Background The aim of the study is to investigate the proportion and clinical features of previous spontaneously ruptured ovarian endometrioma among women who underwent elective surgery for endometrioma. Methods This retrospective study was based on a cohort of elective surgeries for endometrioma performed by the same gynecologic team at Peking Union Medical College Hospital from January 2017 to October 2022. Patients diagnosed with previous spontaneously ruptured endometrioma during elective surgery were enrolled in the ruptured group. In the same cohort, patients with unruptured endometrioma treated during the same period were selected as the unruptured group by 1:2 matching according to age. Demographic and clinical information were collected and compared between two groups. Results A total of 422 patients in the cohort were diagnosed with endometrioma. There were 38 patients (9.0%) in ruptured group and 76 patients in unruptured group. All enrolled participants were treated by laparoscopic surgery. In ruptured group, 86.8% patients had a history of acute abdominal pain, which was only 13.2% in unruptured group ( P < 0.001). Compared to unruptured group, patients diagnosed with ruptured endometrioma had a lower BMI ( P = 0.021), larger maximum diameter of endometrioma ( P = 0.040), higher proportion of cul-de-sac partial obliteration rather than complete obliteration ( P = 0.003). Conclusions Spontaneous rupture of endometrioma is not rare. The proportion of spontaneous rupture of endometrioma in our study was higher than that reported in the literatures. In women with endometrioma, the onset of acute abdominal pain should be considered a rupture of cyst, especially in patients with big cysts.

BackgroundThe objective of our study was to investigate the risk factors for a decrease in ovarian reserve in patients with endometriomas after standardized laparoscopic procedures and evaluation to provide corresponding clinical guidance for patients with fertility requirements.MethodsAnti-Müllerian hormone (AMH) levels and other clinical data from 233 patients with endometriomas and 57 patients with non-endometrioma ovarian cysts admitted to the Peking Union Medical College Hospital between January 2018 and September 2023 were prospectively analysed. The pretreatment AMH levels of the study groups were compared to assess the impact of endometrioma on ovarian reserve, and the decrease in AMH after treatment was analysed to determine potential risk factors contributing to this change.ResultsPretreatment AMH levels did not significantly differ between patients with endometriomas and those with non-endometrioma ovarian cysts. Within the endometrioma group, older age, higher body mass index (BMI), and shorter menstrual cycles were found to be associated with decreased AMH levels prior to treatment (p<0.05). Participants presenting with bilateral cysts, advanced surgical staging, or a completely enclosed Douglas pouch demonstrated significantly lower levels of AMH prior to treatment compared to those without these conditions (p<0.05). Furthermore, their AMH levels further declined within one year after undergoing laparoscopic cystectomy (p<0.05). However, there was no difference in AMH levels after surgery between patients who successfully became pregnant and those who did not (p>0.05).ConclusionLaparoscopic removal of endometriomas can adversely affect ovarian reserve, especially during bilateral cysts removal and when patients are diagnosed as having a higher stage of endometriosis, further impacting ovarian function. It should be noted that a decrease in AMH levels may not necessarily indicate an absolute decline in fertility. Therefore, it is crucial to conduct thorough patient evaluations and provide comprehensive patient education to offer appropriate guidance for fertility preservation.

Background: Adenomyosis (AM) is a common benign gynaecologic disease characterized by dysmenorrhea and heavy menstrual bleeding and requires for long-term management. Levonorgestrel - releasing Intrauterine System (LNG-IUS) is a long-acting hormone-releasing uterine device which has benefits in relieving pain and reducing bleeding. Objectives: To summarise the current available evidence regarding the LNG-IUS for the treatment of AM and to identify potential research gaps. Search Strategy: We performed a systematic search in electronic databases including MEDLINE, The Cochrane Library, EMBASE, CBM, CNKI and Wanfang. Selection Criteria: We included studies of adult patients with a diagnosis of AM and focused on treatments with the LNG-IUS combined with conservative therapy. Data Collection and Analysis: A random-effects model was used for meta-analysis. Quality and risk of bias were assessed using the Newcastle Ottawa Scale for non-RCTs and Cochrane risk of bias tool for RCTs. Main Results: Thirty-nine studies compared the LNG-IUS with other conservative therapeutic drugs, and 32 studies investigated LNG-IUS as the post-operative therapeutic management. In patients who received conservative therapies, the most reported comparison was GnRHa+LNG-IUS versus LNG-IUS alone, followed by LNG-IUS versus mifepristone, gestrinone, blank control, GnRH-a, and androgen. Conclusions: Compared with COC and GnRHa, LNG-IUS could maintain a long-term effect in reducing dysmenorrhea and bleeding. Combined therapeutic treatment with GnRH-a and LNG-IUS was more efficacious than LNG-IUS alone in patients with an enlarged uterus and moderate to severe dysmenorrhea. Moreover, in patients undergoing post-operative therapy, the LNG-IUS showed a significant long-term benefit. Keywords: LNG-IUS evidence mapping adenomyosis

Objective:This study aimed to explore the distribution of nerve fibers in abdominal wall endometriosis (AWE) and discern their association with pain.Methods:A retrospective case-control study was conducted. The cases comprised 30 patients diagnosed with AWE, while the control group consisted of 17 patients who had undergone laparotomy without any history of endometriosis. We analyzed clinical characteristics and examined the innervation patterns in samples using stains for S-100, neuron-specific enolase (NSE), protein gene product 9.5 (PGP9.5), neurofilament (NF), and substance P (SP) antibodies.Results:There was a notable increase in the density of S-100, NSE and PGP9.5 immunoreactive nerve fibers and a higher proportion of SP positivity in AWE lesions compared to standard abdominal wall scars (p < 0.05). However, there were no significant differences in the density or proportion of NF-immunoreactive nerve fibers between the cases and the controls. Moreover, no statistically significant correlation was observed between the density of S-100, NSE, PGP9.5, NF, or SP-positive nerve fibers and pain scores.Conclusion:This study demonstrated an increased immunoreactive nerve fiber density located in AWE lesions compared to normal abdominal wall scars. Further high-quality studies are needed to investigate the mechanisms responsible for pain in women with endometriosis.

The field of nuclear medicine and theranostics has never been as vibrant as it is today (1–3). Over the last decade, largely because of the approval of several new radiopharmaceuticals by the U.S. Food and Drug Administration and the European Medicines Agency for diagnosis and treatment of various types of cancer, a large number of startup companies have been formed around the globe. Numerous research laboratories have devoted significant resources and effort to the development of novel radiopharmaceuticals that can be translated into the clinic for cancer patient management as well. For diagnostic purposes, the most common radioisotopes used in the clinic are still Tc, F, C, and Ga, although there are an increasing number of studies using radioisotopes such as Cu and Zr. For therapeutic purposes, that is, radioligand therapy or targeted radionuclide therapy, there are, generally speaking, 3 types of radionuclides that can be used: a-emitting radioisotopes (e.g., Ra, Ac, At, Bi, and Pb), b-emitting radioisotopes (e.g., I, Lu, Y, Cu, and Sc), and Auger-emitting radioisotopes (e.g., I, Ga, Tc, In, and Tl). This is a decade of unprecedented excitement and high expectations for novel radiopharmaceuticals. Some literature also refers to radioligand therapy and targeted radionuclide therapy as a radionuclide–drug conjugate, which is obviously based on the commercial successes of antibody–drug conjugates. However, we argue that radionuclide–drug conjugate is not a scientifically accurate term because the radionuclide itself is the drug that causes cell killing, not, as the name radionuclide– drug conjugate suggests, the antibody or other ligand. When we compare the 3 relevant types of radionuclides, that is, a-emitters, b-emitters, and Auger-emitters, there are advantages and disadvantages to each choice, and the right choice may be dependent on a variety of factors, such as the targeting ligand, the size of the tumor, the cost, and the risk-to-benefit ratio, to name just a few. b-emitters (e.g., Lu, Y, and I) have been extensively used in the clinical setting (with some radiopharmaceuticals approved or soon to be approved for clinical use); to be effective, Auger-emitters often require precise targeting of the cancer cell nucleus, a requirement that can be challenging to achieve in high efficiency; a-emitters are much more effective in cell killing at a short distance (,100mm) but may have significant toxicity if not targeted properly to the tumor tissue. Such toxicity may be exacerbated by the fact that the strong recoil of an a-emission will cause the radioisotope to detach from the chelator, and the daughter radionuclides may accumulate substantially in other organs such as the kidneys and potentially cause dose-limiting toxicity. This possibility has been one of the major concerns and challenges regarding the clinical use of Ac, as it has 4 a-decays. Therefore, researchers have been investigating various strategies to reduce the potential toxicity of Ac and its daughter radionuclides, such as kidney protection, pretargeting, or the use of nanomaterials to trap Ac and its daughters. In this issue of The Journal of Nuclear Medicine, Chung et al. reported the use of Ac for human epidermal growth factor receptor-2 (HER2)–targeted treatment of small-volume ovarian peritoneal carcinomatosis (OPC) in a mouse model (4). The approach adopted in this comprehensive study was pretargeted radioimmunotherapy (PRIT), which may need some elaboration. The 3 components used for HER2-targeted PRIT were an anti-HER2/anti-DOTA IgG-single-chain variable fragment (scFv) bispecific antibody (BsAb), a clearing agent (CA; DOTA(Y)-conjugated poly-N-acetylgalactosamine glycodendron), and a radiohapten that is either Ac-Pr (“Pr” denotes Proteus-DOTA; for therapy) or In-Pr (for imaging and dosimetry estimation). Pr represents the radiohapten precursor (molecular weight 1,350Da), which consists of 1,4,7,10-tetraazacyclododecane-1,4,7-triacetic acid (DO3A, a radiometal chelator), separated by a tetraethylene glycol (PEG4) linker to a Lu complex of 2-benzyl-DOTA (5). The BsAb (molecular weight 210 kDa) was produced in Chinese hamster ovary cells and purified by protein A affinity chromatography, as the investigators previously reported in 2018 (6). It can bind to HER2 on the ovarian cancer cells for tumor targeting, as well as provide a handle for binding to the radiohapten for imaging (with In) or therapy (with Ac). Since the BsAb circulates for a long time in mice (potentially even longer in humans), the CA (molecular weight 9 kDa) was designed, optimized, and used to rapidly remove the circulating BsAb. This occurs by forming a complex via the DOTA(Y) moiety, which can subsequently be cleared via liver asialoglycoprotein receptor recognition and catabolism (7). After the circulating BsAb is cleared, the radiohapten (i.e., Ac-Pr) was injected, accumulated rapidly in the tumor tissue, and caused cancer cell killing. As a small molecule, Ac-Pr clears rapidly from the mouse body, minimizing the potential toxic side effects caused by the daughter Received Jun. 7, 2023; revision accepted Jul. 20, 2023. For correspondence or reprints, contact Weibo Cai (wcai@uwhealth.org) or Xiaoli Lan (xiaoli_lan@hust.edu.cn). Published online Aug. 17, 2023. COPYRIGHT 2023 by the Society of Nuclear Medicine andMolecular Imaging. DOI: 10.2967/jnumed.123.266026

Background: When ovarian endometrioma coexist with adenomyosis, the risk of postoperative recurrence increased. How is the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) on symptomatic recur-rence for those patients was unknown.Methods: This study retrospectively analyzed 119 women with coexistent endometrioma and diffuse adeno-myosis who received laparoscopic excision of pelvic endometriosis from January 2009 to April 2013. Women were categorized into two groups: intervention group with LNG-IUS and control group with expectant obser-vation after surgery. Data were compared in terms of preoperative history, laboratory and intraoperative findings, and clinical outcomes during follow-up, including pain regression, changes in uterine volume and recurrence.Results: During a median 79 months (range, 6-107) of follow-up, patients with LNG-IUS experienced a signif-icantly lower symptomatic recurrence of either ovarian endometrioma or dysmenorrhea (11.1% vs. 31.1%, p = 0.013), compared with women under expectant observation by Kaplan-Meier survival analysis (x2 = 5.448, p = 0.020) and Cox univariate assessment (hazard ratio of 0.336, 95% confidence interval 0.128 -0.885, p = 0.027). Patients treated with LNG-IUS demonstrated a more prominent reduction in uterine vol-ume (-14.1 +/- 20.9 vs. 8.7 +/- 48.8, p = 0.003) and higher percentage of complete pain remission (95.6% vs. 86.5%). For multivariate analysis, use of LNG-IUS (aHR 0.159, 95%CI 0.033-0.760, p = 0.021) and severity of dysmenorrhea (aHR 4.238, 95%CI 1.191-15.082, p = 0.026) were two independent factors associated with overall recurrence.Conclusion: Postoperative insertion of LNG-IUS may prevent recurrence in symptomatic women with comor-bidity of ovarian endometrioma and diffuse adenomyosis.(c) 2023 Published by Elsevier Masson SAS.

Objective: To review the use of oral gonadotropin-releasing hormone (GnRH) antagonists and synthesize their efficacy and safety parameters for the treatment of endometriosis-associated pain. Design: Systematic review and network meta-analysis. Setting: Not applicable. Patient(s): Premenopausal women with endometriosis who had experienced moderate or severe pain. Intervention(s): The Web of Science, Embase, Scopus, and MEDLINE were searched until April 10, 2022. Only randomized controlled trials were included. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool 2. A Bayesian random-effects network meta-analysis was used to perform indirect comparisons. I-2 was used to assess the global heterogeneity. Relative treatment estimates were performed. Treatment ranking was performed through the surface under the cumulative ranking curve. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. Main Outcome Measure(s): Endometriosis-associated pain, dysmenorrhea, dyspareunia, and noncyclic pelvic pain reduction. Result: (s): Five studies and 6 randomized controlled trials, including a total of 2,796 women and 10 different doses of oral GnRH antagonist treatments, were eligible for inclusion. All studies were considered to have a low risk of bias. Almost all efficacy- and safety-related outcomes showed a dose-response relationship. Regarding endometriosis-associated pain, the top 3 treatments were elagolix 400 mg, linzagolix 75 mg, and linzagolix 200 mg, with mean differences of -1.26 (95% credible interval [CrI], -1.70 to -0.79), -0.98 (95% CrI, -1.84 to -0.15), and -0.98 (95% CrI, -1.90 to -0.064), respectively. The top 3 treatments to decrease dysmenorrhea were relugolix 40 mg, elagolix 400 mg, and relugolix 20 mg, with mean differences of -1.60 (95% CrI, -2.07 to -1.14), -1.25 (95% CrI, -1.56 to -0.95), and -1.10 (95% CrI, -1.59 to -0.62), respectively. However, only high-dose treatments were significantly associated with most quality of life- and adverse effect-related outcomes. Relugolix 40 and 20 mg and elagolix 400 mg, with odds ratios of 6.88 (95% CrI, 2.18-24.58), 1.60 (95% CrI, 0.62-4.13), and 1.85 (95% CrI, 1.05-3.30), had a significantly increased incidence of adverse events. Conclusion: (s): Oral GnRH antagonists are effective for endometriosis-associated pain and dysmenorrhea and the patient global impression. The incidence of ovarian hypoestrogenic effects in a short-term duration was significant in a dose-effect response, particularly the highest dose. (C) 2022 by American Society for Reproductive Medicine.

To classify abdominal wall endometriosis (AWE) according to the invasive levels of tissue mass, and to compare the differences in clinical characteristics between different types of AWE. In this study, we retrospectively analyzed the clinical data of 367 patients who had undergone resection of abdominal-wall endometriotic lesions at the Peking Union Medical College Hospital from January 2008 to December 2018, and we divided the patients into three types according to their deepest level of lesion invasion. Type I designated invasion of skin and subcutaneous tissue; type II, of fascia and rectus abdominis; and type III, of peritoneum. We classified, compared, and analyzed the general conditions, clinical manifestations, auxiliary examinations, surgical conditions, postoperative conditions, and recurrence status of patients. Of the 367 patients, type I patients accounted for 13.62%, type II patients for 56.68%, and type III for 29.7%. With respect to group comparisons, we observed that as the location of the mass deepened, the rate of concurrent pelvic endometriosis increased (P = 0.007), recurrent AWE was augmented (P = 0.02), the size of the mass increased (P < 0.001), the rate of multiple lesions became elevated (P < 0.001), the rate of mesh implantation increased (P < 0.001), the length of postoperative hospital stay (P < 0.001) was lengthened, the number of postoperative fever cases (P = 0.006) increased, and the risk of drainage placement (P < 0.001) was enhanced. The 5-year cumulative recurrence rate was 3.3%, and there was no significant difference in the recurrence rate among various types of AWE. Type III AWE carries more severe clinical manifestations, larger lesion size, longer operative time, greater intraoperative surgical difficulty, higher necessity of mesh implantation, and longer postoperative recovery process. Complete resection of AWE lesion is the main therapeutically approach and shows relatively low long-term recurrency rate.

BackgroundTo examine and compare the differences in clinical characteristics and long-term postoperative outcomes of ovarian endometriomas (OMA) patients with and without dysmenorrhea, including data from at least 8 years of postoperative follow-up examinations.MethodsRetrospective analysis of 334 OMA patients, including their demographic and clinical data. Long-term follow-up record was also collected. All laparoscopic cystectomy procedures were performed by the same surgeon at Peking Union Medical College Hospital between January 2009 and April 2013. Patients were divided into the dysmenorrhea and non-dysmenorrhea groups to perform the analysis of their preoperative characteristics, relevant surgical findings, and postoperative outcomes at the follow-up.ResultsOut of 334 OMA patients, 257 (76.9%) patients were allocated to the dysmenorrhea group, while the rest 77 (23.1%) patients were included in the non-dysmenorrhea group. Compared with the dysmenorrhea group, the non-dysmenorrhea group exhibited a reduced proportion of chronic pelvic pain (CPP) (P = 0.003), dyspareunia (P < 0.001), tenesmus (P < 0.001), concurrency of deep infiltrating endometriosis (DIE) (P < 0.001), and adenomyosis (P = 0.032). Preoperative infertility was significantly higher in the dysmenorrhea group (P = 0.001). The mean operating time in the dysmenorrhea vs. the non-dysmenorrhea group was 68.0 vs. 56.0 min (P < 0.001). According to the revised American Fertility Society (rAFS) scoring system, the mean scores of the two groups were 52.1 vs. 44.6 (P = 0.033). During follow-up, the dysmenorrhea group showed a higher rate of disease relapse (P < 0.001). A minimum postoperative follow-up period of 8 years was required to evaluate the pregnancy outcomes. Successful pregnancies were identified in 97/257 (37.7%) cases in the dysmenorrhea group and 36/77(46.8%) cases in the non-dysmenorrhea group (P = 0.157), respectively. Though the dysmenorrhea group had a higher rate of postoperative infertility, differences were not significant between the two groups.ConclusionsCompared with the dysmenorrhea group, OMA patients without dysmenorrhea exhibited lower proportions of CPP, dyspareunia, tenesmus, lower concurrency of DIE and adenomyosis, shorter mean operating time, lower mean rAFS scores, and lower infertility rates. During the long-term follow-up, a lower recurrence rate was observed in the non-dysmenorrhea group. Regarding fertility outcomes, non-dysmenorrhea patients had a higher likelihood of successful pregnancy after surgery. Postoperative management needs to be evaluated separately according to dysmenorrhea pathology.

Background Malignant struma ovarii (MSO) is a unique type of ovarian malignancy that data on the survival outcome is limited and management strategy remains controversial due to its extreme rarity. Methods To investigate the clinical characteristics and treatment options in patients with MSO confined to the ovary, while also evaluating the recurrent-free survival (RFS) and overall survival (OS) rate in this population, a retrospective study was conducted. One hundred twenty-five cases of MSO confined to the ovary were enrolled and their clinical characteristics, treatment strategies, and results of follow-up were analyzed. OS and RFS were assessed by Kaplan-Meier analyses and Cox regression models. Results The most common pathological subtype in this cohort was papillary carcinoma (44.8%). Other reported subtypes, in order of prevalence, were follicular variant of papillary carcinoma, follicular carcinoma, and mixed follicular-papillary carcinoma. Surgical treatment options varied in this cohort that 8.0% of the patients received ovarian cystectomy, 33.6% underwent unilateral salpingo-oophorectomy (USO), 5.6% received bilateral salpingo-oophorectomy (BSO), 21.6% received total abdominal hysterectomy with BSO (TAH/BSO), and 17.6% were treated with debulking surgery; 20.0% of them received radioiodine therapy (RAI). Twenty-seven patients experienced recurrence with a median RFS of 14.0 years (95% confidence interval [CI], 9.5–18.5). The 5-year and 10-year recurrent rate were 27.1, 35.2%, respectively. Eight patients died during follow-up, with five attributed to MSO; the 5-year, 10-year, and 20-year OS rate was 95.3, 88.7 and 88.7%, respectively. However, the univariate and multivariate Cox regression showed no potential risk factor for RFS and OS. Conclusion Patients with MSO confined to the ovary had an excellent survival outcome, despite varied treatment strategies, and the recurrent rate was relatively high. We recommend USO as the preferred surgical option in this population since more aggressive surgery does not improve outcomes and the benefits of RAI are uncertain.

Objective: To investigate the difference of clinical features and outcomes between EM patients with and without AM after following up for at least 6 years after surgery. Methods: We retrospectively analyzed 358 EM patients who had a minimum of 6 years follow-up after laparoscopic cystectomy, which was performed by one single doctor at Peking Union Medical College Hospital from January 2009 to April 2013. All women were divided into AM group and non-AM group and analysis was performed in preoperative characteristics, surgical findings and postoperative outcomes during follow-up. Results: A total of 358 EM patients were recruited, of which 142 (39.7%) were in the AM group and the rest 216 (60.3%) in the non-AM group. Between the two group, the mean age was 34.6 vs. 32.2 years ( P < 0.001). The mean operating time in the AM and non-AM group was 73.2 vs. 61.9 min ( P < 0.001). According to the revised AFS classification, the mean score of the two group were 60.3 vs. 45.5 ( P < 0.001). At the end of the follow-up, though the AM group was with higher rate of disease relapse, yet no significant difference was found between the two groups in statistical comparison (34/142 [23.9%] vs. 34/216 [15.7%], P = 0.053). With a minimum follow-up of 6 years after laparoscopic cystectomy, failed and successful pregnancy were seen in 107/142(75.4%) and 35/142 (24.6%) patients in the AM group vs. 114/216(52.8%) and 102/216 (47.2%) patients in the non-AM group ( P < 0.05). As for the successfully pregnant patients, live births, including spontaneous pregnancy and IVF-ET, were seen in 34/35 (97.1) vs. 99/102 (97.1) patients between AM and non-AM groups, while others ended in spontaneous abortion. No significant associations were found between the two groups in infertility, leiomyoma presence, the size of ovarian endometrioma, type of deep infiltrating endometriosis (DIE) or type of recurrence ( P > 0.05). Conclusion: Compared with non-AM group, EM patients with concurrent AM may have higher age, longer mean operating time and higher mean AFS score. In terms of fertility outcomes, patients in the AM group were with lower likelihood of pregnancy after surgery during the long-time follow-up.

Background: Adenomyosis and endometriosis are often co-existent. Laparoscopic surgery is one of the main methods to diagnose and treat these conditions. However, very few studies have been done that concentrate on the pregnancy outcomes of infertile women with both adenomyosis and endometriosis after laparoscopic surgery, as well as the relevant influential factors.Methods: This is a retrospective, cross-sectional study including infertile women diagnosed with endometriosis and adenomyosis. All patients had undergone laparoscopic surgery and were divided into two groups according to pregnancy outcomes. Demographic data, operation records, and pregnancy outcomes were collected.Results: Ninety-seven patients had live births, including 81 full-term and 16 preterm deliveries. The biochemical pregnancy, clinical pregnancy, and live birth rates were 80.87%, 67.4, and 55.11% respectively. One hundred thirty-five patients received IVF with 70 (51.85%) patients having live births. Age, size of endometrioma, and size of uterus were significantly lower in those who had a successful delivery. There was no statistical difference in symptoms except anemia (13.40% vs. 25.32%, p=0.044). The group that failed to have a live birth had a higher percentage of ovarian and peritoneal endometriosis (P<.05), while the distribution of deep infiltrating endometriosis and adenomyosis types were similar. Mean uterus diameter (OR: 0.636, 95% CI: 0.434-0.932, p = 0.020) and endometriosis fertility index (EFI) (OR:1.299, 95% CI: 1.101-1.531, p = 0.002) were significantly correlated with live births in the multivariate analysis.Conclusions: Endometriosis and adenomyosis have an adverse effect on fertility. IVF is an important technology improving pregnancy rate even after surgery. The size of the uterus and EFI were independent risk factors for pregnancy outcomes.

Ovarian endometriosis is the most common type of endometriosis (EM), affecting more than 40% of women with EM. Currently, surgical intervention is still controversial in infertile patients with ovarian endometriosis, especially in those with stage III–IV EM. Very few studies have been done to analyze long-term pregnancy results in patients with endometrioma more than 5 years after surgery. Therefore, the aim of this study was to explore the pregnancy outcomes and the related factors in patients with endometrioma and stage III–IV endometriosis during a long-term follow-up postoperatively. We collected 347 patients with ovarian endometriosis, which included 59 infertile patients with stage III–IV endometriosis who had a minimum of 5 years of postoperative follow-up after undergoing laparoscopic excision of ovarian endometriomas performed by a single doctor at the Peking Union Medical College Hospital from January 2009 to April 2013. A total of 59 infertile patients were recruited. The mean age was 31.8 ± 3.6 years. The mean size of the endometriomas was 6.8 ± 3.3 cm. Before surgery, dysmenorrhea was present in 88.1% (52/59) of the cases, while chronic pelvic pain was reported in nine cases (15.3%). A total of 20.3% (12/59) of cases were concurrent with leiomyoma, 52.5% (31/59) with deep infiltrating endometriosis (DIE), and 39.0% (23/59) with adenomyosis. During laparoscopy, 21 cases were diagnosed as stage III (35.6%) and 38 as stage IV (64.4%) EM according to the revised American Fertility Society (AFS) classification. After laparoscopic cystectomy, 38 (64.4%) patients became successfully pregnant by the 5th year. All the patients were divided into two groups according to the postoperative pregnancy outcomes. In univariate analysis, the higher mean age and concurrent diagnosis of adenomyosis were seen to be related to poor postoperative pregnancy outcomes (p < 0.05). In multivariate analysis, however, the mean age, chronic pelvic pain (CPP), and adenomyosis were independent risk factors of pregnancy outcomes between the two groups (p < 0.05). With a minimum follow-up of 6 years, 23.7% (14/59) of recurrence was observed in the entire study cohort. Infertile patients with endometrioma and stage III–IV EM may have lower pregnancy rates after laparoscopic cystectomy if they are older and present with CPP and adenomyosis. Our data showed a lower rate of recurrence but a higher rate of pregnancy after surgery.

Introduction:Metastatic malignant struma ovarii (MSO) is an extremely rare disease that lacks treatment consensus and accurate prognosis. The objective of this study was to present the clinical, pathological, and treatment characteristics of metastatic MSO, while also investigate the overall survival (OS) rate and factors affecting prognosis in this population. Materials and Methods:A total of 79 cases of metastatic MSO were reviewed, including four cases of metastatic MSO from our hospital and 75 cases selected from the literature. Logistic regression was used to identify potential factors affecting disease free survival (DFS). The Kaplan-Meier method and log-rank test were used to determine OS; further Cox regression was used to evaluate factors affecting OS. Results:The mean age of all the patients at diagnosis was 43.8 years. The most common metastatic sites were peritoneum, bone, liver, omentum and lung in descending order. Only two patients (2.6%) coexisted with local primary thyroid cancer. Follicular carcinoma (41.8%) as the most prevalent subtype, followed by papillary carcinoma, follicular variant of papillary carcinoma, and mixed follicular-papillary carcinoma. 36.7% of the patients received conservative surgery, 43.0% of them underwent aggressive surgery, and 15.2% of them did not receive any surgery. 74.7% of patients who received adjuvant therapy underwent radioiodine therapy (RAI). Logistics regression revealed that FIGO stage IV was the only prognostic factor in predicting DFS (P= 0.002; Odds Ratio [OR] 5.333; 95% confidence interval [CI]: 1.839-15.471). Only seven deaths occurred. The OS rates at 5, 10, 15 years were 89.3, 82.4, 65.9%, respectively. Multivariate analysis showed age over 55 years (P= 0.006; OR 9.362; 95%CI: 1.895-46.246) was the only risk factor for OS. Conclusion:Patients with metastatic MSO have an excellent disease-specific OS rate, FIGO stage IV and age over 55 years were two factors affecting disease prognosis. Conservative surgery with residual ablation by RAI after total thyroidectomy should be preferred since the benefits of aggressive surgery are uncertain.

To explore the risk factors for the recurrence of endometrioma and the risk factors for the recurrence of endometriosis-related pain after long-term follow-up. This study retrospectively analyzed 358 women with endometriomas who had a minimum of 5-years follow up after laparoscopic endometrioma excision, which was performed at Peking Union Medical College Hospital from January 2009 to April 2013. All women were divided into recurrence group and nonrecurrence group. Analysis was performed with regard to preoperative history, laboratory analysis, findings during surgery, and symptoms during follow-up, including improvement and recurrence. The cumulative incidence rates of recurrence from 5 to 10 years after surgery were 15.4, 16.8, 19.3, 22.5, 22.5, and 22.5%, respectively. Significant differences were found between two groups in terms of age at surgery (RR: 0.764, 95% CI: 0.615–0.949, p = 0.015), duration of dysmenorrhea (RR: 1.120, 95% CI: 1.054–1.190, p < 0.001), presence of adenomyosis (RR: 1.629, 95% CI: 1.008–2.630, p = 0.046), CA125 level (RR: 1.856, 95% CI: 1.072–3.214, p = 0.021) and severity of dysmenorrhea. The severity of dysmenorrhea (RR: 1.711, 95% CI: 1.175–2.493, p = 0.005) and postoperative pregnancy (RR: 0.649, 95% CI: 0.460–0.914, p = 0.013) were significantly correlated with endometrioma recurrence in the multivariate analysis. No significant associations were found between the recurrence rate and gravida, parity, body mass index, infertility, leiomyoma presence, the size of ovarian endometrioma, the presence of deep infiltrating endometriosis, disease stage or postoperative medication. The severity of dysmenorrhea and postoperative pregnancy were independent risk factors for the recurrence of ovarian endometriomas after surgery during the long-time follow up.

ObjectivesTo evaluate the presentation, assessment, treatment, and pregnancy outcomes of 22 women with a rudimentary uterine horn.MethodsWe reviewed the data regarding the outcomes of patients with a rudimentary horn pregnancy (RHP) who were managed at Peking Union Medical College Hospital over the last 30 years. Twenty-two pregnant patients with a rudimentary horn have been treated at our institute over the last 30 years. All patients with RHP were divided into two groups: Type A (n = 4), a rudimentary horn with a cavity that communicated with the uterus; and Type B (n = 7), a rudimentary horn with a cavity that did not communicate with the uterus. We classified all 22 patients into communicating group or noncommunicating group according to the anatomical connection of the rudimentary horn to the contralateral hemiuterus.ResultsThe mean gestational age of Type A patients (23.5 weeks) was significantly higher (P = 0.046) than that of Type B patients (10 weeks). The rudimentary uterine horn carried 4 of 5 (80%) pregnancies in the communicating group. Three case of rudimentary horn pregnancies ruptured before a gestational age of 12 weeks, and one abortion occurred after a gestational age of 12 weeks. In the noncommunicating group, 7 of 17 (41.2%) cases were RHPs, and 3 ruptured after a gestational age of 12 weeks.ConclusionsThe diagnosis and management of the rudimentary uterine horn continues to be challenging. Medical and radiological personnel must maintain a high degree of alertness to prevent the morbidity associated with this condition. In particular, patients with RHP (Type A), who have a higher chance being misdiagnosed before 12 gestational weeks, have a higher risk of potential complications. If pregnancy in the rudimentary horn is diagnosed, excision of the pregnant horn is recommended, regardless of the type of unicornuate uterus.

OBJECTIVE To study the relationship between the clinic-pathological features and pain symptoms in patients with endometriotic cyst (EM). METHODS The medical data of symptoms, laparoscopy and pathology examination in 416 patients with endometriosis were studied retrospectively. All cases were divided into two groups on the existence of ovarian endometrioma, including 338 patients in cyst group and 78 cases in non-cyst group. The relationship between clinical symptoms and location and type of endometrioma was studied. RESULTS (1) Serum CA125 level: the level of CA125 were (61 ± 39) kU/L in cyst group (28 ± 24) kU/L in non-cyst group, which reached statistical difference (P < 0.01). (2) Pathological features: among 338 cases, 34.0% of cyst were on left side (115/338), 26.3% were right side (89/338), and 39.6% were on both side (134/338). And 95.8% (324/338) of cases were combined with the other type of endometriosis, which were 48.5% (164/338) with peritoneal endometriosis, 47.3% (160/338) with deep infiltrating endometriosis (DIE). In cystic patients, the incidences of endometriosis lesion were 13.9% (47/338) on the uterine surface, 38.5% (130/338) on obstruction of cul-de sac, 40.5% (137/338) on utero-sacral ligament of DIE, which were significantly higher than 5.1%, (4/78), 9.0% (7/78) and 28.2% (22/78) in noncyst group. (3) Pain symptom: the incidence and degree of dysmenorrhea and dyschezia had no statistical difference between two groups (P > 0.05), and the incidence of chronic pelvic pain (CPP) of 24.6% (83/338) and dyspareunia of 29.9% (101/338) in the cyst group were significantly lower than 35.9% (28/78) and 44.9% (35/78) in non-cyst group (P < 0.05). The incidence of dysmenorrheal was 85.1% (114/134) in cases with bilateral cyst, which was higher than 74.0% (151/204) in cases with single cyst. The incidence of dysmenorrheal and dyschezia in moderate-severe adhesion was 89.0% (138/155) and 18.7% (29/155), which was significantly higher than 68.8% (126/183) and 8.2% (15/183) in mild adhesion. In the patients cyst existed with DIE, the risk of dysmenorrheal, CPP, dyspareunia, and dyschezia were obviously raised (OR respectively was 5.17, 3.01, 3.05, 2.75). CONCLUSIONS The endometriotic cyst often co-exists with other type of endometriotic lesions. Ovarian endometrioma was associated with lesion localized on uterine surface, cul-de-sac, sacrum ligament. The risk of all the pain symptoms would be raised when the endometriotic cyst co-exit with the DIE lesions. So the treatment for DIE lesions was as same important as the endometriotic lesions in order to relieve pain symptoms and delay the relapse.

Objective:To investigate the expression of nerve growth factor(NGF)and its two receptors:trkA and p75NTR in eutopic endometrium of patients with endometriosis,and to explore the role of NGF,trkA and p75NTR in the development of endometriosis-associated pain.Methods:A total of 38 patients underwent surgical laparoscopy were studied.28 patients underwent laparoscopic endometriosis lesion excision,while others underwent surgical laparoscopy because of non-endometriosis disease.The preoperative pain scores were determined using a standardized questionnaire with a visual analogue(VAS)scale from 1 to 10.All patients were classified into three groups according to the disease with or without dysmenorrheal:endometriosis patients with dysmenorrhea(group A1),endometriosis without dysmenorrhea(group A2),non-endometriosis patients(group B).Immunohistochemistry were performed to detect the expression of NGF,trkA and p75NTR in eutopic endometrium.Results:Immunohistochemical analysis showed NGF expression in endometrial glands was significantly stronger than in stroma.The level of NGF in endometrium of group A1 was significantly higher than group A2.There was no statistically significant difference of NGF expression between group A2 and group B.The level of p75NTR in eutopic endometrium was as follows:group A1>group A2(A1:58.8±21.1,A2:22.5±16.1,P<0.05),group A>group B(P<0.05).trkA expression was significantly stronger in endometrial stroma than in glands of non-endometriosis patients.There was no statistically significant difference of trkA expression between group A1 and group A2.Conclusion:NGF and p75NTR express in endometrium of patients with dysmenorrhea or pelvic pain may participate in the pathogenesis of endometriosis and endometriosis associated pain.

Background Endometriosis is a controversial and enigmatic disease. Deep infiltrating endometriosis (DIE) is responsible for painful symptoms and is the least understood type of endometriosis. Little work has been devoted to define the location of DIE lesions and its relationships with pain. The aim of the study was to investigate the relationship between the anatomical distribution of DIE lesions and pain symptoms.Methods Clinical data from 354 patients between May 2003 and December 2007 with laparoscopically diagnosed endometriosis were collected including 177 DIE patients and 177 non-DIE patients. The pain symptoms, including dysmenorrhea (DM), chronic pelvic pain (CPP, defined as intermittent or permanent pelvic pain, not related to the menstruation and longer than 6 months), deep dyspareunia (pelvic pain at intercourse) and dyschezia (pelvic pain with defecation), were recorded for every patient before operation. Endometriotic lesions were recorded by their anatomical distributions, the depth of infiltration and lesion colors. And the relationship between the anatomical distribution of DIE lesions and pain symptoms was analyzed. Pearson's chi-square test or Fisher's exact test, one-way analysis of variance (ANOVA) and linear regression and binary Logistic regression were used for statistical analysis.Results The duration ((13.79 +/- 3.94) years) of pain suffering in DIE patients was much longer than that of non-DIE patients (P <0.01). In DIE patients, 60.7% of the uterosacral ligament (USL) nodules were bilateral (P <0.01); 44.6% of the cul-de-sacs were completely blocked. Rectum invasion was observed in 19.9% of DIE patients (P=0.03); pelvic adhesion was also more common. Up to 98.41% of the deep infiltrative lesions were located in the posterior pelvic compartment. DIE lesions were also found in bladder (1.58%), USL (67.08%), cul-de-sac (12.02%), recto-vaginal septum (12.66%), rectum and rectosigmoid junction (2.85%) and ureter (3.80%). The odds ratio of USL-DIE for CPP, deep dyspareunia, dyschezia were 2.52, 1.29 and 2.24 respectively. And the depth of infiltration correlated with the severity of dysmenorrhea.Conclusions DIE lesions were associated with severe pain symptoms. The main distribution of DIE lesions was in the posterior pelvic compartment, and was more widespread and severe in DIE patients. Moreover, resection of these DIE lesions are very important to treat the pain symptoms. Chin Med J 2012;125(2):209-213

OBJECTIVE:To investigate the influence of gonadotropin releasing hormone agonist (GnRH-a) on the expression mRNA of nerve growth factor (NGF) and its receptors (TrkA and P75NTR) in normal and eutopic endometrial stromal cells (ESC). METHODS:From January to April 2009, 3 patients with endometriosis undergoing surgery in Peking Union Medical College Hospital were obtained eutopic endometrium as study group matched with eutopic endometrium from 3 patients with teratoma as control group. ESC were incubated with different concentration of GnRH-a (0, 5×10⁻¹¹, 5×10⁻¹⁰, 5×10⁻⁹, 5×10⁻⁸, 5×10⁻⁷ g/ml). The expression of mRNA of NGF, TrkA and P75NTR were measured by real-time-PCR. RESULTS:At concentration of 0 g/ml, the levels of NGF, TrkA and P75NTR mRNA in ESC were 6.32, 8.55, 8.08 in study group, which were significantly higher than 0.94, 0.67, 1.08 in control group (P < 0.05). Treated by the following concentration of GnRH-a (5×10⁻¹¹, 5×10⁻¹⁰, 5×10⁻⁹, 5×10⁻⁸, 5×10⁻⁷ g/ml), the median expression of NGF, TrkA and P75NTR mRNA was 1.00, 0.96, 1.05; 1.09, 0.82, 1.27; 1.04, 0.52, 0.81;1.00, 0.55, 0.64; 0.78, 0.49, 1.02 in study group. Compared with the expressions of those untreated by GnRH-a in study group, they showed significantly lower trends (P < 0.05). In control group, the median expression of NGF, TrkA and P75NTR mRNA was 0.98, 0.37, 0.92; 0.70, 0.45, 1.15; 1.55, 0.80, 1.35; 1.09, 0.41, 1.35; 0.90, 0.82, 1.18. Compared with the expressions of those untreated by GnRH-a in control group, there were no statistically differences (P > 0.05). And treated by the same concentration of GnRH-a, the expressions of NGF, TrkA and P75NTR mRNA did not show statistically difference between the two groups (P > 0.05). CONCLUSION:The expression of NGF, TrkA and P75NTR mRNA were suppressed by GnRH-a.