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The theory of origin of endometriomas
Hugo Verhoeven, MD and Camran Nezhat, MD Hugo
Verhoeven, MD:
Good morning everybody, my name is Hugo Verhoeven from the Centre for
Reproductive Medicine in Dusseldorf, Germany. I am on the Editorial Board of
OBGYN.net. It is an exceptional honour for me, today, to talk to one of the
leading people in the world, in the field of endoscopic surgery, Camran Nezhat,
from the San Francisco area (Palo Alto) in California. Camran, it is always a very great pleasure for me to meet
you and to talk to you. We are going to stress today what is still a big problem
in the treatment of endometriosis. In fact, we are going to talk about the
endometrioma – or chocolate cysts. But
the origin of those cysts is still a little bit confusing.
Could you give me your opinion on what the origin of endometrioma is? Camran
Nezhat, MD: Thank
you very much Hugo, it is always a pleasure seeing you again. I would be happy
to answer that question. As you know, the origin of the endometrioma has been the
subject of many debates from the time of Sampson's theory.
However, in recent years, many of our colleagues, and ourselves also,
have done many investigations, and different theories have emerged regarding the
endometrioma. Hugo
Verhoeven, MD:
Maybe you should say Sampson said that an endometrioma is an invagination
of the cortex of the ovaries, and metaplasia of the inverted layer of the
endometrioma cyst. That is the theory of Sampson, is that correct? Camran
Nezhat, MD: Sampson
thought endometriomas are from corpus luteums.
We were able to prove his opinion [1].
We went further and developed our theory regarding origin of
endometriomas. According to our
theory there are two types of
endometriomas, Type I or Primary endometriomas.
These endometriomas when submitted to the pathologist always come back as
endometrial glands and stroma [1]. Clinically
they are slow developing and very hard to remove the capsule. The capsule is
very fibrotic and often should be piece mealed at the time of the removal.
They usually develop by small endometrial glands sitting on the surface
of the ovary and gradually into the ovary. They hardly ever get more than 5 or 6
cm. Type II, or secondary endometriomas. These usually can get
very large. We have removed them
even up to 25cm.These are the ones that Sampson referred to.
The origin of all these endometriomas are somehow functional cysts. We
believe they could be corpus luteum or any other functional cyst. They are Type
II A and B. Type II A is when the
cyst looks exactly like a chocolate cyst and contains concentrated blood. When
you remove it, it comes off easily except when superficial endometriosis is
invading. Pathology reports almost always come back as corpus luteum unless the
pathologist is looking at the small segment of the cyst that has been invaded by
endometriosis. Type II B again looks exactly like a chocolate cyst and
almost all of the cyst wall is endometrial glands and stroma. But, if they
continue dissecting and analyzing the cyst wall you will be able to find luteal
cells [2]. Hugo
Verhoeven, MD:
Can you see any difference with ultrasound between those different types
of endometriomas? Is there any difference if you do ultrasound? Camran
Nezhat, MD: Yes,
you would be able to. Type I
endometriomas grow extremely slow. Type II endometriomas have a more rapid
progression. Hugo
Verhoeven, MD:
But if you see those endometrioma with ultrasound, would you always
advise the patients to go in for endoscopic removal of those endometriomas, or
are there some kinds of endometriomas where you would say, “We’ll wait” or
“We prefer eventually medical treatment”? Camran
Nezhat, MD: Very
good and important point. Almost always, the majority of the Type I
endometriomas would end up needing to be surgically removed.
Type II endometriomas, if you catch them very early, as they are
developing, the majority of the time you can suppress them [3]. Hugo
Verhoeven, MD:
Is it true if I would say, that treating those two different types of
endometrioma with medication, with GnRH-analogue for instance, would also be a
very good diagnostic tool because the second type will react with medication and
will maybe disappear? The first one will not react at all, or only very slowly
to a GnRH-analogue, is that correct? Camran
Nezhat, MD: That
is a good generalisation. Type I, or Primary endometriomas, are very difficult
to remove, they are slow growing and respond very poorly to GnRH-analogues. Type
II, especially Type IIA, respond very well to hormonal suppressive therapy.
But, as the Type IIB advances, response is less and less [4,5]. Hugo
Verhoeven, MD:
To finalise this interview, what is for you, the state-of-the-art at this
moment Or, in other words, how are you treating now, laparoscopically,
endoscopically, an endometrioma? What is the technique you use for that? Camran
Nezhat, MD:
If we do not remove Type I endometriomas and only aspirate them the
chance of recurrence is very high. So,
I remove them. For Type IIA the
section involved with endometriosis should be removed.
If the Type II endometrioma is diagnosed very early the majority of the
time it can be suppressed. Hugo
Verhoeven, MD:
You know why I ask you that? Because Ivo Brosens for instance said that
you can also coagulate the vessels, the inner layer of the endometrioma, as an
alternative to the removal of the complete pseudo cystic wall. Camran
Nezhat, MD:
There are multiple ways to play the piano. Ivo’s approach is probably
another way of dealing with this medical condition.
But in general, it is always a good idea to have a tissue biopsy sent to
the pathologist. And also, while
coagulating the lining of the cyst, one should be cognizant of not damaging the
stroma of the ovary.
Hugo
Verhoeven, MD:
To conserve as much ovarian tissue as possible? Camran
Nezhat, MD: Right.
Hugo
Verhoeven, MD:
And do you close the ovary again or do you leave it open? Camran
Nezhat, MD: Most
of the time the ovarian edges overlap together. If there is a big gap and the
ovarian edges do not overlap, one or two sutures could be used inside of the
ovary to close the ovary [6].
Hugo
Verhoeven, MD:
So, again, I think we learned quite a lot today. Thank you very much for
this interview and I wish you a very interesting meeting. Camran
Nezhat, MD: Thank
you very much, it was very nice seeing you again Hugo.
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