases (HALS) and 17 controls (ELAP). Each group was broken up into 2 subsets: Group A, older patients who underwent surgery for pelvic organ prolapse or diverticulitis with adnexectomy and Group B, younger patients who underwent surgery for pelvic pain, endometriosis, or both. Hospital stay in Group B was statistically lower in the HALS cases vs. the ELAP controls, (2.9 vs. 5.4 days, P=0.04). All HALS and ELAP patients were then analyzed for overall trends. HALS cases had shorter hospitalization than ELAP controls had (3.3 vs 4.5 days, P=0.035). Estimated blood loss was also less overall in the HALS cases vs. the ELAP controls (175 vs 355.9 mL, P=0.021). There were 2 adverse outcomes reported in Group A of the HALS cases. These 2 patients experienced postoperative hernias though the hand-assist port-site incision. CONCLUSION: Compared with laparotomy, overall, HALS offers the advantage of decreased hospitalization and decreased intraoperative blood loss. Postoperative hernias through the HA port site may be a potential problem with this technique.

Eur J Gynaecol Oncol. 2010;31(2):211-3.

Primary adenocarcinoma of the rectovaginal septum arising in pregnancy in the absence of endometriosis.

Giordano G, Bersiga A, Marchetti G, Melpignano M.

Department of Pathology and Medicine of Laboratory, Section of Pathology, Parma University, Italy. giovanna.giordano@unipr.it

A case of primary adenocarcinoma of the rectovaginal septum (PARVS) is reported with clinical and pathological findings. A 37-year-old Caucasian woman with a history of sterility and small posterior leiomyoma, a few months after a cesarean section, was admitted because of vaginal spotting, abdominal pain and constipation. Her previous history did not reveal exposure to diethylstil bestrol (DES). Pelvic computed tomography showed a heterogeneous pelvic mass in the Douglas pouch, measuring 9 cm in diameter, located in the rectovaginal septum, involving the rectal and vaginal wall. Histological examination of neoplastic tissue revealed solid sheet structures, occasional tubular lumen, extensive necrotic areas and clear cells. The neoplastic elements showed immunoreactivity for Mullerian markers (cytokeratin 7, CA-125 and vimentin). Because, the present case of PARVS cannot be due to DES exposure, the clear appearance of the neoplastic elements could represent only one differentiation of Mullerian rests. Moreover, because no foci of endometriosis were identified in several sections of the neoplasm, uterine and cervical wall, and tissues nearby the neoplasm could represent a rare subtype of PARVS arising in the absence of endometriosis.

JBR-BTR. 2010 Mar-Apr;93(2):105.

Appendicular endometriosis mimicking appendicitis.

Claus F, Vanbeckevoort D, De Hertogh G, Vandecaveye V, Koninckx P.

Department of Radiology, University Hospitals Leuven, Leuven, Belgium.

JBR-BTR. 2010 Mar-Apr;93(2):56-61.

Cystic lesions of the female reproductive system: a review.

Dujardin M, Schiettecatte A, Verdries D, de Mey J.

Department of Radiology, UZ Brussel, Brussels, Belgium. martine.dujardin@gmail.com

In order to avoid unnecessary therapy or treatment delay, it is important for the radiologist to be aware of the wide range of differential diagnoses for cystic lesions of the female reproductive system. This paper gives an overview of radiological findings in the variety of physiologic and pathologic cysts which may be encountered in this field.

Epidemiology. 2010 Jul;21 Suppl 4:S71-6.

Nonparametric bayes shrinkage for assessing exposures to mixtures subject to limits of detection.

Herring AH.

Department of Biostatistics, UNC Gillings School of Global Public Health and Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7420, USA. aherring@bios.unc.edu

Assessing potential associations between exposures to complex mixtures and health outcomes may be complicated by a lack of knowledge of causal components of the mixture, highly correlated mixture components, potential synergistic effects of mixture components, and difficulties in measurement. We extend recently proposed nonparametric Bayes shrinkage priors for model selection to investigations of complex mixtures by developing a formal hierarchical modeling framework to allow different degrees of shrinkage for main effects and interactions and to handle truncation of exposures at a limit of detection. The methods are used to shed light on data from a study of endometriosis and exposure to environmental polychlorinated biphenyl congeners.

Acta Obstet Gynecol Scand. 2010 Jun 4. [Epub ahead of print]

Menstruation-related spontaneous pneumothorax and diaphragmatic endometriosis.

Härkki P, Jokinen JJ, Salo JA, Sihvo E.

Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.

Abstract

Abstract Menstruation-related spontaneous pneumothorax (MSP), also termed catamenial pneumothorax, is a syndrome of spontaneous pneumothorax during menstruation due to endometriotic lesions in the diaphragm and thoracic cavity. Previously MSP was considered rare, and to cause only 3-6% of all spontaneous pneumothoraces in otherwise healthy women. Current data suggest that the incidence is substantially higher and MSP might be the reason for spontaneous pneumothoraces in up to 25-33% of all cases in women of reproductive age. The typical characteristics are a high recurrence rate and diaphragmatic spread of endometriotic lesions. We report six patients who had been diagnosed to have diaphragmatic endometriosis and four of them had developed MSP. Optimal management requires flexible collaboration between thoracic surgeons and gynecologists. Although treatment is primarily surgical, long-lasting and successful management requires that amenorrhea is induced with hormonal therapy, either by continuous contraceptives, progestins, the levonorgestrel-releasing intrauterine device or GnRH-agonists.

Aust N Z J Obstet Gynaecol. 2010 Apr;50(2):179-83.

Adolescent endometriosis in the Waikato region of New Zealand–a comparative cohort study with a mean follow-up time of 2.6 years.

Roman JD.

Braemar Hospital, and Hamilton Women’s Laparoscopic Centre, 95 Clarence Street, Hamilton, New Zealand. jroman@xtra.co.nz

STUDY OBJECTIVE: To describe our experience with laparoscopic excision of endometriosis on an adolescent population and to compare it with a non-adolescent population treated during the same period. DESIGN: Comparative cohort study of patients with endometriosis treated consecutively between July 2003 and January 2009 with a follow-up between six months and six years. SETTING: Braemar Hospital, Hamilton, New Zealand. RESULTS: We treated 20 adolescents. Ninety-five per cent (19/20) of adolescents were using pain relief other than Paracetamol, in contrast to only 59% (84/143) of non-adolescents. Thirty per cent (6/20) of adolescents had a first-degree relative with endometriosis, in contrast to 8% (11/143) of non-adolescents. Endometriosis was found to be stage I in 40% (8/20) of patients, stage II in 45% (9/20) of patients, stage III in 5% (1/20) of patients and stage IV in 10% (2/20) of patients. The main type of endometriotic lesion in the adolescent was an atypical red vascular lesion, which was present in 60% (12/20) of adolescents; but it was present in only 20% (29/143) of non-adolescents. There were no intra-operative complications. Minor postoperative complications included one case of urinary tract infection and one case of port infection. The operative complications that developed when treating the non-adolescent group are presented for comparison. Pain scores recorded at follow-up revealed a significant reduction in dysmenorrhoea and pelvic pain and there was a positive effect on the quality of life of adolescents as measured by the EQ-5D questionnaire tool. CONCLUSION: Adolescents with endometriosis use significantly more pain relief than non-adolescents to control symptoms. They have a higher rate of a first degree relative with the disease and they present with more atypical endometriotic lesions when compared with an adult population with endometriosis. All the stages of disease are present in the adolescent, including stages III and IV. The laparoscopic excision of endometriosis has a positive effect on the relief of pain symptoms and on the improvement in quality of life in the adolescent.

Arq Gastroenterol. 2010 Mar;47(1):116-8.

Robotic rectosigmoidectomy – pioneer case report in Brazil. Current scene in colorectal robotic surgery.

Averbach M, Popoutchi P, Marques OW Jr, Abdalla RZ, Podgaec S, Abrão MS.

Hospital Sírio Libanês, Centro de Treinamento em Cirurgia Robótica, São Paulo, SP, Brasil. maverbach@uol.com.br

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. Robotic surgery is an attractive mode in performing minimally-invasive surgery once it has several advantages if compared to standard laparoscopic surgery. The aim of this paper is to report the first known case of colorectal resection surgery using the robotic assisted surgical device in Brazil. A 35-year-old woman with deep infiltrating endometriosis with rectal involvement was referred for colorectal resection using da Vinci surgical system. The authors also reviewed the most current series and discussed not only the safety and feasibility but also the real benefits of robotic colorectal surgery.

Hum Reprod. 2010 Aug;25(8):1863-8. Epub 2010 Jun 2.

Non-invasive diagnosis of endometriosis: the goal or own goal?

Somigliana E, Vercellini P, Vigano’ P, Benaglia L, Crosignani PG, Fedele L.

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

Laparoscopy is the gold standard for the diagnosis of endometriosis. Although some forms of the disease, such as ovarian endometriomas or deep infiltrating lesions, can now be reliably diagnosed using non-invasive instruments, adhesions and superficial implants cannot be identified without surgery. Identification of these latter forms of the disease has been the main rationale for claiming the necessity to identify non-invasive diagnostic tests to detect endometriosis. In this opinion paper, we analyse the pros and cons of the availability of this kind of test in the current context of our knowledge of the disease. In particular, we emphasize that this instrument may be of benefit provided that the test is not used as a screening test.

Acta Chir Belg. 2010 Mar-Apr;110(2):210-2.

Deeply infiltrating rectal endometriosis with lymph node involvement.

Rafailidis S, Symeonidis N, Ballas K, Psarras K, Pavlidis T, Patsiaoura K, Sakadamis A.

2nd Propedeutical Department of Surgery, Hippokration General Hospital, Medical School, Aristotles University of Thessaloniki, Greece. svrafail@otenet.gr

BACKGROUND: Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas. CASE: A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement. CONCLUSION: Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

Sao Paulo Med J. 2009 Nov;127(6):342-5.

Frequency of endometriotic lesions in peritoneum samples from asymptomatic fertile women and correlation with CA125 values.

Barbosa CP, de Souza AM, Bianco B, Christofolini D, Bach FA, de Lima GR.

Division of Pathological Gynecology, Department of Gynecology and Obstetrics, Faculdade de Medicina do ABC, Santo André, São Paulo. caiopb@uol.com.br

CONTEXT AND OBJECTIVE: Serological testing for CA125 has been widely used to detect endometriosis and to monitor its progression. However, controversy still exists regarding the usefulness of the plasma CA125 assay for diagnosing endometriosis. Furthermore, some authors have described superficial endometriosis as a cyclical and normal phenomenon in women’s lives, and have indicated that development and progression of this disease would only occur in some women as a result of immunological changes. This study aimed to determine the frequency of endometriosis and the correlation between serum CA125 levels and the presence of endometriotic lesions in the peritoneum of asymptomatic fertile patients. DESIGN AND SETTING: Cross-sectional study at the Family Planning outpatient clinic of Faculdade de Medicina do ABC. METHODS: Eighty asymptomatic fertile patients who underwent tubal sterilization surgery were studied. Blood and peritoneum samples were collected. CA125 levels were measured from blood samples, and peritoneum biopsies were studied using histopathological tests. RESULTS: Histopathological evaluation of the peritoneum revealed that 16.25% of the patients had minimal or mild endometriosis. There was no statistically significant difference in CA125 levels between patients with and without endometriosis. CONCLUSION: The presence of endometriotic lesions in the peritoneum of fertile patients supports the hypothesis that incidental findings of minimal or mild endometriosis may not be of clinical significance, and that the progression of the disease probably occurs as a result of immunological and genetic abnormalities. Serum CA125 levels did not show any diagnostic significance with regard to detecting the disease.

Exp Biol Med (Maywood). 2010 Jun;235(6):668-77.

Prostaglandin E2: the master of endometriosis?

Wu MH, Lu CW, Chuang PC, Tsai SJ.

Department of Obstetrics and Gynecology, National Cheng Kung University, Tainan 701, Taiwan, Republic of China.

Endometriosis is the primary cause of infertility in women, with a prevalence rate ranging from 5% to 10%. Women with endometriosis suffer from symptoms such as chronic pelvic pain, dysmenorrhea and dyspareunia, which significantly reduce the quality of life. Endometriosis is a polygenic disease with a complex, multifactorial etiology. The mechanism responsible for the initiation and development of this disease remains largely unknown. Prostaglandin E(2) (PGE(2)), a versatile eicosanoid that exerts numerous physiological and pathological functions, has been implicated to play critical roles in the development of endometriosis. A growing body of evidence demonstrates that PGE(2) regulates many pathophysiological processes including cell proliferation, antiapoptosis, immune suppression and angiogenesis during the development of endometriosis. This review focuses on recent advances in cellular and molecular mechanisms triggered by PGE(2) that contribute to the pathological processes of endometriosis.

Acta Physiol Hung. 2010 Jun;97(2):234-9.

Pelvic pain in endometriosis: painkillers or sport to alleviate symptoms?

Koppan A, Hamori J, Vranics I, Garai J, Kriszbacher I, Bodis J, Rebek-Nagy G, Koppan M.

Institute of Nursing and Clinical Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary. akoppan@gmail.com

To assess potential individual factors influencing quality of life and pain scores of patients suffering from histologically confirmed endometriosis. Study using a questionnaire among patients of reproductive age undergoing laparoscopy with a presumed diagnosis of endometriosis. Details of fertility, previous treatments and quality of life, sexual activity, as well as linear pain scores for several symptoms, were recorded. Details of intraoperative findings were also collected and only those data were used where endometriosis was intraoperatively and histologically proven. A questionnaire before surgery gathered information from women on the following groups of variables: age, marital status, education, reproductive and medical history including previous pregnancies and parity, knowledge of accompanying pelvic disorders, regular sport activity, as well as general quality of life estimates including self-image. Pelvic pain was scored using a visual analogue scale. Data were statistically evaluated. Eighty-one patients complaining about persistent pelvic pain were later intraoperatively and histologically proven to have endometriosis. Thirty-one of them (38.2%) reported regular sport as part of their daily life schedule while 50 of them (61.8%) performed no physical activity at all. Fourteen patients among regular exercisers and 33 patients among those without physical activity reported the effectiveness of painkillers for pelvic pain, corresponding to 45.1% and 66% of these subgroups, respectively (difference statistically significant, p<0.05). Based on our results, we can conclude, that taking painkillers might be less effective among endometriosis patients performing regular daily sport activities, and, thus it might impose them to an unnecessary burden of possible side-effects.

Am J Obstet Gynecol. 2010 Jun;202(6):e1-4.

Discussion: ‘Early menstrual characteristics and endometriosis’ by Treloar et al.

Jungheim ES, Allsworth JE, Jimenez PT, Schon SB, Doblado MA.

Instructor, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA.

Comment on:

AORN J. 2010 Jun;91(6):730-42; quiz 743-5.

Abdominal wall endometrioma: a case report and review of the literature.

Nissotakis C, Zouros E, Revelos K, Sakorafas GH.

Department of Surgery, 251 Hellenic Air Force Hospital, Athens, Greece.

Endometriosis is the presence of ectopic endometrial tissue that can respond to ovarian hormonal stimulation. Although it is uncommon, extrapelvic endometriosis can form a discrete mass known as an abdominal wall endometrioma. Endometriomas are thought to be caused by transfer of endometrial cells into a surgical wound, most often after a cesarean delivery. Endometriomas are diagnosed via ultrasound, computed tomography, magnetic resonance imaging, and ultrasound-guided fine needle aspiration. Treatment options can be medical, but surgical excision is the treatment of choice. Perioperative nursing care includes patient teaching, taking steps to prevent surgical site infection and inadvertent hypothermia, ensuring availability of supplies (eg, the graft for abdominal wall repair if needed), and postoperative pain management. Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Eur J Obstet Gynecol Reprod Biol. 2010 May 24. [Epub ahead of print]

Caesarean section greatly increases risk of scar endometriosis.

Nominato NS, Prates LF, Lauar I, Morais J, Maia L, Geber S.

Postgraduate Medical School of the Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

OBJECTIVE: To estimate the incidence of scar endometriosis after different surgical procedures. STUDY DESIGN: A retrospective study of 72 patients diagnosed with scar endometriosis between 1978 and 2003 was performed. Patient age, site of endometriosis, previous operations, time-gap between last surgery and onset of symptoms, nodule characteristics, and recurrence were evaluated. RESULTS: Age ranged from 16 to 48 years. Location varied according to the previous surgery: 46 caesarean section, one hysterectomy, one in abdominal surgery, 19 episiotomy, one was a relapse and two pelvic floor procedures, two women with no previous surgery. The incidence of scar endometriosis after caesarean section was significantly higher than after episiotomy (0.2 and 0.06%, respectively: p<0.00001) with a relative risk of 3.3. Pain was the most frequent symptom. The mean time between surgery and onset of symptoms was 3.7 years. CONCLUSION: Our findings confirm that scar endometriosis is a rare condition and indicate, probably for the first time, that caesarean section greatly increases the risk of developing scar endometriosis. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Arch Gynecol Obstet. 2010 May 27. [Epub ahead of print]

Dose-response effect of interleukin (IL)-1beta, tumour necrosis factor (TNF)-alpha, and interferon-gamma on the in vitro production of epithelial neutrophil activating peptide-78 (ENA-78), IL-8, and IL-6 by human endometrial stromal cells.

Bersinger NA, Günthert AR, McKinnon B, Johann S, Mueller MD.

Department of Obstetrics and Gynaecology, University of Berne, Berne, Switzerland, nick.bersinger@dkf.unibe.ch.

PURPOSE: The production of epithelial neutrophil activating peptide-78 (NA-78) and the interleukins IL-8 and IL-6 by endometrial stromal cells is stimulated by pro-inflammatory interleukin-1 (IL-1) and tumour necrosis factor-alpha (TNF-alpha). IL-8 is suggested to play a role in the pathogenesis of endometriosis, and in these women the peritoneal fluid concentrations of ENA-78 and IL-8 are increased. TNF-alpha has been tested together with interferon-gamma because of their cooperative stimulation of IL-6. The release of IL-8, however, is inhibited with increasing interferon levels. The aim of the study was the analysis of the production of ENA-78, IL-6 and IL-8 by cultured human endometrial stromal cells in the presence of varying concentrations of IL-1beta, TNF-alpha, and interferon-gamma. METHODS: Eutopic endometrial tissue was obtained from seven cycling, endometriosis-free women undergoing laparoscopy for reasons of infertility or pain. The release of ENA-78, IL-8 and IL-6 by the isolated and monolayer cultured stromal cell fraction in the presence of IL-1beta (0.08 to 50 ng/mL), TNF-alpha, and interferon-gamma (both 20 to 500 ng/mL) was determined. RESULTS: IL-1beta stimulated the production of IL-8, IL-6, and ENA-78 dose dependently from 0.08 to 2.0 ng/mL (ENA-78) or to 10 ng/mL (IL-8, IL-6); at 50 ng/mL a decrease in release was observed for IL-8 and IL-6. TNF-alpha stimulation yielded a plateau between 20 and 100 ng/mL. Interferon-gamma stimulated IL-6 and inhibited IL-8 production above 20 ng/mL. ENA-78 release was largely unaffected by interferon-gamma. CONCLUSIONS: IL-1beta and TNF-alpha stimulate stromal cytokine production cumulatively with different dose-response curves. The presence of interferon-gamma has opposite effects on IL-8 and IL-6. TNF-alpha and interferon-gamma should be investigated separately in future in vitro studies with endometrial cells and explants.

Hum Reprod.

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