Peritoneal Lesions Research Articles

The Significance of the Morphological Appearance of Peritoneal Lesions on Imaging in Patients With Peritoneal Malignancies-A Report From Phase 1 of the PRECINCT Study.

This is a report from Phase 1 of the prospective, observational, PRECINCT (Pattern of peritoneal dissemination and REsponse to systemic Chemotherapy IN Common and uncommon peritoneal Tumours) study, in which we studied the incidence of disease at pathological evaluation in different morphological appearances of peritoneal malignancies (PM) on imaging. Radiological findings were captured in a specific format that included a description of the morphological appearance of PM and a correlation performed with pathological findings. In 630 patients enroled at seven centres (September 2022-December 2023), 24 morphological terms were used. Among prespecified terms (N = 8 used in 6350 [92.2%] regions), scalloping was pathologically positive in 93.5%, confluent disease in 78.8%, tumour nodules in 69.6%, thickening in 66.1%, infiltration in 56.3%. Among unspecified appearances (N = 16) for 540 (7.8%) regions, 'enhancement' was positive in 41.5%, micronodules in 65.3% and nodularity in 60.2%. Hierarchal clustering placed gastric cancer and rare tumours together and colorectal cancer, ovarian cancer and peritoneal mesothelioma in one cluster. The incidence of disease at pathological evaluation for most morphological appearances was high (> 50%). Morphological description should be provided in routine radiology reports. A set of standardized terms with their description should be developed by a consensus among experienced radiologists.

ASO Visual Abstract: Correlation of Morphological Appearance of Peritoneal Lesions at Laparotomy and Disease at Pathological Assessment in Patients Undergoing Cytoreductive Surgery for Peritoneal Malignancy-Results of Phase 1 of the PRECINCT Study in 707 Patients.

ASO Visual Abstract: Correlation of Morphological Appearance of Peritoneal Lesions at Laparotomy and Disease at Pathological Assessment in Patients Undergoing Cytoreductive Surgery for Peritoneal Malignancy-Results of Phase 1 of the PRECINCT Study in 707 Patients.

Evaluation of 68Ga-FAPI PET/CT and 18F-FDG PET/CT for the diagnosis of recurrent colorectal cancers

ObjectiveThe present study aimed to compare the diagnostic value of gallium-68-labeled fibroblast activation protein inhibitor positron emission tomography/computed tomography (68Ga-FAPI PET/CT) and fluorine-18-labeled fluorodeoxyglucose PET/CT (18F-FDG PET/CT) for detecting recurrent colorectal cancers (CRCs). Materials and MethodsFifty-six patients (age: 18–80 years, 31 men and 25 women) with suspected recurrent CRC were enrolled and underwent 18F-FDG PET/CT and 68Ga-FAPI PET/CT sequentially within 1 week. The maximum standard uptake value (SUVmax), tumor-to-background ratio (TBR), and diagnostic accuracy were estimated and compared between the two modalities by using Student’s t-test. The Wilcoxon signed-rank test was used to compare peritoneal carcinoma index (PCI) scores between the two imaging modalities. Results68Ga-FAPI PET/CT showed higher sensitivity for detecting recurrence (93 % vs. 79 %); lymph node metastasis (89 % vs. 78 %), particularly peritoneal lymph node metastasis (92 % vs. 63 %); and metastatic implantation on the intestinal wall (100 % vs. 25 %) compared to 18F-FDG PET/CT. However, 68Ga-FAPI PET/CT showed lower sensitivity for detecting bone metastasis (67 % vs. 100 %). The mean SUVmax values of peritoneal metastases and metastatic implantation on the intestinal wall were 4.28 ± 2.70 and 7.58 ± 1.66 for 18F-FDG PET/CT and 5.66 ± 1.97 and 6.70 ± 0.25 for 68Ga-FAPI PET/CT, respectively. Furthermore, 68Ga-FAPI PET/CT showed significantly higher TBR for peritoneal metastatic lesions (4.22 ± 1.47 vs. 1.41 ± 0.89, p < 0.0001) and metastatic implantation on the intestinal wall (5.63 ± 1.24 vs. 2.20 ± 0.5, p = 0.02) compared to 18F-FDG PET/CT. For the same patient, 68Ga-FAPI PET/CT yielded a more accurate PCI score and a greater area under the curve value for the receiver operating characteristic curve (p < 0.01) than 18F-FDG PET/CT. Conclusion68Ga-FAPI PET/CT was superior to 18F-FDG PET/CT for detecting recurrence and peritoneal metastases. Hence, we propose the combination of these two modalities for better clinical diagnosis and management of patients with CRC.

Correlation of Morphological Appearance of Peritoneal Lesions at Laparotomy and Disease at Pathological Assessment in Patients Undergoing Cytoreductive Surgery for Peritoneal Malignancy: Results of Phase I of the PRECINCT Study in 707 Patients.

The PRECINCT (Pattern of peritoneal dissemination and REsponse to systemic Chemotherapy IN Common and uncommon peritoneal Tumors) is a prospective, multicenter, observational study. This report from phase I of PRECINCT outlines variations in recording the surgical peritoneal cancer index (sPCI) at experienced peritoneal malignancy centers and the incidence of pathologically confirmed disease in morphologically different peritoneal lesions (PL). The sPCI was recorded in a prespecified format that included the morphological appearance of PL. Six prespecified morphological terms were provided. The surgical and pathological findings were compared. From September 2020 to December 2021, 707 patients were enrolled at 10 centers. The morphological details are routinely recorded at two centers, structure bearing the largest nodule, and exact size of the largest tumor deposit in each region at four centers each. The most common morphological terms used were normal peritoneum in 3091 (45.3%), tumor nodules in 2607 (38.2%) and confluent disease in 786 (11.5%) regions. The incidence of pathologically confirmed disease was significantly higher in 'tumor nodules' with a lesion score of 2/3 compared with a lesion score of 1 (63.1% vs. 31.5%; p<0.001). In patients receiving neoadjuvant chemotherapy, the incidence of pathologically confirmed disease did not differ significantly from those undergoing upfront surgery [751 (47.7%) and 532 (51.4%) respectively; p=0.069]. The sPCI was recorded with heterogeneity at different centers. The incidence of pathologically confirmed disease was 49.2% in 'tumor nodules'. Frozen section could be used more liberally for these lesions to aid clinical decisions. A large-scale study involving pictorial depiction of different morphological appearances and correlation with pathological findings is indicated.

Rare Broad Ligament Cavernous Hemangioma Mimicking Advanced Endometriosis: A Case Report.

Cavernous hemangioma within the female genital tract is an extremely rare pathology, characterized by irregular vascular spaces containing blood or thrombus. We present a unique case of a 42-year-old primiparous woman who presented with typical endometriosis symptoms such as dysmenorrhea, dyspareunia, and heavy menstrual bleeding. The patient also experienced complex postpartum symptoms, which were misdiagnosed as cholecystitis and retained placental products. Imaging studies suggested deep infiltrative endometriosis with extraovarian endometriotic lesions. Surgical exploration revealed a hemangioma within the right anterior broad ligament alongside peritoneal endometriosis lesions. The hemangioma itself expresses estrogen and progesterone receptors in stromal cells. The presence of steroid hormone receptors strongly suggests symptom alleviation during the menstrual cycle and the postpartum period. The coexistence of cavernous hemangioma and endometriosis in the broad ligament, previously unreported, and symptomatic overlap between the two conditions complicates diagnosis and management, emphasizing the need for comprehensive evaluation integrating clinical symptoms and imaging findings.

Jejunal sarcomatoid carcinoma: A case report and review of literature

BACKGROUND Sarcomatoid carcinoma (SCA) of the jejunum is a rare and aggressive neoplasm affecting the smooth muscle cells of the jejunum. This study presents a recent case of jejunal SCA, detailing its diagnosis and treatment, thereby providing a reference for clinical practice. CASE SUMMARY A 65-year-old male presented to Yichang Central People's Hospital with a chief complaint of hemorrhoids. A computed tomography (CT) scan incidentally revealed multiple abnormal signals in the liver. Subsequent positron emission tomography/CT at Wuhan Union Hospital indicated malignant tumor progression, with a primary duodenal tumor and multiple metastases in the upper left abdomen. Intraoperatively, a large tumor was identified on the omentum. Histopathological and immunohistochemical analyses of the resected specimen confirmed the diagnosis of jejunal SCA. The patient received a combination therapy of sintilimab, nanoparticle albumin-bound paclitaxel, and anlotinib. Follow-up imaging demonstrated significant reduction of hepatic and peritoneal lesions. The patient has remained stable for over one year postoperatively. CONCLUSION This case suggests that chemotherapy, immunotherapy, plus targeted therapy may represent an optimal treatment for intestinal SCA, meriting further investigation.

Heterogeneity of claudin 18.2 expression in metastatic gastric cancer

Claudin 18.2 has emerged as a viable therapeutic target in gastric cancer (GC), but little is known about the heterogeneity of its expression in GC. This study investigated the heterogeneity of claudin 18.2 expression in 166 patients with metastatic GC whose surgical or paired primary–metastatic specimens were available. The prevalence of claudin 18.2 positivity (moderate-to-strong expression in ≥ 75% by the 43-14A clone) was 47.0%. Claudin 18.2-positive tumors exhibited more frequent peritoneal metastasis and a lower incidence of hepatic and distant lymph node involvement. Survival outcomes were comparable between patients with claudin 18.2-positive and -negative tumors. Intratumoral heterogeneity was noted in 38.5% of surgical specimens. Paired primary-metastatic site analysis revealed that 25.2% of patients had discordant results for claudin 18.2 positivity. Across different metastatic organ categories, peritoneal lesions showed the highest positivity rate (44.3%) and positive concordance rate (31.4%), whereas liver lesions had the lowest positivity rate (17.9%) and concordance rate (12.8%). In conclusion, claudin 18.2 expression exhibits intratumoral and intrapatient spatial heterogeneity in metastatic GC. Claudin 18.2 positivity is associated with more frequent peritoneal metastasis, and peritoneal lesions are more likely to have positively concordant claudin 18.2 results with the primary site than other metastatic sites.

Endometriotic tissue fragments are viable after cryopreservation in an ex vivo tissue model recapitulating the fibrotic microenvironment.

Is it possible to establish an ex vivo endometriosis model using cryopreserved endometriotic tissue fragments? Cryopreserved endometriotic tissue fragments remain viable after thawing and during at least 3days of culture and can therefore be used to establish an ex vivo endometriosis model to efficiently test potential therapeutic agents. Endometriosis is the most prevalent benign gynecologic disease with an enormous societal burden; however, curative therapies are still lacking. To efficiently test potential new therapies, an ex vivo model based on previously cryopreserved endometriotic tissue that recapitulates the different endometriosis subtypes and their microenvironment is highly desirable. Endometriotic tissue fragments of three different subtypes were obtained from 28 patients by surgical resection. After cryopreservation and thawing, viability and metabolic activity of these tissue fragments were assessed. Viability was compared with fresh fragments from 11 patients directly after surgical removal. Experimental intervention studies were performed in cryopreserved and thawed tissue fragments from two patients to confirm the usability of these tissues for ex vivo intervention studies. Endometriotic tissue fragments (n = 45) were cryopreserved according to three different protocols. After thawing, fragments were cultured for 24 h. A resazurin-based assay was performed to assess the metabolic activity of the tissue fragments. In addition, cell type-specific viability was analyzed by VivaFix, Hoechst 33342, and α-smooth muscle actin immunofluorescence staining and confocal microscopy. The presence of endometriosis was histologically confirmed based on hematoxylin-eosin staining. Cryopreserved and thawed tissue fragments were treated for 72 h with pirfenidone or metformin and COL1A1 and CEMIP gene expressions were assessed using RT-PCR and RT-qPCR, either in the whole tissue fragments or in myofibroblasts isolated by laser capture microdissection. Metabolic activity of endometriotic tissue fragments obtained from peritoneal (PER), ovarian (OMA), and deep (DE) endometriotic lesions was well preserved after cryopreservation in a dimethyl sulfoxide-based medium and was comparable with fresh tissue fragments. Relative metabolic activity compared to fresh tissue was 70% (CI: 92-47%) in PER, 43% (CI: 53-15%) in OMA and 94% (CI: 186-3%) in DE lesions. In fragments from PE lesions 92% (CI: 87-96%), from OMA lesions 95% (CI: 91-98%), and from DE lesions 88% (CI: 78-98%) of cells were viable after cryopreservation and thawing followed by a 24-h culture period. Differences in gene expression of fibrotic markers COL1A1 and CEMIP after 72-h treatment with pirfenidone or metformin could be detected in whole tissue fragments and in isolated myofibroblasts, indicating that cryopreserved and thawed endometriotic tissue fragments are suitable for testing anti-fibrotic interventions. N/A. Viability and metabolic activity of the endometriotic tissue fragments may have been partially compromised by damage sustained during the surgical procedure, contributing to inter-sample variance. The storage of viable endometriotic tissue fragments for later usage in an ex vivo model creates the possibility to efficiently test potential new therapeutic strategies and facilitates the exchange of viable endometriotic tissue between different research laboratories. This study was not financially supported by external funding. The authors declare no competing interest. N/A.

O-267 Extracellular vesicles as biomarkers of endometriosis

Abstract Study question Can extracellular vesicles serve as biomarkers of endometriosis, particularly for stages I and II, which are difficult to detect by ultrasound? Summary answer Our findings suggest the feasibility of defining a protein signature of endometriosis based on EV cargoes. What is known already Endometriosis is characterised by intraperitoneal lesions of endometrial tissue. Although ultrasound detection of severe endometriosis is possible, the diagnosis of peritoneal lesions currently relies on invasive laparoscopy, which leads to a delay of 8-10 years. We have previously shown that peritoneal fluid (PF) of women with endometriosis contains endometriosis specific EVs. Traced in peripheral blood (PB), EVs could serve as biomarkers of endometriosis, particularly for stages I and II, which are difficult to detect by ultrasound. Study design, size, duration Women 18-45 years of age undergoing laparoscopic surgery for endometriosis or unrelated conditions were invited to participate in our study (HREC 20-159A/HREC 20-882A). Following informed consent, we collected PF and PB samples from n = 101 participants (n = 47 controls, n = 54 cases). Exclusion criteria were pregnancy, malignancy, and menopause. Participants/materials, setting, methods We processed PF and PB samples by differential ultracentrifugation and validated the presence of EVs by nanoparticle tracking analysis (NTA), Western blotting and transmission electron microscopy (TEM). EVs were analysed by untargeted, label-based quantitative proteomics using Tandem Mass Tags (TMT). Data analysis was performed using Proteome Discoverer v2.4 (Thermo Fisher) followed by statistical analysis using R. Candidate biomarker proteins were tested by traditional and automated Western blotting (WES, ProteinSimple). Main results and the role of chance We ascertained the identity of EVs by TEM and NTA (mode size 121.8 ± 18.0 nm (blood, n = 5) and 155.9 ± 37.2 (PF, n = 6)), and signals for syntenin and ALIX in immunoblots as well as expression of CD9, CD63 and CD81 in capture bead-flow cytometry. Proteomic analysis identified 9145 protein groups across all sample groups, with 602 significantly regulated between comparisons (adjusted P-value &amp;lt;0.05). In PF, 533 proteins changed significantly in abundance (245 up/288 down), while in blood, only four proteins changed in abundance. We tested the presence/absence of two of these as candidate markers on PB EV protein preparations from n = 32 samples to date; our best marker showed a sensitivity of 67% and a specificity of 90%; upon exclusion of severe endometriosis cases, sensitivity improved to 80%. Limitations, reasons for caution Because of the changes in vesicle composition and amounts with the menstrual cycle, we have to group the samples by menstrual cycle phase and disease severity. This leaves relatively small numbers per group per condition. Another limitation concerns the relatively small amount of sample liquid and thus, EVs available for analysis. Wider implications of the findings Our findings suggest the feasibility of defining a protein signature of endometriosis based on EV cargoes. A non-invasive clinical test would allow for earlier diagnosis and thus treatment of endometriosis. It would also allow patients to initiate fertility treatment early. Trial registration number not applicable

Reliability, diagnostic value, and diagnostic yield of ultrasound-guided percutaneous core needle biopsy for peritoneal lesions.

Peritoneal lesions cannot be definitively distinguished based on clinical and imaging characteristics alone. This study aimed to evaluate the reliability, diagnostic value, and diagnostic yield of ultrasound-guided percutaneous core needle biopsy (PCNB) for peritoneal lesions. A retrospective analysis of 129 patients who underwent PCNB for peritoneal lesions was performed to assessed technical completion and diagnostic yield. The results showed that ultrasound-guided PCNB is a safe and reliable diagnostic tool with high diagnostic yield for peritoneal lesions. Technical feasibility and diagnostic yield rates were 100% and 89.9%, respectively. The diagnostic yield was lower for patients with a known history of cancer and a short anteroposterior diameter of the target lesion. These findings suggest that ultrasound-guided PCNB could be considered as a first-line diagnostic tool for peritoneal lesions, as it offers a minimally invasive and accurate means of obtaining tissue samples for diagnosis.

Fish Welfare – A Case Study: Reviling for the first-time side effects of vaccination in European sea bass (Dicentrarchus labrax) and barramundi (Lates calcarifer) in the Israeli fish farming

Vaccination is an effective way to control many infectious diseases in fish. Israeli fish farming has successfully used two vaccines over the last 30 years and has no problem with the side effects of vaccination. However, after introducing new species, a new problem emerged: these fish, after vaccination, demonstrated peritoneal lesions such as granulomas. At the same time, the fish did not show retarded growth or suffering during the fattening period. This study was conducted to establish the connection between vaccination and the appearance of granulomas. Evidence drawn from this research work and comparing vaccinated and non-vaccinated fish confirms that intraperitoneal granulomas do not impact the growth, performance, or fish fillet quality at harvest.

Development of a video-based deep learning model for differentiation of malignant and benign lesions during staging laparoscopy: Is the machine better than the expert?

e13616 Background: Laparoscopic staging of abdominal cancer is routinely performed to assess the presence of peritoneal metastasis (PM). One major challenge of laparoscopic staging is the ability to distinguish between a malignant and benign peritoneal lesion, particularly scar tissue. Lesions' recognition is subjective to intra-case variability, surgeons' experience, type of primary tumor and response to systemic chemotherapy. The Peritoneal Regression Grading Score (PRGS) offers an objective histologic evaluation of the biopsied lesion by assessing the complete or partial presence of malignant cells (PRGS 2-3-4) and fibrous or benign lesion (PRGS 1). Machine learning-based (ML-based) computer vision has various applications in the medical field and can be useful in deducing clinical information through surgical video analysis. The aim of this study was to develop a ML model that can aid the surgeon in the intra-operative assessment of PM. Methods: Retrospectively collected videos of laparoscopies for the staging of PM before cytoreductive surgery or PIPAC were screened from the institutional database for the presence of recorded biopsies. PRGS from the pathology report of these biopsies was retrieved and reviewed by a pathologist. The surgical phase of the biopsy was annotated by systematic selection of 200 frames before the closure of the biopsy instrument on the tissue. One single frame was selected from each timeframe based on its representativeness. Two trained annotators performed the selection, one surgical expert reviewed each annotation. Discrepancies were solved by consensus. ML models based on multiple (ResEfficientnetV2_L) and single frames (Resnet50) per biopsy were trained on the PRGS using a one-versus-all binary classification. Five-fold cross-validation was applied. Two oncologic surgeons, experts in treating and assessing PM, blindly and independently scored the biopsies with PRGS. Results: A total of 127 videos from 67 patients were identified, showcasing PM of gastric, colorectal, appendix, hepatic, gallbladder, breast carcinomas, primary peritoneal tumors and benign lesions. Annotation was performed on 463 biopsies: PRGS 1: 204, PRGS 2: 164, PRGS 3: 70, PRGS 4: 25. Based on timeframe annotation 5214 (PRGS 1: 2044, PRGS 2: 1814, PRGS 3: 929, PRGS 4: 427) images were identified. The model trained on one-versus-all classification for single and multiple images showed an accuracy of 52.4% (Precision 56.2, Recall 48.2) and 45.7% (Precision 76.8, Recall 36.0) respectively in the validation set. Accuracy of each expert was 36.0% and 30.5%. Conclusions: While the accuracy of computer vision models may not be clinically acceptable as a substitute for biopsies, they outperform surgeons in differentiating PM from benign lesions. Computer vision models might be of aid for the surgeon in the recognition of these lesions.

MRI of pelvic endometriosis: evaluation of the mr#Enzian classification and the importance of adenomyosis subtypes

PurposeThis study aimed to investigate the utility of the #Enzian classification in magnetic resonance imaging (MRI) for endometriosis assessment, focusing on inter-reader agreement, diagnostic accuracy, and the correlation of adenomyosis with deep endometriosis (DE).MethodsThis IRB- approved retrospective single-center study included 412 women who underwent MRI evaluation for endometriosis between February 2017 and June 2022. Two experienced radiologists independently analyzed MRI images using the #Enzian classification and assessed the type of adenomyosis, if any. The surgical #Enzian classification served as the gold standard for evaluating preoperative MRI results of 45 patients. Statistical analysis was performed to assess inter-reader agreement and diagnostic accuracy.ResultsInter-reader agreement was substantial to excellent (Cohen’s kappa 0.75–0.96) for most compartments except peritoneal involvement (0.39). The preoperative MRI showed mostly substantial to excellent accuracy (0.84–0.98), sensitivity (0.62–1.00), specificity (0.87–1.00), positive (0.58–1.00) and negative predictive values (0.86–1.00) for most compartments, except for peritoneal lesions (0.36, 0.17, 1.00, 1.00, 0.26 respectively). A trend with a higher prevalence of concordant DE in women with MR features of external adenomyosis compared to those with internal adenomyosis was visible (p = 0.067).ConclusionsThe mr#Enzian showed mostly high inter-reader agreement and good diagnostic accuracy for various endometriosis compartments. MRI’s role is particularly significant in the context of the current paradigm shift towards medical endometriosis treatment. The inclusion of information about the type of adenomyosis in the mr#Enzian classification could enhance diagnostic accuracy and inform treatment planning.Graphical

Giant intraperitoneal non-pancreatic pseudocyst: a case report

IntroductionNon-pancreatic pseudocysts are rare lesions that typically form from the omentum and mesentery. These cysts have a thick fibrotic wall made up of fibrous tissue and may show signs of calcifications and inflammatory changes. The fluid inside them can vary, ranging from hemorrhage and pus to serous or sometimes chylous content. In most cases, these cysts appear as a result of trauma, surgery, or infection.Case presentationA 35-year-old male patient from Ethiopia presented with swelling in his lower abdomen that had been present for 2 years. Initially, the swelling was small but gradually increased in size. The patient experienced frequent urination but no pain or difficulty during urination, urgency, intermittent urination, or blood in the urine. The swelling was initially painless but became painful 2 months prior to his presentation. Abdominal computed tomography scans revealed a well-defined, lobulated peritoneal lesion measuring 16 × 12 × 10 cm, consisting primarily of fluid-filled cysts with a thick, enhancing wall and septa. Additionally, there was a large, heterogeneous enhancing soft tissue component measuring 8 × 6 cm. As a result, the cystic mass was surgically removed in its entirety with partial removal of the bladder wall, and the patient was discharged in an improved condition.ConclusionPrimary non-pancreatic pseudocysts are extremely rare lesions that must be differentiated from other possible causes of cystic lesions within the peritoneal or retroperitoneal regions. Surgeons should be aware of the potential occurrence of these lesions, which may have an unknown origin.

Saliva-based microRNA diagnostic signature for the superficial peritoneal endometriosis phenotype

ObjectivePatients with superficial peritoneal endometriosis (SPE) present with symptoms suggestive of endometriosis but clinical and imaging exams are inconclusive. Consequently, laparoscopy is usually necessary to confirm diagnosis. The present study aimed to evaluate the accuracy of microRNAs (miRNAs) to diagnose patients with SPE from the ENDOmiARN cohort Study DesignThis prospective study (NCT04728152) included 200 saliva samples obtained between January and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy and/or MRI to confirm the presence of endometriosis. Among the patients with endometriosis, two groups were defined: an SPE phenotype group of patients with peritoneal lesions only, and a non-SPE control group of patients with other endometriosis phenotypes (endometrioma and/or deep endometriosis). Data analysis consisted of two parts: (i) identification of a set of miRNA biomarkers using next-generation sequencing (NGS), and (ii) development of a saliva-based miRNA signature for the SPE phenotype in patients with endometriosis based on a Random Forest (RF) model. ResultsAmong the 153 patients with confirmed endometriosis, 10.5 % (n = 16) had an SPE phenotype. Of the 2633 known miRNAs, the feature selection method generated a signature of 89 miRNAs of the SPE phenotype. After validation, the best model, representing the most accurate signature had a 100 % sensitivity, specificity, and AUC. ConclusionThis signature could constitute a new diagnostic strategy to detect the SPE phenotype based on a simple biological test and render diagnostic laparoscopy obsolete. PrécisWe generated a saliva-based signature to identify patients with superficial peritoneal endometriosis which is the most challenging form of endometriosis to diagnose and which is often either misdiagnosed or requires invasive laparoscopy.

Plasma proteins and persistent postsurgical pelvic pain among adolescents and young adults with endometriosis

Noninvasive biomarkers that predict surgical treatment response would inform personalized treatments and provide insight into potential biologic pathways underlying endometriosis-associated pain and symptom progression. To use plasma proteins in relation to the persistence of pelvic pain following laparoscopic surgery in predominantly adolescents and young adults with endometriosis using a multiplex aptamer-based proteomics biomarker discovery platform. We conducted a prospective analysis including 142 participants with laparoscopically-confirmed endometriosis from the Women's Health Study: From Adolescence to Adulthood observational longitudinal cohort with study enrollment from 2012-2018. Biologic samples and patient data were collected with modified World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project tools. In blood collected before laparoscopic ablation or excision of endometriosis, we simultaneously measured 1305 plasma protein levels, including markers for immunity, angiogenesis, and inflammation, using SomaScan. Worsening or persistent postsurgical pelvic pain was defined as having newly developed, persistent (ie, stable), or worsening severity, frequency, or persistent life interference of dysmenorrhea or acyclic pelvic pain at 1-year postsurgery compared with presurgery. We calculated odds ratios and 95% confidence intervals using logistic regression adjusted for age, body mass index, fasting status, and hormone use at blood draw. We applied Ingenuity Pathway Analysis and STRING analysis to identify pathophysiologic pathways and protein interactions. The median age at blood draw was 17 years (interquartile range, 15-19 years), and most participants were White (90%). All had superficial peritoneal lesions only and were treated by excision or ablation. One-year postsurgery, pelvic pain worsened or persisted for 76 (54%) of these participants with endometriosis, whereas pelvic pain improved for 66 (46%). We identified 83 proteins associated with worsening or persistent pelvic pain 1-year postsurgery (nominal P<.05). Compared with those with improved pelvic pain 1-year postsurgery, those with worsening or persistent pelvic pain had higher plasma levels of CD63 antigen (odds ratio, 2.98 [95% confidence interval, 1.44-6.19]) and CD47 (odds ratio, 2.68 [95% confidence interval, 1.28-5.61]), but lower levels of Sonic Hedgehog protein (odds ratio, 0.55 [95% confidence interval, 0.36-0.84]) in presurgical blood. Pathways related to cell migration were up-regulated, and pathways related to angiogenesis were down-regulated in those with worsening or persistent postsurgical pelvic pain compared with those with improved pain. When we examined the change in protein levels from presurgery to postsurgery and its subsequent risk of worsening or persistent postsurgical pain at 1-year follow-up, we observed increasing levels of Sonic Hedgehog protein from presurgery to postsurgery was associated with a 4-fold increase in the risk of postsurgical pain (odds ratio [quartile 4 vs 1], 3.86 [1.04-14.33]). Using an aptamer-based proteomics platform, we identified plasma proteins and pathways associated with worsening or persistent pelvic pain postsurgical treatment of endometriosis among adolescents and young adults that may aid in risk stratification of individuals with endometriosis.

Metabolomics as a Candidate for Endometriosis Biomarker: A Systematic Review

Background: To date, diagnosis is still a challenge in managing endometriosis. There is a need to develop a less invasive yet accurate approach, such as a biomarker, to help diagnose endometriosis earlier and more precisely. Metabolomics, the study of metabolites, are thought to provide a more accurate relation to phenotype compared to other omics technology and may help develop endometriosis biomarkers. This review aims to systematically summarize evidence regarding the use of metabolomics studies in the diagnosis of endometriosis. Methods: This review was conducted according to PRISMA 2020 guidelines. Including studies on endometriosis and metabolomics in Medline, Embase, and Cochrane Library to May 2022. Inclusion: Women of reproductive age, laparoscopically diagnosed — exclusion criteria: no full-text, languages other than English, and animal studies. Papers were screened and extracted using Covidence, appraised using Newcastle-Ottawa Scale (NOS), by two independent reviewers. Results: A total of 33 studies are included in this review, and 24 showed positive results regarding the metabolites identified and their association with endometriosis. Twenty-four studies reported good area under curve (AUC), sensitivity, and specificity scores in diagnosing endometriosis using a prediction model from the attained metabolites. However, the summary of these scores is not feasible due to the lack of standardization in reporting metabolomics studies. Both serum and endometriotic lesion microenvironments, such as peritoneal fluid, endometrioma, follicular fluid, and tissue lesions, give essential information on which metabolites are altered in endometriosis. Phosphatidylcholine (PC), acylcarnitines (AC), and sphingomyelins (SM) are these studies’ most frequent significant metabolites, but their levels vary. Although all studies had an overall good appraisal score, regarding confounders included, the variation in their methods of analysis and prediction model approach should be interpreted with caution. These predictions are also mostly done without using two different data groups for test and validation. Conclusions: Metabolomics studies may become an alternative for a less invasive approach to diagnosing endometriosis. This review revealed how encouraging results from metabolomics studies are. However, the need for more standardization in the study report and preliminary design for making a prediction model is still in the way of fully trusting metabolomics studies to account for endometriosis diagnostic biomarkers. Registration: PROSPERO CRD42022334916

Ayurvedic Management of Primary Infertility Due to Chocolate Cyst: A Case Report

Background: Endometriosis presents in three different entities, which are frequently found together: peritoneal lesions, deep endometriosis and ovarian endometriotic cysts (endometriomas) Ovarian endometrioma is a benign estrogen dependent cystic mass arising from ectopic endometrial tissue within the ovary. It contains thick, brown, tar like fluid, which may be referred to as a chocolate cyst. The presence of endometriomas indicates more severe stage of endometriosis. Endometriomas can lead to chronic pelvic pain and infertility, and often requires surgery for treatment. Endometriosis has been found in nearly 50% of women experiencing issues with infertility, and nearly 70% of women with pelvic pain. Classic symptoms includes dysmenorrhoea, dyspareunia, menorrhagia and infertility. Management of the ovarian cyst through surgery is available to meet urgent need of the patient, but to establish a satisfactory conservative medical treatment is the need of the hour. According to Ayurveda, depending upon most common symptoms it can be compared as a syndrome complex of Granthi, Vidradhi, Udavartini Yonivyapada, Paripluta yonivyapada and Vataja Yonivyapada. It is a Tridoshaja vyadhi with vitiation of Vata And Artava. Chocolate cysts can also be managed on the line of treatment of Granthi, (nodular/glandular swellings) Vidradhi (abscess), Raktapachana and Raktaprasadana. Aim: To manage Female infertility with chocholate cyst with shodhana and shamana therapy. Materials and methods: A patient aged 25years came to outdoor patient department of Prasutitantra Evum Streeroga with the complaint of lower abdominal pain and infertility since2 years. Her Ultrasonography report reveals bilateral chocolate cyst with no dominant follicle. She has tendency of formation of recurrent chocolate cyst since 3 years. She was administered Virechana after completion of menses on 1st cycle, Dashmoola Shodhan Basti along with Uttara Basti with uttarabasti with kasisadi taila and sahachara taila in 2nd cycle, Yastimadhu Ksheera Basti for 3rd cycle along with the Uttara Basti with kasisadi taila and sahachara taila, on the fourth month Uttarabasti with 5 ml of Dhanvantra taila was done, Shigru Patra Avagaha Swedana and Jeevaniya Choorna 3 gm orally with warm milk after Basti treatment. Results: Patient has marked reduction in the size of the chocolate cyst and she conceived with the treatment protocol of 4 months Conclusion: Above mentioned treatment plan has effective result due to Shothahara, Vatanulomana, Raktaprasadana properties which may have effectively curtailed the progress of ovarian cyst and helped in treating infertility.

A159 MALIGNANT PERITONEAL MESOTHELIOMA: A CASE OF MISTAKEN IDENTITY

Abstract Background In the Western hemisphere, cirrhosis is the most common cause of ascites. One of the least common causes is malignant peritoneal mesothelioma (MPM), which occurs in one in one million cases. MPM can be a diagnostic challenge due to its rarity and features that mimic other causes of ascites. Aims To describe a complex case of MPM, highlighting the diagnostic dilemma stemming from the subtleties of presentation, confounders in ascites diagnostic criteria, and indeterminate testing. Methods We performed a detailed retrospective chart review of a patient who presented with ascites. He was initially given the diagnosis of decompensated cirrhosis and eventually was diagnosed with MPM. He provided his consent for this case report. Results A 37-year-old male presented with progressive ascites and peripheral edema. He had no known exposure to asbestos and consumed 6 standard drinks a day for 2 years; with a prior history of 10 standard drinks a week for over 3 years. His physical examination was unremarkable for cardiac, renal or liver disease. His transthoracic echocardiogram and urinalysis were normal. Abdominal ultrasound showed features of liver cirrhosis with large-volume ascites and a FIB-4 score of 0.34, excluding advanced fibrosis Laboratory investigations including liver tests were normal; with a platelet count of 568 x 109/L. Viral, metabolic and autoimmune liver disease were excluded. A diagnostic paracentesis demonstrated a serum albumin-ascites gradient (SAAG) of 1.3 g/dL. Due to his history of alcohol misuse, imaging findings and high SAAG, he was diagnosed with alcohol-related cirrhosis. His repeat abdominal ultrasound showed multiple liver nodules. Magnetic resonance imaging was done to investigate for hepatocellular carcinoma; revealing diffuse peritoneal carcinomatosis, cirrhosis and large-volume ascites. Investigations to identify the primary malignancy included a computed tomography chest, colonoscopy and EGD. His EGD was the only positive test; showing a 2cm submucosal gastric lesion with normal gastric mucosa pathology. An endoscopic ultrasound (EUS) with fine needle aspiration was then performed; the lesion appearance in keeping with a gastrointestinal stromal tumor (GIST). Pathology favored a diagnosis of poorly differentiated gastric carcinoma. Cytology was positive for malignancy, with the differential being mesothelioma or adenocarcinoma and a repeat SAAG was 1.0 g/dL. Given the discordances, an ultrasound-guided core biopsy was performed of the peritoneal lesions. Pathology revealed features of poorly differentiated epithelioid mesothelioma. A subsequent review of his gastric biopsies revealed similar cells in retrospect were in keeping with mesothelioma. Conclusions The presentation of MPM is not easily distinguishable from other causes of ascites. There must be a high degree of suspicion for malignant ascites in the face of inconsistent clinical and diagnostic findings. Funding Agencies None

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy to Treat Pseudomyxoma Peritonei of Ovarian Origin: A Retrospective French RENAPE Group Study

BackgroundOvarian pseudomyxoma peritonei (OPMP) are rare, without well-defined therapeutic guidelines. We aimed to evaluate cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) to treat OPMP.MethodsPatients from the French National Network for Rare Peritoneal Tumors (RENAPE) database with proven OPMP treated by CRS/HIPEC and with histologically normal appendix and digestive endoscopy were retrospectively included. Clinical and follow-up data were collected. Histopathological and immunohistochemical features were reviewed.ResultsFifteen patients with a median age of 56 years were included. The median Peritoneal Cancer Index was 16. Following CRS, the completeness of cytoreduction (CC) score was CC-0 for 9/15 (60%) patients, CC-1 for 5/15 (33.3%) patients, and CC-2 for 1/15 (6.7%) patients. The median tumor size was 22.5 cm. After pathological review and immunohistochemical studies, tumors were classified as Group 1 (mucinous ovarian epithelial neoplasms) in 3/15 (20%) patients; Group 2 (mucinous neoplasm in ovarian teratoma) in 4/15 (26.7%) patients; Group 3 (mucinous neoplasm probably arising in ovarian teratoma) in 5/15 (33.3%) patients; and Group 4 (non-specific group) in 3/15 (20%) patients. Peritoneal lesions were OPMP pM1a/acellular, pM1b/grade 1 (hypocellular) and pM1b/grade 3 (signet-ring cells) in 13/15 (86.7%), 1/15 (6.7%) and 1/15 (6.7%) patients, respectively. Disease-free survival analysis showed a difference (p = 0.0463) between OPMP with teratoma/likely-teratoma origin (groups 2 and 3; 100% at 1, 5, and 10 years), and other groups (groups 1 and 4; 100%, 66.6%, and 50% at 1, 5, and 10 years, respectively).ConclusionThese results suggested that a primary therapeutic strategy using complete CRS/HIPEC for patients with OPMP led to favorable long-term outcomes.