Antiangiogenic Therapy as a New Strategy in the Treatment of Endometriosis? The First Case Report.

Angiogenesis plays a pivotal role in implantation and development of ectopic endometrial lesions. Thus, the potential usefulness of anti-angiogenic therapies has been speculated. Several reports describe their usefulness in animal models. Nonetheless this therapy has not been tested on humans yet. Here we report the outcome of a patient treated for a severe endometriosis with Bevacizumab (Avastin®), a monoclonal antibody directed against the vascular endothelial growth (VEGF). After a first-look laparoscopy with confirmatory biopsies was performed, three doses of Bevacizumab at 2-week intervals were administered. The therapy showed a well-tolerated profile and the prompt disappearance of the therapy-refractory chronic dysmenorrhea. A suppression of metabolic activity at the PET-scan compared to the basal one performed at diagnosis was also recorded. Furthermore, compared to the diagnostic biopsies prior the treatment, we documented a shift in the hormonal receptors profile toward a higher expression of progesterone and estrogen receptors in the endometriotic lesions.

Metformin, the Rise of a New Medical Therapy for Endometriosis? A Systematic Review of the Literature.

Medical treatments for endometriosis aim to control pain symptoms and stop progression of endometriotic lesions. However, their adverse effects and their contraceptive effect in women who desire pregnancy, limit their long terms use. Although there is only one study investigating the effects of metformin on women with endometriosis, metformin seems to have a unique therapeutic potential. It may be a helpful anti-inflammatory and antiproliferative agent in the treatment of endometriosis. As such metformin may be more beneficial thanks to the lack of serious side effects.

Surgical management of a large postoperative vulvar haematoma following vulvar phlebectomy and ovarian vein embolization for vulvar varicose veins: A case report.

Vulvar varicose veins (VVs) are seen in 4% of women, most of them secondary to pregnancy and usually regressing spontaneously. The treatment of choice during pregnancy is conservative and symptomatic. Management of vulvar varicosities in non-pregnant women consists of various techniques, including phlebectomy, endovascular embolization or surgical ligation of contributing veins, sclerotherapy and, recently, conservative treatment with the venoactive agent MPFF (micronized purified flavonoid fraction). We report an unusual case of a large hematoma of the right labium majus following bilateral vulvar phlebectomy and embolization of the left ovarian vein. The patient was a non-pregnant woman, who underwent incision and drainage of this rare complication. At follow-up almost a year after this procedure the patient reported comfort and cosmetic satisfaction regarding her vulvar symptoms. A multidisciplinary team approach to vulvar varicosities is important, with the involvement of gynecologists, angiologists, interventional radiologists and vascular surgeons.

It Is Necessary to Purpose an Add-on to the American Classification of Endometriosis? This Disease Can Be Compared to a Malignant Proliferation While Remaining Benign in Most Cases. EndoGram® Is a New Profile Witness of Its Evolutionary Potential.

Endometriosis is a curious pathology that has been the topic of many international publications. Its etiology remains mysterious but seems to have multiple causes. It is a complex disease whose lesions are very heterogeneous in where they can occur (deep endometriosis, superficial, ovarian cyst), extent, associated symptoms, evolution or aggressiveness of the disease, and response to treatments. Furthermore, it evolves in pushes, remains autonomous, and is responsible for both superficial and deep lesions that explain its two most well know challenges: pain and infertility. It has always been classified by the size of its anatomical lesions-Acosta classification (1), revised by the American fertility society (AFS) (2), and the American society of reproductive medicine (ASRM) classification with a description of the disease at different stages: minimal (score of 1 to 5), mild (3-12), moderate (16 to 40), and severe (>40) (13). If this classification provides a complete repertoire of implants (anatomic) (10), the attribution of points is arbitrary. In fact, the size of the lesions is not synonymous with the difficulty to treat them surgically. Their location, if deep, is larger than the size of ovarian endometriomas. In addition, small anatomical but evaluative lesions will have a larger impact than big fibrous and stable lesions (Figure 1). Thus, attempts to explain their inflammatory side effects have been proposed (14, 15). The French classification nodule, ovaries, adhesions, tube, and inflammation (FOATI) (10) has had the merit of taking this phenomenon into account. In our opinion, we must go much further and propose an amendment in this classification, taking into account the evolution of the lesions and their deep molecular biology because in reality, the lesions are not at the same stage.

Endometriotic Mass After Hysterectomy in a 61 Year Old Post-menopausal Woman: A Case Report and Update.

Endometriosis is a common, hormone-dependent gynecologic disease. Undiagnosed in large proportion of women, managing therapies depend on the impact of quality of life and includes hormonal treatment and pelvic surgery. Less likely endometriosis can occur in post-menopausal women. Malignant transformation of endometriosis is a rare but well-described process, most of time occurring in the ovary, and justifies the practitioner not to underestimate this pathology. We present a case of a 61 year old woman with a symptomatic endometriotic pelvic mass, status post hysterectomy, with no history of endometriosis diagnosed beforehand.

The Sentinel Lymph Node in Breast Cancer: Problems Posed by Examination During Surgery. A Review of Current Literature and Management.

The presence of tumor cells can be identified in the lymph node when metastasis has occurred from the primary cancer site into the lymph node (1) If the sentinel lymph node ganglion is negative for the presence of tumor cells at the time of histological examination, the other lymph nodes are also negative in 99% of cases. If no tumor cells are identified in the sentinel lymph node ganglion by histological examination, the other lymph nodes are also negative for the presence of tumor cells in 99% of cases. The sentinel lymph node advantageously replaces axillary dissection as a staging method in breast cancer T1 and T2 (2). Approximately 40% of breast cancers metastasize to axillary lymph nodes and metastatic extension depends on disease stage. Sentinel lymph nodes are affected in the following stages: T1a (4.3%), T1b (19.5%), T1c (23.8%), T2 (48.9%), T3 (66.7%).

Paget's Breast Disease: A Case Report and Review of the Literature.

Paget's disease of the breast is a rare cancer. This typical clinical case illustrates the different epidemiological, clinical, histological, therapeutic, and evolving aspects of the disease. We report a case of Paget's disease in a 43-year-old woman who presented eczema of the nipple. Mammography and ultrasounds did reveal a lesion in situ. The patient was scheduled for mastectomy and sentinel node biopsy. She had chosen a radical bilateral surgery. The histological diagnosis was Paget's disease of the breast with a carcinoma in situ. There was no metastasis in either of the sentinel nodes. Paget's disease must be considered with the presence of a persistent eczematous involvement of the nipple, which does not respond to local treatment. Ultrasounds, mammography, and magnetic resonance imaging can allow searching an underlying cancer and guiding the surgical management. There is no evidence at this time that one of the two surgical techniques (conservative or mastectomy) would improve survival. The prognosis depends on the presence of a palpable mass and the invasiveness of the cancer.

Laparoscopic Adnexectomy for Ovarian Torsion during Late Pregnancy: Case Report of a Non-Conservative Treatment and Literature Analysis.

Diagnosis of adnexial torsion is difficult during pregancy (1). The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. The loss of an ovary can compromise the following fertility. Even if concerns related to laparoscopy in pregnant patients include a limited surgical field, with a risk of uterine injury and negative fetal effects of CO2 insufflation. Evidence base suggests that minimally invasive surgery can be safe and better than laparotomy for management of adnexal masses during late pregnancy with good postoperative and obstetric outcomes. If for most authors laparoscopy appears to become the best approach for ovarian torsion during pregnancy (2), nonetheless, the ideal surgical laparoscopic approach of adnexa in late pregnancy remains controversial. Since there is no technical gold standard to overcome surgical difficulties which could make laparoscopic procedures as real challenge in patients in second and third trimester (3); at least, in case of radical and non-conservative treatment, the risk for a first trimester of pregnancy is to remove the corpus luteum (1).

Pseudomyxoma Peritonei: A Case Report Diagnosed in a 47-Year-Old Woman with Chronic Pelvic Abdominal Pain and Appendicular Origin: Review of the Literature and Management.

The authors report a case of pseudomyxoma peritonei with gelatinous peritoneum in a 47-year-old-woman. The main symptom for discovery was a chronic pelvic abdominal pain. This disease is particularly rare. The gelatinous substance is often associated with a malignant ovarian tumor or appendicitis perforated. Currently, on the whole, an exploratory laparoscopy allows diagnosis, biopsies, and appendectomy. The treatment is essentially surgical. The prognosis depends on grade (1/3) and response to chemotherapy. This case was presented to the tumor board.

Robotic Surgery in Gynecology.

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon's skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Laparoscopic myomectomy.

The gold standard access for myomectomy is laparoscopy in selected cases, including intramural and sub-serous symptomatic leiomyomas. The main contraindications concern inexperience of the surgeon, severe necrobiosis, suspected leiomyosarcoma and excessive size. The tips and tricks of the laparoscopic technique are described, specially enucleation, myometrium suture and prevention adhesions.

Laparoscopic Lateral Suspension: Benefits of a Cross-shaped Mesh to Treat Difficult Vaginal Vault Prolapse.

STUDY OBJECTIVE: To show an original technique of laparoscopic lateral suspension (LLS) with a precut mesh in a difficult case of vaginal vault prolapse. DESIGN: Step-by-step descriptions of the technique using videos (educational video). SETTING: Vaginal vault prolapse affects up to 1% of patients who had a hysterectomy. Sacrocolpopexy is considered the gold standard in the treatment of apical pelvic organ prolapse. However, dissection at the level of the promontory may be challenging, particularly in obese patients or when an anatomic variation exists. This may be associated with rare but serious neurologic or ureteral morbidity as well as life-threatening vascular injury. LLS with mesh represents an alternative procedure, avoiding dissection at the promontory. The originality of this video is to describe the procedure of LLS in a difficult case of vaginal vault prolapse related to adhesions and difficulties of fascia cleavage. The use of a precut cross-shaped mesh simplified the technique and facilitated the attachment of the mesh to the fascia and the lateral suspension for a smaller period of time. This point is not negligible, especially in cases with technical difficulties. Institutional review board approval was obtained through the local ethics committee of Geneva University Hospitals (Canadian Task Force classification III). INTERVENTIONS: After dissections, positioning of the mesh on the dome and on the anterior and posterior vaginal walls is explained. The out-in technique of lateral suspension with the specific mesh is described. CONCLUSION: In this difficult case of vaginal vault prolapse, the LLS using a precut cross-shaped mesh was placed in good conditions, providing the patient with a minimum risk of complications and with the benefits of minimally invasive approach.

Verrucous Carcinoma of the Vulva: A Case Report and Review of the Literature.

Verrucous carcinoma of the vulva is a rare lesion (1). Affecting essentially postmenopausal women, this lesion is a distinct and particular entity in vulval carcinoma classification and its scalability is uncertain and unpredictable. Here, we present a case concerning a 48-year-old patient, without follow-up after a condyloma acuminate of the vulva (large left lip). The origin of this case will be discussed in this article. The treatment decided was only surgical. A review of literature shows the rarity of this lesion of the female genital tract.

Endometriosis and Vesico-Sphincteral Disorders.

OBJECTIVES: The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function). MATERIALS AND METHODS: We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms, and surgery. RESULTS: The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction. CONCLUSION: A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.

A Case Report: Pseudoangiomatous Stromal Hyperplasia Tumor Presenting as a Palpable Mass.

We report a case of woman with a palpable lump on her left breast. On mammography, a huge mass located between the inner and the outer inferior breast quadrants of the left breast was found. The ultrasound examination realized later revealed a heterogeneous mass with smooth and lobulated borders. An MRI was also performed, showing an oval mass with heterogeneous areas of enhancement. Finally, a core biopsy under sonographic guidance revealed a pseudoangiomatous stromal hyperplasia of the breast.

Laparoscopic treatment of placenta percreta retention in a cesarean scar: a case report.

Placenta percreta retention within the scar of a previous cesarean section is rare. We report here one of these cases treated successfully by laparoscopy, with uterine repair. Different therapeutic options are described.

Endometriosis: a new cellular and molecular genetic approach for understanding the pathogenesis and evolutivity.

Endometriosis is a benign disease with high prevalence in women of reproductive age estimated between 10 and 15% and is associated with considerable morbidity. Its etiology and pathogenesis are controversial but it is believed to involve multiple genetic, environmental, immunological, angiogenic, and endocrine processes. Altered expressions of growth factors, cytokines, adhesion molecules, matrix metalloproteinases, and enzymes for estrogen synthesis and metabolism have been frequently observed in this condition. The possibility of genetic basis of endometriosis is demonstrated in studies of familial disease, in which the incidence of endometriosis is higher for first-degree relatives of probands as compared to controls. This review describes mainly the cellular, cytochemical, cytogenetic, and molecular genetic features of endometriotic lesions and cultured endometriotic cells. In attempts to identify candidate gene (s) involved in the pathogenesis of endometriosis, a tissue-based approaches including conventional cytogenetics (RHG-banding), loss of heterozygosity (LOH), and comparative genomic hybridization (CGH) were employed. In addition to the karyotypic anomalies, consistent chromosome instability was confirmed by CGH and fluorescence in situ hybridization (FISH). The nature and significance of the molecular genetic aberrations in relation to the locations and function of oncogenes and tumor suppressor genes will be discussed. At last, a possible pathogenic role of embryonic duct remnants was observed in seven female fetal reproductive tract in endometriosis and may induce a discussion about the beginning of ovarian tumors and malignant proliferations.

Identification of displaced endometrial glands and embryonic duct remnants in female fetal reproductive tract: possible pathogenetic role in endometriotic and pelvic neoplastic processes.

BACKGROUND: Recent findings strongly promoted the hypothesis that common pelvic gynecological diseases including endometriosis and ovarian neoplasia may develop de novo from ectopic endometrial-like glands and/or embryonic epithelial remnants. To verify the frequency, the anatomical localization and the phenotype of misplaced endometrial tissue along the fetal female reproductive tract, histological and immunohistochemical analyses of uteri, fallopian tubes, and uterosacral ligaments were performed. METHODS: Reproductive organs were collected from seven female fetuses at autopsy, five of them from gestational ages between 18 and 26 weeks and two fetuses with gestational ages of 33 and 36 weeks deceased of placental anomalies. Serial sections from areas containing ectopic glands and embryonic duct residues were analyzed by histological and immunohistochemical procedures. RESULTS: Numerous ectopic endometrial glands and stroma were detected in the myometrium in two fetuses with low levels of expression of estrogen receptor-alpha (ER-α) and progesterone receptors (PR). The embryonic ducts were localized in the uterine broad and ovarian ligaments and under the fallopian tube serosa in six fetuses. Low levels of steroid receptors expression were found in the embryonic residues, whereas the carcino-embryonic antigen (CEA) and the tumor marker Ca 125 were not detected. The embryonic residues stromal component strongly expressed the CD 10 and vimentin proteins. CONCLUSION: The anatomical and the immunohistochemical features of the ectopic organoid structures identified in fetal female reproductive tract suggest that endometriotic as well as neoplastic disease in adult women may develop on the basis of misplaced endometrial glands and/or embryonic cell remnants.