Case Of Endometriosis Research Articles

Proteomic analysis of peritoneal fluid identified COMP and TGFBI as new candidate biomarkers for endometriosis

Endometriosis is a common non-malignant gynecological disease that significantly compromises fertility and quality of life of the majority of patients. The gold standard for diagnosis is visual inspection of the pelvic organs by surgical laparoscopy and there are no biomarkers that would allow non-invasive diagnosis. The pathogenesis of endometriosis is not completely understood, thus analysis of peritoneal fluid might contribute in this respect. Our prospective case–control study included 58 patients undergoing laparoscopy due to infertility, 32 patients with peritoneal endometriosis (cases) and 26 patients with unexplained primary infertility (controls). Discovery proteomics using antibody microarrays that covered 1360 proteins identified 16 proteins with different levels in cases versus the control patients. The validation using an ELISA approach confirmed significant differences in the levels of cartilage oligomeric matrix protein (COMP) and transforming growth factor-β-induced protein ig-h3 (TGFBI) and nonsignificant differences in angiotensinogen (AGT). A classification model based on a linear support vector machine revealed AUC of > 0.83, sensitivity of 0.81 and specificity of 1.00. Differentially expressed proteins represent candidates for diagnostic and prognostic biomarkers or drug targets. Our findings have brought new knowledge that will be helpful in the understanding of the pathophysiology of endometriosis and warrant further studies in blood samples.

Vulvar Endometriosis by Suspected Spread Via the Round Ligament

Study Objective To present a rare case of vulvar endometriosis by suspected spread through the round ligament and review the literature regarding vulvar endometriosis. Design Case report. Setting Tertiary care hospital. Patients or Participants One patient. Interventions Patient with a painful 4 × 3 cm well-circumscribed, subcutaneous mobile mass on the left labia majora deep in the subcutaneous tissue with no overlying skin changes was worked up with CT-guided IR core biopsy that revealed endometriosis. Pelvic MRI revealed a fibroid uterus and 3.8 × 2.6 × 3.1 cm infiltrative soft tissue mass within the left mons pubis extending into the superior aspect of the left labia majora. The mass was noted to be contacting the distal aspect of the round ligament with resultant cyst in the canal of Nuck. Patient underwent laparoscopic myomectomy and local excision of the left vulvar mass for management. Measurements and Main Results Operative findings were consistent with endometrioma in the left vulva and endometriotic implant on the left round ligament at the insertion site into the inguinal canal. Pathology of both the left vulvar mass and excised left round ligament lesion revealed endometriosis. We suggest direct spread via the round ligament as the source of patient's vulvar endometriosis given these findings. Conclusion Spontaneous perineal and vulvar endometriosis is extremely rare, but in cases of clinically suspected vulvar endometriosis, the round ligament should be considered as the potential route of disease spread. Endometriosis should be suspected in extrapelvic lesions with observed cyclic response to the menstrual cycle and considerations should be given for diagnostic laparoscopy to look for pelvic disease in these cases. To present a rare case of vulvar endometriosis by suspected spread through the round ligament and review the literature regarding vulvar endometriosis. Case report. Tertiary care hospital. One patient. Patient with a painful 4 × 3 cm well-circumscribed, subcutaneous mobile mass on the left labia majora deep in the subcutaneous tissue with no overlying skin changes was worked up with CT-guided IR core biopsy that revealed endometriosis. Pelvic MRI revealed a fibroid uterus and 3.8 × 2.6 × 3.1 cm infiltrative soft tissue mass within the left mons pubis extending into the superior aspect of the left labia majora. The mass was noted to be contacting the distal aspect of the round ligament with resultant cyst in the canal of Nuck. Patient underwent laparoscopic myomectomy and local excision of the left vulvar mass for management. Operative findings were consistent with endometrioma in the left vulva and endometriotic implant on the left round ligament at the insertion site into the inguinal canal. Pathology of both the left vulvar mass and excised left round ligament lesion revealed endometriosis. We suggest direct spread via the round ligament as the source of patient's vulvar endometriosis given these findings. Spontaneous perineal and vulvar endometriosis is extremely rare, but in cases of clinically suspected vulvar endometriosis, the round ligament should be considered as the potential route of disease spread. Endometriosis should be suspected in extrapelvic lesions with observed cyclic response to the menstrual cycle and considerations should be given for diagnostic laparoscopy to look for pelvic disease in these cases.

Primary Umbilical Endometriosis: A Systematic Literature Review

Study Objective To determine the characteristics of primary umbilical endometriosis. Design Systematic literature review from 2007-2020. Setting N/A. Patients or Participants Literature was reviewed via PubMed, EMBASE, and Web of Science for case reports of primary umbilical endometriosis using search terms “umbilical” and “endometriosis: from 2007-2020. Results were limited to articles published in English. Interventions No intervention was performed. Measurements and Main Results Three hundred and fifty-two articles were returned. Ninety-three case reports met inclusion criteria and 104 individual patient cases of primary umbilical endometriosis were identified. The mean age of presentation was 36.8 (±7.8) and the majority were nulliparous (55% vs 45%). he time to presentation from first symptoms varied widely from 3 days to 240 months with an average of 12 months. There were 8 patient who presented from 120-240 months. Forty three percent of patients reported dysmenorrhea and 26% reported pelvic pain. Sixty one percent had previously used hormonal contraception. Mass characteristics are presented in table 2. Ninety seven percent presented with a mass, 86 percent with pain, and 64% with bleeding or discharge. Color was variable with 38% brown, 24% red, 13% blue, 10% normal skin tone, 8% black, and 7% purple. Discharge was present in 62% with 60% of the cohort having bleeding. On average, lesions were 1-1.5cm and 61% invaded the umbilical fascia. Correlations between age, time to presentation, mass size, and presence of bleeding were evaluated. Time to presentation and mass dimension 1 were positively correlated (N=96, Spearman correlation coefficient=0.16, p=0.128) as were age and mass dimension 2 (N=42, Spearman correlation coefficient=0.29, p=0.059). Conclusion Primary umbilical endometriosis is not uncommon. There are no significant correlations between age, time to presentation, mass size and bleeding. Primary umbilical endometriosis should be in the differential diagnosis of patients presenting with umbilical pain, mass, or bleeding. To determine the characteristics of primary umbilical endometriosis. Systematic literature review from 2007-2020. N/A. Literature was reviewed via PubMed, EMBASE, and Web of Science for case reports of primary umbilical endometriosis using search terms “umbilical” and “endometriosis: from 2007-2020. Results were limited to articles published in English. No intervention was performed. Three hundred and fifty-two articles were returned. Ninety-three case reports met inclusion criteria and 104 individual patient cases of primary umbilical endometriosis were identified. The mean age of presentation was 36.8 (±7.8) and the majority were nulliparous (55% vs 45%). he time to presentation from first symptoms varied widely from 3 days to 240 months with an average of 12 months. There were 8 patient who presented from 120-240 months. Forty three percent of patients reported dysmenorrhea and 26% reported pelvic pain. Sixty one percent had previously used hormonal contraception. Mass characteristics are presented in table 2. Ninety seven percent presented with a mass, 86 percent with pain, and 64% with bleeding or discharge. Color was variable with 38% brown, 24% red, 13% blue, 10% normal skin tone, 8% black, and 7% purple. Discharge was present in 62% with 60% of the cohort having bleeding. On average, lesions were 1-1.5cm and 61% invaded the umbilical fascia. Correlations between age, time to presentation, mass size, and presence of bleeding were evaluated. Time to presentation and mass dimension 1 were positively correlated (N=96, Spearman correlation coefficient=0.16, p=0.128) as were age and mass dimension 2 (N=42, Spearman correlation coefficient=0.29, p=0.059). Primary umbilical endometriosis is not uncommon. There are no significant correlations between age, time to presentation, mass size and bleeding. Primary umbilical endometriosis should be in the differential diagnosis of patients presenting with umbilical pain, mass, or bleeding.

Endometriosis Affecting the Base of Appendix and the Middle Rectal Artery: A Case Report

Study Objective To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Design Case report for anatomical study and description of the procedure using video. Setting Tertiary Hospital. Patients or Participants A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. Interventions We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Measurements and Main Results Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. Conclusion We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix. To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Case report for anatomical study and description of the procedure using video. Tertiary Hospital. A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix.

Suburethral Endometriosis as a Clinical Finding of Extensive Disease - a Case Report and Review of Literature

Study Objective Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Design Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Setting Video laparoscopy, hysteroscopy and cystourethroscopy were performed. Patients or Participants A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Interventions Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Measurements and Main Results Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Conclusion Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions. Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. Our objective is to present a case of primary vaginal suburethral endometriosis and a literature review of the only 4 previously published suburethral endometriosis cases. Case report and literature review using key words: urethral endometriosis, suburethral endometriosis and urethral diverticulum. Video laparoscopy, hysteroscopy and cystourethroscopy were performed. A 31-year-old patient who presented with chronic pelvic pain that worsened with menstruation, dyspareunia and dysuria. Physical exam revealed a 2 cm suburethral bluish cystic-appearing lesion. Her exam was also significant for enlarged, tender uterus and adnexa. Based on examination and imaging, adenomyosis and endometriosis were suspected. Surgical excision of a 2 cm suburethral lesion revealing a chocolate like material with a fibrocystic wall adherent to the paraurethral tissue with no urethral muscularis invasion. Cystourethroscopy examination revealed no evidence of mucosal involvement of the urethra and no evidence of bladder endometriosis. Laparoscopic treatment of endometriosis was performed with pelvic sidewall and rectovaginal dissection with vaporization, excision of endometriotic lesions and restoration of the anatomy. There was one enlarged presacral lymph node that was excised and was positive for endometriosis on frozen section. A wedge cytoreductive resection of fundal adenomyotic lesion was performed without cavity penetration. The uterus was reconstructed in multiple layers with absorbable polyglactin 910 sutures. Surgical evaluation revealed extensive endometriosis with lymph node involvement at laparoscopic exploration. Suburethral endometriotic lesion was excised confirmed to be endometriosis by histopathology. Dysuria and dyspareunia symptoms completely resolved, and her pelvic pain markedly improved after the surgery. Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination, surgical excision and laparoscopic evaluation when identifying suburethral vaginal endometriotic lesions.

Evaluation of Plasma MMP-9 and VEGF-A mRNAs as Non-invasive Diagnostic Biomarkers in Women with Endometriosis

Background: Endometriosis is one of the common gynecological diseases and can lead to pelvic pain, dysmenorrhea, dyspareunia, and infertility in women. Thus, accurate and early diagnosis is a pivotal issue and an essential need for managing this disorder. At the present, the gold standard diagnostic method for endometriosis is laparoscopic surgery that is an invasive method and can lead to delay in diagnosis. Thus, there is an immediate necessity to search for non-invasive diagnostic biomarkers, such as blood-based ones. Objectives: Matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor-A (VEGF-A) have essential roles in the pathogenesis of endometriosis. Therefore, in this study, we evaluated the plasma mRNA levels of MMP-9 and VEGF-A, as potential non-invasive diagnostic biomarkers for endometriosis. Methods: This study included 48 women (24 cases and 24 controls) who underwent laparoscopy for suspected endometriosis. Preoperative plasma samples were collected, and after RNA extraction, the levels of MMP-9 and VEGF-A mRNAs were determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Results: Plasma MMP-9 mRNA level was statistically higher in endometriosis patients compared with the control group (P value = 0.01). However, plasma VEGF-A mRNA level did not show a significant difference between the two groups (P value =0.5). Conclusions: It seems that the plasma level of MMP-9 mRNA in endometriosis patients is significantly higher than in non-endometriosis women. This finding can provide new insights regarding this mRNA’s applicability as a non-invasive diagnostic biomarker for discovering new cases of endometriosis (newly diagnosed). According to our results, despite the suggested role of VEGF-A in endometriosis pathogenesis, it seems that the plasma level of VEGF-A mRNA does not have the potential to be used as a non-invasive diagnostic biomarker.

Deep Endometriosis: An Anatomical Challenge - Unraveling and Restoring Anatomy

<h3>Study Objective</h3> Demonstrate a complex case of deep endometriosis, with the restoration of the pelvic anatomy and identification of important anatomical landmarks. <h3>Design</h3> Sequential demonstration of deep endometriosis treatment with narrated video footage <h3>Setting</h3> Deep endometriosis is defined as endometriosis infiltrating more than 5 mm of the peritoneum, and should be suspected in women presenting dysmenorrhea, chronic pelvic pain, deep dyspareunia and intestinal symptoms. In most of the cases, deep endometriosis requires surgical treatment. However, in the majority of these cases there are anatomic distortion due to its severity. Therefore, the anatomical knowledge and the surgeon experience is fundamental for the success of the surgery. <h3>Patients or Participants</h3> Female 47-years old patient. <h3>Interventions</h3> The patient underwent Total Laparoscopic Hysterectomy with bilateral salpingoophorectomy, linear rectosigmoidectomy and excision of deep endometriosis. During the surgery a fundamental step to safely perform the surgery was to identify the ureter, hypogastric plex nerves, splanchnic nerves and the iliac artery. <h3>Measurements and Main Results</h3> The patient progressed with complete remission of the pelvic pain. She returned to sexual activity with light dyspareunia (VAS 2/10). <h3>Conclusion</h3> Endometriosis is a challenging disease, as it determines important anatomical distortion in severe form. It requires surgeons experience and knowledge of the pelvic anatomy to obtain a satisfactory surgical result.

Isthmocele Endometriosis- the Relationship between Cesarean Section and Endometriosis.

<h3>Study Objective</h3> We present a unique case of diffuse peritoneal endometriosis following cesarean section, involving the cesarean scar isthmocele and associated with secondary infertility, failed embryo transfers, and progressive pelvic pain. <h3>Design</h3> Case report of endometriosis within an isthmocele membrane and concomitant peritoneal endometriosis. <h3>Setting</h3> A combined hysteroscopic and laparoscopic approach in lithotomy position. <h3>Patients or Participants</h3> A 44-year-old patient with three prior cesarean-sections and a laparoscopic appendectomy, in none of which, endometriosis was visualized. She presented with dysmenorrhea, dyspareunia, and recurrent embryo transfer failures. The progressively debilitating symptoms started 14 years ago, shortly after her last cesarean-section. MRI and ultrasound demonstrated a retroverted uterus and a prominent, thin, fluid filled, cesarean scar defect. <h3>Interventions</h3> A combined hysteroscopic and laparoscopic approach was performed. Indocyanine green dye was used to identify the bladder borders and methylene blue was added to the hysteroscopy irrigation solution to create contrast. A wide excision of the isthmocele was performed followed by a three-layer closure and excision of all apparent peritoneal lesions using the AquaBlue contrast technique (ABCt™). <h3>Measurements and Main Results</h3> In the pathological assessment, multiple foci of endometriosis were identified within the isthmocele membrane, clearly differentiated from intrauterine endometrial tissue. Additionally, all seven excised peritoneal specimens contained peritoneal endometriosis. Two weeks following the procedure, transvaginal sonographic scan confirmed thick anterior uterine wall, and the patient reported only minor discomfort with almost complete resolution of her symptoms. <h3>Conclusion</h3> This case demonstrates endometriosis within the isthmocele membrane, with concomitant symptomatic peritoneal endometriosis. We propose a laparoscopic isthmocele excision technique with three-layer reconstruction, and peritoneal endometriosis excision using methylene blue contrast. We suggest a possible link between isthmocele and endometriosis and emphasize the need for wide excision of the isthmocele margins and maintaining clean borders, given the possibility of endometriosis within the isthmocele, which might be a cause or a contributor to the tissue weakness and isthmocele formation.

7 Golden Steps of Surgery for Endometriosis – a Simplified Approach to Difficult Cases of Endometriosis

<h3>Study Objective</h3> to assess the feasibility, benefits, ease of doing and repetitiveness of all 7 steps designed. <h3>Design</h3> this study was a prospective study. <h3>Setting</h3> patient laid in dorsal lithotomy position with reverse Trendelenburg position. <h3>Patients or Participants</h3> we had selected 10 patients diagnosed with endometriosis. TVS is chosen as a preferred diagnostic tool. <h3>Interventions</h3> fixed 7 steps followed in all cases. 1. <b>Mobilisation of sigmoid colon</b>- adhesions of sigmoid colon with lateral pelvic wall were released. 2. <b>identifying the left ureter</b>- open the retroperitoneum near to the ureter, identify & follow it till it enters into the tunnel. 3. <b>Dissection into the left pararectal space</b>- dissect into the left pararectal space till the base of uterosacral ligament [USL]. Identify the hypogastric nerve here. 4. <b>identifying the right ureter –</b> same as step 2. 5. <b>Dissection into the right pararectal space –</b> same as step 3. 6. <b>Dissection of rectum into POD –</b> pull the rectum cranially and dissect between the two layers of Denonvilliers fascia into the POD. 7. <b>Excision of endometriotic nodules or cyst-</b> take out any nodules present with involved peritoneum. <h3>Measurements and Main Results</h3> in this study, all patients operated with success without any injury to any vital structure, taking out all endometriotic tissue with increasing ease of doing consequently. average operating time was 130.6minutes and average blood was 100.5ml. patient allowed orally after 6 to 12 hours of surgery, average stay in post-operative period was 36 hours. <h3>Conclusion</h3> if we follow these 7 steps properly during surgery, we can definitely avoid unintended injury to ureter and rectum, fellow colleagues can learn the technique easily and reproducible nature of these steps make it more operator friendly. Further studies needed to be followed by masses.

Efficacy of mifepristone and GnRH-a in patients with endometriosis after operation

Objective: The effect of mifepristone and GnRH-a on patients with endometriosis after operation. Methods: 100 cases of endometriosis treated by laparoscopic surgery in our hospital from May 2017 to October 2019 were divided into GnRH-a group (34 cases), mifepristone group (33 cases) and non-drug group (33 cases) according to the numerical random method, and the treatment effect of the three groups was compared. Result: After the drug treatment, the cumulative recurrence rate of non misoprostone group and GnRH-a group was 18.18% and 21.21%, P &gt; 0.05 between the two groups, and 33.33% between the two groups, P &lt; 0.05. After treatment, FSH, LH and other hormone indexes in mifepristone group were compared with those before treatment (P &gt; 0.05), while E2 levels were compared with those before treatment (P &lt; 0.05); FSH, LH, E2 levels in GnRH-a group were compared with those before treatment (P &lt; 0.05), and those in mifepristone group were compared with those after treatment (P &lt; 0.05). After treatment, the complete remission rate of the patients in the non misoprostone group and the GnRH-a group were 51.52% and 55.88%, respectively, P &gt; 0.05 for the comparison between the groups, and 36.36% for the comparison between the patients in the non misoprostone group and the GnRH-a group, P &lt; 0.05 for the comparison between the two groups. There was no significant difference between the two groups (P &gt; 0.05). Conclusion: Mifepristone and GnRH-a have good effect on patients with endometriosis after operation. They can effectively reduce the recurrence rate and adverse reactions after EMT.

Early identification of women with endometriosis by means of a simple patient-completed questionnaire screening tool: a diagnostic study

To assess the value of a self-completed questionnaire based on patients' verbal descriptors of pelvic painful symptoms to identify women with endometriosis. Prospective 1:2 nonmatched case-control study. Three French endometriosis referral centers. Endometriosis cases were women aged 18-45 years with endometriosis confirmed by histology. Controls were as follows: asymptomatic women attending a gynecologic consultation for routine examination; women without evidence of endometriosis consulting for pain/infertility; and population-based controls from the same urban locations. All women completed the 21-item yes/no questionnaire about painful symptoms. The area under the receiver operating characteristic curve of the full question set model based on binary logistic regression and the diagnostic accuracy of low- and high-risk classification rules based on selected threshold of the prediction model. We included 105 cases and 197 controls (45 asymptomatic consultation-based controls, 66 women without endometriosis consulting for pain/infertility, and 86 population-based controls). The full question set prediction model, including age, had an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.87-0.95) after internal validation. The high-risk classification rule had a specificity of 98.0% and a positive likelihood ratio of 30.5. The low-risk classification rule had a sensitivity of 98.1% and a negative likelihood ratio of 0.03. For a hypothesized pretest prevalence of 10%, the high- and low-risk prediction rules ascertained endometriosis with posttest probability rates of 77.2% and 0.3%, respectively. A self-completed patient-centered questionnaire can identify women at low or high risk of endometriosis with a high diagnostic accuracy and, thus, may help early identification of women with endometriosis.

Primary umbilical endometriosis – A rare presentation of cutaneous endometriosis

Primary umbilical endometriosis is a rare condition with an overall incidence of around 0.5% to 1% among all the endometriosis cases, but at times it poses a diagnostic dilemma. In our institution we encountered a case of primary umbilical endometriosis presented to multiple surgical speciality departments. A prompt clinical examination with surgical biopsy was the key tool which lead to the diagnosis and providing a complete cure for the patient. Pelvic endometriosis affects 5-10% of women in the child bearing age group. The most pronounced symptoms are dyspareunia, pelvic pain, and infertility. Clinical presentations of umbilical endometriosis are as a nodule with or without associated umbilical pain and bleeding. This patient was given primary hormonal therapy and later underwent a biopsy which paved way for an accurate diagnosis of primary umbilical endometriosis. In this case of umbilical swelling, conditions like a benign nevus, lipoma, abscess, cyst, hernia, as well as metastatic deposit from a systemic malignancy were considered in the clinical differential diagnosis. However surgical excision helped us arrive at a definitive diagnosis and cure for the patient.

Markedly Raised Ca-125 In A Case of Bilateral Ovarian Endometriosis Mimicking Ovarian Cancer: A Case Report

We report a case of bilateral endometriosis with very high Serum CA 125 levels who presented with pain abdomen. Intra operative finding suggestive of stage IV endometriosis which finally proved in histopathological report. We conclude that very high CA 125 may not be always indicative of ovarian cancer.

ISTHMOCELE ENDOMETRIOSIS- THE RELATIONSHIP BETWEEN CESAREAN SECTION AND ENDOMETRIOSIS

We present a unique case of diffuse peritoneal endometriosis following cesarean section, involving the cesarean scar isthmocele and associated with secondary infertility, failed embryo transfer, and progressive pelvic pain.

28321 Cutaneous endometriosis of the umbilicus

Cutaneous endometriosis is a rare disorder characterized by the presence of endometrial glands and/or stroma in the skin. Endometriosis most commonly affects pelvic organs in women of reproductive age. Symptoms often include dysmenorrhea and deep pelvic pain but will vary depending on the location. Endometriosis of an extrapelvic site represents less than 1% of all cases of endometriosis. The most common presentation of cutaneous endometriosis is a nodule on the umbilicus, which can be classified as primary or secondary based on the absence or presence of abdominopelvic surgical history, respectively. While a majority of the nodules are benign, there is potential for malignant transformation. In a literature review, 61 cases of primary umbilical endometriosis were found from the period of 2000 to 2020. This case reports on a 42-year-old multiparous woman who presented with a 6-year history of a nodule on the umbilicus measuring 2.2 cm in diameter. She was diagnosed with endometriosis 7 years prior after episodes of dysmenorrhea, and subsequently underwent an endometrial ablation. Both of her children were delivered vaginally, and she had no history of abdominopelvic surgery. She reported that the nodule would swell in a cyclical manner every 3-4 months, associated with intense pain but no bleeding or discharge. Upon histopathologic examination of the nodule, the patient was diagnosed with cutaneous endometriosis. No malignant cells were detected. The nodule was removed by complete excision, and she was referred for gynecological examination.

A rare case of left Nuck’s canal cystic endometriosis: Computed Tomography findings

Introduction:Endometriosis is a common and chronic gynaecological condition but the implant in the canal of Nuck constitutes a very unusual state with an estimated prevalence of 0.3%–0.6% of all endometriosis cases. The canal of Nuck is an abnormal patent pouch of parietal peritoneum extending anteriorly from the round ligament of the uterus into the labia majora, thus represents a communication between the peritoneal cavity and the female inguinal canal. This condition may permit the seeding of endometriotic tissue in the inguinal soft tissues, becoming a possible cause of inguinal swelling or pain.Case description:A 43-years-old woman presented with painful swelling in her left groin. Ultrasound and a subsequent pelvic computed tomography showed a cystic lesion as for a Nuck’s canal encysted hydrocele. The patient underwent an anterior open surgery and the histologic examination revealed an endometrium-like tissue in the cystic wall.Conclusion:In women presenting with painful swelling of the groin, despite its rarity, endometriosis of the Nuck’s canal must be differentiated from other more common pathologies like hernias, varicoceles, neoplasms, and lymphadenopathies. Imaging can aid in differential diagnosis, but the final diagnosis is entrusted to histology, which enable to exclude an underlying malignancy.

P–292 Transcriptome signature of receptive endometrium is not affected by the presence of mild adenomyosis

Abstract Study question Does the presence of mild adenomyosis, a common acquired uterine anomaly, affect the endometrial gene expression levels during window of receptivity? Summary answer Mild adenomyosis has no significant influence on gene expression signature in the window of implantation (WOI). What is known already The improvements in imaging techniques have led to frequent detection of adenomyosis in women undergoing investigations for infertility. Although the data are conflicting, some clinical studies have shown that the presence of adenomyosis may interfere with embryo implantation and lead to poor pregnancy outcomes. The knowledge of molecular background that would lead to the phenomenon of altered endometrial receptivity in women with adenomyosis is limited and mainly demonstrated by selected candidate genes. Next-generation sequencing platforms enable genome-wide transcriptomic profiling of desired tissue samples and present a powerful tool to identify differentially expressed genes (DEGs) between women with adenomyosis and controls. Study design, size, duration We designed a prospective case-control study comparing women with sonographic evidence of mild adenomyosis (n = 10) and women with normal uteri seeking assisted reproduction due to male factor infertility as the control group (n = 10). All eligible women underwent infertility treatment at the Department of Reproductive Medicine and Gynaecological Endocrinology, University Medical Centre Maribor, Slovenia between years 2018 and 2020. For the present study, they were scheduled for cycle monitoring by urinary luteinizing hormone (LH) tests. Participants/materials, setting, methods Each endometrial biopsy was obtained in the presumed window of implantation (WOI) on days LH + 7 to LH + 9 after LH surge (LH + 0). Isolated total RNA was applied for mRNA + lncRNA sequencing (RNA-seq) by Illumina Novaseq 6000. An aliquot of RNA samples was used to verify the WOI by the endometrial receptivity test “beREADY” (CCHT, Estonia). Gene Ontology and Reactome pathway enrichment analyses were conducted in ClueGO bioinformatics tool to study biological role behind obtained DEGs. Main results and the role of chance The R program language and Bioconductor packages were used to align generated RNA-seq reads on the human reference genome assembly (hg19) and to calculate gene expression differences between study groups using normalized counts per million (CPM)&amp;gt;10 in at least 10 samples. A total 233 DEGs (p &amp;lt; 0.05) was identified of which 126 genes were up- and 107 were down-regulated in adenomyosis compared to the control group. However, there was no significantly DEG according to the adjusted p-value. According to the beREADY test, all 20 samples were in receptive phase, however two samples were early-receptive and five were late-receptive. In a sensitivity analysis, all border receptive samples were removed and RNA-seq data sets were re-analysed only by 8 adenomyosis cases and 5 controls. A total of 382 DEGs (p &amp;lt; 0.05) were detected in adenomyosis group (216 up- and 166 down-regulated genes), again with no statistical difference between both groups after adjustment. Functional enrichment analyses of 233 and 382 DEGs identified pathways (adjusted p-value&amp;lt; 0.05) associated with positive regulation of exosomal secretion and expression of IFN-induced genes, respectively. The comparison of 233 and 382 DEGs revealed 28 common genes that may present stronger candidate of adenomyosis-related markers associated with endometrial receptivity. Limitations, reasons for caution Only mild adenomyosis was considered in this study, which is most commonly detected in women. The results could differ in women in severe cases of adenomyosis. Multicellular whole-tissue endometrial samples that were used for RNA isolation could mask gene expression differences of specific cell types between study groups. Wider implications of the findings: According to our results of transcriptome analysis, the presence of mild adenomyosis has no significant influence on the gene expression signature during endometrial receptivity in natural menstrual cycle. Women being investigated for infertility can be reassured that this common acquired anomaly does not significantly influence the chances of successful conception. Trial registration number 0120–259/2018/16

P–340 Novel non-invasive diagnostic options for endometriosis - based on glycome analysis

Abstract Study question Could glycosylation changes on serum and/or urine glycoproteins be suitable biomarkers for the non-invasive diagnosis of endometriosis? Summary answer The glycosylation pattern on serum and urine glycoproteins differed significantly in endometriosis patients compared to controls, suggesting a novel role as biomarkers of the disease. What is known already There is little published on endometriosis and glycosylation, and most of the studies are conducted with tissue or peritoneal fluid samples, collected by invasive means. An Iraqi study draws attention to the importance of serum sialylation, which is dramatically changed in endometriosis patients after zoladex therapy, indicating that changes in serum sialylation may be a new biomarker of the disease. While glycosylation of urine in endometriosis has not been studied so far, in a study of endometrial cancer, the urinary level of two glycoproteins was significantly increased in the patients compared to the control group. Study design, size, duration This was a prospective study. In this basic research project, serum and urine samples were collected for glycome analysis in women with and without endometriosis, as diagnosed at laparoscopy. Glycated haemoglobin (HbA1c), fasting glucose levels as well as hormone levels were also collected from the patients to link our glycomic findings with metabolic and hormone profiles. The study was approved by the Research and Ethics Committee of the National Maternity Hospital, Dublin (EC19.2018). Participants/materials, setting, methods Samples from 24 cases of endometriosis (patients without previous anti-inflammatory or hormonal therapy, endometriosis was confirmed by laparoscopy) and 27 control patients (patients without endometriosis) were processed to analyse N-glycans (total serum), urine glycoproteins, and IgG. The pre-processed, PNGase F-digested serum and urine samples were labelled with fluorescent tag and then analysed by mass spectrometry, ultra-performance liquid chromatography (UPLC) in combination with exoglycosidase digestions and Glycostore (https://glycostore.org/). Main results and the role of chance Glycosylation on total serum and urine glycoproteins and IgG was investigated and differed in endometriosis compared to controls. The N-glycome from the total glycoproteins in serum and urine was also different. The proportion of the galactosylation and sialylation differed between urine and serum IgG and these alterations have an impact on the IgG function. Our preliminary data indicate, that there is an increase in alpha 2–3 sialylation, galactosylation, and fucosylation on urine glycans from endometriosis patients compared to the control pool. Urine is a good source of biomarkers as it can be collected non-invasively. Our group is the first to have developed a protocol for the recovery of N-glycans in urine and to have identified the total N-glycome in urine. The urine N-glycome contains mostly complex N-glycans and also some oligomannosylated and hybrid glycans. Our results may lead to non-invasive biomarkers for the diagnosis of endometriosis and the monitoring of the disease. Limitations, reasons for caution The number of participants involved in this basic research is low but this is a pilot study. A larger, validation study, is warranted in the future. Furthermore, the follow-up of treated patients also would be an interesting field of research. Wider implications of the findings: Glycomics may be a potent source of biomarkers of endometriosis, with a number of glyco-biomarkers already approved by the FDA. Endometriosis-associated glycomic profiles from serum and/or urine glycoproteins may represent viable targets for development of innovative non-invasive or minimally invasive diagnostics in this debilitating disease. Trial registration number Not applicable

帝王切開手術瘢痕に生じた腹壁子宮内膜症の1例

帝王切開手術瘢痕に生じた腹壁子宮内膜症の1例

Primary umbilical endometriosis: Radical excision (omphalectomy) and laparoscopic management of associated pelvic endometriosis in a low resource tertiary hospital.

Primary umbilical endometriosis (PUE) is a rare condition affecting 0.5 - 1% of all extragenital endometriosis cases. We reviewed the data of five women with umbilical endometriosis retrospectively. The age range was 29 - 46 years, and they were all nulligravid at presentation. Common clinical presentation was umbilical pain and masses, dysmenorrhea, and primary infertility. Radical umbilical excision was performed to remove the nodule as a definitive treatment. Diagnostic laparoscopy was performed, followed by varying degrees of operative laparoscopic procedures. They all had endometriosis in the pelvis. Three out of five women operated became pregnant and had live births. Complete resolution of clinical symptoms with a reduction in umbilical and menstrual pain scores occurred. In resource-constrained settings, diagnosis, and treatment of PUE may be challenging. Clinical suspicion and appropriate case management are critical for good reproductive outcomes and quality of life.