pelvic endometrioma.prof.salah

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Pelvic

Endometriomas

By

DR. SALAH ROSHDY (MD)

Professor of OB/GYN


Introduction

• Endometriomas of the ovary were described by Samspan as endometrial cysts almost 80 years ago.

• Endometriomas may arise by invagination of surface endometriosis into ovarian tissue .


• The endometrial glands and stroma then grow & proliferate inside the ovary, leading to development of the cyst.

• The size of the cyst depend on degree of growth & proliferation of endometrial tissue & on haemorrhagic products that are shed into the cyst


Definition

• Endometriomas are “nodules” or

tumours of endometrial tissue are

found mainly in peritoneum lining

of pelvis & ovaries which appear

either in the form of small

superficial islands or in the form

of epithelial (chocolate cyst).


Epidemiology

• The exact incidence of endometriosis is not known because this disease can be only diagnosed by visualization during surgical procedure.

• Its prevalence are probably in the range of 5% of women of reproductive age with peak incidence in between 25-30y.


• The endometriosis is found in

• 25-40% of women with infertility &

• in 2-5% of the general population.

• 12-32% of women in childbearing period undergoing laparoscopy because of pelvic pain.

• 1% of women having gynacological operation for any reason.


Risk Factors

1. Duration of menstrual period.

2. Familial & genetic factor.

3. Genital obstruction.

4. Uterine retroversion.

5. Obesity.


Aetiology & Pathogenesis

1) Endometrial implantation

A - retrograde menstruation

B - lymphatic & vascular theory

C - mechanical theory

2) In situ development

A - Coelomic metaplasia theory

B - induction theory

3) Immunological theory

4) Composite theory


Hypothesis for aetiology of

endometriosis

1. Cell adhesion.

Cell adhesion molecules especially integrin & cadherin are the main mediator of intercellular & cell matrix adhesions, and may be important for the adhesion of endometrial tissue to the pelvic wall.

2. Proteolytic enzymes.

After adhesion of endometrial cells to the pelvic wall successful implantation of tissue require digestion of extra-cellular matrix.


3) Angiogenesis ,growth factor &

tumour suppressor gene.

Angiogenesis is complex process

involving proliferation, migration &

extension of endothelial cells

,adherence of these cells to extra-

cellular matrix & formation of new

lumen.


4) Hormonal factor.

Oestrogen is required for the growth

of endometriotic lesion although the

exact mechanism is unknown, it is

likely via a complex pathway of up-

regulation of cytokines and growth

factors such as VEGF & IL8


Pathology

1-Growth pathology.

The ovary most commonly affected pelvic structure, followed by posterior broad lig., uterosacral lig., posterior cul-de-sac, peritoneum, fallopian tubes & bowel.

Endometriomas occur bilaterally in one third to one half of the patient & may become relatively large (10-15).


Pathology - cont.

2- Microscopic picture.

The pathological diagnosis is confirmed when 2 of the following 3 feature are identified:-

• Endometrial glands

• Stroma

• Hemosiderin pigment

Free powerpoint template: www.favorideas.com 15 Growth specimen of endometrioma


Clinical Presentation

Signs Symptoms

1. Local tenderness in cul-de-sac or uterosacral ligaments.

2. Adnexal enlargement or tenderness

3. Pelvic masses

1. Pelvic pain

2. infertility

3. Hypermenorrhea

4. Premenstrual staining

5. Dysparonia

6. Supra pubic pain

7. Dysuria

8. Haematuria

9. Dyschezia

10. Lower back pain


Classification

Endometrioma size (1-2cm) & contain

dark fluid. They develop from surface

endometrial implants.

Microscopically, endometrial tissue

seen in all of them.

Type I

Endometriomas are hemorrhagic cyst

, the cyst wall is separated easily from

ovarian tissue. Endometrial implants

are superficial and adjacent to

hemorrhagic cyst which is either

follicular or luteal in origin ,

microscopically no endometrial lining

is seen.

Type II A


The cyst lining is separated easily from

ovarian capsule & stroma except near

endometrial implant.

Type

II B

the surface endometrial implant penetrate

deeply into the cyst wall, type IIB,C

endometriomas are large & associated with

peri-ovarian adhesion.

Type

II C

Ovarian endometrial cyst at least 3 cm in

diameter, the other characters are similar to

stage III &IV endometriosis.

Type

III &

IV


Diagnosis of pelvic

endometriomas

Physical examination

Imaging studies

A- Ultrasonography

Trans-vaginal sonography is the most commonly indicated test to diagnose endometriomas. Accuracy in diagnosis varies with experience of the radiologist.

B- MRI.

It appear most useful for the detection of endometriomas, with diagnostic sensitivity similar to ultrasound.


Ultrasound picture of endometrioma


Ovarian endometrioma


C-Computerized tomography (CT).

Rarely used due to the widely differing appearance of the lesion .

D-Optical coherence tomography (OCT).

It is recently developed real time imaging technology, it is analogous to ultrasound measuring the intensity of back – reflected infrared light rather than acoustic waves, the ability to obtain an optical biopsy.a high resolution cross sectional image of tissue in-situ.


Laparoscopy

• The gold standard for definitive diagnosis of endometriomosis is laparoscopy.

• Typical picture is powder burn lesion & 20 different morphological appearance (fibrotic white, brown ,black, clear vesicle, flat red lesion, yellow brown patches, peritoneal pockets & adhesion.).

• endometriomas ( grape ,grape fruit & chocolate cyst).


Large ovarian endometrioma


Endometriotic lesions in the DP & left tube


Endometriotic lesions in the ovary


Ovarian Endometrioma


Endometriotic lesions in the USL


Endometriotic lesions in UVP


Endometriotic lesions in the liver


endometriotic lesions in the cervix


Endometriotic lesions in the RVS


Endometriotic lesions in the urinary bladder


Endometriotic lesions in the appendix


Transvaginal hydro-laparoscopy (THL).

• It has become available as an office technique using 3-mm needle system introduced through the posterior fornix & saline as distention medium, the technique is more accurate than laparoscopy in the early detection of endometriotic lesion.

Serum CA-125. • Level of CA-125 decrease following treatment

& it may prove to be a reliable parameter for clinical course follow up.


Histopathological diagnosis.

Thermo-colour test.

It is diagnostically accurate in in 85%of cases. The test best applied at the beginning of the cycle. Here, healthy peritoneum become white at 100 c while pale red endometriotic implants become dark brown or black owing to its haemosidirin content.


Treatment of Pelvic

Endometriomas

Aim of treatment

• Destroy or remove most of implants.

• Restore the normal anatomy.

• Prevent or delay progression.

• Relieve the patient symptoms.


1 - Medical treatment

1. It is used conventionally in treatment of endometriosis however endometriomas are invariably unresponsive to drug therapy .

2. There is rational to use post operative GnRh analogue treatment to .

• Accomplish complete resection of lesions that can not be surgically removed .

• Treat microscopic foci .

• Prevent iatrogenic dissemination of endometriotic cell.


2 - Conservative surgical Procedure It is frequently the treatment of choice for

symptomatic endometriomas

A. Conservative Laparoscopic Procedure

Laparoscopy is the first choice technique in the treatment of endometriomas because of

low morbidity, high tolerance,

faster patient recovery ,short hospital stay

& reduced cost.


• Excision of the cyst

(endometriomectomy) by capsular

stripping & laser vaporization or

excision diathermy.

• Incision & drainage without removal of

the cyst.

• Fenestration & coagulation.

• Laser or cautery ablation of the cyst

wall


Laparoscopic drainage of endometriomas


Laparoscopic excision of endometriomas


B. Conservative Laparotomy

• The traditional surgical approach to endometriomas has been to perform a laparotomy & microsurgery, however this strategy has been changed & laparotomy should no longer the surgical technique of the 1st choice.


• Although the pregnancy rate & cyst recurrence & adhesion were found to be comparable between the two procedure, yet blood loss at operation, the length of hospital stay and the recovery time of the patient were significantly lower in laparoscopic group.


3 - Sclerotherapy

• The technique involve needle aspiration of the liquid content of the cyst, followed by injection of 4-5% tetracyclin into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 w, in more than 75% of cases

• It is a safe & effective alternative to surgery for definitive treatment of recurrent cases & in select group of the patient planned to undergo IVF.


4 - Radical treatment

• Hysterectomy & bilateral salpingo –oophorectomy are indicated in patient with severe symptoms &not responding to other measures & are not interested in pregnancy.


5 - Immunotherapy

• It is a very new approach using tumour vaccine RESAN, which trigger T-cell immune response against endometriosis, showing promising results.

pelvic endometrioma.prof.salah

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