Magnetic resonance imaging and endometriosis: deeply infiltrating endometriosis does not originate from the rectovaginal septum

The goal of this study was to describe the magnetic resonance (MR) imaging signs of deeply infiltrating endometriosis (DIE) lesions and above all to find out if MR imaging can pinpoint the location of these lesions. We made a retrospective study of 8 patients presenting with histologically proven DIE lesions. The MR imaging results were compared with intraoperative findings. Nodules revealed on T1-weighted images as isointense to myometrium with hyperintense spots remained visible on the fat-suppressed spin echo images. When there was no rectal involvement, the T1- and T2-weighted images showed a hypointense transition area between the nodule and the rectum. The DIE nodules were in identical locations in every case, lying below the torus uterinum, level with the posterior vaginal fornix and the upper third of the posterior vaginal wall. Without exception, the DIE nodules were located above the upper edge of the rectovaginal septum, with the latter appearing fine and regular with no image of any nodule. Our MR imaging results suggest that DIE lesions do not originate from the rectovaginal septum.     

Utility of rectal endoscopic ultrasonography for digestive involvement of pelvic endometriosis. Technique and results

Intestinal endometriosis present in up to 37% of cases is difficult to diagnose and treatment remains complex. Until recently barium enema and colonoscopy are the only two diagnostic tools. However there were many drawbacks and technical limitations due to the particular development of the endometrial lesions with frequent respect of the mucosa. Digestive involvement was often preoperative discovery and treatment was frequently incomplete. Development of endoscopic ultrasonography has improved the potential for preoperative diagnosis of digestive endometriosis. Many publications have now demonstrated its utility. Compared to other imaging techniques endoscopic ultrasonography has better sensibility close to 100%. Endoscopic ultrasonography is superior to Magnetic Resonance Imaging for the diagnosis of rectosigmoid endometriosis. Magnetic Resonance Imaging however gives a largest view of the pelvis. Using preoperatively endoscopic ultrasonography in patients who are at risk of digestive involvement will help to choose between different therapeutic modalities and surgical techniques.     

PPARgamma-independent increase in glucose uptake and adiponectin abundance in fat cells

Although thiazolidinediones (TZD) effectively improve hyperglycemia and increase adiponectin, a proinsulin-sensitizing adipokine, they also increase adipogenesis via peroxisome proliferator-activated receptor (PPAR)γ induction, which may be undesirable. Recent safety concerns about some TZD have prompted the search for next generation agents that can enhance glycemic control and adiponectin independent of PPARγ or adipogenesis. Reminiscent of TZD action, a human adenovirus, adenovirus 36 (Ad36), up-regulates PPARγ, induces adipogenesis, and improves systemic glycemic control in vivo. We determined whether this effect of Ad36 requires PPARγ and/or adipogenesis. Glucose uptake and relevant cell signaling were determined in mock-infected or human adenoviruses Ad36 or Ad2-infected cell types under the following conditions: 1) undifferentiated human-adipose-tissue-derived stem cells (hASC), 2) hASC differentiated as adipocytes, 3) hASC in presence or absence of a PPARγ inhibitor, 4) NIH/3T3 that have impaired PPARγ expression, and 5) PPARγ-knockout mouse embryonic fibroblasts. Mouse embryonic fibroblasts with intact PPARγ served as a positive control. Additionally, to determine natural Ad36 infection, human sera were screened for Ad36 antibodies. In undifferentiated or differentiated hASC, or despite the inhibition, down-regulation, or the absence of PPARγ, Ad36 significantly enhanced glucose uptake and PPARγ, adiponectin, glucose transporter 4, and glucose transporter 1 protein abundance, compared with mock or Ad2-infected cells. This indicated that Ad36 up-regulates glucose uptake and adiponectin secretion independent of adipogenesis or without recruiting PPARγ. In humans, natural Ad36 infection predicted greater adiponectin levels, suggesting a human relevance of these effects. In conclusion, Ad36 provides a novel template to metabolically remodel human adipose tissue to enhance glycemic control without the concomitant increase in adiposity or PPARγ induction associated with TZD actions.     

Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis

STUDY OBJECTIVE: To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS: Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). CONCLUSION: High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term "deep endometriosis infiltrating the rectovaginal septum" is generally incorrect in the true anatomic sense.     

Histologic appearance of endometriosis infiltrating uterosacral ligaments in women with painful symptoms

STUDY OBJECTIVE: To describe the histologic appearance of deep endometriosis infiltrating the uterosacral ligaments (USL). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred forty-nine women with pain due to endometriosis. INTERVENTION: Resection of one or both USL. MEASUREMENTS AND MAIN RESULTS: One hundred seventy-two USL were examined by histology after unilateral resection in 126 patients (84.6%) and bilateral resection in 23 (15.4%). Two-thirds of women (122, 70.9%) had a classic appearance of endometriosis. Lesions of myoproliferative endometriosis with a histologic appearance of so-called adenomyotic nodules were observed in 25 (14.5%). Associated fibrosis was most frequent in patients with positive compared with negative histology (85, 69.7% vs 18, 36.0%). CONCLUSION: Anatomicopathologic lesions of deep endometriosis infiltrating the USL are heterogeneous. Adenomyotic nodules are not frequently observed.     

Accounting for the multidimensional nature of the relationship between adult obesity and socio-economic status: the French second National Individual Survey on Food Consumption (INCA 2) dietary survey (2006-07)

The objective was to study the multidimensional nature of the relationship between adult obesity (OB) and socio-economic status (SES), using comprehensive indices of SES taken separately or synthesised in an overall index. A nationally representative sample of adults aged 18-79 years was taken from the French second National Individual Survey on Food Consumption (INCA 2) dietary survey (2006-07). Weight and height were measured and OB defined as BMI?≥?30?kg/m2. SES variables were reported in questionnaires and included occupation, education and characteristics of household wealth. Composite indices of SES (household wealth and overall SES indices) were computed by correspondence analysis, and relationships with OB were investigated with logistic regression analysis. In total, 11·8 (95?% CI 10·1, 13·4) % of French adults were obese, without significant difference by sex. While no significant relationship was observed in men, all SES indicators were inversely correlated to OB in women. Both education and the household wealth index were retained in the stepwise multivariate model, confirming that different socio-economic variables are not necessarily proxies of each other regarding the OB issue. On the other hand, 'controlling for SES' while including several measures of SES in multivariate models may lead to collinearity, and thus over-adjustment. A more integrative approach may be to derive a synthetic index by including the SES factors available in a given study. Beyond this methodological perspective, understanding how OB is related to the different dimensions of SES should help to target the more vulnerable groups and increase the effectiveness of prevention.     

Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study

Study ObjectiveFew reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation.Design ClassificationProspective study.SettingUniversity hospital.PatientsThirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation.InterventionsElectromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented.Measurements and Main ResultsSystematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases.ConclusionThe results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.     

A focus group study on breast cancer risk presentation: one format does not fit all

Identifying a strategy that would optimize both the communication and understanding of the individual breast cancer risk remains a considerable challenge. This study explored the preferences of women with a family history of breast cancer about six presentation formats of individual breast cancer risk, as calculated from a risk prediction model. Thirty-four unaffected women attending genetic counseling because of a family history of breast cancer participated in six focus groups conducted in Québec City (2), Montréal (2) and Toronto (2), Canada. Six risk formats were presented for a fictitious case involving a 35-year-old woman (1—numerical: cumulative risk probabilities by age until 80 years; 2—risk curves: probabilities expressed in a risk curve that also provided a risk curve for a woman with no family history in first-degree relatives; 3—relative risk of breast cancer by age 80 years; 4 and 5—absolute risk of breast cancer and absolute chance of not developing breast cancer in the next 20 years; 6—qualitative: color-coded figure). Participants were asked to indicate their appreciation of each format. A group discussion followed during which participants commented on each format. The most and least appreciated formats were risk curves and relative risk, respectively. Overall, participants advocated the use of formats that combine quantitative, qualitative and visual features. Using a combination of approaches to communicate individual breast cancer risks could be associated with higher satisfaction of counselees. Given the increasing use of risk prediction models, it may be relevant to consider the preferences of both the counselee and the professional.