Manejo conservador del endometrioma ovárico con escleroterapia usando etanol previo a fecundación in vitro

El endometrioma ovárico es un quiste con tejido endometrial ectópico que se asocia a disminución de la reserva ovárica, siendo su manejo en infertilidad controversial. Presentamos el caso de una mujer de 32 años con reserva ovárica disminuida y endometrioma mayor de 100 mm. Fue sometida a aspiración transvaginal ecoguiada y a escleroterapia con etanol, lográndose reducción del tamaño en 65% a los tres meses. Posteriormente se realizó fecundación in vitro (FIV), consiguiéndose embarazo. La exéresis del endometrioma es controversial, debido a que reduce la reserva ovárica. La escleroterapia demuestra conservarla, se asocia a una tasa baja de recurrencia y facilita la accesibilidad ovárica. La escleroterapia con etanol del endometrioma es una técnica ambulatoria, segura y eficaz que permite el embarazo en mujeres con infertilidad.

Ovarian endometrioma is a cyst with ectopic endometrial tissue associated with decreased ovarian reserve. Its management in infertility is controversial. We present the case of a 32-year-old woman with decreased ovarian reserve and endometrioma larger than 100 mm. She underwent ultrasound-guided transvaginal aspiration and subsequent sclerotherapy with ethanol, achieving a 65% reduction in size after three months. Subsequently, in vitro fertilization (IVF) was performed, and pregnancy was achieved. The excision of the endometrioma is controversial because it reduces the ovarian reserve. Sclerotherapy has been shown to preserve ovarian reserve, is associated with a low recurrence rate and facilitates ovarian accessibility. Ethanol sclerotherapy of endometrioma is a safe and effective outpatient technique that allows pregnancy in women with infertility.

Investigating the efficacy of ultrasound-guided ethanol retention technique for endometrioma sclerotherapy and its effect on pro-inflammatory cytokine levels: A single-arm clinical trial

Abstract Background Endometriosis is a chronic inflammatory disease affecting about 10% of women of reproductive age. Endometrioma is the most common presentation of endometriosis in ovaries. Objectives Herein, the authors study the effect of the ultrasound-guided ethanol retention technique for endometrioma sclerotherapy and its effect on the plasma levels of pro-inflammatory cytokines. Materials and methods Each endometrioma was aspirated and washed with 0.9% saline until clearance and then 2/3 of the cyst volume was filled with ethanol 98%. Patients were followed for 3 months. After that, changes in their cyst diameter, dyspareunia, dysmenorrhea, and antral follicular count were assessed. Also, the sera levels of Interleukin 1β (IL-β), IL-6, and IL-8 were assayed before and after the treatment. The primary sera levels were also compared with a control group. Results In the treatment and control groups, 23 and 25 individuals (respectively) with a matched mean age (p-value = 0.680) were enrolled in the study. Among the laboratory variables, IL-1β (p-value = 0.035), as well as AMH (p-value = 0.002), were lower, and IL-6 (p-value = 0.011) was higher in the endometriosis group compared to the controls. Following the treatment, dysmenorrhea, dyspareunia, and the mean diameter of all cysts were significantly (p-values < 0.001) decreased in the treatment group. Also, right (p-value = 0.022) and left (p-value = 0.002) ovaries' antral follicular counts were increased following the treatment. No significant change was found among any of the investigated laboratory levels (p-value > 0.05). Conclusion Ethanol retention method is proven to be safe and could improve the clinical status of patients with endometrioma. Although further studies are necessary.

Role of cystatin C levels as an inflammatory marker in predicting endometriosis

SUMMARY OBJECTIVE: Endometriosis is a common chronic inflammatory disease associated with infertility and pelvic pain. Diagnosis is based on the appearance of endometriotic lesions at the time of surgery. Our study aimed to determine whether cystatin C can be used as a predictor of endometriosis and to investigate its potential role in doing so. METHODS: The study included 45 patients with endometriosis between the ages of 18 and 40 years whose pathology results were compatible with endometriosis and were operated on, and a control group of 45 healthy women. These two groups were compared in terms of serum cystatin C levels, demographic-clinical characteristics, operation results, and other laboratory values. RESULTS: The cystatin C and hs-CRP levels of the endometriosis patients were found to be significantly higher than the control subjects (p<0.005). Whether the endometriosis disease could be detected for serum cystatin C levels was determined by the receiver operating characteristic analysis and the most appropriate positive cutoff value for cystatin C was found to be 5.14 ng/mL (86.7% sensitivity and 77.8% specificity). In the linear regression analysis, it was observed that the probability of endometriosis increased 2.5 times when cystatin C levels increased above the threshold value of 5.14 ng/mL (OR: 2.5; 95%CI 2.24-2.76). CONCLUSION: Our study shows that the serum cystatin C levels can be used as a guide for diagnosis in patients with advanced endometriosis. However, more research is needed to prove its reliability and accuracy in order to put it into practice.

Intususcepción apendicular por foco endometriósico: un caso clínico / Appendiceal intussusception caused by endometriosis: a clinical case

Resumen Objetivo: Reportar el caso de una paciente con intususcepción apendicular (IA), condición infrecuente, secundario a foco de endometriosis, patología que en los últimos años ha presentado un aumento en su incidencia. Material y Método: Historia clínica, imágenes preoperatorias e intraoperatorias obtenidas de la ficha clínica. Resultados: Mujer de 35 años con dolor abdominal crónico de 4 meses de evolución. Se realiza estudio colonoscópico evidenciando lesión de 15 x 8 mm en ostium apendicular intususceptada al lumen cecal, y enteroclisis por tomografía axial computarizada (TC) que confirma IA. Se realiza una resección ileocecal laparoscópica demostrando la invaginación del apéndice con biopsia que muestra un foco de endometrioma. Discusión: La IA es una condición infrecuente con una incidencia cercana al 0,01% en la población general. Las patologías benignas son la principal causa (77%), siendo la endometriosis la causa más frecuente. Conclusión: La IA por endometriosis es anecdótica, con sintomatología poco específica. Los estudios disponibles pueden orientar adecuadamente la presencia de IA, sin embargo, en algunas ocasiones puede confundirse con patologías neoplásicas, donde cobra importancia la cirugía para dilucidar la etiología.

Objective: To report the case of a patient with appendicular intussusception (AI), an infrequent condition secondary to a focus of endometriosis, a pathology that has increased incidence in recent years. Material and Method: Clinical case, history and images obtained from the clinical file and intraoperative records with the consent of the patient. Results: A 35-year-old woman with abdominal pain. Colonoscopy study showing a 15 × 8 mm lesion in the appendicular ostium intussuscepted to the cecal lumen, and a computerized tomography (CT) enteroclysis confirming AI. A laparoscopic ileocecal resection is performed, demonstrating invagination of the appendix secondary to an endometrioma focus. Discussion: AI is a rare condition, with an incidence close to 0.01% in the general population. Benign pathologies are the main cause (77%), endometriosis being the most frequent cause. Conclusion: AI due to endometriosis is anecdotal, with unspecific symptoms. The available studies can adequately guide the presence of AI, however, on some occasions it can be confused with neoplastic pathologies, where surgery is important to elucidate the etiology.

Ascitis secundaria a endometriosis / Ascites secondary to endometriosis

RESUMEN Introducción: La endometriosis es una enfermedad benigna, inflamatoria, dependiente de estrógenos, caracterizada por la existencia de tejido endometrial fuera de la cavidad uterina. Afecta del 10 % al 20 % de las mujeres en edad reproductiva. La ascitis es la acumulación patológica de líquido dentro de la cavidad peritoneal. La ocurrencia de ascitis secundaria a endometriosis se encuentra raramente y aparece más a menudo en mujeres nulíparas de piel negra. Objetivo: Presentar el caso de una paciente a quien se le practicó laparotomía exploradora electiva por ascitis secundaria a endometriosis. Caso clínico: Paciente femenina de 30 años de edad, color de piel negra, con antecedentes de infertilidad primaria. Atendida en consulta de ginecología por aumento de volumen y molestias abdominales de varios meses de evolución; se detectó ascitis y una masa anexial izquierda. Se realizó laparotomía y se constató ascitis hemorrágica, adherencias pélvicas y quiste de ovario izquierdo. Se realizó aspiración del líquido ascítico, anexectomía y biopsia de epiplón y ombligo. El diagnostico histológico informó endometriosis anexial de ombligo y epiplón. Se indicó tratamiento con danazol y evolucionó satisfactoriamente sin más ascitis. Conclusiones: La asociación ascitis-endometriosis es muy rara. Es una entidad infrecuente que afecta mayormente a mujeres nulíparas, en edad fértil y de color de la piel negra. Imita un tumor ginecológico y rara vez se reconoce antes de la exploración quirúrgica del abdomen, por lo que se hace necesario su estudio para lograr un diagnóstico y tratamiento oportuno.

ABSTRACT Introduction: Endometriosis is a benign, inflammatory, estrogen-dependent disease characterized by the existence of endometrial tissue outside the uterine cavity. It affects 10-20 % of women of reproductive age. Ascites is the pathological accumulation of fluid within the peritoneal cavity. The occurrence of ascites secondary to endometriosis is rarely found and appears more often in black nulliparous females. Objective: To present a patient who underwent elective exploratory laparotomy for ascites secondary to endometriosis. Clinical case: 30-year-old female patient, black skin color, with a history of primary infertility. Attended in Gynecology consultation for presenting increase in volume and abdominal discomfort of several months of evolution; detecting ascites and a left adnexal mass. Laparomoty was performed, finding hemorrhagic ascites, pelvic adhesions, and a left ovarian cyst. Ascites fluid aspiration, adnexectomy and biopsy of omentum, and umbilicus were performed. The histological diagnosis reported adnexal endometriosis, umbilicus and omentum. Treatment with danazol was indicated and she had a satisfactory evolution without further ascites. Conclusions: The ascites-endometriosis association is very rare. It is an infrequent entity that mainly affects nulliparous women, of childbearing age and of black skin color. It mimics a gynecologic malignancy and is rarely recognized prior to surgical exploration of the abdomen. Therefore, its study is necessary to achieve a timely diagnosis and treatment.

Endometriosis de la pared abdominal en relación con cicatriz de operación cesárea: serie de casos / Abdominal wall endometriosis in relation to cesarean section scar: number of cases

RESUMEN: La endometriosis (E), se define como presencia de glándulas endometriales y estroma fuera del útero. Ocasionalmente se presenta como masa sensible en la pared abdominal (PA), en relación con una cicatriz quirúrgica (EPA). Aunque el tratamiento es quirúrgico, existe poca información respecto de la morbilidad postoperatoria (MPO) y la recurrencia de la EPA. El objetivo de este estudio fue determinar MPO y recurrencia en pacientes resecadas quirúrgicamente por EPA. Serie de casos de pacientes con EPA, sometidos a cirugía de forma consecutiva, en Clínica RedSalud Mayor, entre 2011 y 2021. Las variables resultados MPO y recurrencia. Otras variables de interés fueron: tiempo quirúrgico, estancia hospitalaria y mortalidad. Las pacientes fueron seguidas de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión. Se intervinieron 14 pacientes, con una mediana de edad de 33 años. La medianas del tiempo quirúrgico y estancia hospitalaria; fueron 55 min y 2,5 días respectivamente. La MPO fue 14,2 % (2 casos). Con una mediana de seguimiento de 31 meses, no se verificó recurrencia. Aunque la EPA es poco común, estas lesiones deben sospecharse en mujeres en edad reproductiva con masa palpable en relación con una cicatriz de cirugía ginecológica u obstétrica. Los resultados obtenidos, en términos de MPO y recurrencia, fueron similares a series internacionales.

SUMMARY: Endometriosis (E) is defined as the presence of endometrial glands and endometrial stroma outside the uterus. Occasionally it presents as a sensitive mass in the abdominal wall (AW), in relation to a surgical scar (AWE). Although the treatment is surgical, there is scarce information regarding postoperative morbidity (POM) and recurrence of AWE. The aim of this study was to determine POM and recurrence in patients surgically resected by AWE. Case series of patients with AWE, consecutively submitted to surgery, at RedSalud Mayor Clinic, between 2011 and 2021. Outcome variables were POM and recurrence. Other variables of interest were surgical time, hospital stay and mortality. Patients were followed-up clinically. Descriptive statistics were used, applying central tendency and dispersion measures. 14 patients were intervened, with a median age of 33 years. Median of surgical time and hospital stay were 55 min and 2,5 days respectively. POM was 14.2 % (2 cases). With a median follow-up of 31 months no recurrence was verified. Although AWE is uncommon, these lesions should be suspected in women in fertile age with a palpable mass associated with a scar from gynecologic or obstetric surgery. The results obtained, in terms of POM and recurrence, were like international series.

Exclusión renal por endometriosis profunda ureteral: a propósito de un caso / Renal exclusion due to deep infiltrating ureteral endometriosis: a case report

INTRODUCCIÓN: La endometriosis ureteral es una afección rara que afecta al 0.01-1,7% de las mujeres con endometriosis. Hasta un 30% cursa de forma asintomática y un 11,5-14,7% pueden evolucionar con falla renal. La falta de diagnóstico de la enfermedad puede terminar en una uropatía obstructiva y falla renal irreversible. Se presenta el caso de una paciente con afectación grave de la función renal secundaria a endometriosis profunda con compromiso ureteral. CASO CLÍNICO: Mujer de 35 años con endometriosis que consultó por exacerbación de los síntomas. En su estudio destaca, en la resonancia magnética, el hallazgo de endometriosis pélvica profunda y compromiso endometriósico intrínseco del uréter distal derecho, provocando una acentuada hidroureteronefrosis. El cintigrama renal demuestra acentuado compromiso de la función renal derecha, con una función relativa del 7%. Se realizaron nefrectomía total derecha y resección de enfermedad pélvica profunda laparoscópica, sin incidentes. CONCLUSIONES: La endometriosis ureteral representa un desafío diagnóstico y terapéutico. El manejo multidisciplinario entre radiólogos, ginecólogos y urólogos, mediante el diseño de una estrategia quirúrgica individualizada, es imprescindible para definir el tratamiento óptimo de estas pacientes.

INTRODUCTION: Ureteral endometriosis is a rare entity that affects 0.01-1,7% of women with endometriosis. Up to 30% of the patients are asymptomatic and 11.5-14.7% will develop renal failure. Misdiagnosis can lead to obstructive uropathy and permanent renal failure. We present the case of a patient with severe compromise of renal function secondary to deep infiltrating endometriosis with ureteral involvement. CASE REPORT: A 35-year-old woman with endometriosis presented with exacerbation of symptoms. Magnetic resonance showed deep pelvic endometriosis and intrinsic endometriotic involvement of the right distal ureter, causing a marked hydroureteronephrosis. Renal scintigram showed a severe compromise of the right renal function, with a relative function of 7%. Through laparoscopy a total right nephrectomy and resection of deep infiltrating endometriosis was performed. The patient had a satisfactory recovery in the postoperative period. CONCLUSIONS: Ureteral endometriosis presents a diagnostic and therapeutical challenge. Joint multidisciplinary management between radiologists, gynecologists and urologists through the design of an individualized surgical strategy is essential to define the optimal treatment for these patients.

Laparoscopic cystectomy in treating women with endometrioma and pregnancy outcome – a case series

@#Introduction: The aim of this study was to determine the spontaneous pregnancy rate and safety of our surgical technique of performing laparoscopy cystectomy for endometrioma

Change in ovarian reserve after treatment of endometrioma / Монголын Анагаах Ухаан

Background@#Endometriosis is a condition in which cells in the endometrium, layer of tissue normally covers uterine cavity, which grows outside to ovaries and other pelvic organs [1-4]. That may happen chronic pelvic pain, adhesion and pelvic organs dysfunction which leads to infertility later life [1-4]. In worldwide, 19-45 aged women have endometriosis, which is counted for 176 million, from 44% women have ovarian endometrioma [5]. In our country, 56% women received laparoscopic surgery due to ovarian cysts, which is diagnosed endometrioma. In recent years, ovarian endometriosis treated by synthetic progestin, gonadotropin analogues, combined contraceptive pills, intra-uterine device containing with progestin, and non-steroid anti-inflammatory drugs and laparoscopic surgeries [6, 7]. Serum antimullerian hormone (AMH) is key marker to define ovarian reserve, which correlates ovarian number of antral follicle counts [6, 7].@*Material and Methods@#We studied 129 patients who has diagnosed with ovarian endometrioma, aged 20-46 years, using case-control study design. There are 4 groups with medication and surgeries. </br> Approval for the study was obtained from the review board and the ethics committee of MNUMS. All the recruited patients provided their informed written consents. @*Results@#When treatment groups were compared, level of AMH before synthetic progestin therapy was 3.48±0.9 and after it 3.41±1.0 (p-0.456), and that was before non-steroid anti-inflammatory drugs 3.68±0.8 and after it 3.11±0.8 ng/ml (p-0.212). Before laparoscopic surgeries for severe endometrioma, average level of AMH was 2.3±1.8ng/ml for synthetic progestin therapy group and it was 1.68±0.2ng/ml (p-0.007) after surgical peeling of endometrioma. For patients of 4th group who had not taking oral synthetic progestin before laparoscopic surgeries average level of AMH was 3.11±1.88 ng/ml before surgery and it became 2.21±0.28 ng/ml (p-0.005). Level of СА-125 marker was before medical therapy for group 1 was 37,9±5,25 IU/ml and after therapy - 20,6±2,03 IU/ml. For group 2 it was 69,9±9,79IU/ml and 35.1±6.76 IU/ml respectively. Average level for group 4 before surgical treatment it was 96.6±36.6 IU/ml, and after surgery became 25.71±2.96 IU/ml, and that for group 3 was before surgery 102±29.1 IU/ml and decreased after surgery to 29.2±4.15 IU/ml.</br> There are significant reduction of pain in patients who received synthetic progestin (p=0.001) groups. Serum AMH were 3.48±0.9 before treatment and 3.41±1.0 after treatment respectively (p=0.456). Prior treatment of laparoscopic surgery with progestin 3 months, it decreases abdominal lower pain (p=0.001) and dysmenorrhea (p=0.001). Serum AMH level were 3.11±1.8 before surgery and 2.21±0.2 after surgery,respectively, (p=0.005).@*Conclusion@#</br> 1. There were little decrease in level of antimullerian hormone and less risk for ovarian reserve when mild endometrioma was treated with synthetic progestin and non-steroid anti-inflammatory drugs in two groups. </br> When severe and middle degree of endometrioma was treated with laparoscopic surgery there were significant decrease of antimullerian hormone, but it was less in group that had synthetic progestin therapy before surgery and it was more effective that surgical therapy without preparation. </br> 2. Comparison of Serum level of СА-125, marker of ovarian tumor, was decreased less in group of non-steroid anti-inflammatory drugs, and was decreased more or it was more effective.

Protective effect of laparoscopic removal of water and suture hemostasis on ovarian function / 中国综合临床

Objective@#To investigate the protective effect of laparoscopic water separation and removal combined with suture hemostasis on ovarian reserve function after bilateral ovarian endometriotic cyst (OEC) stripping.@*Methods@#From January 2016 to January 2018, 60 patients with bilateral ovarian endometriosis cystectomy underwent laparoscopic surgery in the Department of Obstetrics and Gynecology, Jiading Hospital of traditional Chinese medicine.According to the random number table method, they were divided into study group (water separation and stripping combined suture hemostasis group) and the control group (direct stripping combined with electrocoagulation hemostasis group), 30 cases in each group.The changes of operation time, hemoglobin level before and after operation and the levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) and anti Mullerian hormone (AMH) were compared between the two groups.@*Results@#There was no significant difference in operation time (47.52 ±10.11) min, hemoglobin decrease (0.55 ±0.26) g/L, hospital stay (6.1 ±0.3) d, control group (48.01 ±10.24) min, hemoglobin decrease (0.56 ±0.25) g/L and hospitalization time (6.2 ±0.4) d before and after operation (t=0.056, 0.964, 0.863, all P>0.05). The levels of FSH, E2, LH and AMH in the study group before operation were (6.15 ±2.31) U/L, (152.41 ±41.40) nmol/L, (5.44 ±1.52) U/L and (2.21 ±0.13) μg/L, respectively.One month after operation, they were(6.21±2.24) U/L, (150.63±40.33) nmol/L, (5.13±1.58) U/L, (2.18±0.16) μg/L, respectively.Three months after operation, they were (6.52±2.41) U/L, (149.57±42.37) nmol/L, (5.30±1.45) U/L, (2.17± 0.15) μg/L, respectively.Six months after operation, they were (6.53±2.44) U/L, (151.36±41.54) nmol/L, (4.98±1.61) U/L, (2.20±0.08) μg/L, respectively.The levels of FSH, E2, LH and AMH in the control group before operation were (6.14±2.21) U/L, (153.31±40.39) nmol/L, (5.51±1.46) U/L, (2.23±0.13) μg/L, respectively.One month after operation, they were (8.11±2.44) U/L, (131.43±41.23) nmol/L, (5.92±1.64) U/L, (1.58±0.14) μg/L, respectively.Three months after operation, they were (8.42±2.35) U/L, (135.67±40.38) nmol/L, (6.12±1.51) U/L, (1.54±0.16) μg/L, respectively.Six months after operation, they were (9.17±2.64) U/L, (133.66±40.44) nmol/L, (6.28±1.74) U/L, (1.51±0.13) μg/L, respectively.There was no significant difference in the levels of FSH, E2, LH and AMH between the two groups (all P>0.05). There was significant difference between the preoperative FSH level and the postoperative 1, 3, 6 months in the control group (all P<0.05); there was significant difference between the preoperative E2 level and the postoperative 1 month in the control group (P<0.05); there was statistical significance between the preoperative AMH level and the postoperative 1, 3 months in the control group (all P<0.05). The levels of FSH, LH, E2 and AMH in the study group were significantly higher than those in the control group (all P<0.05).@*Conclusion@#Laparoscopic hydrodissection combined with suture hemostasis does not increase the operation time and the amount of bleeding, and does not affect the ovarian reserve function after operation.

Recurrent Endometriosis: Contemporary Challenges

@#<p>Background: The recurrence of endometriosis after fertility sparing surgery poses a challenge to clinicians. Presently, no treatment option is curative and available medication only changes the hormonal milieu to suppress or delay disease recurrence.<br />Objective: The aim of this review was to present current literature on recurrent endometriosis including dilemmas in definition, risk factors for recurrence and medical options for the prevention of recurrent endometriosis after surgery.<br />Methods: A review of literature was done using PubMed, EMBASE and HERDIN, with the following keywords: endometriosis, endometrioma, endometriosis-associated pelvic pain, recurrence of endometriosis. The authors identified reviews, trials and guidelines. The population was limited to reproductive-aged women suspected of having endometriosis.<br />Results and Discussion: The recurrence rate of endometriosis after conservative surgery ranges from 7.1-56%. The incidence varies according to the criteria used to define recurrence: relapse of pain, physical examination findings, presence of endometrioma on imaging studies, increase in serum CA-125, and intraoperative findings during repeat surgery. The risk factors for disease recurrence include: young age, high body mass index, large endometriomas at diagnosis, severe pre-operative pain, intraoperative findings of extensive adhesions, and positive surgical margins. The identification of patients at high risk for recurrence will enable clinicians to give appropriate post-surgical therapy to prevent recurrence. The choice of pharmacologic agent after conservative surgery includes: combined hormonal contraceptive pills, progestogens, and GnRH agonist. Although no major difference was seen in the effect of available drugs used to relieve endometriosis- associated pain and prevent disease recurrence, differences exist in safety, tolerability and costs.<br />Conclusion: There is an urgent need to standardize the definition of recurrent endometriosis. Patients should be counselled on the need for long term medical management to delay disease recurrence. A step-wise approach and algorithm in the medical management for the prevention of endometriosis recurrence are proposed.</p>

Carcinoma intraepitelial tubárico seroso como hallazgo posquirúrgico de endometriosis y útero miomatoso. Reporte de un caso / Seuous tubal intraepithelial carcinoma as a post-surgical finding of endometriosis and myomatous uterus. A case report

Resumen: ANTECEDENTES: El carcinoma intraepitelial tubárico seroso es una lesión precursora del carcinoma invasivo de las trompas de Falopio que con frecuencia se diagnostica en el contexto de una salpingooforectomía bilateral profiláctica por patología ginecológica benigna. CASO CLÍNICO: Paciente nulípara, de 51 años, con cuadro clínico de dolor abdominal y elevación de marcadores tumorales CA-125 y CA-19.9, diagnosticada con útero polimiomatoso y sospecha de endometrioma en el ovario derecho. Después de la histerectomía subtotal con anexectomía bilateral, el estudio histológico de la pieza tubárica extirpada reportó focos microscópicos de carcinoma intraepitelial tubárico seroso, sin signos de invasión estromal. Por los hallazgos se solicitaron pruebas de imagen mamarias y el estudio genético de mutación BRCA 1 y 2. CONCLUSIÓN: La salpingooforectomía bilateral profiláctica es un procedimiento que reduce el riesgo de carcinomas peritoneales, tubáricos y serosos de ovario. Las pacientes con carcinoma intraepitelial tubárico seroso deben tener seguimiento basado en controles ecográficos, pruebas de imagen mamarias, determinación de marcadores tumorales y estudios genéticos, debido a su asociación con mutaciones en los genes BRCA 1 y 2.

Abstract: BACKGROUND: Serous tubal intraepithelial carcinoma (STIC) is a precursor lesion of invasive high-grade tubal and serous carcinoma of the ovary, frequently diagnosed in the context of prophylactic bilateral salpingoophorectomy for benign gynecological pathology. The objective of this work is to carry out a literature review on the most relevant aspects of the follow-up of this injury, after its incidental diagnosis in gynecological surgery. CLINICAL CASE: A 51-year-old nulliparous patient who, in the context of a clinical situation of abdominal pain with elevation of tumor markers CA125 and CA19.9, was diagnosed with polymomatous uterus and suspected endometrioma in the right ovary. After a subtotal hysterectomy with bilateral adnexectomy, the histological study of the excised tubal specimen found microscopic foci of STIC without signs of stromal invasion. Given this finding, breast imaging tests and a genetic study of the BRCA 1/2 mutation was requested. CONCLUSION: Prophylactic bilateral salpingoophorectomy in gynecological surgery is a procedure that can reduce the risk of developing peritoneal, tubal, and serous ovarian carcinomas. Patients diagnosed with STIC should be subsidiaries of follow-up based on ultrasound controls, mammary imaging tests, tumor markers, and genetic studies, due to their association in many cases with mutations in the BRCA 1/2 genes. It is necessary to establish a series of standardized clinical protocols for the management of patients with STIC and to continue advancing our understanding of this pathology and its subsequent evolution to high-grade serous carcinoma.

Anterior abdominal wall endometrioma: a diagnostic dilemma

The presence of functioning endometrium outside the uterine cavity is often encountered in gynaecological practice but an extremely rare entity is its extra pelvic variant is seen sometimes around the umbilicus, anterior rectus sheath vesical region, also rarely seen around the kidney’s nasal mucosa, lungs and the pleura. The incidence of this condition is as low as 0.03% to 0.15%. Endometrioma of the anterior rectus sheath is well documented in literature but because of its rarity may pose a diagnostic dilemma. Reporting herewith a case of anterior rectus sheath endometrioma where medical line of treatment failed and surgical excision was required.

Quality of life assessment by the endometriosis health profile (EHP-30) questionnaire prior to treatment for ovarian endometriosis in brazilian women / Avaliação da qualidade de vida através do questionário Endometriosis Health Profile (EHP-30) antes do tratamento da endometriose ovariana em mulheres Brasileiras

Abstract Objective To evaluate the existence of an association between ultrasound findings and epidemiological and clinical factors using results obtained from the EHP-30 questionnaire in women with ovarian endometriosis. Methods A cross-sectional observational study was performed between July 2012 and May 2015, in which patients with chronic pelvic pain suggestive of endometrioma, as indicated by the results from a transvaginal pelvic ultrasonography, completed the standardized Endometriosis Health Profile - 30 (EHP-30) questionnaire to access quality-of-life scores before beginning treatment for endometriosis. A total of 65 patients were included. The data was analyzed in the statistical program IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) for the comparison of data through linear multiple regression. Results The suitability of the linear regression model was confirmed by the histogram of the dependent variable and the residue distribution plot, confirming the trend of linearity as well as the homogeneous dispersion of the residues. The mean age of the patients was 39.7 ± 7.1 years old. Themajority was Caucasian (64.5%), had completed higher education (56.5%) and was nulligravida (40.3%). Infertility was present in 48.4% of the patients studied. Out of the total sample, 80.6% of the cases were symptomatic and complained mainly of acyclic pain, 79% of dysmenorrhea, and 61.3% of dyspareunia. This reflects the negative influence of endometriosis on the quality of life of patients with this disease. Conclusion Dyspareunia and acyclic pain were independent factors of correlation with high scores in the EHP-30 questionnaire, reflecting a worse quality of life.

Resumo Objetivo Avaliar a existência de associação entre os achados ultrassonográficos e os fatores epidemiológicos e clínicos com os resultados obtidos no questionário EHP-30 em mulheres com diagnóstico de endometriose ovariana. Métodos Realizou-se um estudo observacional transversal entre julho de 2012 emaio de 2015, no qual as pacientes com dor pélvica crônica com imagem sugestiva de endometrioma na ultrassonografia pélvica transvaginal preencheram o questionário padronizado Endometriosis Health Profile - 30 (EHP-30) para acessar os escores de qualidade de vida antes de iniciar qualquer tratamento para a endometriose. Foram incluídas 65 pacientes. Os dados foram analisados no programa estatístico IBM SPSS Statistics for Windows, Versão 22.0 (IBM Corp., Armonk, NY, EUA) para a comparação dos dados através de regressão múltipla linear. Resultados A adequabilidade do modelo de regressão linear foi confirmada através do histograma da variável dependente e do gráfico de distribuição dos resíduos, confirmando a tendência de linearidade, assim como a dispersão homogênea dos resíduos. A idade média das pacientes foi de 39,7 ± 7,1 anos. Amaioria era caucasiana (64,5%), apresentava ensino superior completo (56,5%), e era nuligesta (40,3%). Infertilidade estava presente em 48,4% das pacientes estudadas. Do total de casos 80,6% eram sintomáticas e queixaram-se principalmente de dor acíclica, 79%de dismenorreia , e 61,3% de dispareunia em , refletindo a influência negativa da endometriose sobre a qualidade de vida das pacientes portadores desta doença. Conclusão Dispareunia e dor acíclica foram fatores independentes de correlação com altos escores no EHP-30, refletindo uma pior qualidade de vida.

Manejo del endometrioma ovárico

Ovarian endometrioma is the most frequent endometriotic lesion, affecting about 55% of patients suffering of endometriosis. It is a marker of severity of the disease, associated with deep endometriotic lesions independently of its size. Its compromise is usually multifocal. Though commonly diagnosed in women of reproductive age, it can develop in adolescent girls and even before menarche. Treatment of the ovarian endometrioma is either medical or surgical. Medical treatment, which aims to relieve pain, is mostly used as an adjuvant following surgery in order to decrease recurrence. Surgical treatment plays a major role, despite its effects on the ovarian reserve; rates of pain relief and spontaneous pregnancy favor this approach. Four conservative surgical techniques can be used, all of them feasible by laparoscopy: pseudo capsule excision (cystectomy), ablation, the two-stage technique and the combined technique. Besides chosen technique, surgery quality and the sensible use of energy during the procedure affect the outcome. In cases of ovarian endometrioma, the best approach is individualized treatment considering the patient's needs and associated factors.

El endometrioma ovárico es la forma más frecuente de lesión endometriósica, que afecta aproximadamente a 55% de las pacientes con endometriosis. Es el marcador de severidad de la enfermedad e, independiente de su tamaño, está asociado con lesiones profundas, siendo habitualmente el compromiso multifocal. Comúnmente diagnosticado en mujeres en edad reproductiva, también puede desarrollarse en niñas adolescentes y aún antes de la menarquia. El tratamiento del endometrioma ovárico puede ser médico o quirúrgico. El tratamiento médico está orientado básicamente a aliviar el dolor, pero sobre todo al tratamiento coadyuvante posquirúrgico, con la finalidad de disminuir la recurrencia. El tratamiento quirúrgico tiene rol fundamental, a pesar de sus efectos sobre la reserva ovárica; los beneficios en términos de alivio del dolor y tasas de embarazo espontáneo favorecen este enfoque. Cuatro técnicas quirúrgicas conservadoras son utilizadas en la actualidad, con sus ventajas y desventajas y todas perfectamente realizables por vía laparoscópica: escisión de la pseudocápsula (quistectomía), ablación, la técnica en dos etapas y la técnica combinada. Más importante que la cirugía en sí misma, es la calidad de la cirugía y el uso juicioso de la energía con la que se trabaja. La mejor visión del manejo es la individualización de cada caso, teniendo en consideración las necesidades de la paciente y los factores asociados.

Clinicopathologic characteristics of ovarian clear cell carcinoma in the background of endometrioma: a surveillance strategy for an early detection of malignant transformation in patients with asymptomatic endometrioma

OBJECTIVE: This study aimed to analyze the clinical features of clear cell carcinoma in relation to endometriosis and to determine an appropriate surveillance strategy for the early detection of malignant transformation of endometrioma in asymptomatic patients. METHODS: We retrospectively reviewed the clinicopathologic data of 50 patients with ovarian clear cell carcinoma. Clinicopathologic characteristics, treatment outcomes, and the association between endometriosis and the risk of malignant transformation were analyzed. RESULTS: Ten (20%) patients had been diagnosed with endometrioma before the diagnosis of clear cell carcinoma. The median period from the diagnosis of endometrioma to clear cell carcinoma diagnosis was 50 months (range, 12–213 months). After complete staging surgery, histological confirmation of endometriosis was possible in 35 (70%) patients. Of the 50 patients, 39 (78%) had not undergone any gynecologic surveillance until the onset of symptoms, at which time many of them presented with a rapidly growing pelvic mass (median 10 cm, range 4.6–25 cm). With the exception of 2 patients, all cancer diagnoses were made when the patients were in their late thirties, and median tumor size was found to increase along with age. Asymptomatic patients (n=11) who had regular gynecologic examinations were found to have a relatively smaller tumor size, lesser extent of tumor spread, and lower recurrence rate (P=0.011, 0.283, and 0.064, respectively). The presence of endometriosis was not related to the prognosis. CONCLUSION: Considering the duration of malignant transformation and the timing of cancer diagnosis, active surveillance might be considered from the age of the mid-thirties, with at least a 1-year interval, in patients with asymptomatic endometrioma.

Endometriosis / Endometriosis

Resumen La endometriosis es una enfermedad inflamatoria benigna, dependiente de estrógeno, que se caracteriza por la presencia de glándulas y estroma endometrial en un sitio distinto a la cavidad uterina. Las principales teorías sobre su patogénesis involucran la menstruación retrograda, La metaplasia del epitelio germinal, y la diseminación metastásica. Las lesiones típicamente se localizan en la pelvis; en ovarios, ligamentos uterosacros y saco de Douglas, sin embargo también pueden encontrarse fuera de esta. La enfermedad ocasiona un cuadro clínico variado que involucra dismenorrea, dispareunia, dolor pélvico e infertilidad. Su diagnóstico definitivo ES quirúrgico. El tratamiento médico es solo sintomático y no curativo, mientras que el quirúrgico pese a ser curativo, presenta variables tasas de recurrencia. Las técnicas de reproducción asistida mejoran significativamente las tasas de nacimientos en caso de infertilidad asociada a la enfermedad.

Abstract Endometriosis is a benign, estrogen dependent, inflammatory disease, which is characterized by the presence of endometrial glands and stroma in a site different from the uterine cavity. The main theories about it's pathogenesis involve retrograde menstruation, metaplasia of the germinal epithelium, and metastatic spread. The lesions are typically located in the pelvis; in ovaries, utero sacral ligaments and Douglas pouch, but can also have an extra pelvic location. This disease has a variable clinical presentation that involves dysmenorrhea, dyspareunia, pelvic pain and infertility. It's definitive diagnosis is surgical. Medical treatment is only symptomatic and non-curative, while the surgical treatment despite being curative has important recurrence rates. Assisted reproduction techniques are very useful to improve birth rates in case of infertility associated with the disease.

Supernumerary ovary on recto-sigmoid colon with associated endometriosis

A supernumerary ovary is a rare gynecological anomaly, and is usually excised due to its malignant transformation potential. We report a case of a supernumerary ovary and endometriosis situated on the anterior rectosigmoid colon. When laparoscopy was conducted, a firm, 5-cm mass was discovered on the anterior rectosigmoid colon along with normal ovaries. In this case, the discovery of a supernumerary ovary implied the presence of endometriosis. It is unusual for endometriosis and a supernumerary ovary to exist simultaneously.

Expression difference of Treg, Th17 cells and related cytokines between pre and post laparoscopic treatment of ovarian endometrioma / 中华内分泌外科杂志

Objective To investigate the changes and clinical significance of Treg and Th17 cells in patients with ovarian endometrioma (OEM) pre-and post-laparoscopy.Methods 36 patients with OEM undergoing laparoscopic surgery and confirmed by the pathology were enrolled as the experiment group,and 25 patients with fallopian tube obstruction who received laparoscopic examination were enrolled as the control group.The peripheral blood samples were collected from the control group and the experiment group before operation as well as from the experiment group 3 months after operation.Intraoperative peritoneal fluid were also collected from both groups.The levels of IL-17,IL-22,IL-23,IL-10 and TGF-β in serum and peritoneal fluid were detected by ELISA.The proportion of Treg and Th17 cells in peripheral blood was detected by flow cytometry.Results Compared with the control group,the levels of IL-17,IL-22 and IL-23 in the peritoneal fluid and serum of the experiment group increased significantly,while the levels of IL-10 and TGF-β were significantly decreased (P＜0.05).The proportion of Th17 cells in the peripheral blood of the experiment group increased significantly,and the proportion of Treg cells decreased significantly (P＜0.05).Compared with pre-laparoscopic treatment,the serum IL-17,IL-22 and IL-23,and the proportion of Th17 cells in peripheral blood were significantly decreased in the experiment group,and the levels of IL-10 and TGF-β in serum increased significantly (P＜0.05).Conclusions In patients with OEM,Treg and Th17 cell imbalance and the expression of related cytokines in disorder may be an important factor in the occurrence and development of disease.Detection of Treg/Th17 cells and their cytokines plays an important role in evaluating the severity of the disease and judging the efficacy of laparoscopic treatment and prognosis of OEM.

Endometrioma subcutáneo en la pared abdominal. A propósito de un caso / Subcutaneous endometrioma in abdominal wall. Case report

La endometriosis se define como un tejido endometrial ectópico que responde a estímulos hormonales ováricos. En 1899 se describió por primera vez la presencia de tejido endometrial en un ovario; desde entonces se ha identificado diversos sitios de localización; v.gr.: órganos urogenitales, epiplón, intestino, ganglios linfáticos, pulmones, pleura, ombligo, episiotomías y cicatrices quirúrgicas. Cuando el tejido endometrial ectópico se presenta como un tumor circunscrito se denomina endometrioma o granuloma endometriósico. La endometriosis en la cicatriz quirúrgica ocurre con mayor frecuencia después de una cirugía uterina o de las trompas de Falopio; también se ha presentado después de apendicectomías y plastias inguinales. La anamnesis y los exámenes complementarios son recursos necesarios para una impresión diagnóstica de endometrioma. Presentamos un caso debido a que el diagnóstico aún es un verdadero reto, como se describe a continuación. (AU)

Endometriosis was defined as an ectopic endometrial tissue that responds to ovarian hormonal stimuli. In 1899 the presence of endometrial tissue was first described in an ovary. Since then various, localization sites have been identified, such as urogenital organs, omentum, intestine, lymph nodes, lungs, pleura, navel, episiotomies and surgical scars, among others. When ectopic endometrial tissue presents as a circumscribed tumor it is called endometrioma or endometriosic granuloma. Endometriosis in the surgical scar occurs more frequently after uterine or fallopian tube surgery, it has also occurred after appendectomies and inguinal plasties. Anamnesis and complementary examinations are necessary tools for a diagnostic impression of endometrioma. A case is presented because the diagnosis is still a real challenge, as described below. (AU)