Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence. • This report provides guidelines for MRI in endometriosis. • Minimal and optimal MRI acquisition protocols are provided. • Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.

https://link.springer.com/content/pdf/10.1007%2Fs00330-016-4673-z.pdf

European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis

background: Classical surgical management of endometriotic ovarian cysts using the laparoscopic stripping technique has been recently questioned because of the surgical-related injury to the ovarian reserve. Accordingly, available guidelines suggest that endometriomas with a mean diameter below 4 cm should not be systematically removed before IVF procedures. However, conservative management may have some poten- tial drawbacks and risks. The presence of the endometrioma may theoretically interfere with ovarian responsiveness to hyperstimulation and oocyte competence, the retrieval of the oocytes may be more difficult and risky, the disease may progress during the procedure, pregnancy outcome may be affected and there is the risk of missing occult malignancies with cancer development later in life. In the present review, we aimed at assessing whether these risks do exist and, if so, at estimating their clinical relevance. methods: We searched PubMed for articles published in the English language between January 1990 and August 2014 that reported on endo- metriomas and assisted reproductive techniques. Special care was given to studies reporting data purporting to distinguish the effects of ovarian endometriomas per sefrom those consequent to surgery for endometriosis or from endometriosis in general. results: Based on the evidence reviewed in the present study, it can be concluded that conservative management may actually expose women to four of the following theoretical risks, i.e. infection of the endometriomas, follicular fluid contamination with the endometrioma content, higher risk of pregnancy complications and cancer development later in life. The first three conditions do not justify surgery because these events are uncommon and the number of women needed to be treated would be exceedingly high and would not justify the costs and risks of the interven- tion. Albeit also very rare, the possibility of developing ovarian cancer later in life is more troublesome because it is a life-threatening condition.

/pdf/risks-of-conservative-management-in-women-with-ovarian-4elxm5t6kj.pdf

Risks of conservative management in women with ovarian endometriomas undergoing IVF

New thinking has arisen about the origin of adult onset diseases stemming from a collective body of evidence commonly referred to as the developmental origins of health and disease. This conceptual paradigm posits that certain adult onset diseases arise during critical or sensitive windows of human development or even transgenerationally. The testicular dysgenesis hypothesis (TDS) postulates an in utero origin for adverse male reproductive outcomes, and is an excellent example of the early origins of the paradigm. Despite similarities in the development of the male and female reproductive tracks, noticeably absent is a collective body of evidence focusing on the plausibility of an early origin for gynecologic outcomes and later onset of adult diseases. Using the TDS paradigm, we synthesized the available literature relative to the ovarian dysgenesis syndrome (ODS), which we define as alterations in ovarian structure or function that may manifest as fecundity impairments, gynecologic disorders, gravid diseases or later onset adult diseases. We evaluated environmental exposures, particularly the role of endocrine disrupting chemicals, in relation to these outcomes, and found evidence (although fragmented) consistent with an in utero origin of gynecologic outcomes, which in turn is associated with later onset of adult diseases. The findings are interpreted within the ODS paradigm while delineating methodological challenges and future research opportunities designed to answer critical data gaps regarding the origin of fecundity, gravid health and chronic diseases affecting the female population.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S2040174410000693

The ovarian dysgenesis syndrome

Key content
Thyroid disease is a common condition in the reproductive medicine setting due to the complex interplay between the hypothalamo-pituitary axis and the thyoid gland.
Abnormalities in thyroid function, including hyperthyroidism and hypothyroidism, can have an adverse effect on reproductive health and result in reduced rates of conception, increased early pregnancy loss, and adverse pregnancy and neonatal outcomes.
There is increasing evidence for the role of autoantibodies in subfertility and early pregnancy loss, even in euthyroid women.
Evidence suggests that treating thyroid disorders and keeping thyroid-stimulating hormone levels at the lower end of normal in euthyroid women may improve conception rates in subfertile women and reduce early pregnancy loss.


Learning objectives
To gain an overview of the effect of thyroid disorders on reproductive health.
To review the evidence on how to optimise thyroid function to improve reproductive outcomes.


Ethical issues
Screening for thyroid disease should be considered in women presenting with subfertility and recurrent early pregnancy loss.

Thyroid dysfunction and reproductive health

OBJECTIVE. This article reviews unusual distant metastatic patterns of infiltrating lobular carcinoma (ILC) of the breast. CONCLUSION. ILC of the breast tends to spread to the gastrointestinal tract, genitourinary tract, peritoneum, retroperitoneum, and leptomeninges in addition to common visceral sites such as the liver, bone, and lung. Knowledge of these unusual metastatic manifestations and disease patterns may aid in differentiating distant metastatic disease from secondary primary cancers and help plan appropriate therapy.

Distant Metastatic Disease Manifestations in Infiltrating Lobular Carcinoma of the Breast

Introduction The purpose of this study was to delineate the association between endometriosis and pelvic inflammatory disease (PID) and the prevalence of this coexistence. Materials & methods The records of all patients with endometriotic ovarian cysts treated at the 3rd Department of Obstetrics and Gynecology of the University of Athens and in "Lito" Maternity Hospital of Athens from 2000 through 2007 were reviewed. Results During this 7-year period 720 women underwent surgery due to endometriotic ovarian cysts. The average age was 40.9 years (range: 17-70). Median diameter of the cysts was 4.495 cm and 59% were located in the right ovary. PID was identified in 21 (2.9%) cases. The average age of these women was 31 years (range: 21-39). Half of the women presented with fever (10/21; 47.6%). Ultrasound examination was performed in all women, followed by laparoscopy. In 47.6% (10/21) the PID abscess was located in the right ovary and the rest (52.38%) in the left. The mean diameter of the endometriotic cysts in these women was 3.52 cm. Laparoscopy was the treatment of choice in all the women with the exception of five cases, where due to technical difficulties during laparoscopy, a laparotomy was performed. In all the cases with PID, abscesses were evacuated laparoscopically. No operative complications were observed. Conclusions Endometriosis and PID are two conditions that can easily confuse the physician in setting the diagnosis, especially in the situation where they co-exist. In our study we report that the prevalence of PID in women with endometriosis is sufficiently higher than the prevalence in the general population.

Prevalence of severe pelvic inflammatory disease and endometriotic ovarian cysts: a 7-year retrospective study.

Objective. To reevaluate the long-term effectiveness and safety of laparoscopy in benign ovarian pathology. Materials and Methods. 1522 women with benign adnexal cysts, laparoscopically treated in the 3rd Department of Ob/Gyn, General University hospital “Attikon” and “Lito” Maternity Hospital between July 1998 and December 2006, were included. Results. The diagnosis in 1222 (80,6%) cases was endometriosis of the ovary, 60 (4%) hydrosalpinx, 51 (3,3%) serous cystadenomas, 44 (2,9%) dermoid ovarian cyst, 38 (2,5%) borderline tumors, 35 (2,3%) unruptured follicles, and 33 (2,2%) paraovarian cysts. In 174 cases (11,5%) laparoscopy was converted to laparotomy due to technical difficulties or suspicion of cancer. In particular, laparotomy was performed in 119 (8%) women due to severe adhesions and 18 (1,2%) women due to bleeding that could not be controlled safely by laparoscopy. In 36 (2,4%) women frozen section during operation revealed malignancy and laparoscopy was converted to laparotomy. A few operative complications were recorded like post-op fever, small hematomas at the trocar entries. Conclusions. Laparoscopic surgery seems to offer significant advantages such as reduced hospital stay, less adverse effects, better quality of life, and superior vision especially on surgical treatment of cases like endometriosis.

/pdf/laparoscopic-treatment-of-1522-adnexal-masses-an-8-year-3vojjiv4kd.pdf

Laparoscopic Treatment of 1522 Adnexal Masses: An 8-Year Experience

Conclusions: Women with synchronous primary cancers of the endometrium and ovary have distinct clinical characteristics including younger age, premenopausal status, and nulliparity. This suggests that a hormonal ‘field effect’ may account for the development of these simultaneous endometrioid cancers, supporting the theory of estrogen receptors.

Endometrium and ovarian cancer synchronous to endometriosis--a retrospective study of our experience of 7 years.

Metastatic lobular carcinoma of the breast to the vulva: a case report and review of the literature.

Introduction It is widely supported that multicentric disease of the breast (MCDB) is a contraindication of breast conservative surgery (BCS). Materials and methods This is a multicentric study (two breast cancer units from Greece, one from France) involving patients with at least two primary tumors in separate quadrants of the breast and no diffuse suspicious microcalcifications on mammography. Sixty-one patients were included in the study, but 49 were followed up to the end. Patients were randomly assigned in total mastectomy (TM) and BCS groups. End point of the study was disease-free survival rates three and five years after initial operation. Results Three years after BCS, local recurrence (LR) was observed in two patients (7%) and one after five years (total recurrence rate: 11%). A TM was performed in these patients, and in two there was no LR or distant metastasis (DM) five years after. The third patient was disease free two-years later. Three years after TM, eight patients (36.4%) had DM and 14 (63.6%) did not (p = 0.004). Five years after TM, eight patients (36.4%) had DM and 14 patients (63.6%) di not (p = 0.03). Conclusion The results showed that conservative surgery was an alternative surgical option in multicentric breast cancer with good results regarding disease-free survival and recurrence.

Breast conserving surgery in multicentric breast cancer, preliminary data of our experience.

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