Vincent Anaf

Endometriosis: Contribution of 3.0-T Pelvic MR Imaging in Preoperative Assessment—Initial Results

PURPOSE To determine the accuracy of 3.0-T pelvic magnetic resonance (MR) imaging in the preoperative assessment of endometriosis and to evaluate colon wall involvement after intrarectal gel administration. MATERIALS AND METHODS Institutional review board approval for this study was obtained, and each patient gave written informed consent. Forty-one consecutive patients with clinical suspicion of endometriosis underwent pelvic MR imaging at 3.0 T before surgery. Single-shot and high-spatial-resolution axial T2-weighted, sagittal fat-suppressed T2-weighted, and axial fat-suppressed T1-weighted sequences were performed. T2-weighted sequences were repeated after the rectum was filled with ultrasonographic (US) gel. Two blinded readers interpreted images independently. Image quality was scored by using a four-point scale. Detailed mapping of deep endometriosis was performed. Colon wall infiltration was graded (none, serosa, muscularis, submucosa, mucosa). MR imaging results were compared with surgical and pathologic findings. Interobserver agreement was assessed by using kappa statistics. Nonparametric tests were performed to compare colon wall infiltration scores without and those with US gel and between observers. RESULTS Twenty-seven of 41 patients had deep endometriosis at surgery and histopathologic examination. Sensitivity, specificity, positive and negative predictive values, and accuracy for the diagnosis of deep endometriosis at MR imaging were 96.3% (26 of 27), 100% (14 of 14), 100% (26 of 26), 93.3% (14 of 15), and 97.6% (40 of 41), respectively. kappa Values ranged from 0.65 to 1.0, depending on the location of deep endometriosis. Colon wall infiltration assessment by both readers correlated well with pathologic findings (Spearman coefficient, >0.93), although median wall involvement scores were lower at pathologic examination than for both readers both before (P = .042 and P = .011) and after (P = .079 and P = .011) intrarectal gel filling. CONCLUSION MR imaging of the pelvis at 3.0 T is accurate in the diagnosis and staging of deep endometriosis for the preoperative assessment of patients clinically suspected of having endometriosis.

Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis

BACKGROUND The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA). METHODS Three hundred consecutive patients with histologically proven OMA were enrolled at a single university tertiary referral centre between January 2004 and May 2010. Complete surgical excision of all recognizable endometriotic lesions was performed for each patient. Pain intensity was assessed with a 10-cm visual analogue scale (VAS). Pain was considered as severe when VAS was ≥ 7. Prospective preoperative assessment of type and severity of pain symptoms (VAS) was compared with the peroperative findings (surgical removal and histological analysis) of endometriomas and associated deeply infiltrating endometriosis. Correlations were sought with univariate analysis and a multiple regression logistic model. RESULTS After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1-4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1-3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2-55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7-10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3-15.3). CONCLUSIONS In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.

Impact of Surgical Resection of Rectovaginal Pouch of Douglas Endometriotic Nodules on Pelvic Pain and Some Elements of Patients' Sex Life

STUDY OBJECTIVE To assess the impact of laparoscopic resection of endometriotic nodules in the rectovaginal pouch of Douglas on womens pain symptoms, analgesic intake, work absenteeism, work difficulties, and some elements of sex life. DESIGN Observational study (Canadian Task Force classification II-2). SETTING Gynecology department at a university hospital. PATIENTS Twenty-six women with rectovaginal pouch of Douglas endometriotic nodules and no evidence of other potential cause of pain at physical examination, laparoscopy, and transvaginal ultrasonography. INTERVENTION Laparoscopic resection of endometriotic nodules with the CO2 laser until no residual induration was felt in surrounding tissues. MEASUREMENTS AND MAIN RESULTS Significant statistical differences were found between preoperative and postoperative pain scores, percentages of women absent from work, percentages taking analgesics or nonsteroidal antiinflammatory drugs, and percentages having work difficulties due to pain. A significant difference also was found in frequencies of sexual desire and coitus. CONCLUSION Endometriotic nodules in the rectovaginal pouch of Douglas may be responsible for major pelvic pain and also for sexual dysfunction (lack of sexual desire, dyspareunia). Laparoscopic resection of the nodules significantly improves these conditions. (J Am Assoc Gynecol Laparosc 8(1):55-60, 2001)

Anatomic significance of a positive barium enema in deep infiltrating endometriosis of the large bowel.

PurposeThe anatomopathological significance of a positive double-contrast barium enema (DCBE) for suspicion of deep infiltrating endometriosis of the large bowel was studied. This is a retrospective study of a prospective database.MethodsA large-bowel resection was proposed for patients who were suspicious for large-bowel endometriosis and had a positive DCBE. In a series of 73 patients, 71 large-bowel resections were performed. Histology and immunohistochemistry with the monoclonal antibody CD-10 were performed on the resection specimen. Outcome measures were the length of the resected specimen, the largest diameter of the lesion, the positivity of the resection margins, and the degree of infiltration of the large bowel. We also compared the mean largest diameters of the lesions with the degree of infiltration of the large bowel.ResultsBetween December 1997 and October 2005, 80 patients were suspicious for large-bowel endometriosis: 73 (91%) had positive DCBEs, and 7 (9%) had negative DCBEs. Of the 73 with positive DCBEs, 4 (5%) refused digestive resection and 1 (1.4%) was excluded. Three patients underwent two large-bowel resections because of the presence of bifocal lesions (left and right colon). A total of 71 resections were performed. In case of positive DCBE, the perivisceral fat and the whole muscularis were infiltrated in 100% of cases. The infiltration reached the submucosa and the mucosa respectively in 82% and 18% of cases. A total of 9.9% of resection margins were positive at histology but only focally. The mean largest diameter of the lesions infiltrating the whole thickness of the large bowel was not statistically different from the mean largest diameter of more superficial lesions.ConclusionsFindings of mass effect with indentations and ridging of the mucosa on DCBE in a setting suspicious for large-bowel endometriosis correspond well with pathologic findings of deep infiltration of the large-bowel wall. Clinicians dealing with deep infiltrating endometriosis should be aware of these findings, which could influence their choice of surgical treatment.

Report of 7 Uterine Rupture Cases After Laparoscopic Myomectomy: Update of the Literature

The objective of this article is to report 7 previously unpublished uterine rupture cases in pregnancy after laparoscopic myomectomy and to update the medical literature. All cases were reported to the Board of Endoscopic Gynecologic Surgery (Athens, Greece) from 1998 to 2011. Myomas were single in 85.7% of patients, subserosal or pedunculated in 85.7%, and ≤5 cm in 71.4%. Bipolar diathermy was the sole method used for hemostasis in 28.6%, and could be characterized as excessive in 85.7%. A 2-layer closure with stitches of the myometrium was performed in just 14.3% of cases. Mean (SD) time between surgery and pregnancy was 1.4 (0.5) years. Uterine rupture occurred at 34 weeks of gestation or later in 85.7%, and during labor in 14.3% of cases. All women survived. Fetal demise was reported in 1 twin pregnancy (both fetuses) with rupture at 24 weeks of gestation. Laparoscopic myomectomy should be performed by adequately trained and experienced surgeons. Excessive use of diathermy for hemostasis should be avoided, and multiple-layer suturing should always be used for repairing the myometrial defect in cases of intramural and subserosal myomas with deep intrusion.

Neurotrophines et douleur : étude d’expression et de corrélation dans l’endométriose

OBJECTIVES To evaluate the expression of five members of the neurotrophins family in ovarian endometriotic cyst (endometrioma) (OMA), compared to eutopic endometrium (EE) and to examine the correlation between the levels of induction and the pain intensity. PATIENTS AND METHODS Twelve Caucasian women in luteal phase, operated for painful stage IV endometriosis were assigned to 2 groups according to a total Visual Analog Scale (tVAS) score above 15 or below 10. tVAS takes into account all VAS scores for dysmenorrhea, deep dyspareunia, non cyclic chronic pelvic pain, gastrointestinal and lower urinary symptoms. Samples of OMA and EE were processed by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) for NGF, BDNF, NT-3, NT-4/5 and NTRK2 mRNA expression. Expression levels in OMA were compared to those in EE on one hand and between two groups of 6 mild painful and 6 highly painful patients on the other. RESULTS All neurotrophins were significantly higher expressed in OMA than in EE, in particular NGF and BDNF (induction ratios: 20.6 and 9.7, respectively). In contrast, no correlation was observed between induction ratios and pain intensity. CONCLUSION AND DISCUSSION This is the first study reporting an over-expression of all neurotrophins in endometriosis, as only NGF was previously documented. It confirms the central role of this family in the genesis and modulation of pain in endometriosis. Anti-neurotrophin selective therapy might be a promising way of analgesia in the future.

Estrogen and progesterone receptors in smooth muscle component of deep infiltrating endometriosis

OBJECTIVE To analyze the expression of estrogen (ER) and progesterone (PR) receptors in the smooth muscle component (SMC) of deep infiltrating endometriosis (DIE). DESIGN A prospective clinical and pathologic study of 60 cases of DIE. SETTING University Hospital Department of Gynacology. PATIENT(S) Sixty patients with symptomatic DIE (uterosacral endometriosis n = 14; bladder endometriosis n = 10; colonic endometriosis n = 16; rectovaginal endometriosis n = 20). INTERVENTION(S) Laparoscopic surgery. MAIN OUTCOME MEASURE(S) The expression of ER and PR was studied by immunohistochemistry in the SMC directly around endometriotic foci and at distance (at least >1.5 cm) from them in correlation with proliferative and secretory phases of cycle. RESULTS The ER and PR were present in the SMC of DEI in each location excepting colonic endometriosis where ER were absent. Independently of cycles phases the PR were more abundant than ER. With the exception of rectovaginal endometriosis, where the ER and PR were more abundant in the proliferative than in the secretory phase, in other locations the ER and PR did not differ significantly with cycles phases. Last, if ER and PR were more abundant in SMC around endometriotic foci than at a distance from them. However, the difference was not significant. CONCLUSIONS Our data substantially confirm for the first time that in various forms of DIE, ER and PR are present not only in glands and stroma but also in the smooth muscle major histologic component of this disease.

Hormonal Therapy Deregulates Prostaglandin-Endoperoxidase Synthase 2 (PTGS2) Expression in Endometriotic Tissues

CONTEXT Endometriosis is a common gynecologic condition characterized by an important inflammatory process mediated by the prostaglandin pathway. Oral contraceptives are the treatment of choice for symptomatic endometriotic women. However the effects of oral contraceptives use and prostaglandin pathway in endometriotic women are actually still unknown. OBJECTIVE To investigate the expression of prostaglandin pathway key genes in endometriotic tissue, affected or not by hormonal therapy, as compared with healthy endometrial tissue. DESIGN This was a comparative laboratory study. SETTING This study was conducted in a tertiary-care university hospital. PATIENTS Seventy-six women, with (n = 46) and without (n = 30) histologically proven endometriosis. MAIN OUTCOME MEASURES Prostaglandin-endoperoxidase synthase (PTGS)1, PTGS2, prostaglandin E receptor (PTGER)1, PTGER2, PTGER3, and PTGER4 mRNA levels in endometrium of disease-free women and in eutopic and ectopic endometrium of endometriosis-affected women. PTGS2 expression was further investigated by immunohistochemistry, using specific monoclonal antibodies. PTGS2 expression was analyzed at mRNA and protein levels and correlated with taking hormonal treatment. RESULTS PTGS2 expression was significantly increased in eutopic and ectopic endometrium as compared with healthy tissue (induction of 9.6- and 6.3-fold, respectively; P = .001). PTGS2 immunoreactivity increased gradually from normal endometrium to eutopic and ectopic endometrium (h-score of 96.7 ± 55.0, 128.3 ± 66.1, and 226.7 ± 62.6, respectively, P < .001). PTGER2, PTGER3, and PTGER4 expression increased significantly and gradually from normal to eutopic and ectopic endometrium, whereas PTGER1 remained unchanged. Patients under hormonal treatment had a higher PTGS2 expression at transcriptional and protein levels as compared with those without treatment (P = .002 and P = .025, respectively). CONCLUSIONS Prostaglandin pathway is strongly deregulated in eutopic and ectopic endometrium of women suffering from endometriosis for the benefit of an increased PTGS2 expression. We show for the first time that hormonal treatment appears to enhance even more PTGS2 expression. These results contribute to explain why medical treatment could fail to control endometriosis progression.

Increased nerve density in deep infiltrating endometriotic nodules.

Background/Aims: Deep infiltrating endometriosis is a very painful condition and the mechanism of pain is still poorly understood. Pain and hyperalgesia can partly be explained by an increased number of nerve structures in the painful lesion. In order to clarify this issue, we assessed the nerve density in deep infiltrating endometriotic nodules of the posterior vagina and in the adjacent healthy vaginal tissue of the same patient. Methods: A prospective clinical and pathological study of 31 cases of deep infiltrating vaginal endometriotic nodules was conducted. Fifteen patients were in the proliferative phase and 16 in the secretory phase. The nerve density was studied by immunohistochemistry with the monoclonal antibody NF against neurofilaments in deep infiltrating endometriosis and in the adjacent unaffected vaginal tissue in the proliferative and in the secretory phases. Neurofilaments constitute the main structural elements of neuronal axons and dendrites. Results: The nerve density was significantly different in the endometriotic nodule than in the adjacent unaffected vaginal tissue (p = 0.0013). The same significant difference was found between endometriotic nodules and the unaffected vagina in the proliferative phase (p = 0.009) and in the secretory phase (p = 0.04). This difference was not significant between the proliferative and the secretory phases in the endometriotic lesions and in the controls. Conclusions: We hypothesize that the significantly increased number of nerve structures in the endometriotic nodules may contribute to the occurrence of severe and neuropathic pain that characterizes these lesions

Galectin-3 is overexpressed in various forms of endometriosis.

Endometriosis is an enigmatic disease of unknown etiology and pathogenesis, which is defined as the presence of endometrial glands and stroma outside the uterus. The most widely accepted theory to explain endometriosis is probably the transplantation of an endometrial fragment during menstruation to ectopic sites, but the development of endometriosis is extremely complex and includes the adherence to the peritoneal surface and secondary invasion of the underlying tissues. In this study, we have investigated the potential role of galectin-3 (gal-3), a member of a group of carbohydrate-binding proteins, which plays a major role in cell adhesion, migration, angiogenesis, and invasion. The expression of gal-3 has been carried out by immunohistochemistry, according to the different phases of cycle in 50 cases of endometriosis (peritoneal endometriosis: n=10; ovarian endometriosis: n=10; deeply infiltrating endometriosis: n=30) and in 34 cases of eutopic endometrium (10 without endometriosis and 24 with endometriosis). In the proliferative and secretory phases of the cycle, the nuclear and membranous gal-3 expression was higher, first in each variant of the endometriosis than in the eutopic endometrium (P<0.05), and second in the eutopic endometrium of women with endometriosis than in eutopic endometrium of women without endometriosis. Our data suggest that gal-3 may have a potential role in the development of endometriosis.