International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Discussion: Evolving Perspectives and Evidence on Endometriosis
Speaker 1:
Yeah, we are open your questions for discussion or comments. Okay. Dr.
Speaker 2:
I would like to thank to all speakers. I would like to ask you, so you know that when we face endometrial a young woman, we commonly choose the endometrium cyst excision when they're close to menopausal age, we can easily apply the ectomy if we apply the cystectomy. Do you think that we can solve the problem about creating a ovarian cancer in future or lady a little bit coming to late age? Do we apply the or ectomy to solve the problem? Is there any difference between them?
Speaker 3:
That's a very good question. Unfortunately I didn't have time to go. Two more slides. As I mentioned, we don't have any screening tests right now for any group. Forget about even patient with BRCA mutation. We don't have any screening tests for general population. We don't have any screening tests and we don't have anything for endometriosis patients. So what can we do? One of the important things, as we discussed earlier, put the patient on hormonal suppressive therapy. If you're diagnosed to have endometriosis and if you put the patient on suppressive therapy, that PD s ovulation. So as I mentioned, majority of OY cancer coming from the customer, endometriosis from the art ovary. So if you put the patient on sive therapy and doesn't ovulate, so she will not form a endometrioma, that's number one. We believe any endometrial was diagnosed. It has to be restricted no matter what age because we publish a paper majority, almost 90, more than 90% of the patient endometrioma have a stage three or four.
So that endometrioma is the tip of the iceberg. The sooner you go, you remove the endometrioma carefully. That is the reason you guys are here. Learn from the experts and put the patient with suppressive therapy and you follow them if you don't want to operate on them and has endometrioma, follow them with the ultrasound. And if the characteristic of endometrioma changes in two ways, develops neural nodule, the solid component as I showed you, or the size increases, all of a sudden these are the sign of the malignant transformation. So long to short answer to your question, if you have to individualize the patient, if the young patients you remove endometriosis, put them with receptor therapy of the want to get pregnant, get pregnant or send them for the egg freezing or embryo freezing, you have to operate. Unfortunately, majority of these patients, they have endometriosis and they have another surgery before you go to the operating room. Consult the patient is one study was shown by mil Sweden that if one side of ectomy and eradication of the infected endometriosis decreases the risk of the OAN cancer by 30%. So if you have a perimenopausal patient and hazard endometrial, take the out, take the over out because the consequences if they develop clear cell carcinoma is bad, they will not respond to chemotherapy is better. They take the over out and they put the patient on therapy, hormonal replacement therapy.
Speaker 1:
So if you allow me, I would humbly make a comment and ask you concerning the recent rise in the risk of endometriosis related cancers, especially in endometriosis related ovarian cancers, I always remind Heisenberg's saying that the nature what we observe depends and alters on our method of questioning. If you examine it epidemiologically and you search for association statistically significant association, then you talk about risk of getting cancer later on. But as a pathologist, I myself practicing in a country in Japan for more than 20 years where clear cell ovarian cancer incidents is the highest. I personally examine old ovarian clear cell and endometrioid ovarian cancers. And I find endometriosis associated endometriosis together with the cancer in almost all the cases. And furthermore, I examined the transformation of the endometrioid epithelium to the cancer on the report that we wrote with Dr. Kin in 2013. We also found molecular alterations convincing molecular alterations start in the background endometriosis. So there is no discussion that clear cell and endometrioid ovarian cancer arise in the background of endometriosis, but it doesn't show you the risk of transformation or the risk of patient will have endometriosis related cancer. So they are different for me a hundred percent. So if I have someone, some loud one, have an endometrioma without any trouble of reproduction, then I would ask for removal of the lesion.
Of course, the iron is the most concentrated no matter the chocolate cyst, it bitter or is bitter or sweet or whatever. It contains ferric iron and it is the reason for the phantom reaction for the patient to the transformation of the epi. Thank you very
Speaker 4:
Speaker 1:
Speaker 5:
Yes, I would like to congratulate all the speakers for excellent presentation. My question is for Dr. Giovanni, do you do any bowel preparation? I mean, I really enjoyed your talk as usual, do you use any enema or anything before you do the ultrasound? And also what is the role of rectal ultrasound on upper lesions?
Speaker 6:
Thank you. Thank you Professor Naja for your appreciation and thank you all the committee for this invitation. I'm very, very pleased to be here with you. Thank you for asking. Yes. Used to ask any patients undergoing ultrasonography for endometriosis about preparation with a glass of micro inma performance a few hours before the procedure. It's usually well tolerated. Of course it's, it's not a rule, it's just comes from my experience. It's demonstrated in literature that it doesn't change the diagnostic accuracy. But on personal opinion, it allows a better vision of the entire pelvis and probably there can be some changes in the detection rate of a small OSM lesions. Concerning the transrectal approach, I'm used to proceed with this kind of procedure in that patients under that cannot, which transvaginal root cannot be performed such as young patients who didn't have intercourses before or in patients, which I can perform both transvaginal and transrectal approach. And I usually need this kind of observation when have a vaginal nodule because with the transvaginal root, the risk is to press on the nodule and to underestimated the nodule. So when I found by pelvic examination or by transvaginal root, a vaginal nodule, I usually perform also the transrectal examination.
Speaker 5:
Thank you very much. Looking forward to seeing you in Atlanta. Thank you.
Speaker 6:
Thank you. Yes, of course. Thank you. Thank you so much. I have one question
Speaker 3:
From you, so thank you very much for your comments. You're a pathologist and you are in Japan and the land of cal cell carcinoma. So I have to ask this burning question that I am puzzling with if the highest cancer of the endometrial adenocarcinoma, why in endometriosis CHO cell carcinoma is more common than endometrial adenocarcinoma?
Speaker 1:
So the place where you sit, if it is your chair, it welcomes you, but someone else chair may not welcome you. So alter it environment is the reason
Speaker 3:
I know for
Speaker 1:
Those changes
Speaker 3:
I know, but I don't know why there's more severe SAR carcinoma than end.
Speaker 1:
Yeah, okay. Okay. Iners and clear cell carcinomas are less. That's right, but it doesn't mean the type. It's carcinoma transformation. The cell doesn't know which dress to wear. Mostly they wear endometrial in Utes, but some of them may change their dress, but they are all carcinoma. This is the problem. But endometrial carcinomas also increase in patients with endometrial. Yeah, that's why he's asking, but not clear cell endometrial. Okay.
Speaker 3:
So is it possible that it has something to do with the environment and the diet? Of
Speaker 1:
Course diet is the environment.
Speaker 3:
You guys have to think about it. Okay. You are young people and that has been burning me for past 25 years and I have not been able to answer this question myself so far. And I am working with several group about the molecular alterations, why we have more cin, all the data shows.
Speaker 4:
Is there an age difference where clear cell happens the younger generation of cancer, more end between certain group versus,
Speaker 3:
No, unfortunately not. Because my youngest patient that had Clio cell carcinoma is 27 and the oldest one that, for example, I showed you that case she was 57. So there are two ranges, the postmenopausal and premenopausal. That is the reason that you guys, most of you are just your oncologist. You don't see it. My oldest patient that had endometriosis coming, cancer and endometriosis, 85 years old.
Speaker 4:
Are there any studies with respect to postmenopausal and ovarian cancer, postmen, endometrial suggestive symptoms they had during their menstrual years? Are there any study on that?
Speaker 3:
Speaker 4:
Know that non, a lot of things that frustrat with endo associated with ovarian cancer, but nobody has looked at it. I mean, the cancer society is so nonchalant about endo. It is, as much as it's challenging for down surgically, they really don't care about it. They
Speaker 3:
Don't it
Speaker 4:
Speaker 3:
It goes back to her talk dysmenorrhea. People have dysuria. They're saying your mom had DYS men. And a lot of these patient when they come to me and I asked them a lot of the patient that had used birth control pills to control the symptoms and then later on they don't want to get pregnant. They stop and know they have pain or they have endometrioma. Unfortunately, we have a lot to learn. Yes, but DYS mania, it is not normal in my opinion.
Speaker 1:
For your question, almost all of those cases had endometriosis or aosis. And furthermore, unfortunately you have right to say that cancer people don't undermine underestimate
Speaker 4:
Speaker 7:
My question is to Dr. Giovanni, thank you for attending. It must be very late at night there. How long does it take averagely, your procedure when you look for rectum and beyond? What's the challenges that you have? I mean, when do you fail? Do you fail?
Speaker 6:
Thank you. Thank you for asking Tamir and thank you. Thank you again for limitation. I think that with the increasing experience, the risk of fail is getting lower and lower and what I think is the hardest part to explore in the patients affected by deep endometriosis is probably the parametal area and the pelvic sidewall concerning the power deep infiltrating lesion of the bowel are usually really clearly seen, especially in the rectosigmoid segment. Some reasons for fail can be the concomitant presence of very large adal masses that can displace the bowel or very, very large uterus. But the risk of false negative results on the bowel is really, really low. Probably sensitivity is a little bit lower at the level of the small bowel and the appendix, probably their ultrasonography. But any way, our sensitivity is above 90%. So in the majority of cases we can identify deletion. I have to tell that specificity is very high in all the pelvic compartments that we explore.
Speaker 7:
Thank you. Philip. Do you hear me? Philip? You're almost to go to bed there.
Speaker 8:
Speaker 7:
To ask something to you. You are the man of evidence with statistics and you really push that hard. I think ethically and everything, we try to do best evidence in the end per case. Evidence per case is the most valuable thing for patient outcome. I mean, because I know you did, I'm not sure you're still practicing as much, but video documentation, especially excision for pathological evidence should be the sole core of how we perform and do things. I don't see you talking about those anymore. That's why, I mean, where do you put the pathological evidence in overalls at the top of your pyramid when you talk about in the end, ethically moving forward with endometriosis? In many failed cases, when I had my statistics today, I didn't have time to explain, but many times I do second surgery for other people that have done, I mean my element, my number of biopsies that are positive is probably 10 times as much than my repeat surgery, my own failure or repeat surgeries that I do, which I think I removed all, but I still have recurrences. So where is that level of pathological evidence in your writings? I don't see that much anymore much.
Speaker 8:
It's a very long answer. And let me be very short for pathology. Nobody knows the value because pathology is the gold standard and the gold standard cannot be compared to anything else, which means that you never know the value of the gold standard. And I very recently wrote a paper on breast cancer, and if you see that the estimations today that for all women treated for breast cancer, surgery, chemotherapy and so on, that between estimated 10 up to 40% never had the breast cancer. This is the main problem of pathology. We don't know what the value of pathology is. It looks like endometriosis, but this is not the end of the study. It's not because the pathology says, and maybe I'm going to have a big discussion with Dan Martin there, but pathology is has not the last word and it is overrated. Osis,
Speaker 7:
Did you say pathology is overrated? Did I say hear that right? Okay. Yes.
Speaker 1:
If you allow me, I would like to say yes, I was prepared for that, but Turner didn't allow me to talk. I believe the pathologist in your country, although I'm very good friend of Dr. Kote, Dr. Kote in Belgium, he respects pathologist. I know he's a gynecologic oncologist surgeon. And I also want to ask you do all the gynecologist, I, all the gynecologists, do the same thing with the people here or with the endometriosis people so that if they are not specified, they don't see as good as specified people do. If you don't have in your mind, your eyes would not see. So change your pathologist. Sorry about saying that you got
Speaker 7:
To change your pathologist.
Speaker 1:
And furthermore, in our definition, pathologist is the person who starts with etiology, eio pathogenesis, not only microscopy, but all different steps of the disease including post therapy alterations including after chemotherapy, morphology, et cetera. And the drug effect until the final final examination. So it's the role of pathologist. Probably some pathologists do it only for practicing or they don't like their job. I don't know. But for me, it is the pathologist who needs to examine the tissues no matter it's molecular, no matter it is electro microscopic, no matter it's immunohistochemical, no matter it is any technique. So if any technique would be useful for pathological patient purpose, then it enters into the pathology. Unfortunately, not most pathologists do not perform research. Thank you. Thank you very much. So please, please,
Speaker 6:
Giovanni, please can I have the comment? I fully agree with your vision, but I fully agree with the Philip too because what I think is that in any of our field in pathology, ultrasonography, radiology with the MRI and surgery, it's a matter of experience. So of course the results that I showed you with that really high diagnostic accuracy were reached over years of hard work and experience and comparison with surgery work. But of course, we cannot expect that kind of a accuracy from the ultrasonography that is performed by the general gynecologist. And I think that the same happens with a pathology who is fully dedicated to gynecologic disease. The degree of experience will be absolutely higher than a general pathologist that sees that kind of disease in very, very few occasion in his life. And so I completely agree with Philip that probably also in this field, prevalence of the disease makes the difference. And we had several opportunity of discuss about this issue. Probably the prevent of the disease makes the difference in every of our fields.
Speaker 1:
