Evaluation of Immune Infiltrates in Ovarian Endometriosis and Endometriosis-Associated Ovarian Cancer: Relationship with Histological and Clinical Features.

BACKGROUND: the association between ovarian endometriosis (OE) and endometriosis-associated ovarian cancer (EAOC) is extensively documented, and misfunction of the immune system might be involved. The primary objective of this study was to identify and compare the spatial distribution of tumour-infiltrating lymphocytes (TILs) and tumour-associated macrophages (TAMs) in OE and EAOC. Secondary objectives included the analysis of the relationship between immunosuppressive populations and T-cell exhaustion markers in both groups. METHODS: TILs (CD3, CD4, and CD8) and macrophages (CD163) were assessed by immunochemistry. Exhaustion markers (PD-1, TIM3, CD39, and FOXP3) and their relationship with tumour-associated macrophages (CD163) were assessed by immunofluorescence on paraffin-embedded samples from n = 43 OE and n = 54 EAOC patients. RESULTS: we observed a predominantly intraepithelial CD3+ distribution in OE but both an intraepithelial and stromal pattern in EAOC (p < 0.001). TILs were more abundant in OE (p < 0.001), but higher TILs significantly correlated with a longer overall survival and disease-free survival in EAOC (p < 0.05). CD39 and FOXP3 significantly correlated with each other and CD163 (p < 0.05) at the epithelial level in moderate/intense CD4 EAOC, whereas in moderate/intense CD8+, PD-1+ and TIM3+ significantly correlated (p = 0.009). Finally, T-cell exhaustion markers FOXP3-CD39 were decreased and PD-1-TIM3 were significantly increased in EAOC (p < 0.05). CONCLUSIONS: the dysregulation of TILs, TAMs, and T-cell exhaustion might play a role in the malignization of OE to EAOC.

Quality of life and low anterior resection syndrome before and after deep endometriosis surgery.

PURPOSE: Deep endometriosis (DE) is defined by the presence of ectopic endometrial glands, with rectal involvement ranging from 5.3 to 12%. The prevalence of low anterior resection-like syndrome (LARS) in patients with DE, how it affects quality of life (QoL), and its evolution after surgery is unclear. The objective of this study was to assess the gastrointestinal functional outcomes and QoL in patients who underwent surgery for DE. PATIENTS AND METHODS: A prospective study was conducted from 2017 to 2019, recruiting patients who underwent DE surgery with and without rectal resection. Patients completed LARS and SF-36 questionnaires before, at 6 months and at 1 year after surgery. RESULTS: Eighty-two patients were enrolled. Rectal segmental resection was required in 16 (19.5%) patients, shaving in 16 (19.5%) and discoid resection in 8 (9.8%). All 8 domains of the SF-36 questionnaire showed improvement during follow-up, reflecting improved QoL after surgery (p ≤ 0.05) in all patients. Mean LARS scores for patients without rectal surgery were 7.5 ± 10.4 before and 13.7 ± 14.2 1 year after surgery; rectal surgery was 13.6 ± 13.6 and 14.6 ± 13.1, respectively (p = 0.17). No significant differences were found in the rectal surgery patients' postoperative LARS score among the 3 rectal DE surgical techniques (p = 0.97), and the SF-36 scores improved independent of the technique performed. CONCLUSIONS: Patients with DE present a LARS-like syndrome before surgery that does not appear to be negatively affected after rectal surgery, independent of the technique performed. Rectal surgery improves the QoL of patients with DE patients as measured by the SF-36 questionnaire at 1 year of follow-up.

Surgeons' workload assessment during indocyanine-assisted deep endometriosis surgery using the surgery task load index: The impact of the learning curve.

Objective: Assess the surgeons' workload during deep endometriosis surgery after ureteral ICG. Design: Prospective, consecutive, comparative, single-center study. Population: 41 patients enrolled to deep endometriosis surgery with ureteral ICG from January 2019 to July 2021 at La Paz University Hospital. Methods: Patients were divided into 2 groups: patients operated during the learning curve of ureteral ICG instillation and patients operated after the technique was implemented and routinely performed. After surgery, the SURG-TLX form was completed by the surgeons. We evaluated whether a workload reduction occurred. Main outcomes measures: Surgeon's workload was measured using the SURG-TLX form, obtaining the total workload and 6 different dimensions (distractions, temporal demands, task complexity, mental demands, situational stress and physical demands). Results: A significant positive correlation was found between surgical complexity and situational stress (p = 0.04). Mental demands (p = 0.021), physical demands (p = 0.03), and total workload (p = 0.025) were significantly lower when the technique was routinely performed. The mental demand, physical demands, and total workload perceived by the surgeons at the beginning of the implementation was higher (68 [39-72], 27 [11-46.5], 229 [163-240], respectively) than in the latter ones (40 [9-63], 11.5 [0-32.8], 152 [133.3-213.8], respectively). Distractions appeared to be higher in the latter surgeries (8.5 [0-27.8]) than in the first surgeries (0 [0-7]; p = 0.057). Conclusions: Ureter ICG instillation prior to DE surgery significantly reduces the mental and physical demands and total workload of the surgeons in DE surgeries after overcoming the learning curve. Distractions appear to increase as surgical stress decreases.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study.

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

Endometriosis umbilical primaria: reporte de dos casos / Primary umbilical endometriosis: two case reports

INTRODUCCIÓN: La endometriosis es una patología benigna, dependiente de estrógenos, en la que el tejido que normalmente crece dentro del útero aparece fuera de este. Su localización habitual es en la pelvis, pero en ocasiones puede aparecer en otras áreas, como es el caso de la endometriosis umbilical. OBJETIVO: Familiarizar al ginecólogo con esta patología y entregar una serie de herramientas para diagnosticar, tratar y seguir a las pacientes que la presentan. CASOS CLÍNICOS: Se presentan dos casos clínicos de endometriosis umbilical primaria diagnosticados en el Hospital La Paz, en Madrid (España), entre los años 2018 y 2019. Las pacientes, de 30 y 34 años, consultaron por dolor o sangrado umbilical durante la menstruación. Ninguna tenía antecedentes de patología ginecológica ni cirugía abdominal previa. Tras una exhaustiva exploración física y una ecografía de alta resolución, se decidió extirpar la lesión con la colaboración del servicio de cirugía plástica. En ambos casos, el estudio anatomopatológico confirmó que se trataba de tejido endometriósico. Las dos pacientes presentaron una buena evolución posquirúrgica, sin recidivas hasta la fecha. CONCLUSIONES: La endometriosis umbilical primaria es una patología infrecuente, pero es necesario incluirla en el diagnóstico diferencial de una mujer con un nódulo umbilical. Siempre deben realizarse una exploración física exhaustiva y una ecografía ginecológica, para descartar posibles patologías concomitantes. El tratamiento de elección es la extirpación quirúrgica de la lesión y el diagnóstico final se establece con el estudio anatomopatológico.

INTRODUCTION: Endometriosis is an estrogen-dependent benign pathology in which endometrial tissue develops outside the uterus. Its most frequent location is the pelvis, although it can appear in other areas such as the umbilicum. OBJECTIVE: To familiarize the gynecologist with this pathology and provide a series of tools to diagnose, treat and provide continued care to these patients. CASE REPORTS: Retrospective study of two clinical cases of primary umbilical endometriosis diagnosed at La Paz University Hospital, in Madrid (Spain), between 2018 and 2019. Both patients (30 and 34 years old respectively) presented with pain and/or bleeding around the umbilical area during menstruation. Neither of them had any previous gynecologic conditions or abdominal surgeries. After exhaustive physical examination and a high-resolution ultrasound, lesions were surgically removed in collaboration with the plastic surgery department. In both cases, histology confirmed the presence of endometrial tissue. Both patients made a full recovery after surgery and havent had a recurrence of said lesions. CONCLUSIONS: Primary umbilical endometriosis is an infrequent disease. However, it must be included in the differential diagnosis of umbilical nodes in women. Exhaustive physical examination and gynecologic ultrasound should always be performed to rule out any other pathologies. Surgical removal of the nodes is the preferred treatment, and the final diagnosis is reached through histology.

Post-operative complications and recurrence rate after treatment of bowel endometriosis: Comparison of three techniques.

OBJECTIVE: The aim of the present study was to compare post-operative complications and recurrence of three surgical techniques: segmental resection, discoid excision and nodule shaving. STUDY DESIGN: From January 2014 to December 2017, 143 patients who underwent segmental bowel resections for endometriosis at "La Paz" University Hospital, were enrolled and grouped by different techniques. We compared post-operative complications and recurrence rate in three groups: 76 (53%) patients underwent segmental resection (group I), 20 (14%) patients underwent discoid resection (group II) and 47 (33%) patients underwent rectal shaving (group III).Qualitative data was defined by absolute values and percentages, and quantitative data by mean and standard deviation. Qualitative variables between groups were compared using Chi- squared test. While quantitative data between groups was performed by means of t-test and ANOVA test. For all statistical tests a value of p < 0.05 will be considered statistically significant. RESULT: Segmental resection was associated with higher rate of severe post-operative complications in comparison with discoid resection or shaving technique (23.5% versus 5% versus 0% respectively) (p = 0.005). We showed statistical differences among the three study groups for nodule size (p < 0.001) and localization (p = 0.02). Our analysis showed statistical differences among the three groups in term of additional procedures performed at the same time of bowel surgery, in particular in case of endometriosis of the ureter (p = 0.001) and the parametrium (p = 0.04).After a long follow-up (46.4 ± 0.5 months for the group I, 42.2 ± 1.6 months for the group II, 39.7 ± 1.8 months for the group III), the shaving group was associated to higher recurrence rate (12.7%) in comparison with the discoid group (5%) and the segmental resection group (1.3%) (p = 0.01). CONCLUSION: We showed that segmental resection is associated with high rate of postoperative complications. Conversely, this strategy should avoid the need of further interventions in young patients. Conservative surgery, such as discoid resection and shaving, revealed a higher recurrence rate and could be more appropriate in women approximating menopause because of the lower possibility of recurrence.

Ileocecal endometriosis: diagnosis and management.

OBJECTIVE: Ileocecal endometriosis is rare. Symptoms range from no symptoms, cramps, vomiting, to acute intestinal obstruction. Our objective was to review our cases, clarify, and resume its most appropriate management focusing on the factors to determine diagnosis. This is a retrospective study by revision of medical charts of all ileal endometriosis cases of our unit from 2006 to 2014. CASE REPORT: Seven cases were found; three (43%) had previous endometriosis laparoscopic diagnosis, four (57%) had partial bowel obstruction episodes, three (43%) had chronic pelvic pain, and one developed acute intestinal obstruction in postoperative ileostomy closure. In three (43%), the diagnosis was made with magnetic resonance imaging (MRI) and double contrast barium enema, in one (14%) only with MRI, and the other three (43%) during surgery. All patients underwent resection of the ileum and evolved favorably. CONCLUSION: Variability in symptoms hinders diagnosis. The gold standard for diagnosis is MRI, but clinical suspicion optimizes imaging test diagnosis. Segmental resection should be indicated in the majority of the cases.

Management of thoracic endometriosis: single institution experience.

OBJECTIVE: Thoracic endometriosis is a relatively rare type of endometriosis and includes catamenial pneumothorax, hemothorax and hemoptysis, and presence of intrathoracic endometriotic nodules. We want to clarify and resume the most appropriate management of this pathology. STUDY DESIGN: We retrospectively reviewed all the cases of thoracic endometriosis diagnosed and followed up in our Unit from 2005 to 2013. This search revealed five women, with a mean age of 34.5 (26-44). Four had previous history of endometriosis or severe dysmenorrhea. One patient complained of chronic shoulder pain with diaphragmatic implants, another one presented catamenial hemoptysis, and three women suffered from catamenial pneumothorax, with right-side preference. RESULTS: Three patients underwent surgery and all of them were treated with GnRH agonists at least during 6 month referring improvement in symptoms. After 1-8 years follow-up, all these patients remain asymptomatic. CONCLUSION: The optimal management of thoracic endometriosis needs further evaluation but the combined approach by hormonal therapy and surgery could be the best option.

Complete loss of unilateral renal function secondary to endometriosis: a report of three cases.

OBJECTIVES: To report the impact that urinary tract endometriosis may have on renal function. Ureteral endometriosis is an uncommon and silent cause of renal injury. It is therefore very important to be highly suspicious in order to be able to make an early diagnosis and thus prevent renal failure. STUDY DESIGN: Case reports of the management and outcome of three cases of premenopausal women with deep endometriosis affecting the ureter, associated with secondary unilateral complete loss of renal function. RESULTS AND CONCLUSIONS: Ureteral involvement by endometriosis is a rare and often silent disease which is capable of producing significant morbidity, as it can lead to hydronephrosis and ultimately to renal failure. Because of the lack of specific symptoms and the limitations of imaging methods, a high index of suspicion is necessary to obtain an early diagnosis. On diagnosis of deep infiltrating endometriosis, urinary tract ultrasound is a screening tool to detect ureterohydronephrosis due to ureteral obstruction. MRI is of value to map the extent of disease. Surgery is the treatment of choice to remove endometriotic lesions and relieve ureteral obstruction if the kidney is still functional, or to perform a nephrectomy if there is a complete loss of renal function.

Luteoma estromal ovárico como causa de virilización en la mujer posmenopáusica / Ovarian stromal luteoma as a cause of postmenopausal virilization

Objetivo. Se presenta el caso de una paciente diagnosticada luteoma estromal de ovario con efecto virilizante. Material y métodos. Mujer de 67 años que presenta cuadro de virilización. A pesar de que no fue posible detectar mediante pruebas de imagen ningún tumor productor de andrógenos, se decidió someter a la paciente a una histerectomía y doble anexectomía debido a la fuerte sospecha clínica y analítica de un tumor productor de andrógenos de origen ovárico. Resultados. El estudio anatomopatológico de la pieza quirúrgica demostró la presencia de un luteoma estromal de ovario como causa del cuadro de virilización que presentaba la paciente. Conclusiones. El luteoma estromal de ovario es una rara neoplasia ovárica que se presenta habitualmente en mujeres posmenopáusicas y puede comenzar con síntomas virilizantes o derivados de un ambiente hiperestrogénico. En un 20% de los casos, se diagnostica como un hallazgo incidental (AU)

Objective. We report the case of a patient diagnosed with a stromal luteoma of the ovary with a virilizing effect. Material and methods. A 67-year-old woman presented with symptoms of virilization. Although no androgen-producing tumor was detected on imaging tests, the patient underwent hysterectomy and double oophorectomy due to strong clinical and laboratory suspicion of an androgen-producing tumor of the ovary. Results. Pathologic study of the surgical specimen showed the presence of an ovarian stromal luteoma causing the patient's virilization. Conclusions. Ovarian stromal luteoma is a rare ovarian neoplasm that usually occurs in postmenopausal women and may present as virilization or hyperestrogenism. In 20% of cases, the diagnosis is incidental (AU)