Postoperative Hormonal Therapy Research Articles

Breast cancer with biomarker reversal during the course of treatment: a case report

Breast cancer with biomarker reversal during the course of treatment: a case report

Abstract PO5-12-05: A Retrospective Study of the Rate of Cognitive Impairment and Influencing Factors during Postoperative Endocrine Therapy for Breast Cancer

Abstract Background Although cancer-related cognitive impairment (CRCI) has been gradually recognized, general cognitive function tests such as the MMSE are not sensitive enough to diagnose CRCI. There is also a lack of evidence on the incidence and its response. However, even mild cognitive impairment can have a significant impact on quality of life. In this study, we retrospectively analyzed the prevalence of cognitive impairment in patients undergoing endocrine therapy at our hospital and the factors influencing the symptoms. Subjects 349 patients who continued single-agent postoperative endocrine therapy for at least 6 months between January 1 and October 31, 2022, and who responded to the cognitive dysfunction questionnaire at least once. Data from the cognitive dysfunction items of the endocrine therapy questionnaire administered during the period were used to retrospectively examine the CRCI awareness rate and factors involved. Results and Discussion The patients who were aware of cognitive dysfunction was 170, or 49% of all patients, and univariate analysis showed that age was significantly higher in the group with CRCI, but there were no significant differences in type of endocrine therapy or history of chemotherapy between the groups with and without CRCI. Physical symptoms such as menopausal symptoms (hot flashes and sweats), arthralgia, myalgia, fatigue, depressed mood, and malaise were significantly more frequent in patients with CRCI, which could be considered side effects of endocrine therapy. Risk factors such as low cognitive reserve, low level of education, advanced age, race, depression, fatigue, and anxiety have been reported in the past, and in this study, fatigue, depressed mood, and malaise were found significantly more frequently in patients with cognitive dysfunction. However, the diagnosis of depression and dementia may also be important.Non-pharmacological interventions, especially cognitive rehabilitation and exercise, are expected to be effective in improving symptoms, but there is no certain opinion yet. The limitation of this study is that it was a single-center, retrospective analysis. In addition, it was difficult to evaluate the results over time, including before the start of oral medication, so we are considering conducting a prospective data collection study so that comparisons can be made in the future. Conclusion: This study was a simple screening, based only on subjective symptoms. In recent years, postoperative endocrine therapy has been prolonged to 10 years, and there is a possibility to improve the quality of life of patients by recognizing the possibility of cognitive dysfunction in both providers and patients, and by taking measures that include multiple factors. Citation Format: Akari Murakami, Mayuko Aono, Kaho Utsunomiya, Kumiko Okujima, Kana Takemoto, Megumi Takaoka, Erina Kusakabe, Kana Taguchi, Kanako Nishiyama, Yoshiaki Kamei, Yasutsugu Takada, Hitoshi Tanimukai. A Retrospective Study of the Rate of Cognitive Impairment and Influencing Factors during Postoperative Endocrine Therapy for Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-12-05.

Recurrent severe hypocalcemia following chemotherapy regimen changes in advanced breast cancer: two case reports

BackgroundAs an oncologic emergency related to abnormalities in calcium metabolism, hypercalcemia associated with paraneoplastic syndrome and bone metastases is well known. Meanwhile, the incidence of hypocalcemia is low, except in cases associated with bone-modifying agents used for bone metastases. Hypocalcemia induced by bone-modifying agents typically occurs early after the initial administration, and its incidence can be significantly reduced by preventive administration of calcium and vitamin D3 supplements.Case reportWe report two cases of recurrent severe hypocalcemia occurring during chemotherapy for metastatic breast cancer with multiple bone metastases.Case 1: A 35-year-old Japanese woman developed metastases in the bone, liver, and ovaries during postoperative endocrine therapy for invasive lobular carcinoma of the breast. She underwent chemotherapy and treatment with denosumab. She experienced recurrent episodes of severe hypocalcemia subsequent to a change in the chemotherapy regimen. Case 2: A 65-year-old Japanese woman encountered multiple bone metastases after postoperative anti-human epidermal growth factor receptor 2 therapy and during endocrine therapy for invasive ductal carcinoma of the breast. She underwent anti-human epidermal growth factor receptor 2 therapy and treatment with denosumab. She experienced recurrent severe hypocalcemia subsequent to a change in the chemotherapy regimen to letrozole + lapatinib, trastuzumab emtansine, and lapatinib + capecitabine.ConclusionsWe observed two cases of recurrent severe hypocalcemia in patients with advanced breast cancer and bone metastases after modifications to their therapy regimens. These cases differed from the typical hypocalcemia induced by bone-modifying agents. It is possible that antitumor drugs affect calcium and bone metabolism associated with bone metastases. While these cases are rare, it is crucial for oncologists to be aware of hypocalcemia not only at the initiation of bone-modifying agents but also throughout the entire antitumor therapy, as hypocalcemia can lead to fatal outcomes.

Analysis of the Effect of Letrozole on Patients Undergoing Postoperative Endocrine Therapy for Breast Cancer

Objective: To investigate the effect of letrozole on patients undergoing postoperative endocrine therapy for breast cancer. Methods: The period of the study was from June 2021 to January 2023, and 40 patients who were undergoing postoperative endocrine therapy for breast cancer were grouped into two groups by randomized numerical table method: the observation group and the control group. The observation group was given letrozole and the control group was given tamoxifen. At the end of the medication, the results of each index of the two groups were compared. Results: After medication, The Kupperman score of the observation group was lower and Karnofsky Performance Scale (KPS) score was higher compared to the control group (P < 0.05). Besides, the high-density lipoprotein cholesterol (HDL-C) level of the observation group was higher than that of the control group after treatment (P < 0.05). Moreover, the adherence to medication and regular follow-up rate of the observation group was higher than that of the control group (P < 0.05). Lastly, all liver function indexes of the observation group were lower than those of the control group after treatment (P < 0.05). Conclusion: Letrozole is more effective in treating breast cancer patients who are undergoing postoperative endocrine therapy, with less impact on blood lipids and liver function. Therefore, it is worthy of further research and application.

#376 : Septoplasty: Breaking the Divide. Management of Septate Uterus Presenting with Recurrent Pregnancy Loss

Objective: To address Septate Uterus causing Recurrent Pregnancy Loss (RPL) with Septoplasty by creating an adequate adhesion-free uterine cavity. Methods: A 44-year old G4P0(0040) with recurrent pregnancy losses with 2 previous curettages after an abortion consulted. 3D ultrasound showed a uterus with a symmetrical septum extending up to the level of the isthmus with internal indentation of 2.04 cm. Hysteroscopic Septoplasty was done using a Bipolar Colin’s Electrode, resecting the septum in anterograde movement in the median plane of the septum. High dose estrogen was given for 8 weeks for faster re-epithelization. Second look hysteroscopy and 3D ultrasound after two menstrual cycles. Results: Post-operatively, the procedure and hormonal regimen were well-tolerated. The second look hysteroscopy revealed a small remnant of the septum and no adhesions present while the repeat 3D scan showed a 45% reduction of the internal indentation at 1.12 cm. Conclusion: In cases of Recurrent Pregnancy loss due to a septate uterus, it is reasonable to perform a Septoplasty with post-operative hormonal therapy to ensure sufficient intrauterine space and faster endometrial recovery to facilitate implantation and delivery at a viable age of gestation. A Second look Hysteroscopy is recommended to evaluate the procedure.

Concurrent uterine surgery and uptake of hormone therapy in patients undergoing bilateral salpingo-oophorectomy for risk-reducing or therapeutic indications

ObjectiveThis study aimed to analyze factors associated with concurrent uterine surgery in patients undergoing bilateral salpingo-oophorectomy (BSO) for risk reducing or therapeutic purposes. Additionally, trends in surgical choice and uptake of post-operative hormone therapy (HT) were examined. MethodsA 10-year retrospective study was conducted on patients who underwent risk-reducing or therapeutic BSO at one institution. Multinomial regression analysis of patient and case characteristics was performed evaluating associations with surgery type (BSO, BSO and hysterectomy, or BSO and endometrial sampling). Trends in surgery type and uptake of HT post operatively are described. ResultsAmong the study sample of 643 patients, 140 (22%) patients underwent therapeutic BSO for a history of hormone receptor (HR) positive breast cancer, while the remainder underwent risk-reducing BSO due to a pathogenic variant and/or family history. Pathogenic variants included BRCA1 (141, 40%) BRCA2 (173, 49%), and Lynch syndrome genes (15, 4%). Regression analysis revealed significant associations between concurrent hysterectomy and Black race (RR = 3.55, CI = 1.51–8.38, p = 0.004), history of HR positive breast cancer (RR = 1.88, CI = 1.03–3.42, p = 0.04), and surgeon (Surgeon 1, RR = 2.43, CI = 1.36–4.35, p = 0.003). Among eligible patients under age 51, 36% initiated HT. Over the study period, concurrent hysterectomy rates declined while endometrial sampling increased. ConclusionsRates of hysterectomy declined over the study period and slightly more than one-third of eligible patients utilized post-operative HT. Further research on concurrent uterine surgery is needed to establish standardized treatment recommendations in the risk-reducing and therapeutic BSO population. Additionally, education regarding the benefits of postoperative HT in eligible patients is warranted.

Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes.

Diaphragmatic endometriosis is rare and forms 0.67-4.7% of all endometriosis cases. Evidence regarding its optimal management is lacking. In this study, we retrospectively analyzed the patient characteristics and long-term treatment outcomes of diaphragmatic endometriosis patients. Over a 4-year period, 23 patients were diagnosed with diaphragmatic endometriosis. The majority of patients had coexisting deep pelvic endometriosis. Cyclic upper abdominal pain was reported by 60.9% of patients, while cyclic chest and shoulder pain were reported by 43.5% and 34.8% of patients, respectively. Most patients were treated with laparoscopic lesion ablation, while 21.1% were treated with minimally invasive excision. The mean follow-up time was 23.7 months. Long-lasting resolution of the chest, abdominal, and shoulder pain occurred in 50%, 35.7%, and 25% of patients, respectively. Nonetheless, 78.9% of patients reported major improvement in their symptoms postoperatively. Significantly higher rates of postoperative shoulder, abdominal, and chest pain were observed in patients who received postoperative hormonal therapy compared with those who did not. All patients treated expectantly remained stable. Therefore, we recommend treating diaphragmatic endometriosis only in symptomatic patients. The risk of incomplete surgery should be minimized by a multidisciplinary diagnostic and therapeutic approach with a careful assessment of the diaphragm and the thoracic cavity.

Is HER2 ultra-low breast cancer different from HER2 null or HER2 low breast cancer? A study of 1363 patients.

This study aims to analyze whether there are any differences in clinicopathological features and prognosis between HER2 ultra-low, HER2-null, and HER2-low expression in Chinese breast cancer (BC) patients. The clinicopathological data of 1363 HER2-negative BC patients were retrospectively collected (from January 2018 to December 2019). HER2 status was further classified into HER2-null, HER2 ultra-low, and HER2-low. HER2-null expression is defined as infiltrating cancer cells completely free of staining. HER2 ultra-low expression is defined as ≤10% of infiltrating cancer cells showing incomplete and faint/weak membrane staining. HER2-low expression is defined as HER2 immunohistochemistry (IHC) 1+ or 2+ with negative in situ hybridization (ISH) assay. Of 1363 patients, there were 86 (6.3%) HER2-null patients, 395 (29.0%) HER2 ultra-low patients, and 882 (64.7%) HER2-low patients. HER2 ultra-low patients were different from HER2-low patients in terms of N stage, hormone receptor (HR) status, Ki-67 expression, and type of surgery. There were also significant differences in histologic type and postoperative endocrine therapy between HER2 ultra-low and HER2-null patients. HR+ (81.0%) tumors was more common than HR- (19.0%) in HER2 ultra-low patients. In addition, there was a significant difference in HR status between HER2 ultra-low and HER2-low patients (P = 0.001). The survival analysis showed that HER2 status had no effect on disease-free survival (DFS) in HER2-negative patients (all P>0.05). However, regardless of HER2 status, HR+ patients had better DFS than HR- patients (P = 0.003). Cox multivariate analysis revealed that age (HR [95% CI] = 0.950 [0.928, 0.972], P < 0.001), HR status (HR [95% CI] = 3.342 [1.658, 6.736], P = 0.001), and postoperative endocrine therapy (HR [95% CI] = 0.048 [0.048, 0.023], P < 0.001) were important influencing factors of DFS in HER2-negative BC patients. HER2 ultra-low BC patients demonstrated distinct clinicopathological features from HER2-null and HER2-low tumors; while, HER2 status (null, ultra-low, or low) had no prognostic value in these HER2-negative BC population. Consistent with the published literature, HR status was an independent prognostic factor for DFS in HER2-negative BC patients.

Endometriosis of the skeletal muscular system (ESMS): a systematic review

BackgroundExtrapelvic endometriosis occurring at skeletal muscle and joint sites is not rare and is prone to delayed diagnosis and inappropriate treatment. Herein, endometriosis of the skeletal muscular system (ESMS) is systematically reviewed to facilitate early diagnosis and treatment.MethodsLiterature on ESMS published before March 2022 was retrieved from the Ovid Medline and Web of Science databases, and the major clinical data were extracted for descriptive analysis.ResultsA total of 62 studies (78 ESMS cases) met these requirements. The ESMS included the abdominal muscles (50.7%), pelvic floor muscles (11.6%), lower limb muscles (11.6%), hip muscles (8.7%), lumbar muscles (7.2%), joints (5.8%), upper limb muscles (2.9%), and shoulder–neck muscles (1.4%). The age was 34.0 ± 7.2 years (range 17–49 years). Approximately 63.8% of patients had at least one previous pelvic surgery, and 76.8% of local symptoms were related to the menstrual cycle. The course of disease was 29.6 ± 25.4 months (range 0.5–96 months). Only 30.3% of the patients sought initial medical advice from gynecologists, while 69.7% sought initial medical advice from a nongynecological physician. Twenty-seven patients underwent fine-needle aspiration (FNA) under ultrasound or CT monitoring, and only 44.4% (12/27) were confirmed to have endometriosis by FNA tissue pathology. Approximately 47.4% (37/78) of the patients had a normal pelvic cavity appearance. Surgical resection was performed in 92.3% (72/78) of the patients, of whom 88.9% (64/72) underwent complete resection of the lesion (negative surgical margin) and 20.8% (15/72) received postoperative hormone therapy. At 16.7 months of follow-up, 83.3%, 13.8%, 2.9%, and four patients had complete response, partial response, recurrence, and permanent function impairment, respectively.ConclusionEndometriosis can occur at almost any site in the musculoskeletal system. For women of reproductive age with catamenial pain or a mass in the musculoskeletal system, endometriosis should be suspected. Fine-needle aspiration can easily lead to missed diagnoses. Surgical resection for negative margins is the main treatment, and permanent impairment of function may occur in a few patients due to delayed diagnosis. Vascular lymphatic metastasis is the most likely mechanism of pathogenesis.

Патогенетические особенности сигнального пути прогестерона и экспрессия PR-B при глубоком инфильтративном эндометриозе

Objective. To study the expression of progesterone receptor isoform B (PR-B) in patients with deep infiltrating endometriosis (DIE). Patients and methods. This article presents a comparative analysis of PR-B expression in eutopic and ectopic endometrial tissue samples obtained from patients with DIE (study group, n = 50) and tubo-peritoneal factor infertility (comparison group, n = 9). PR-B expression was analyzed by immunohistochemistry. Results. In the group of patients with DIE, PR-B expression in ectopic endometrial glandular and stromal cells of endometriosis lesions in the peritoneum and colon was significantly higher compared to the capsule of ovarian endometriotic cyst (p &lt; 0.05). Analysis of PR-B expression in eutopic endometrium showed no significant differences between patients in the study group and comparison group (p &gt; 0.05). Stromal cell PR-B expression in patients with infertility in the study group was significantly lower compared to fertile patients with DIE (p = 0.04). Conclusion. No decrease in PR-B expression in the endometrium of patients with DIE was found, which may indicate a favorable response to postoperative hormonal therapy in this group of patients. At the same time, we observed a decrease in PR-B expression in eutopic endometrial stromal cells in patients with DIE and infertility compared to fertile patients, which confirms the role of PR in disrupting pregnancy onset in endometriosis. Search for prognostic markers is currently implemented to develop a personalized approach to the treatment of endometriosis and individual selection of hormone therapy for preventing primary and subsequent surgical interventions and reducing severe pain syndrome in endometriosis. Key words: progesterone, PR-B expression, deep endometriosis, pain syndrome, dienogest

Clinical Features and Management of Umbilical Endometriosis: A 30 Years' Monocentric Retrospective Study.

Umbilical endometriosis (UE) is defined as the presence of endometrial-like tissue within the umbilicus and represents around 0.5-1% of all cases of endometriosis. UE is classified into primary or secondary UE. In this retrospective study, we aimed to assess symptoms, signs, recurrence rate of treated lesions, psychological wellbeing and health-related quality of life in women with UE. We retrospectively reviewed all cases of women diagnosed with UE in the period 1990-2021 in our center. Post-operative recurrence of UE was considered as the reappearance of the umbilical endometriotic lesion, or as the recurrence of local symptoms in the absence of a well-defined anatomical recurrence of the umbilical lesion. Moreover, participants were invited to fill in standardized questionnaires on their health conditions. A total of 55 women with histologically proven UE were assessed in our center during the study period. At time of diagnosis, local catamenial pain and swelling were reported by 51% and 53.2% of women, respectively. A total of 46.8% of women reported catamenial umbilical bleeding. Concomitant non-umbilical endometriosis was identified in 66% of cases. As regards the treatment of UE, 83.6% of women underwent an en-bloc excision with histological confirmation of UE. During the follow-up period, 37 women (67.3%) agreed to undergo a re-evaluation. Recurrence of either umbilical symptoms, or umbilical nodule, was observed in 27% of patients, 11% of which did not receive post-operative hormonal therapy. Specifically, a recurrence of the umbilical endometriotic lesion was observed only in two women. Among the 37 women which we were able to contact for follow-up, 83.8% were satisfied with the treatment they had received. The high rate of patient satisfaction confirmed that surgical excision should be considered the gold standard treatment for umbilical endometriosis. Future studies should investigate the role of post-operative hormonal therapy, particularly in reducing the risk of symptom recurrence.

7360 Surgical Management of Ileocecal Endometriosis, 6 Cases Treated with Laparoscopic Ileocecal Resection

<h3>Study Objective</h3> To present and discuss clinical features of ileocecal endometriosis (ICE) and feasibility of laparoscopic surgery for ICE. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Gynecology and Obstetrics department of a general hospital. <h3>Patients or Participants</h3> All patients who underwent laparoscopic surgery for ICE. <h3>Interventions</h3> Between December 2010 and January 2021, 6 patients underwent laparoscopic ileocecal resection for ICE. <h3>Measurements and Main Results</h3> A total of 6 patients (median age 37.0) underwent laparoscopic ileocecal resection. Five of the six cases had preoperative symptoms from ileocecal lesions such as bowel obstruction and abdominal pain. Three cases were diagnosed with ileal stenosis by contrast X-ray with nasointestinal tubes, and the other three were diagnosed with ICE by colonoscopy or double contrast barium enema (DCBE). All 6 patients had concomitant rectal endometriosis and underwent simultaneous laparoscopic lower anterior resection. In one case, ureteral stent placement was required for ureteral injury, and in one case, intestinal obstruction occurred postoperatively, but both cases improved without sequel. Postoperative hormone therapy with dienogest was performed in five patients. One patient underwent bilateral adnexectomy. No recurrence was observed in all patients (the median observation time: 48 month). <h3>Conclusion</h3> All patients with ileocecal endometriosis had rectal endometriosis and required two segmental intestinal resections. Laparoscopic surgery for ICE needs deep understanding of the gastrointestinal tract and advanced techniques of laparoscopic surgery, as well as cooperation with surgeons.

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Is ovarian cystectomy for atypical ovarian endometrioma safe?: A single center study.

Ovarian atypical endometriosis (AE) is a premalignant lesion, and its potential to progress to endometriosis-associated ovarian cancer emphasizes its significance. However, the true risk of malignancy in AE remains unclear. Therefore, this study aimed to investigate the clinical outcomes of ovarian AE after ovarian cystectomy. We retrospectively reviewed the medical records and histopathological reports of 41 patients who had been diagnosed with ovarian AE between January 2011 and April 2020. We reviewed age, obstetric history, age at menarche, preoperative CA 125 level, C-reactive protein level, erythrocyte sedimentation rate, endometriosis stage, mean follow-up duration, postoperative hormonal therapy, and prognosis, including recurrence of endometriosis and malignant transformation. Among 41 patients with pathologically diagnosed ovarian AE, 26 were followed up after cystectomy only. The average follow-up period was 58.27 ± 33.22 months in cystectomy only patients. The mean age of the patients with cystectomy only versus that of patients with endometriosis-associated ovarian carcinoma was 32.73 ± 6.10 versus 48.29 ± 4.35 (P < .01) years. The preoperative CA 125 level was 115.63 ± 219.06 versus 225.75 ± 163.39 (P < .051) U/mL. Patients with endometriosis-associated ovarian carcinoma or other diseases and those who underwent oophorectomy were excluded. After surgery, hormone therapy was administered to 22 of 26 patients, and the remaining 4 patients were followed up without additional treatment. Endometriosis recurrence occurred in 5 patients, 1 of whom underwent second-line laparoscopic ovarian cystectomy. However, no malignant transformations were observed. Ovarian AE has a low possibility of malignant transformation. Conservative treatment is recommended after appropriate ovarian cystectomy, such as enucleation.

Hormone Therapy Reduces Recurrence in Stage II-IV Uterine Low-Grade Endometrial Stromal Sarcomas: A Retrospective Cohort Study.

Low-grade endometrial stromal sarcoma (LG-ESS) is a rare and indolent malignancy. Hormone therapy has been reported as an adjuvant treatment for LG-ESS, although its effectiveness is controversial. Here we aimed to investigate the effects of postoperative hormone therapy on recurrence in patients with uterine LG-ESS. Between January 2010 and December 2019, a total of 152 patients (23 with and 129 without fertility-sparing) with a diagnosis of primary uterine LG-ESS confirmed by pathologists were enrolled in this study. In the cohort without fertility-sparing, 22 (17.7%) patients had recurrence, and the median disease-free survival (DFS) was 47 (2-130) months; only one of these patients died of LG-ESS. No significant difference was found in recurrence between the groups with and without hormone therapy (p=0.802). However, subgroup analysis showed that hormone therapy decreased the recurrence rate in stage II-IV (p=0.001, HR 0.144, 95% CI: 0.038-0.548), but not in stage I disease (p=0.256). High-dose progestins notably reduced recurrence (p=0.012, HR 0.154, 95% CI: 0.036-0.660), whereas non-progestin therapy marginally influenced recurrence (p=0.054) compared with no hormone therapy in stage II-IV disease. Moreover, hormone therapy within 12 months was effective in reducing recurrence (p=0.038, HR 0.241, 95% CI: 0.063-0.922). Ovarian preservation (p=0.004, HR 6.250, 95% CI: 1.786-21.874) and negative expression of ER/PR (p=0.000, HR 23.249, 95% CI: 4.912-110.026) were high-risk factors for recurrence in patients without fertility-sparing. In the fertility-sparing cohort, 15 (65.2%) patients experienced recurrence, and the median DFS was 24 (3-107) months. Six patients successfully delivered healthy fetuses, and five received hormone therapy. Twelve patients finally accepted hysterectomy after repeated recurrence, and only two of them had given birth before surgery. Patients who received hormone therapy showed longer DFS, although this difference was not statistically significant (p=0.466). In conclusion, postoperative hormone therapy reduces recurrence in patients with stage II–IV uterine LG-ESS without fertility-sparing, and high-dose treatment with progestins within 12 months is recommended. Bilateral oophorectomy can also reduce the risk of recurrence. Patients with fertility-sparing have a high risk of recurrence and poor pregnancy outcomes, and hormone therapy may be a reasonable choice in postoperative management.

The importance of diaphragmatic surgery, chemical pleurodesis and postoperative hormonal therapy in preventing recurrence in catamenial pneumothorax: a retrospective cohort study.

Catamenial pneumothorax (CP) is defined as a recurrent, spontaneous pneumothorax occurring within a day before or 72h after the onset of menstruation. Most first episodes go undiagnosed and treated as primary spontaneous pneumothorax, and only after recurrence is the clinical suspicion of CP raised. No gold-standard management approach exists, especially in terms of managing diaphragmatic involvement. This study is a single-centre cohort retrospective study of 24 female patients who underwent surgery for pneumothorax due to diaphragmatic endometriosis between January 2008 and December 2016. Two groups were compared: a group that underwent pleurodesis alone (8 patients) and a group that underwent diaphragmatic surgery and pleurodesis (16 patients). There were differences in BMI and smoking habits between the two groups. The right diaphragm was involved more often (6vs15, p = 0.190). VATS was the preferred surgical approach and only one conversion occurred in the diaphragmatic surgery group (p = 0.470). Diaphragmatic abnormalities were present in all the patients, brown/violet spots (100%) in the pleurodesis group and perforations (100%) in the diaphragmatic surgery group (p < 0.001). There were no differences in days of chest tube removal and length of stay. The recurrence rate was 100% in the pleurodesis alone group while it was only 12.5% in the diaphragmatic surgery group (< 0.001). In our experience, diaphragmatic surgery and pleurodesis followed by hormonal therapy was an effective approach in preventing recurrence in patients with catamenial pneumothorax and diaphragmatic involvement.

Эффективность профилактики рецидивов после хирургического лечения эндометриоза яичников

Objective. To study the effectiveness of therapy with dienogest (Zafrilla) in the prevention of ovarian endometriosis recurrence after surgical treatment. Patients and methods. This prospective observational comparative study enrolled 104 patients aged 20 to 49 years with morphologically verified diagnosis of ovarian endometriosis. Patients were divided into groups. Group 1 (n = 82) received postoperative therapy with dienogest (Zafrilla) (2 mg once daily for 24 weeks); group 2 (n = 22) did not receive postoperative hormonal therapy. The duration of postoperative follow-up was 12 months. Results. The recurrence rate of ovarian endometriosis within 12 months was 1.22% (1 out of 82) in group 1 and 22.7% (5 out of 22) in group 2. Against the background of postoperative therapy with dienogest in group 1, there was a statistically significant decrease in the average pain intensity and its transformation from moderate to mild after 3 months of therapy (2.5-fold on average) and to mild or complete relief after 6 months (5-fold on average, compared to the values before therapy), according to pain assessment scales (NRS, VAS). Group 2 showed a statistically significant increase in the average pain intensity on all scales and no statistically significant change in serum concentrations of the examined markers (IL-17, IL-6, IL-10, TNF-α), while group 1 demonstrated a statistically significant decrease in serum concentrations of all the examined inflammatory markers and the CA-125 marker. Conclusion. Dienogest (Zafrilla) can be considered as the main therapeutic approach for the long-term prevention of ovarian endometriosis recurrence after surgical treatment. Key words: endometriosis, ovarian endometriomas, pelvic pain, dienogest, quality of life, inflammatory markers

Эндометриоидная цистаденома – глубокий яичниковый эндометриоз

Among all endometriosis lesions of female reproductive organs, ovarian endometrioma is the most discussed nosology. Since 2014, ovarian endometrioid cysts have been classified as benign tumors (WHO Classification of Tumours of Female Reproductive Organs, 4th edition). In 2021, the 11th revision of the International Classification of Diseases (ICD-11) was amended, according to which the term “endometrioid ovarian cyst” (from 2018 to 2021 – heading GA18.3 Ovarian endometriotic cyst, section GA18 Acquired abnormalities of ovary) is no longer used, and the clinical and morphological signs of these cysts are presented in the heading GA10.B5 Deep ovarian endometriosis. In 2020, WHO updated the histological classification of female genital tumors (Female Genital Tumours WHO Classification of Tumours, 5th Edition), in which the section “endometrioid tumors” is presented only with endometrioid cystadenoma and endometrioid adenofibroma without mentioning the endometrioid cyst, but in accordance with the ICD-11, endometrioid cystadenoma is coded as “GA10.B5 Deep ovarian endometriosis”. Thus, on the one hand, ovarian endometrioma is a neoplastic process and requires appropriate approaches when choosing treatment tactics, on the other hand, cystectomy for endometrioma is accompanied by a pronounced loss of ovarian reserve. A possible consensus in this problem seems to be a minimally invasive method in the treatment of patients with ovarian endometriomas – ethanol sclerotherapy with cytological examination of the aspirate obtained from the neoplasm. The effectiveness of sclerotherapy largely depends on the choice of postoperative hormonal therapy. Today, dienogest is considered to be the most effective “anti-endometrioid” progestogen. However, there is an erroneous opinion that ethinylestradiol neutralizes the antiproliferative effect of dienogest and stimulates the growth of endometriosis. On the contrary, ethinylestradiol enhances the inhibitory effect of progestogen on the growth of ovarian endometrioma cells. Key words: endometrioid cystadenoma, ovarian endometrioma, deep ovarian endometriosis, sclerotherapy, dienogest

Endometriosis and Pelvic Pain in the Adolescent: Delayed Diagnosis Leading to Long-Term Suffering and the Need for Intervention

<h3>Study Objective</h3> To discuss the atypical presentation of endometriosis in adolescents, importance of decreasing delays in diagnosis and management and reducing long-term suffering in our adolescent population <h3>Design</h3> Narrative Review. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A database search was performed using MEDLINE/PubMed and CINAHL Plus. Keywords included, adolescent endometriosis, pelvic pain adolescents, secondary dysmenorrhea in adolescents, adolescent endometriosis presentation, adolescent endometriosis management. The committee opinion from the American College of Obstetrics and Gynecologists on dysmenorrhea and endometriosis in the adolescent was utilized. A manual search from reference lists of relevant articles was conducted. Endometriosis is the most common cause of secondary dysmenorrhea in adolescents. Delay in diagnosis of endometriosis in adolescents, continues to be a barrier in early intervention and management, leading to chronic pelvic pain and long-term suffering well into adulthood. Atypical presentation of endometriosis in adolescents contributes to the delay in diagnosis. In adolescents, endometriotic lesions present as red, clear, white, or glandular lesions rather than the powder burn lesions seen in adult women. Additionally, adolescents develop non-cyclical pain, not the classic cyclic pain associated with endometriosis. Pelvic ultrasounds and Magnetic Resonance Imaging are helpful in diagnosis, however laparoscopy remains the gold standard, even in adolescents, because the likelihood of discovering endometriosis in an adolescent presenting with dysmenorrhea and chronic pelvic pain refractory to medical therapy is at least 50%. Hormonal therapy, NSAIDs, GNRHa and, surgical management with postoperative hormonal therapy are the recommended treatments for adolescent patients. <h3>Conclusion</h3> Early intervention and management of endometriosis and pelvic pain in the adolescent population can decrease delay in diagnosis, long-term suffering, and potentially a reduction in disease progression. Diagnostic laparoscopy with biopsy and surgical therapy should not be delayed in the adolescent patients who are refractory to medical therapy; it still remains the gold standard in the diagnosis of endometriosis.

Combined Hysteroscopic and Laparoscopic Approach to a Complicated Case of Asherman's Syndrome

<h3>Study Objective</h3> We aim to present a combined hysteroscopic and laparoscopic approach to the resection of a post-cesarean section scar causing complete obstruction of the endometrial cavity. <h3>Design</h3> Video presentation. <h3>Setting</h3> Ambulatory surgery center, academic hospital. <h3>Patients or Participants</h3> 31-year-old multiparous patient with history of c-section who presented with secondary amenorrhea and infertility due to Asherman's Syndrome. She underwent laparoscopic guided hysteroscopic adhesiolysis followed by postoperative hormone therapy and close follow up. <h3>Interventions</h3> The patient's workup included saline infusion sonohysterogram, 2D ultrasound, and 3D ultrasound. She underwent a combined hysteroscopic and laparoscopic procedure in which hysteroscopic scissors were used to remove the adhesion under laparoscopic guidance. An intrauterine balloon catheter was placed postoperatively. She took postoperative antibiotics while the balloon remained in situ as well as postoperative hormone therapy to promote growth of healthy endometrium and prevent new adhesion formation. <h3>Measurements and Main Results</h3> The use of a combined hysteroscopic and laparoscopic approach resulted in a safe and successful removal of post-cesarean uterine scar tissue and treatment of Asherman's Syndrome with subsequent resumption of menses. <h3>Conclusion</h3> Asherman's Syndrome should remain on the differential for women who present with secondary amenorrhea. The addition of 3D ultrasound to saline infusion sonohysterogram is useful for surgical planning. A combined hysteroscopic and laparoscopic approach to the resection of uterine adhesions should be considered when managing severe cases of Asherman's Syndrome and dense adhesions, especially when the location of adhesions is not clear from imaging.