Laparoscopic evaluation of the onset and progression of endometriosis

Nonhormonal therapy for endometriosis: a randomized, placebo-controlled, pilot study of cabergoline versus norethindrone acetate

Objective

To estimate the efficacy and safety of a novel nonhormonal therapeutic agent, cabergoline, compared with that of the standard clinical therapy, norethindrone acetate (NETA), for the treatment of endometriosis-associated pain in young women with endometriosis.

Design

Randomized, double-blind, placebo-controlled pilot study.

Setting

Tertiary care center.

Patient(s)

Women (n = 9) with surgically confirmed endometriosis.

Intervention(s)

A random, double-blind assignment to either NETA (5 mg/day) + placebo twice weekly or cabergoline (0.5 mg) twice weekly + placebo daily for 6 months.

Main Outcome Measure(s)

We collected the measures of pelvic pain and laboratory parameters every 3 months.

Result(s)

We observed a decrease in pain scores and increase in pain relief in women randomized to receive cabergoline, who appeared to show similar or more improvements than women treated with NETA. The serum measures of vascular endothelial growth factor receptor 1 declined over 6 months in those who received cabergoline. Cabergoline was well tolerated, and no serious adverse events occurred.

Conclusion(s)

Safe, effective adjunct treatments are lacking for patients with endometriosis who do not respond to standard care. Because the growth of endometriosis requires angiogenesis, blood vessel growth is an attractive therapeutic target. This pilot study suggests that cabergoline, a vascular endothelial growth factor pathway inhibitor, is an effective therapeutic option for women with chronic pain due to endometriosis. Building upon this investigation, we will conduct larger, randomized trials of cabergoline, advancing research on the best treatments for endometriosis—particularly disease resistant to hormonal therapies.

Clinical Trial Registration Number

clinicaltrials.gov; registration number NCT02542410.

Evidence in Support for the Progressive Nature of Ovarian Endometriomas

CONTEXT

Whether endometriosis is a progressive disease is a highly contentious issue. While progression is reported to be unlikely in asymptomatic deep endometriosis, progression in symptomatic deep endometriosis has recently been reported, especially in menstruating women. However, pathophysiological reasons for these differences are unclear.

OBJECTIVE

This study was designed to investigate whether ovarian endometrioma (OE) is progressive or not.

SETTING, DESIGN, PATIENTS, INTERVENTION AND MAIN OUTCOME MEASURES

Thirty adolescent patients, aged 15 to 19 years, and 32 adult patients, aged 35 to 39 years, all laparoscopically and histologically diagnosed with OE, were recruited into this study after informed consent. Their demographic and clinical information were collected. Their OE tissue samples were collected and subjected to immunohistochemical analysis for E-cadherin, α-smooth muscle actin (α-SMA), desmin, and adrenergic receptor β2 (ADRB2), as well as quantification of lesional fibrosis by Masson trichrome staining.

RESULTS

OE lesions from the adolescent and adult patients are markedly different, with the latter exhibiting more extensive and thorough progression and more extensive fibrosis, suggesting that lesions in adults progressed to a more advanced stage. Adult lesions and higher staining level of α-SMA and ADRB2 are positively associated with the extent of lesional fibrosis, while the lesion size and the E-cadherin staining are negatively associated.

CONCLUSIONS

Our data provide a more definitive piece of evidence suggesting that OE is a progressive disease, since the adult lesions have had a longer time to progress. In addition, the pace of progression depends on lesional age as well as the severity of endometriosis-associated dysmenorrhea, if any.

Retrospective evaluation of tumor markers in ovarian mature cystic teratoma and ovarian endometrioma

AIM

The aim of this study was to evaluate the correlation between clinicopathological characteristics and serum levels of tumor markers in patients with ovarian endometrioma (OE) and ovarian mature cystic teratoma (MCT).

MATERIAL AND METHODS

Values of CA125, CA19-9, and sialyl Tn antigen (STN) were retrospectively investigated in 321 patients with OE. CA125, CA19-9, STN, and squamous cell carcinoma antigen (SCC) were examined in 435 patients with MCT.

RESULTS

Mean values of CA125, CA19-9, and STN were 105.3 U/mL, 58.0 U/mL, and 31.1 U/mL in OE, while the values were 26.8 U/mL, 246.8 U/mL, and 24.7 U/mL in MCT. Abnormal elevation of CA125, CA19-9, and STN was observed in 53.3%, 38.9, and 13.5 of OE, and in 12.9, 50.6, and 4.6% of MCT, respectively. CA125 level was significantly higher in bilaterally occurring OE and premenopausal patients with MCT, while the value of CA19-9 was significantly higher in cases of bilaterally occurring MCT. Furthermore, the levels of CA125 and CA19-9 showed significant correlations with tumor diameter, while the levels of STN and SCC showed no significant correlations with tumor diameter. The highest CA125 level (9513 U/mL) was observed in OE and the highest CA19-9 level (25 590 U/mL) was observed in MCT.

CONCLUSION

Although abnormal increases in the levels of CA125 and CA19-9 were often observed, the levels of STN were not influenced by clinicopathologic factors in OE and MCT. Further studies of the clinical usefulness of STN for detecting malignant tumors in OE and MCT are needed.

Primary adenomyoma of the fallopian tube mimicking tubal malignant tumor

We report a rare case of adenomyoma localized only in the left fallopian tube mimicking tubal malignant tumor. A 45-year-old woman presented with mild pelvic pain, dysmenorrhea and left adnexal mass. Magnetic resonance imaging showed a solid tumor, suspected primary cancer of the fallopian tube, and serum carbohydrate antigen 125 was elevated to 72 U/mL (normal; 0-35). At surgery, the tumor was revealed as a left fallopian tube tumor without torsion. Postoperative histopathology showed that the tumor included bundle-like growing non-atypical leiomyoma cells and ectopic normal endometrium accompanied with endometrial stroma and we diagnosed primary adenomyoma of the left fallopian tube. Adenomyoma localized only in the fallopian tube is a rare entity and it can occur only in the fallopian tube.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Future directions in endometriosis research

Future research in endometriosis must focus on pathogenesis studies in the baboon model, the early interactions between endometrial and peritoneal cells in the pelvic cavity at the time of menstruation, and potential differences between eutopic endometrium and myometrium in women with and without endometriosis. More integration is needed between the areas of epidemiology and genetics. Pelvic inflammation in women with endometriosis could be the target for new diagnostic and therapeutic approaches. Important questions remain regarding the relationship between endometriosis and environmental factors. Systemic and extrapelvic manifestations of endometriosis must be analyzed carefully, and better tools are needed to measure quality of life in women with chronic pain caused by endometriosis. Most current evidence supports a causal relationship between endometriosis and subfertility, and the spontaneous progressive nature of endometriosis has been demonstrated in 30% to 60% of patients. Recurrence of endometriosis after classic medical and surgical therapy is a major and underestimated problem, especially in women with advanced disease. Integrated clinical and research teams are needed that combine expert medical, surgical, and holistic care with state-of-the-art research expertise in immunology, endocrinology, and genetics to discover new diagnostic methods and medical treatments for endometriosis.

Surgical management of endometriosis-associated pain

General surgical guidelines are reasonable, but treatment frequently must be individualized. Laparoscopic coagulation can be used for many cases of superficial endometriosis. Resection seems to be associated with an increased resolution of endometriosis. Resection increases the difficulty of the procedure, the time of the operation, and the cost, however. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. Distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. Care is needed to attempt to ensure that patients are neither overtreated nor undertreated.

Clinical aspects of endometriosis

Endometriosis is one of the most commonly encountered gynecologic diseases requiring medical and/or surgical therapy. It is a leading cause of hysterectomy in the United States and has significant associated morbidity. The most frequent symptoms of genital tract endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Endometriosis occurs in the pelvis, most commonly the ovaries and the dependent areas covered with peritoneum. Diagnosis requires surgical intervention and is usually made by laparoscopy. In women being evaluated for pelvic pain, the diagnosis of endometriosis is made frequently (40-60%) and varies with the population being studied. Infertility and endometriosis have long been associated. Although women with infertility may have pelvic pain, subfertility (20-30%) can be the only presenting symptom. In asymptomatic women, the diagnosis of endometriosis ranges from 2% to 22% of reproductive-age women. Its true incidence and natural history remain to be clarified. Endometriosis is a significant public health issue because of the large number of women it affects and the significant morbidity associated with this disease.

Theories of endometriosis

Endometriosis is characterised by the presence of abnormally located tissue resembling the endometrium with glands and stroma. Several hypotheses have attempted to explain the development of such tissue. The oldest theory, that of metaplasia, suggests that under diverse influences coelomic tissue could be transformed into endometrium. The most often cited theory, that of implantation, proposes that the physiological phenomenon of endometrial reflux in the fallopian tubes during menstruation may, in certain conditions, overcome local defense mechanisms, implant, and proliferate. The peritoneal fluid in unaffected women possesses the capacity to prevent endometriotic tissue from becoming established. The reasons for the occurrence of endometriosis and its consequences (pain, sterility, adhesions) are probably numerous and involve the endometrium, the immune system (macrophages, natural killer cells), the peritoneum, and fallopian tubes. The failure to clear the peritoneal cavity of fragments of endometrium could cause a state of local inflammation with hyperactivation of macrophages secreting a variety of different compounds. Some of these compounds may bring about metaplasia of the peritoneum or the development of Mullerian residues.

Is endometriosis an endometrial disease?

Endometriosis is characterised by the presence of abnormally located tissue resembling the endometrium with glands and stroma. Several hypotheses have attempted to explain the development of such tissue. The most often cited theory, that of implantation, proposes that the physiological phenomenon of endometrial reflux in the fallopian tubes during menstruation may, in certain conditions, overcome local defense mechanisms, implant, and proliferate. The implantation theory does not explain why endometriosis will develop only in approximately 10-15% of women, while the reflux of endometrial tissue via the fallopian tubes during menstruation is a quasi-universal phenomenon. The endometrium of women affected by endometriosis could be abnormal compared with endometrium of healthy women. The abnormal endometrium could be able to protect itself from harmful effects of immune cells by expressing specific antigens, by harbouring a different immune cell population and by synthetizing and secreting immunosuppressive factors. Several others characteristic features of endometrium have been described in women with endometriosis: (1) production of its own estrogens in too heavy amount; (2) aptitude for setting up on peritoneum; (3) tendencies to proliferate and to invade tissue; (4) aggressiveness for the peritoneum; (5) auto-protection from physiological apoptosis; (6) abnormal expression of heat shock proteins; and (7) excessive angiogenesis.

Endometriosis and pain

Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.

Peritoneal cellular immunity and endometriosis

PROBLEM

An immunologic basis has long been considered to be very important in the pathogenesis of endometriosis. Interactions of the peritoneal cells, which comprise macrophages, B cells, T cells, natural killer (NK) cells, and retrograde endometrial cells, are critical, but remain controversial, for exploring the pathogenesis of endometriosis.

METHOD OF STUDY

Accumulated data from the literature were reviewed, and our data were analyzed.

RESULTS

The data show that peritoneal macrophages are activated by the recurrent reflux of menstrual shedding. Humoral and local endometrial autoantibodies are detected in patients with endometriosis, but B cells are not quantitatively increased. There is decreased NK cell activity in the peritoneal cavity and peripheral blood, and this decreased activity may be related to the failure to clear out the ectopic endometrial tissue. Peritoneal T cells are predominant by Th1 inflammatory cells, and these cells are impaired because of a decrease in activation (especially HLA-DR+CD4+CD3+ population) and in the production of interleukin-2. Inflammatory cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-alpha are elevated in the peritoneal fluid of women with endometriosis.

CONCLUSIONS

The peritoneal NK and T lymphocytes are suppressed in women with endometriosis, but whether these immunologic deviations are the cause or the result of endometriosis is still unclear. Further studies are required to determine what role immunologic factors play in the pathophysiology of endometriosis.

Danazol induced thrombocytopenia

A 34-year-old woman with a left ovarian cyst (clinically diagnosed as endometrial cyst) was treated with 400 mg of danazol per day. On the next day, after a total dose of only 600 mg of danazol, gingival bleeding and purpura occurred. Her laboratory findings were as follows: platelet count 1000/ mm3 hematocrit 39%, WBC 7300/mm3 and RBC 466 x 10(4)/mm3. Immune thrombocytopenic purpura (ITP) was diagnosed, and she was treated with 40 mg of methylprednisolone per day for 19 days. Her platelet count increased to 130,000/ mm3. Her left ovarian cyst was extirpated surgically, and the histological diagnosis was endometrial cyst. Danazol at 400 mg per day was therefore again administered. On the next day, she complained of gingival bleeding and purpura again, and her platelet count was 5000/mm3. We diagnosed this case as danazol induced thrombocytopenia.

Tubal endometriosis diagnosed within one month after menarche: a case report

A 13-year-old nulligravida girl, 158.5 cm in height and 76.0 kg in body weight, came to our department complaining of continuous right lower abdominal pain. One month earlier, an ovarian cyst in the right ovary, about 3 cm in diameter, was found when she underwent appendectomy at another hospital, but was left untreated. Menarche occurred at the age of 13 years and 1 month, which was after the appendectomy and 24 days before the present operation. Right hematosalpinx with peripheral obstruction and a para-ovarian serous cyst on the same side were diagnosed, and therefore right salpingectomy with para-ovarian cyst resection was performed. The bilateral ovaries and uterus were completely normal by inspection. The post operative histological examination confirmed hematosalpinx and revealed tubal endometriosis.