Post on 07-May-2015
Free powerpoint template: www.favorideas.com 1
Pelvic
Endometriomas
By
DR. SALAH ROSHDY (MD)
Professor of OB/GYN
Free powerpoint template: www.favorideas.com 3
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 .
Free powerpoint template: www.favorideas.com 4
• 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
Free powerpoint template: www.favorideas.com 5
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).
Free powerpoint template: www.favorideas.com 6
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.
Free powerpoint template: www.favorideas.com 7
• 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.
Free powerpoint template: www.favorideas.com 8
Risk Factors
1. Duration of menstrual period.
2. Familial & genetic factor.
3. Genital obstruction.
4. Uterine retroversion.
5. Obesity.
Free powerpoint template: www.favorideas.com 9
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
Free powerpoint template: www.favorideas.com 10
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.
Free powerpoint template: www.favorideas.com 11
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.
Free powerpoint template: www.favorideas.com 12
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
Free powerpoint template: www.favorideas.com 13
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).
Free powerpoint template: www.favorideas.com 14
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
Free powerpoint template: www.favorideas.com 16
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
Free powerpoint template: www.favorideas.com 17
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
Free powerpoint template: www.favorideas.com 18
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
Free powerpoint template: www.favorideas.com 19
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.
Free powerpoint template: www.favorideas.com 20
Ultrasound picture of endometrioma
Free powerpoint template: www.favorideas.com 21
Ovarian endometrioma
Free powerpoint template: www.favorideas.com 22
Ovarian endometrioma
Free powerpoint template: www.favorideas.com 23
Free powerpoint template: www.favorideas.com 24
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.
Free powerpoint template: www.favorideas.com 25
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).
Free powerpoint template: www.favorideas.com 26
Large ovarian endometrioma
Free powerpoint template: www.favorideas.com 27
Endometriotic lesions in the DP & left tube
Free powerpoint template: www.favorideas.com 28
Endometriotic lesions in the ovary
Free powerpoint template: www.favorideas.com 29
Ovarian Endometrioma
Free powerpoint template: www.favorideas.com 30
Endometriotic lesions in the USL
Free powerpoint template: www.favorideas.com 31
Endometriotic lesions in UVP
Free powerpoint template: www.favorideas.com 32
Endometriotic lesions in the liver
Free powerpoint template: www.favorideas.com 33
endometriotic lesions in the cervix
Free powerpoint template: www.favorideas.com 34
Endometriotic lesions in the RVS
Free powerpoint template: www.favorideas.com 35
Endometriotic lesions in the urinary bladder
Free powerpoint template: www.favorideas.com 36
Endometriotic lesions in the appendix
Free powerpoint template: www.favorideas.com 37
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.
Free powerpoint template: www.favorideas.com 38
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.
Free powerpoint template: www.favorideas.com 39
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.
Free powerpoint template: www.favorideas.com 40
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.
Free powerpoint template: www.favorideas.com 41
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.
Free powerpoint template: www.favorideas.com 42
• 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
Free powerpoint template: www.favorideas.com 43
Laparoscopic drainage of endometriomas
Free powerpoint template: www.favorideas.com 44
Laparoscopic excision of endometriomas
Free powerpoint template: www.favorideas.com 45
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.
Free powerpoint template: www.favorideas.com 46
• 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.
Free powerpoint template: www.favorideas.com 47
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.
Free powerpoint template: www.favorideas.com 48
4 - Radical treatment
• Hysterectomy & bilateral salpingo –oophorectomy are indicated in patient with severe symptoms ¬ responding to other measures & are not interested in pregnancy.
Free powerpoint template: www.favorideas.com 49
5 - Immunotherapy
• It is a very new approach using tumour vaccine RESAN, which trigger T-cell immune response against endometriosis, showing promising results.
Free powerpoint template: www.favorideas.com 50