Extensive pelvic endometriosis with malignant change in tamoxifen-treated postmenopausal women

Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review

Endometriosis is a chronic inflammatory disease, characterized by the presence of ectopic endometrial tissue, that leads to dysmenorrhea, painful intercourse and infertility. The shift in paradigm from the previous belief that endometriosis exclusively impacts women of reproductive age has brought attention to the condition in both premenarchal and postmenopausal women. Currently, 2-4% of postmenopausal women have endometriosis. Many women experience menopausal symptoms during the peri- and postmenopausal periods and require extensive investigations and monitoring in order to avoid the recurrence of endometriosis symptoms or the risk of malignant transformation when treatment with menopausal hormones is elected. Our goal was to compile and present a clear and concise overview of the existing literature on postmenopausal endometriosis, offering an up-to-date and precise summary of the available information.

Rare Clinical Presentation of Postmenopausal Endometriosis: A New Perspective

Endometriosis affects 2-5 % of postmenopausal women with menopause hormone therapy and is less common in women without treatment with exogenous estrogen or tamoxifen. Postmenopausal endometriosis has more unknown aspects in its pathogenesis and clinical manifestation than in the case of premenopausal patients. The aim of this review was to summarize the clinical presentation of rare cases of endometriosis, including deep infiltrating (DIE) and extragenital endometriosis, in women. The symptoms of endometriosis in the post-reproductive age are more heterogeneous than in women of childbearing age, often resembling symptoms of gastrointestinal tumors or urinary tract diseases. We summarize cases of endometriosis of the intestines, liver, pancreas, and stomach, as well as endometriosis of the urinary tract and skin, with non-gynecological manifestations. We also describe the pathogenesis of endometrial tissue activity in the context of reduced estrogen levels after menopause, which is also not clear, and demands more molecular and genetic studies. NAD+-dependent deacetylases called Sirtuins are metabolic sensors for maintaining body homeostasis. In the context of endometriosis, Sirtuins are being studied for their potential role in modulating inflammation, cell proliferation, and sex hormone sensitivity, but their role in postmenopausal endometriosis is not well researched. Treatment in postmenopausal women includes mostly for now surgery, depending on the location of the lesion, and aromatase inhibitors. The complete genetic and epigenetic profile in women post-reproductive age is needed to propose target therapy, especially in severe cases such as endometriosis that is deeply infiltrating and located outside the pelvis.

Total laparoscopic hysterectomy in patients with deep endometriosis: Different technical and postoperative considerations, in comparison with a procedure performed for other benign indications

OBJECTIVE

Total laparoscopic hysterectomy (TLH) may be indicated in patients with deep infiltrative endometriosis (DIE) to treat severe chronic pelvic pain symptoms, recurrences, or co-existing uterine disease. This study discusses the challenges and specific operative and postoperative considerations in patients submitted to TLH and excision of DIE, in comparison with those undergoing a procedure for other benign indications.

MATERIALS AND METHODS

Patients undergoing TLH and excision of DIE were included (N = 18, group 1). These were matched with cases, treated with TLH for other benign indications during the same period (2010-2019), at a 2:1 ratio (N = 36, group 2). The two groups were compared with regards to their characteristics, and intraoperative and postoperative data, including operative time, estimated blood loss (EBL), hospital stays, and rates of complications.

RESULTS

In group 1, median DIE nodule size was 2.5 cm (range: 1.3-4.2). Simple hysterectomy was performed in 10, and a more extended procedure in 8 cases. All nodules were removed from the bowel wall using the shaving technique. Average EBL was significantly higher (p = .027), and duration of surgery and hospital stays longer (p = .003, and p = .0001, respectively), in group 1 vs. group 2. The rates of long-term (L-T) complications were higher in group 1 but not to a significant level (p = .087). Analysis within the DIE group showed that operative time was significantly related to nodule size, type of hysterectomy (p = .021), presence of adenomyosis (p = .041), uterine size ≥12weeks (p = .039), and the occurrence of L-T complications (p = .016). Increasing nodule size and an extended procedure (p = .005) increased significantly the EBL, which had also a significant effect on the risk of L-T complications (p = .006).

CONCLUSIONS

TLH in DIE patients is a different, complex and potentially more dangerous procedure compared with TLH for other benign indications. Thorough knowledge of retroperitoneal anatomy, a clear operative plan, and excellent laparoscopic skills are necessary for concomitant radical excision of lesions, with low rates of adverse events.

Malignant Transformation of Postmenopausal Endometriosis: A Systematic Review of the Literature

Objective: This study aimed to systematically review the existing literature on malignant transformation of postmenopausal endometriosis to provide information about patient characteristics, hormonal replacement therapy (HRT) use, and outcomes over a period of 52 years (1969-2021). Methods: According to PRISMA guidelines, we searched for (endometriosis OR endometriotic) AND (cancer OR malignancy OR malignant transformation) AND (menopause OR menopausal OR postmenopause OR postmenopausal) in Pubmed (all fields) (accessed on 12 February 2021) and Scopus (Title/Abstract/Keywords) (accessed on 12 February 2021) databases. The only filter used was the English language. Relevant articles were obtained in full-text format and screened for additional references. Eligibility/inclusion criteria: studies including full case description of malignant transformation of endometriosis-related lesions in postmenopause. Results: 75 studies, including 90 cases, were retrieved. The mean age was 55.8 ± 8.5 years. Overall, about 65% of women had a positive personal history of endometriosis/adenomyosis, and 64% of women underwent previous hysterectomy ± bilateral salpingo-oophorectomy. Forty-nine of 74 women used HRT (66.2%). Among the women who used HRT, estrogen-only treatment was taken by approximately 75%. Duration of HRT was longer than five years in 63.3% of cases. About 70% of subjects had histology of endometrioid adenocarcinoma or clear cell carcinoma. Follow-up outcome, available for 61 women, showed a survival rate of 78.7%, recurrence of 9.8%, death of 11.5%. The duration of follow-up had a median of 12 months (interquartile range, 6.75-25 months). Interestingly, over the years of case publication there was a significant inverse correlation with previous history of endometriosis (r = -0.28, p = 0.007), HRT use (r = -0.31, p = 0.006), and previous definitive surgery (r = -0.42, p < 0.001). Conclusions: In the malignant transformation of postmenopausal endometriosis, there are some recurrent clinical conditions: previous endometriosis, major definitive surgery before menopause, and estrogen-only HRT for a relatively long time. However, these clinical conditions have shown a drastic decrease over time. This could likely be the consequence of different attitudes and management of gynecologists linked to up-to-date scientific evidence about the use of major surgery in gynecological pathologies. Malignant transformation of postmenopausal endometriosis is a clinical challenge to be explored further.

Asymptomatic Atypical Hyperplasia and Endometriosis Following Treatment with Tamoxifen: A Case Report and Review of the Literature

BACKGROUND

Tamoxifen may cause proliferative effects in the endometrium. Patients on tamoxifen have an increased risk for endometriosis, but are not routinely screened for this.

CASE

A 49-year-old postmenopausal patient presented for a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy several years after initiating tamoxifen for breast cancer. She had no clinical history to suggest endometriosis, but was found to have extensive pelvic endometriosis intraoperatively with polypoid hyperplasia found on the pathology of the uterine and the ovarian tissue.

CONCLUSION

This is the first case reported of an asymptomatic patient on tamoxifen with a new diagnosis of endometriosis along with atypical hyperplasia in the ectopic tissue. The potential for pre-malignant/malignant transformation may alter the treatment course if identified following tamoxifen exposure.

Endometriosis in the postmenopausal female: clinical presentation, imaging features, and management

Postmenopausal endometriosis is an important clinical entity which is likely under-recognized and in which the Radiologist can play a valuable role. In this review, we describe the clinical presentation and management of postmenopausal endometriosis, appraising the literature and providing case examples. Persons with postmenopausal endometriosis may present with symptoms including pelvic pain or dyschezia, but endometriosis may also be an asymptomatic, incidental finding. Women may or may not have a prior history of endometriosis or a history of symptoms consistent with it. Therapies and conditions which increase exogenous or endogenous estrogen, respectively, increase the risk. Endometriosis can be found in different locations throughout the body, and the possibility of malignancy should be assessed, especially in the postmenopausal population, where age increases cancer risk. Treatment may involve surgery or medical interventions. Guidelines describing appropriate imaging surveillance in these patients are lacking. In the postmenopausal population, Radiologists need to consider endometriosis as a diagnosis, recommend appropriate exams such as MRI and US, and suggest endometriosis-associated malignancies when appropriate, based on classic morphologic features.

Endometriosis in Menopause-Renewed Attention on a Controversial Disease

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

Postmenopausal endometriosis, where are we now?

PURPOSE OF REVIEW

Postmenopausal endometriosis is a gynecologic disease, affecting 2-5% of postmenopausal woman. Current literature assessing the prevalence, pathogenesis, and treatment of this uncommon condition is limited, stressing the necessity for future research. This review examines the current literature on postmenopausal endometriosis to help inform clinical decision-making and point to novel approaches for treatment and management.

RECENT FINDINGS

Although one unifying theory to explain the pathogenesis of endometriotic lesions has not been elucidated, estrogen dependence is central to the pathophysiological process. The total quantity of estrogen production is mediated by multiple enzymes in complex pathways. Recent studies have confirmed the presence of these necessary enzymes in endometriotic lesions thereby suggesting a local source of estrogen and a likely pathogenic contributor. More research is needed to fully elucidate the mechanism of local estrogen biosynthesis; however, the current data provide possible explanations for the presence of postmenopausal endometriosis in an otherwise systemically hypoestrogenic environment.

SUMMARY

All suspected endometriosis lesions should be surgically excised for optimization of treatment and prevention of malignant transformation. If hormone replacement therapy is initiated, combined estrogen and progestin is recommended, even in the setting of previous hysterectomy, given the risk of disease reactivation and malignant transformation of endometriotic lesions. Further research is needed to understand the true prevalence, cause, and progression in this patient demographic. Histologic studies evaluating tissue lesions and peritoneal fluid for estrogen receptors, estrogen metabolizing enzymes, immune cells, and nerve fibers will aide in clinical management and treatment planning.

Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: a systematic review and seven case reports

Background

To review women with symptomatic and clinically progressive endometriosis after menopause in the absence of estrogen intake or excessive systemic endogenous production.

Design

Seven case reports and a systematic review of the literature from 1995 till February 2018.

Results

Only 7 case reports from the authors and 29 cases from the literature described women with either cystic ovarian or deep endometriosis. Severity, symptoms, and localization are highly variable. No case report describes symptomatic superficial typical lesions. In 22 of 36 women (61%), symptoms started more than 10 years after menopause.

Conclusions

Symptomatic and clinically progressive endometriosis after menopause in the absence of increased systemic estrogen concentrations or exogenous estrogen intake starts more than 10 years after menopause in the majority of women. This observation suggests that a genetic and/or epigenetic incident caused estrogen-independent progression, increased sensitivity to estrogens or increased local production of estrogens. This observation is important for understanding the pathophysiology of endometriosis, for the management of postmenopausal endometriosis, and for individualization of medical therapy of endometriosis since estrogen-independent endometriosis growth probably also occurs before menopause.

Polypoid endometriosis mimicking invasive cancer in an obese, postmenopausal tamoxifen user

Background

Tamoxifen is a medication often used for the treatment and prevention of breast cancer. It is classically associated with several gynecological side effects to include a thickened endometrial stripe, increased uterine polyp formation, and an increased risk of uterine cancer. Rarely tamoxifen use has been associated with proliferation of endometriosis often severe enough to mimic a late-stage gynecologic malignancy.

Case

A 62-year-old Gravida 0 postmenopausal female with a medical history of severe obesity, infertility, and preventative tamoxifen use presented for evaluation of gross hematuria. A CT urogram was performed and demonstrated findings concerning for carcinomatosis, likely gynecologic in origin. Cervical cancer screening was up-to-date and she had a negative colonoscopy within the prior 2 years. Serum tumor markers were remarkable only for a mildly elevated CA125 of 37.6. Diagnostic laparoscopy demonstrated apparent operable carcinomatosis limited to the pelvis. The procedure was converted to an exploratory laparotomy, where radical tumor cytoreduction was performed to no gross residual disease. Frozen sections performed intraoperatively were unclear of origin but suggestive of low malignant potential. Final pathology resulted for endometriosis.

Conclusion

This case illustrates a presentation of endometriosis in a postmenopausal woman mimicking advanced mullerian malignancy. The patient's estrogenic state from obesity in combination with the agonist action of the tamoxifen likely contributed to her rare presentation. While findings such as a thickened endometrial stripe are typical of tamoxifen use, such widespread proliferation of endometriosis resulting in a pelvic mass, genito-urinary obstruction, and plaque-like pelvic spread are not.

Précis

Endometriosis is a benign estrogen dependent condition rarely problematic in a postmenopausal patient. Tamoxifen use in the setting of an obese patient may contribute to a proliferation of pre-existing endometriosis which resembles an aggressive late-stage gynecological malignancy.

Expect the unexpected: Endometriosis mimicking a rectal carcinoma in a post-menopausal lady

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

Endometriosis after menopause

Endometriosis is a common but an enigmatic disease in which endometrial glands and stroma are found outside the uterus. Worldwide, 80 million women are affected by the disease. It has generally been accepted as a problem of reproductive ages and affects 6-10% of those women. It is more common in women with infertility. Moreover, since it is an estrogen dependent problem, it is generally believed that endometriosis connotes 'active ovarian function' and is 'healed' after the menopause. However, there are reports on endometriosis beyond the reproductive ages. In this article, endometriosis after the menopause will be discussed.

Transmembrane estrogen receptor GPR30 is more frequently expressed in malignant than benign ovarian endometriotic cysts and correlates with MMP-9 expression

OBJECTIVE

Molecular studies supporting the idea of malignant transformation of endometriosis are sparse and not well substantiated. The aims of this study were to detect expression levels of the novel estrogen-responsive receptor G protein-coupled estrogen receptor 1 GPER, also termed GPR30, and to determine its correlation with matrix metalloproteinase-9 (MMP-9) in benign and malignant ovarian endometriotic cysts and to explore the significance of GPR30.

METHODS

Immunohistochemical staining with the streptavidin-peroxidase method was conducted to determine the expression of GPR30 and MMP-9 in 24 cases of endometriosis-associated ovarian carcinoma (EAOC) and 32 specimens of ovarian endometriosis without malignant transformation. Reverse transcriptase polymerase chain reaction was performed to determine messenger RNA expression of GPR30 and MMP-9 in benign and malignant ovarian endometriotic cysts. We also investigated their associations with known clinic pathological parameters and the interrelationship between the expressions of the 2 proteins.

RESULTS

The positive staining ratio of GPR30 was 95.8% (23/24) in EAOC cases, and the HScore was 268; whereas the positive ratio was 25% (8/32) in benign endometriotic cysts, and the Hscore was 95. Matrix metalloproteinase-9 was expressed in all 24 EAOC cases and 87.5% (28/32) of the benign samples, and the Hscores were 280 and 260, respectively (P > 0.05). The receptor GPR30 was significantly higher in EAOCs than in benign endometriotic cysts (P < 0.05). The expression of GPR30 messenger RNA was also significantly higher in malignant ovarian endometriotic cysts than in the benign group. The receptor GPR30 was positively related to tumor size, tumor stage, and lymph node metastasis. A positive relationship between GPR30 and MMP-9 was found (P = 0.002).

CONCLUSIONS

The results suggest that the abnormal expression of GPR30 may be involved in malignant transformation, invasion, and metastasis of EAOCs. Testing of GPR30 expression levels may present both diagnostic and therapeutic options for the treatment of ovarian malignancies.

[Ureteral endometriosis in estrogen-treated postmenopausal woman]

A 56-year-old woman was admitted to our hospital due to gross hematuria. Cystoscopy and contrast-enhanced abdominal CT scan revealed a solid tumor at the right terminal ureter. She underwent transurethral resection of the right ureteral tumor. The ureteral tumor included proliferative endometrial stroma and glands under urothelial cells, and the histopathological diagnosis was ectopic endometriosis. Before the surgery, the patient had underwent hormone replacement therapy using estrogen patches to treat menopausal disorders, however, the dose of estrogen was five times higher than regular dose. Therefore, in this case, the serum level of estrogen was elevated over the normal value. Ectopic endometriosis is rare in urinary tract especially ureter. Furthermore, endometriosis is an uncommon disease in women during postmenopausal period. Our case suggests that an excessive hormone replacement therapy might cause endometriosis in postmenopausal women.

Endometriosis: associations with menopause, hormone replacement therapy and cancer

Endometriosis is an estrogen-dependent condition and is characterized by the presence of ectopic endometrial tissue. The pathogenesis of this condition remains an enigma. Endometriosis has well known associations with menopause both in terms of secondary outcomes from medical and surgical therapy in premenopausal women, as well as a natural occurrence/recurrence of the disease in women going through menopause naturally. This review article aims to discuss the current day modalities of management of endometriosis with their pros and cons especially in the context of menopause and cancer.

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

INTRODUCTION

The prevalence of pelvic endometriosis is high, affecting approximately 6% to 10% of women of reproductive age. Although endometriosis has been associated with the occurrence of menstrual cycles, it can affect between 2% to 5% of postmenopausal women.

CASE PRESENTATION

We present a case of ovarian endometriosis in a 62-year-old Spanish Caucasian woman with no previous use of hormonal therapy and no history of endometriosis or infertility.

CONCLUSION

ALTHOUGH THE REPORTED SITUATION IS RARE, IT IS IMPORTANT TO BE AWARE OF ENDOMETRIOSIS AFTER THE MENOPAUSE: post-menopausal endometriosis confers a risk of recurrence and malignant transformation.

Endometrioid adenocarcinoma arising from endometriosis of the uterine cervix: a case report

Endometrioid adenocarcinoma arising from endometriosis of the uterine cervix is rare in premenopausal woman. We describe here a patient with this condition and review the clinical and pathological features of these tumors. A 48-yr-old woman complaining of severe dysmenorrhea was referred for investigation of a pelvic mass. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Histological examination revealed an endometrioid adenocarcinoma directly adjacent to the endometriosis at the uterine cervix, with a transition observed between endometriosis and endometrioid adenocarcinoma. The patient was diagnosed as having endometrioid adenocarcinoma arising from endometriosis of the uterine cervix and underwent postoperative chemotherapy. Gynecologists and pathologists should be aware of the difficulties associated with a delay in diagnosis of endometrioid adenocarcinoma arising from endometriosis when the tumor presents as a benign looking endometrioma.

Endometrial Stromal Sarcoma Development after Hysterectomy and Tamoxifen Therapy

Tamoxifen therapy is well known for its success in adjuvant therapy for breast carcinoma; however, despite its benefits, the agents’ estrogenic influence on the uterus, and subsequent endometrial cell proliferation may result in development of invasive uterine tumors. It has been estimated that tamoxifen may increase the risk of endometrial-based cancer two- to threefold, but uterine sarcomas remain relatively rare, accounting for 2 to 5 per cent of all uterine malignancies. We report the case of a 72-year-old woman having received tamoxifen for a breast carcinoma and having a hysterectomy nearly 30 years prior who presented with an intra-abdominal, omentum-based mass that on excision was identified as an endometrial stromal sarcoma.

Pelvic endometriosis is rarely associated with ovarian borderline tumours, cytologic and architectural atypia: a clinicopathologic study

Endometriotic foci, especially ovarian ones, with epithelial cytologic atypia may be precursors of cancer. This study presents an overview of the atypical cytological and histopathological findings associated with endometriosis. Six cases of endometriosis, with atypical histological and cytological changes, were obtained from the archives of the Department of Pathology at Cleveland Clinic Foundation between year 2000 and 2003. The size of the base from which these cases were drawn was 2000 cases of endometriosis. The age range of the patients was from 29 to 52 years. The clinical presentations included infertility (three cases), pelvic pain (three cases), adenexal and pelvic masses (four cases). Stage IV endometriosis with extensive pelvic involvement was found in two patients. Intraoperatively, the endometriotic lesions involved the ovaries (all cases); Cul de sac (four cases); urinary bladder (two cases); sigmoid colon, hemidiaphragms, and uterine vessels (one case each). The endometriotic lesions were associated with uterine leiomyomas (two patients) and adenocarcinoma of the vagina (one patient). Histologically, in addition to endometrial type glands and stroma, usually found in endometriosis, we observed both cytologic and pattern atypism involving the epithelium in all cases. The features of cytologic atypia included nuclear stratification, hyperchromatism, and pleomorphism. The features of pattern atypia were complex glandular pattern, papillary formations and psammoma bodies. In two cases, these features were sufficient for diagnosis of borderline Mullerian seromucinous tumours. One patient had recurred with metastatic adenocarcinoma of the vault. She died later from disseminated metastatic disease. There is a rare association between pelvic endometriosis and borderline ovarian tumours (three cases), cytologic and pattern atypia (two cases); mesothelial hyperplasia, endosalpingiosis (two cases), and metastasis (one case). Cytologic and pattern atypia can develop in the endometriotic foci and therefore, these lesions should be thoroughly scrutinized for presence of these changes. Our findings recommend surgical excision of these foci rather than their simple cauterization.

An Unexpected Presentation of Endometriosis – A “Parasitic” Cyst of the Bowel in a Menopausal Woman on Hormone Therapy

Introduction: This report describes a “parasitic” endometriotic cyst of the small bowel. Clinical Picture: A menopausal woman with a pelvic mass presenting years after commencing hormone therapy. Treatment: We performed laparoscopic excision of a cystic tumour attached to the small bowel with a solitary vascular pedicle. Outcome: Histology confirmed it to be an endometriotic cyst of ovarian origin, probably resulting from spillage during previous surgery and reactivation with hormone therapy. Conclusions: We discuss the possible aetiology of this unusual presentation of endometriosis and review the literature on parasitic gynaecological tumours. Key words: Menopause

Primary Endometrioid Adenocarcinoma of the Vagina

Vaginal adenocarcinoma is the second most common primary cancer of the vagina, yet there has been very little study of most subtypes other than clear cell carcinoma. We reviewed 18 cases of primary vaginal endometrioid adenocarcinoma, in our experience the second most common subtype. The patients ranged from 45 to 81 years of age (mean 60). Most presented with vaginal bleeding, and had had a prior hysterectomy. Five had a history of unopposed estrogen therapy but none had a history of intrauterine diethylstilbestrol exposure. The tumors were at the vaginal apex in 10 cases, in the posterior wall in 3, the lateral wall in 3, and the anterior wall in 1. On microscopic examination, each of the tumors had a pure or predominant component of typical endometrioid adenocarcinoma. There was squamous metaplasia in 4 cases, mucinous metaplasia in 4, and prominent nonvillous papillae in 2. The tumors were grade 1 of 3 in 4 cases, grade 2 in 13, and grade 3 in 1. Eleven cases were FIGO stage I, 5 stage II, and 2 stage IV. Vaginal endometriosis was identified in 14 cases, and is important in indicating a primary vaginal tumor, rather than secondary spread from the endometrium. Other subtypes of adenocarcinoma (such as serous when the tumor has a papillary pattern) and atypical forms of endometriosis, including polypoid endometriosis, are the most common other differential diagnostic considerations. The prognosis seems to be good in low-stage patients, with 11 patients alive and well and 2 alive with recurrent disease.

Endometriosis as a model for inflammation–hormone interactions in ovarian and breast cancers

Chronic inflammation has been implicated in a variety of cancers. In this review, we consider associations between endometriosis and cancers both local (ovarian) and distant (breast). We review the epidemiological data linking endometriosis to ovarian and breast cancers. We then consider evidence for a role for sex steroid hormones and for inflammation in the aetiology of each of these cancers. Finally, we consider that endometriosis may promote alterations in sex steroid hormones and inflammatory mediators. A possible explanation for the association between endometriosis and these reproductive cancers may then be local and systemic enhancement of aberrant inflammatory and hormonal mediators. If this hypothesis is true, endometriosis may need to be considered as a risk factor for ovarian and breast cancers, triggering increasingly intensive surveillance. Moreover, treatments for endometriosis may require consideration of the impact on long-term cancer risk.

Association between endometriosis and cancer: a comprehensive review and a critical analysis of clinical and epidemiological evidence

OBJECTIVE

This review was aimed to critically evaluate observational, cohort, and case-control studies performed so far in order to assess the association between endometriosis and malignant diseases. Based on the observations herein presented, clinical indications that might avoid physicians' mismanaging of affected patients are proposed.

METHODS

Search strategies included online searching of the MEDLINE database and hand searching of relevant publications and reviews. Additional reports were collected by systematically reviewing all references from retrieved papers.

RESULTS

Endometriosis is not associated with an increased risk of cancer in general. Data from large cohort and case-control studies indicate an increased risk of ovarian cancers in women with endometriosis. The observed effect sizes are modest varying between 1.3 and 1.9. Evidence from clinical series consistently demonstrates that the association is confined to the endometrioid/clear-cell histotypes. Available studies are characterized by several limitations, some of which potentially bias results towards the null hypothesis whereas others leading to overestimate the association. Evidence for an association with melanoma and non-Hodgkin's lymphoma is increasing but still to be verified whereas an increased risk for other gynecological cancer types is not supported.

CONCLUSIONS

Epidemiological findings on the association between endometriosis and cancer are still elusive. At present, endometriosis should not be considered a medical condition associated with a clinically relevant risk of any specific cancer. On the basis of the present findings, modifications of the standard treatment options for the disease are not justifiable.

Endometrial thickness of postmenopausal breast cancer patients treated with tamoxifen

The effect of administration time of tamoxifen was assessed in 52 postmenopausal patients with mammary cancer in order to evaluate its effect on endometrium and serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estradiol. Mean age of the patients was 61.5 years, 23% had a history of smoking, mean body mass index (BMI) was 26.9 kg/m(2), and mean age at menarche, menopause and administration time of tamoxifen was 12.9, 48 and 3.5 years, respectively. Serum FSH and LH concentrations were decreased by 41.8% and 44.9%, respectively, compared with mean normal postmenopausal levels. The FSH decrement was associated with BMI and LH level, whereas the LH decrement was associated with patient age and FSH concentration. Endometrium thickness <5 mm was reported in 60.5% of the patients, while endometrium thickness >/=5 mm was found in 39.5% of the cases. Histology revealed that 75% of the patients had atrophic endometrium; the remaining patients (25%) did not show atrophic changes. Administration time of tamoxifen was not associated with endometrial thickness or with serum FSH and LH concentrations.

Recent Advances in Endometriosis With Emphasis on Pathogenesis, Molecular Pathology, and Neoplastic Transformation

This article reviews recent advances in our understanding of endometriosis with special reference to its pathogenesis, recent molecular studies, and relationship to neoplasia. Pathogenetic factors include familial predisposition, immunological factors, cell adhesion factors, angiogenic factors, and hormonal factors. Recent molecular findings in endometriosis include the monoclonality of endometriotic cysts and loss of heterozygosity in the majority of cases associated with adenocarcinoma. Women with a long-standing history of endometriosis have an increased risk of ovarian cancer, most commonly endometrioid and clear cell adenocarcinomas. In these cases, there is a high frequency of atypia in the endometriosis, and the endometriosis and the associated ovarian carcinoma may show identical PTEN mutations.