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Pelvic   Endometriomas         ByDR. SALAH ROSHDY (MD)Professor of OB/GYN
Introduction•   Endometriomas of the ovary were    described    by      Samspan       as    endometrial cysts almost 80 ye...
•   The endometrial glands and stroma    then grow & proliferate inside the    ovary, leading to development of the    cys...
Definition   •   Endometriomas are “nodules” or       tumours of endometrial tissue are       found mainly in peritoneum l...
Epidemiology•   The exact incidence of endometriosis is    not known because this disease can be    only diagnosed by visu...
•   The endometriosis is found in•   25-40% of women with infertility &•    in 2-5% of the general population.•   12-32% o...
Risk Factors  1.   Duration of menstrual period.  2.   Familial & genetic factor.  3.   Genital obstruction.  4.   Uterine...
Aetiology & Pathogenesis 1) Endometrial implantation     A - retrograde menstruation     B - lymphatic & vascular theory  ...
Hypothesis for aetiology ofendometriosis1. Cell adhesion.        Cell adhesion molecules especially   integrin & cadherin ...
3) Angiogenesis ,growth factor &   tumour suppressor gene.    Angiogenesis is complex process  involving proliferation, mi...
4) Hormonal factor.     Oestrogen is required for the growth  of endometriotic lesion although the  exact mechanism is unk...
Pathology1-Growth pathology.    The ovary most commonly affected pelvic structure, followed by posterior broad lig., utero...
Pathology - cont.   2- Microscopic picture.          The pathological diagnosis is       confirmed when 2 of the following...
Growth specimen of endometrioma        Free powerpoint template: www.favorideas.com   15
Clinical Presentation            Symptoms                                               Signs1.    Pelvic pain            ...
Classification             Endometrioma size (1-2cm) & contain             dark fluid. They develop from surfaceType I    ...
Type    The cyst lining is separated easily fromII B    ovarian capsule & stroma except near        endometrial implant.Ty...
Diagnosis of pelvicendometriomas Physical examination Imaging studies  A- Ultrasonography        Trans-vaginal sonograph...
Ultrasound picture of endometrioma                                                           20            Free powerpoint...
Ovarian endometrioma                                                       21        Free powerpoint template: www.favorid...
Ovarian endometrioma                                                       22        Free powerpoint template: www.favorid...
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C-Computerized tomography (CT).    Rarely used due to the widely differingappearance of the lesion .D-Optical coherence to...
 Laparoscopy•   The gold standard for definitive diagnosis of    endometriomosis is laparoscopy.•   Typical picture is po...
Large ovarian endometrioma                                                        26         Free powerpoint template: www...
Endometriotic lesions in the DP & left tube                27            Free powerpoint template: www.favorideas.com
Endometriotic lesions in the ovary                        28           Free powerpoint template: www.favorideas.com
Ovarian Endometrioma                                                  29   Free powerpoint template: www.favorideas.com
Endometriotic lesions in the USL                                                      30       Free powerpoint template: w...
Endometriotic lesions in UVP                                                       31        Free powerpoint template: www...
Endometriotic lesions in the liver                                                         32          Free powerpoint tem...
endometriotic lesions in the cervix                       33           Free powerpoint template: www.favorideas.com
Endometriotic lesions in the RVS                                                          34           Free powerpoint tem...
Endometriotic lesions in the urinary bladder                                                            35             Fre...
Endometriotic lesions in the appendix                       36             Free powerpoint template: www.favorideas.com
Transvaginal hydro-laparoscopy (THL).•   It has become available as an office technique    using 3-mm needle system intro...
Histopathological diagnosis.Thermo-colour test.     It is diagnostically accurate in in 85%of cases. The test best appli...
Treatment of PelvicEndometriomasAim of treatment•   Destroy or remove most of implants.•   Restore the normal anatomy.•   ...
1 - Medical treatment   1. It is used conventionally in treatment of      endometriosis however endometriomas are      inv...
2 - Conservative surgical ProcedureIt is frequently the treatment of choice forsymptomatic endometriomasA. Conservative La...
•   Excision of the cyst    (endometriomectomy) by capsular    stripping & laser vaporization or    excision diathermy.•  ...
Laparoscopic drainage of endometriomas                    43           Free powerpoint template: www.favorideas.com
Laparoscopic excision of endometriomas                                                           44            Free powerp...
B. Conservative Laparotomy   •   The traditional surgical approach to       endometriomas has been to perform a       lapa...
•   Although the pregnancy rate & cyst    recurrence & adhesion were found to be    comparable between the two procedure, ...
3 - Sclerotherapy   •   The technique involve needle aspiration of       the liquid content of the cyst, followed by      ...
4 - Radical treatment   •   Hysterectomy & bilateral salpingo –       oophorectomy are indicated in patient       with    ...
5 - Immunotherapy  •   It is a very new approach using      tumour vaccine RESAN, which      trigger T-cell immune respons...
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Pelvic endometrioma.prof.salah

  1. 1. 1Free powerpoint template: www.favorideas.com
  2. 2. Pelvic Endometriomas ByDR. SALAH ROSHDY (MD)Professor of OB/GYN
  3. 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 . 3 Free powerpoint template: www.favorideas.com
  4. 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 4 Free powerpoint template: www.favorideas.com
  5. 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). 5 Free powerpoint template: www.favorideas.com
  6. 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. 6 Free powerpoint template: www.favorideas.com
  7. 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. 7 Free powerpoint template: www.favorideas.com
  8. 8. Risk Factors 1. Duration of menstrual period. 2. Familial & genetic factor. 3. Genital obstruction. 4. Uterine retroversion. 5. Obesity. 8 Free powerpoint template: www.favorideas.com
  9. 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 9 Free powerpoint template: www.favorideas.com
  10. 10. Hypothesis for aetiology ofendometriosis1. 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. 10 Free powerpoint template: www.favorideas.com
  11. 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. 11 Free powerpoint template: www.favorideas.com
  12. 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 12 Free powerpoint template: www.favorideas.com
  13. 13. Pathology1-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). 13 Free powerpoint template: www.favorideas.com
  14. 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 14 Free powerpoint template: www.favorideas.com
  15. 15. Growth specimen of endometrioma Free powerpoint template: www.favorideas.com 15
  16. 16. Clinical Presentation Symptoms Signs1. Pelvic pain 1. Local tenderness in2. infertility cul-de-sac or3. Hypermenorrhea uterosacral ligament4. Premenstrual staining 2. Adnexal enlargemen or tenderness5. Dysparonia 3. Pelvic masses6. Supra pubic pain7. Dysuria8. Haematuria9. Dyschezia10. Lower back pain 16 Free powerpoint template: www.favorideas.com
  17. 17. Classification Endometrioma size (1-2cm) & contain dark fluid. They develop from surfaceType I endometrial implants. Microscopically, endometrial tissue seen in all of them. Endometriomas are hemorrhagic cyst , the cyst wall is separated easily from ovarian tissue. Endometrial implants are superficial and adjacent toType II A hemorrhagic cyst which is either follicular or luteal in origin , microscopically www.favorideas.com Free powerpoint template: no endometrial lining 17
  18. 18. Type The cyst lining is separated easily fromII B ovarian capsule & stroma except near endometrial implant.Type the surface endometrial implant penetrateII C deeply into the cyst wall, type IIB,C endometriomas are large & associated with peri-ovarian adhesion.Type Ovarian endometrial cyst at least 3 cm inIII & diameter, the other characters are similar to IV stage III &IV endometriosis. 18 Free powerpoint template: www.favorideas.com
  19. 19. Diagnosis of pelvicendometriomas 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. 19 Free powerpoint template: www.favorideas.com
  20. 20. Ultrasound picture of endometrioma 20 Free powerpoint template: www.favorideas.com
  21. 21. Ovarian endometrioma 21 Free powerpoint template: www.favorideas.com
  22. 22. Ovarian endometrioma 22 Free powerpoint template: www.favorideas.com
  23. 23. 23Free powerpoint template: www.favorideas.com
  24. 24. C-Computerized tomography (CT). Rarely used due to the widely differingappearance of the lesion .D-Optical coherence tomography (OCT). It is recently developed real time imagingtechnology, it is analogous to ultrasoundmeasuring the intensity of back – reflectedinfrared light rather than acoustic waves, theability to obtain an optical biopsy.a highresolution cross sectional image of tissue in-situ. 24 Free powerpoint template: www.favorideas.com
  25. 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). 25 Free powerpoint template: www.favorideas.com
  26. 26. Large ovarian endometrioma 26 Free powerpoint template: www.favorideas.com
  27. 27. Endometriotic lesions in the DP & left tube 27 Free powerpoint template: www.favorideas.com
  28. 28. Endometriotic lesions in the ovary 28 Free powerpoint template: www.favorideas.com
  29. 29. Ovarian Endometrioma 29 Free powerpoint template: www.favorideas.com
  30. 30. Endometriotic lesions in the USL 30 Free powerpoint template: www.favorideas.com
  31. 31. Endometriotic lesions in UVP 31 Free powerpoint template: www.favorideas.com
  32. 32. Endometriotic lesions in the liver 32 Free powerpoint template: www.favorideas.com
  33. 33. endometriotic lesions in the cervix 33 Free powerpoint template: www.favorideas.com
  34. 34. Endometriotic lesions in the RVS 34 Free powerpoint template: www.favorideas.com
  35. 35. Endometriotic lesions in the urinary bladder 35 Free powerpoint template: www.favorideas.com
  36. 36. Endometriotic lesions in the appendix 36 Free powerpoint template: www.favorideas.com
  37. 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. 37 Free powerpoint template: www.favorideas.com
  38. 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. 38 Free powerpoint template: www.favorideas.com
  39. 39. Treatment of PelvicEndometriomasAim of treatment• Destroy or remove most of implants.• Restore the normal anatomy.• Prevent or delay progression.• Relieve the patient symptoms. 39 Free powerpoint template: www.favorideas.com
  40. 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. 40 Free powerpoint template: www.favorideas.com
  41. 41. 2 - Conservative surgical ProcedureIt is frequently the treatment of choice forsymptomatic endometriomasA. 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. 41 Free powerpoint template: www.favorideas.com
  42. 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 42 Free powerpoint template: www.favorideas.com
  43. 43. Laparoscopic drainage of endometriomas 43 Free powerpoint template: www.favorideas.com
  44. 44. Laparoscopic excision of endometriomas 44 Free powerpoint template: www.favorideas.com
  45. 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. 45 Free powerpoint template: www.favorideas.com
  46. 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. 46 Free powerpoint template: www.favorideas.com
  47. 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. 47 Free powerpoint template: www.favorideas.com
  48. 48. 4 - Radical treatment • Hysterectomy & bilateral salpingo – oophorectomy are indicated in patient with severe symptoms &not responding to other measures & are not interested in pregnancy. 48 Free powerpoint template: www.favorideas.com
  49. 49. 5 - Immunotherapy • It is a very new approach using tumour vaccine RESAN, which trigger T-cell immune response against endometriosis, showing promising results. 49 Free powerpoint template: www.favorideas.com
  50. 50. 50Free powerpoint template: www.favorideas.com

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