Endometriosis-associated Ovarian Cancer Research Articles

Research progress in endometriosis-associated ovarian cancer.

Endometriosis-associated ovarian cancer (EAOC) is a unique subtype of ovarian malignant tumor originating from endometriosis (EMS) malignant transformation, which has gradually become one of the hot topics in clinical and basic research in recent years. According to clinicopathological and epidemiological findings, precancerous lesions of ovarian clear cell carcinoma (OCCC) and ovarian endometrioid carcinoma (OEC) are considered as EMS. Given the large number of patients with endometriosis and its long time window for malignant transformation, sufficient attention should be paid to EAOC. At present, the pathogenesis of EAOC has not been clarified, no reliable biomarkers have been found in the diagnosis, and there is still a lack of basis and targets for stratified management and precise treatment in the treatment. At the same time, due to the long medical history of patients, the fast growth rate of cancer cells, and the possibility of eliminating the earliest endometriosis-associated ovarian cancer, it is difficult to find the corresponding histological evidence. As a result, few patients are finally diagnosed with EAOC, which increases the difficulty of in-depth study of EAOC. This article reviews the epidemiology, pathogenesis, risk factors, clinical diagnosis, new treatment strategies and prognosis of endometriosis-associated ovarian cancer, and prospects the future direction of basic research and clinical transformation, in order to achieve stratified management and personalized treatment of ovarian cancer patients.

Immune pathway through endometriosis to ovarian cancer.

Endometriosis is an estrogen-dependent inflammatory disease, defined by the presence of functional endometrial tissue outside of the uterine cavity. This disease is one of the main gynecological diseases, affecting around 10%-15% women and girls of reproductive age, being a common gynecologic disorder. Although endometriosis is a benign disease, it shares several characteristics with invasive cancer. Studies support that it has been linked with an increased chance of developing endometrial ovarian cancer, representing an earlier stage of neoplastic processes. This is particularly true for women with clear cell carcinoma, low-grade serous carcinoma and endometrioid. However, the carcinogenic pathways between both pathologies remain poorly understood. Current studies suggest a connection between endometriosis and endometriosis-associated ovarian cancers (EAOCs) via pathways associated with oxidative stress, inflammation, and hyperestrogenism. This article aims to review current data on the molecular events linked to the development of EAOCs from endometriosis, specifically focusing on the complex relationship between the immune response to endometriosis and cancer, including the molecular mechanisms and their ramifications. Examining recent developments in immunotherapy and their potential to boost the effectiveness of future treatments.

Endometriosis-Associated Ovarian Cancer: From Molecular Pathologies to Clinical Relevance.

Endometriosis is a chronic condition affecting reproductive-aged women, characterized by the growth of ectopic endometrial tissue. Despite being benign, endometriosis is associated with an increased risk of certain cancers, including endometriosis-associated ovarian cancer (EAOC). Ovarian cancer is rare, but more common in women with endometriosis, particularly endometrioid and clear-cell carcinomas. Factors such as hormonal imbalance, reproductive history, environmental exposures, and genetic predisposition contribute to the malignant transformation of endometriosis. Thus, understanding potential risk factors causing malignancy is crucial. Over the past few decades, various genetic mutations, microRNAs, as well as tumor microenvironmental factors have been identified, impacting pathways like PI3K/AKT/mTOR, DNA repair mechanisms, oxidative stress, and inflammation. Thus, this review aims to summarize molecular studies involved in EAOC pathogenesis as potential therapeutic targets. However, further research is needed to better understand the molecular and environmental factors driving EAOC development, to target the susceptibility of endometriotic lesions to malignant progression, and to identify effective therapeutic strategies.

Endometriosis-Related Ovarian Cancer: Where Are We Now? A Narrative Review towards a Pragmatic Approach.

Endometriosis affects more than 10% of reproductive-aged women, causing pelvic pain and infertility. Despite the benign nature of endometriosis, ovarian endometriomas carry a higher risk of developing endometrioid carcinomas (EnOCs) and clear cell ovarian carcinomas (CCCs). Atypical endometriosis, defined as cytological atypia resembling intraepithelial cancer, is considered the precursor of endometriosis-associated ovarian cancer (EAOC). This narrative review aims to provide an overview of EAOC, proposing a practical approach to clinical and therapeutic decision making. An electronic literature search was conducted from inception up to January 2023, using the MEDLINE database via PubMed to evaluate the existing literature on EAOC, including its pathogenesis, the diagnostic process, and the therapeutic possibilities, with articles not relevant to the topic or lacking scientific merit being excluded. Eighty-one articles were included in the review to present the current state of the art regarding EAOC. A pragmatic clinical flowchart is proposed to guide therapeutic decisions and improve patient outcomes. Endometriosis patients may have an increased risk of developing EAOC (either EnOC or CCC). Despite not being fully accepted, the concept of AE may reshape the endometriosis-ovarian cancer relationship. Further research is needed to understand the unaddressed issues.

Endometriosis-associated ovarian cancer: a different clinical entity

ObjectiveTo compare survival outcomes and patterns of recurrence between endometriosis-associated ovarian cancer patients and non-endometriosis-associated ovarian cancer patients.MethodsThis retrospective study included data of consecutive patients with endometrioid or clear cell...

PTEN and PI3K Mutation Markers and Expression of CD68 and IL-6 Inflammatory Markers in Endometrioid and Clear Cell Ovarian Carcinoma with Underlying Endometriosis

The objective of this research endeavour was to ascertain whether there existed a distinction in the protein expression levels of phosphatase and tensin homolog (PTEN), phosphatidylinositol-4,5-biphosphate3-kinase (PI3K), macrophage (CD68), and interleukin-6 (IL-6) among women who had been diagnosed as having ovarian carcinoma (endometrioid and clear cell subtypes) underlying endometriosis. Tissue microarray (TMA) slides were fabricated using donor’s formalin-fixed paraffinembedded (FFPE) blocks that comprised specimens of ovarian carcinomas tissues with the subtypes of endometrioid and clear cell that were retrieved for a duration of nine years. A total of 19 FFPE blocks represented 19 cases of carcinoma of the ovary, which were categorised into two groups: ovarian cancer with endometriosis (EAOC, n=10) and ovarian cancer without endometriosis (n=9). All of these protein expressions were analysed using immunohistochemistry (IHC) technique. Following that, comparisons were made regarding the clinical and pathological characteristics of the ovarian carcinomas, as well as any discernible variations in expression levels between the two groups. In EAOC, PTEN expression was lower (88.9% vs. 100%, P=0.47) compared to those without endometriosis. Our findings revealed an increase of PI3K and IL-6 in EAOC than those devoid of endometriosis; 80% vs. 77.8%, P=1.00 and 70% vs 11.11%, P=0.35, respectively. In contrast, CD68 was significantly lower in endometriosis-associated ovarian cancer compared to those without endometriosis (40% vs. 66.67%, P=0.16). In conclusion, there were no significant difference in the mutational and inflammatory marker modifications between clear cell carcinoma and endometrioid adenocarcinoma of ovary with endometriosis.

Abstract 1614: Macroscopic clonal expansion with driver mutations in normal human endometrium

Abstract Introduction: The epithelial cells of the endometrium undergo rapid proliferation and shedding each month under the influence of estrogen and progesterone. Recent studies have demonstrated pervasive driver mutations in the endometrium with ageing. However, previous observations have been limited to the microscopic scale, and it is still unclear how clonal expansion occurs over the entire endometrium and what driver mutations are responsible therein. To address these issues, we performed multisampling of the endometrium with extensive spatial mapping. Methods: We collected multiple endometrial glands from normal endometrium in a 5mm lattice in 19 patients aged 30 to 85 years who underwent hysterectomy (3-31 samples per case), followed by DNA extraction, detected somatic mutations by whole exome sequencing, to identify large clones that spread across samples based on shared mutations. Results: In total, 213 bulk endometrial glands were analyzed. The number of detected somatic mutations per sample ranged from 4 to 81 (mean±SD: 32.5±14.1), with at least one known driver gene mutation detected in 204 of 213 samples (mean±SD: 3.03±1.78). The mutational signature analysis revealed the predominance of the age-related SBS1 and SBS5 signatures. dN/dS analysis identified 20 genes that were positively selected in normal endometrium, including PIK3CA, PIK3R1, KRAS, PPP2R1A, ARHGAP35, and FBXW7, most of which are also known as driver genes for endometrial cancer. The number of mutations and their frequency for each driver gene did not differ by background diseases: endometriosis, endometriosis-associated ovarian cancer and other non-endometrial related diseases. In contrast to the high frequency of driver gene mutations, copy-number alterations were found in only 3 samples, such as +1q, +7, +10 and +12. We found clones showing a large expansion involving multiple samples in 8 cases, most of which harbored one or more driver mutations, such as PIK3CA and KRAS. The size of the largest clone carrying a KRAS mutation, which was found in a 32-year-old woman with cervical cancer, spanned as long as 10 mm in diameter. This suggests that clonal expansion in the endometrium could be very rapid even in healthy women, which contrasts to the observations that clonal expansion in other organs is usually seen in aged individuals. Conclusion: We confirmed the high frequency of driver mutations in the normal endometrium, most of which overlapped to those found in endometrial cancers, suggesting that these driver genes are involved in the early phase of the development in the endometrial cancer. Some of the driver-mutated clones expanded in macroscopic size. Our findings provide an interesting insight into the clonal structure and underlying genetic variation in the normal endometrium. Citation Format: Koichi Watanabe, Nobuyuki Kakiuchi, Kosuke Ieiri, Hirona Maeda, Tomonori Hirano, Sachiko Kitamura, Mana Taki, Koji Yamanoi, Ryusuke Murakami, Ken Yamaguchi, Junzo Hamanishi, Hiroko Tanaka, Satoru Miyano, Masaki Mandai, Seishi Ogawa. Macroscopic clonal expansion with driver mutations in normal human endometrium [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1614.

Abstract 3647: Digital spatial transcriptomic reveals different epithelial and immune cells signatures across endometriosis-related diseases: From simple ovarian endometriosis to ovarian cancer

Abstract Endometriosis represents a pressing medical concern, imposing a relevant burden on patients including potential malignant transformation into endometriosis-associated ovarian cancer (EAOC). Despite the process of cancer development remains unclear, immune cells abnormalities arose as putative biomarkers in the neoplastic progression. One-third of ovarian endometriosis cases exhibit PD-1/PD-L1 expression levels comparable to those observed in cancer. To substantiate the biological basis of these findings, this study aimed to elucidate the spatial transcriptomic profile of epithelial and immune components from different endometriosis-related conditions, along with their genetic interplay. Formalin-fixed paraffine embedded (FFPE) specimens from 4 ovarian endometriosis (OE) cases, two of which displayed elevated levels of PD-1/PD-L1 expression and were referred to as cancer-like endometriosis (CLE), 1 Clear Cell Ovarian Cancer (CCOC) and 1 Endometrioid Ovarian Cancer (EOC) were cut in 5um section for spatial transcriptomic analysis using GeoMX Human Whole Transcriptome Atlas (WTA) probe-set (>18000 genes). For all sections, the regions of interest (ROIs) were identified using a set of morphology markers: anti-human CD3, CD68 and PanCK antibodies. Spatial transcriptomic analysis revealed condition-specific gene enrichment of epithelial and immune cells across the different conditions. In spite of similar H&E findings, PanCKpos epithelial cells from CLE showed an increased expression of genes involved in stress response and defense regulation pathways (e.g. CXCL6, S100A9, and PECAM-1), when compared to OE, in which PanCKpos cells were enriched in DUSP1/2 and VIM. Interestingly, in CCOC, location-specific gene-enrichment was found in PanCKpos cells, with a significant up regulation of tumor suppressor genes (e.g. EGR-1, NR4A1) in normal-looking peri-tumoral epithelium compared to cancerous intra-tumoral PanCKpos cells. Similarly, in the immune compartment, spatial transcriptomic analysis revealed that CD3pos cells from CLE displayed an up-regulation of genes involved in IL-17 signaling, response to oxydative stress and complement activation (e.g. CXCL6, HMOX1, S100A9, and PECAM-1), when compared to OE. Moreover, in CCOC, CD68pos cells of the tumoral mass showed over-expression of tumor growth and progression markers (e.g. SPP1) compared to their counterpart in the outer area of the tumoral mass. In this first comprehensive spatial transcriptomic study of endometriosis-related diseases with GeoMx WTA, our findings uncovered remarkable differences in epithelial and immune cells among different stages and tissue locations. Importantly, CLE emerged as a transitional entity with a unique immune profile. Ongoing analysis of six additional samples will further refine our results. Citation Format: Valentina Iacobelli, Camilla Nero, Stefano Alivernini, Giulia Scaglione, Floriana Camarda, Francesca Sillano, Rita Trozzi, Alessia Piermattei, Barbara Tolusso, Giulia Mantini, Luciano Giacò, Gloria Anderson, Gian Franco Zannoni, Elisa Gremese, Anna Fagotti, Giovanni Scambia. Digital spatial transcriptomic reveals different epithelial and immune cells signatures across endometriosis-related diseases: From simple ovarian endometriosis to ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3647.

Endogenous Microbacteria Can Contribute to Ovarian Carcinogenesis by Reducing Iron Concentration in Cysts: A Pilot Study.

Among epithelial ovarian cancer, clear cell carcinoma is common for chemo-resistance and high mortality. This cancer arises from benign ovarian endometrioma (OE), which is a high oxidative stress environment due to the cystic retention of menstrual blood produced during menstruation and the "iron" liberated from the cyst. There has been strong evidence that the iron concentration in OE decreases when they become cancerous. A decrease in iron concentration is a necessary condition for the formation of cancer. However, the mechanism of carcinogenesis is not yet clear. In the current study, the bacterial flora in endometriosis-associated ovarian cancer (EAOC), including clear cell carcinoma, and their origin, OE, were investigated using next-generation sequencing. The Shannon index in the genus level was significantly higher in EAOC than in OE fluids. Among several bacterial flora that were more abundant than benign chocolate cysts, a number of bacterial species that correlate very well with iron concentrations in the cysts were identified. These bacterial species are likely to be associated with decreased iron concentrations and cancer development.

Histologic Subtypes in Endometriosis-Associated Ovarian Cancer and Ovarian Cancer Arising in Endometriosis: A Systematic Reviewand Meta-Analysis.

The definition of the association between ovarian cancer and endometriosis was first reported by Sampson in 1925. He identified the following criteria: (a) clear evidence of endometriosis in proximity to the tumour, (b) exclusion of a metastatic tumour to the ovary, (c) presence of tissue resembling endometrial stroma surrounding epithelial glands. The naming of these cancers is "endometriosis-associated ovarian cancer" (EAOC). Scott proposed an additional stringent criterion: evidence of histological transition from endometriosis to cancer is to define "ovarian cancer arising in endometriosis" (OCAE). The aim of this systematic review is to analyse the distribution of different ovarian cancer histotypes in EAOC and OCAE to understand their similarities and differences. A total of 31 studies were included. Four studies added data for both EAOC and OCAE. Twenty-three studies were selected for EAOC, with a total of 800 patients, and 12 studies were selected for OCAE, with a total of 375 patients. The results show no significant differences in the distribution of histotypes in the two populations analysed. Clear cell carcinoma (CCC) and endometrioid carcinoma (EC) were the most common subtypes and were less frequent in EAOC compared to OCAE; the odd ratios were 0.58 (0.26-1.29) and 0.65 (0.33-1.26) respectively, although the difference was not statistically significant. The other histotypes were present in small proportions. This analysis shows that the histological profiles of EAOC and OCAE are similar, suggesting a similar aetiopathological mechanism, which requires further research to investigate whether EAOC and OCAE may be in the same way but at different points of the process to malignancy or have different pathways of progression to malignancy.

Clinical significance of initial symptoms in endometriosis-associated ovarian cancer.

Endometriosis is associated with various symptoms, but their severity varies from case to case. In this study, we investigated the reality of symptoms presented by patients with clinically early-stage endometriosis-associated ovarian cancer (EAOC) and explored the relationship between symptoms and laboratory/imaging findings, pathological findings, and prognosis. This was a retrospective case-control study of patients who received initial surgical treatment and were diagnosed with clinically early-stage EAOC, including ovarian endometrioid carcinoma (OEC), ovarian clear cell carcinoma (OCCC), and seromucinous borderline tumor (SMBT). Patients with OEC/OCCC diagnosed between 2006 and 2016 and those with SMBT diagnosed between 2006 and 2020 were included. Chi-square and Kaplan-Meier estimates were used for statistical analyses. One hundred-seven patients (OEC, n=31; OCCC, n=39; SMBT, n=37) were included. Fifty-nine (55.1%) patients presented with symptoms, and the proportion of patients with OEC who presented with symptoms was significantly higher than that of others (OEC, 77.4%; OCCC, 43.6%; SMBT, 48.6%). The details of symptoms differed significantly among the pathological types (lower abdominal pain/abdominal discomfort/abnormal bleeding, OEC: 11/8/9; OCCC: 6/12/1; SMBT: 15/5/3). Only in the OEC group did symptomatic patients show significantly higher white blood cell (WBC) count and neutrophil/lymphocyte (N/L) ratio (symptomatic vs. asymptomatic, median: WBC count: 7250 vs. 5000, p=0.008; N/L ratio: 4.6 vs. 1.7, p=0.013). None of the asymptomatic patients showed recurrence during follow-up. Patients with EAOC show varying symptoms depending on the histological type of the tumor. Laboratory findings underlying symptoms also vary by histopathological type, which may reflect differences in the carcinogenesis process.

Abstract IA009: Epigenetic approaches to endometriosis-associated ovarian cancer

Abstract IA009: Epigenetic approaches to endometriosis-associated ovarian cancer

New insights about endometriosis-associated ovarian cancer: pathogenesis, risk factors, prediction and diagnosis and treatment.

Previous studies have shown that the risk of malignant transformation of endometriosis in premenopausal women is approximately 1%, significantly impacting the overall well-being and quality of life of affected women. Presently, the diagnostic gold standard for endometriosis-associated ovarian cancer (EAOC) continues to be invasive laparoscopy followed by histological examination. However, the application of this technique is limited due to its high cost, highlighting the importance of identifying a non-invasive diagnostic approach. Therefore, there is a critical need to explore non-invasive diagnostic methods to improve diagnostic precision and optimize clinical outcomes for patients. This review presents a comprehensive survey of the current progress in comprehending the pathogenesis of malignant transformation in endometriosis. Furthermore, it examines the most recent research discoveries concerning the diagnosis of EAOC and emphasizes potential targets for therapeutic intervention. The ultimate objective is to improve prevention, early detection, precise diagnosis, and treatment approaches, thereby optimizing the clinical outcomes for patients.

Derivation and validation of a nomogram based on clinical characteristics to diagnose endometriosis associated ovarian cancer preoperatively

PurposeThe preoperative diagnosis of endometriosis associated ovarian cancer (EAOC) remains challenging for lack of effective diagnostic biomarker. We aimed to study clinical characteristics and develop a nomogram for diagnosing EAOC before surgery.MethodsA total of 87 patients with EAOC and 348 patients with ovarian endometrioma (OEM) were enrolled in our study. Least absolute shrinkage and selection operator (LASSO) regression and Logistic regression were utilized to select variables and construct the prediction model. The performance of the model was assessed using receiver operating characteristic (ROC) analyses and calibration plots, while decision curve analyses (DCAs) were conducted to assess clinical value. Bootstrap resampling was used to evaluated the stability of the model in the derivation set.ResultsThe EAOC patients were older compared to the OEM patients (46.41 ± 9.62 vs. 36.49 ± 8.09 year, P < 0.001) and proportion of postmenopausal women was higher in EAOC group than in the OEM group (34.5 vs. 1.5%, P < 0.001). Our prediction model, which included age at diagnosis, tumor size, cancer antigen (CA) 19–9 and risk of ovarian malignancy algorithm (ROMA), demonstrated an area under the curve (AUC) of 0.858 (95% confidence interval (CI): 0.795–0.920) in the derivation set (N = 304) and an AUC of 0.870 (95% CI: 0.779–0.961) in the validation set (N = 131). The model fitted both the derivation (Hosmer–Lemeshow test (HL) chi-square = 12.600, P = 0.247) and the validation (HL chi-square = 8.210, P = 0.608) sets well.ConclusionCompared to patients with OEM, those with EAOC exhibited distinct clinical characteristics. Our four-variable prediction model demonstrated excellent performance in both the derivation and validation sets, suggesting its potential to assist with preoperative diagnosis of EAOC.

Endometriosis and Ovarian Cancer: Should we be worried? Five Cases Report and Literature Review

Endometriosis is a chronic inflammatory disease caused by the presence of extra-uterine endometrial tissue that affects women of reproductive age. Although the etiology remains not totally elucidated, recent advances in molecular technology, especially the ability for whole genome sequencing, have gradually revealed both genetic and epigenetic backgrounds for the development of the disease. Endometriosis has been recognized as a precursor lesion for certain types of ovarian cancer (endometriosis-associated ovarian cancers - EAOC) and the knowledge of this malignant potential is of paramount importance to seek for predictive factors and to select patients at risk. We report five different EAOC cases in our recent clinical practice, in order to draw attention to this issue through a literature review, and to provide clinicians with tools to communicate accurately and effectively with patients with endometriosis about their risk of ovarian cancer.

MiRNA Expression Profiles in Ovarian Endometriosis and Two Types of Ovarian Cancer-Endometriosis-Associated Ovarian Cancer and High-Grade Ovarian Cancer.

Endometriosis-associated ovarian cancer (EOC) consisting of endometrioid cancer and clear-cell ovarian cancer could be promoted by many factors. miRNAs, which are small, non-coding molecules of RNA, are among them. The aim of this study was to detect miRNAs connected with the malignant transformation of endometriosis. FFPE (formalin-fixed, paraffin-embedded) samples of 135 patients operated on for endometriosis and different types of ovarian cancer (EOC and HGSOC-high-grade serous ovarian cancer) were studied. Healthy ovarian tissue was used as a control group. From the expression panel of 754 miRNAs, 7 were chosen for further tests according to their ROC (receiver operating characteristic) curves: miR-1-3p, miR-125b-1-3p, miR-31-3p, miR-200b-3p, miR-502-5p, miR-503-5p and miR-548d-5p. Furthermore, other potentially important clinical data were analysed, which included age, BMI, Ca-125 concentration, miscarriages and deliveries and concomitant diseases such as hypertension, type 2 diabetes and smoking. Among the miRNAs, miR200b-3p had the lowest expression in neoplastic tissues. miR31-3p had the highest expression in women without any lesions in the ovaries. miR-502-5p and miR-548-5p did not differ between the studied groups. The examined miRNA panel generally distinguished significantly normal ovarian tissue and endometriosis, normal ovarian tissue and cancer, and endometriosis and cancer. The malignant transformation of endometriosis is dependent on different factors. miRNA changes are among them. The studied miRNA panel described well the differences between endometriosis and EOC but had no potential to differentiate types of ovarian cancer according to their origin. Therefore, examination of a broader miRNA panel is needed and might prove itself advantageous in clinical practice.

Correlation of clinicopathological and prognostic characteristics between endometriosis-associated and primary ovarian cancer

BackgroundThe main aim of this study was to establish the clinicopathological and prognostic correlations between endometriosis-associated and non-endometriosis-associated primary ovarian cancer, with a view to providing a reference guide for revision of diagnostic criteria for malignant transformation of endometriosis.MethodsClinicopathological and follow-up data of 174 patients with clear cell and endometrial ovarian cancer were retrospectively extracted. Cases were divided into endometriosis-associated and non-endometriosis-associated primary ovarian cancer for comparative analysis of clinicopathological characteristics and prognosis.ResultsAverage age and post-menopausal rate in the endometriosis-associated ovarian cancer group were lower relative to the primary ovarian cancer group (P < 0.05). Body mass index, age at menopause, operation history, dysmenorrhea, complications, tumor size, tumor side, ascites, CA125, HE4, CA19.9, stage, differentiation, expression of ER, PR, P53, P16, Ki67, MMR, HNF-1β and Napsin A were not significantly different between the groups (P > 0.05). Furthermore, rates of resistance to platinum chemotherapy, relapse, progression-free survival and overall survival were comparable between the two groups (P > 0.05).ConclusionEndometriosis-associated and primary ovarian cancers of the same pathological type are speculated to be homologous in terms of origin from malignant transformation of endometriosis. It may therefore be necessary to revise the diagnostic criteria for ovarian endometriosis malignancy.

#387 : Enlightening the Management of Chocolate Cysts Before IVF Treatment: Case Reports of 3 Young Endometriosis-Associated Ovarian Cancer Patients with Ovulation Induction History

Background and Aims: Endometriosis is a common estrogen-dependent disease that occurs mostly in women of childbearing age and is characterized by ectopic growth of endometrial glands and stroma. Endometriosis may present as malignant transformation and the two most common malignancies in this situation are ovarian clear cell carcinoma and endometrioid adenocarcinoma. Rare cases of endometriosis-associated ovarian cancer (EAOC) after in-vitro fertilization (IVF) treatment were reported before, and the relationship between the usage of ovulation induction medications and the development of ovarian cancer is controversial. This study aims to summarize the characteristics of EAOC patients with IVF treatment history. Method: All history, clinical data, imaging data, operative documents, and follow-up of 3 cases of endometriosis-associated ovarian cancer with IVF treatment history were reviewed, among the 793 patients undergoing surgeries for ovarian malignancy at the Gynecology Department, Renji Hospital affiliated to Shanghai Jiao Tong University, School of Medicine, from 2019 to 2022. Results: 3 EAOC patients under the age of 40 who had undergone controlled ovarian hyperstimulation (COH) for IVF treatment were identified in the cases review. The 3 infertility women underwent 3, 4, and 6 cycles of ovulation induction and achieved 1, 0, and 1 time of pregnancy, respectively. Unfortunately, none of them reached a pregnancy outcome over 12 weeks. After staging surgery, the 3 patients were diagnosed with Stage IA clear cell carcinoma, Stage IIB clear cell carcinoma, and Stage IIB adenosquamous carcinoma, respectively. The latter two patients had undergone two times of needle aspiration and sclerosis for chocolate cysts, and the surgical records also showed more severe abdominal adhesion and poor prognosis. Conclusion: Patients with endometriosis cysts need to be very careful when seeking IVF treatment, especially in the order of treatment of cysts and ovulation induction. Repeated needle aspiration and sclerosis for ovarian cysts are not recommended.

Endometriosis in clear cell and endometrioid carcinoma ovary: its impact on clinicopathological characteristics and survival outcomes.

Malignant transformation in endometriosis was first described by Sampson in 1925. There is now sufficient evidence of its association specifically with endometrioid (EOC) and clear cell ovarian cancer (CCOC). Whether endometriosis-associated ovarian cancer (EAOC) is a distinct clinicopathological entity from non-endometriosis-associated ovarian cancer (NEAOC) remains uncertain. This study aimed to assess the impact of endometriosis on clinical characteristics and survival outcomes in EOC and CCOC. This is a retrospective single-institution analysis of patients diagnosed with CCOC AND EOC between 2010 and 2021. Demographic and clinical presentation data were obtained from medical records. Patients were followed up till March 2023. Statistical analysis was done using the IBM SPSS Statistics 20 Windows. Of the 77 cases of CCOC and EOC ovary, 38 had histopathologically proven endometriosis. There was no difference in age (51.62 and 50.05 years, respectively), body mass index, parity, menopausal status and CA 125 levels at presentation. Ascites was more frequent in the absence of endometriosis (30% versus 8.1%, p = 0.015). However, this did not translate to a statistical difference in the stage, with the majority presenting in the early stage. (94% versus 83%). All 78 patients underwent primary cytoreduction with equal rates of optimal resection.There was no difference in the mean disease-free interval between EAOC and NEAOC (107.6 and 109.4 months, p 0.484). Recurrences were predominantly pelvic in both groups. The disease-specific survival was 111.7 and 120.1 months, respectively, with and without endometriosis. This was however not statistically significant (p 0.751). In the Indian population, endometriosis did not have any impact on the age at presentation, CA 125 levels, stage of the disease and survival outcomes in EOC and CCOC ovary.

Endometriosis-Associated Ovarian Carcinomas: How PI3K/AKT/mTOR Pathway Affects Their Pathogenesis.

Ovarian clear cell (OCCC) and endometrioid (EnOC) carcinomas are often subsumed under the umbrella term "endometriosis-associated ovarian cancer" (EAOC), since they frequently arise from ectopic endometrium settled in the ovaries. The phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway is known to be aberrantly activated both in endometriosis and EAOC; however, its role in the progression of endometriosis to ovarian cancer remains unclear. In fact, cancer-associated alterations in the mTOR pathway may be found in normal uterine epithelium, likely acting as a first step towards ovarian cancer, through the intermediary stage of endometriosis. This review aims to summarize the current knowledge regarding mTOR signaling dysregulation in the uterine endometrium, endometriosis, and EAOC while focusing on the interconnections between the PI3K/AKT/mTOR pathway and other signaling molecules that give rise to synergistic molecular mechanisms triggering ovarian cancer development in the presence of endometriosis.