Progression of deep infiltrating rectosigmoid endometriotic nodules

Abstract

STUDY QUESTION What is the risk of progression of deep endometriotic nodules infiltrating the rectosigmoid? SUMMARY ANSWER There is a risk of progression of deep endometriotic nodules infiltrating the rectosigmoid, particularly in menstruating women. WHAT IS KNOWN ALREADY Currently, there is a lack of acceptance in the literature on the probability that deeply infiltrating rectosigmoid endometriotic nodules progress in size. STUDY DESIGN, SIZE, DURATION We conducted a monocentric case–control study between September 2016 and March 2018 at Rouen University Hospital. We enrolled 43 patients who were referred to our tertiary referral centre with deep endometriosis infiltrating the rectosigmoid, who had undergone two MRI examinations at least 12 months apart and had not undergone surgical treatment of rectosigmoid endometriosis during this interval. PARTICIPANTS/MATERIALS, SETTING, METHODS MRI images were reinterpreted by a senior radiologist with experience and expertise in endometriosis, who measured the length and thickness of deep infiltrating colorectal lesions. Intra- and inter-observer reliability were tested on 30 randomly selected cases. We defined ‘progression’ of a nodule as an increase of ≥20% in length or in thickness and ‘regression’ of a lesion as a decrease of ≥20% in length or in thickness between two MRIs. Any nodule for which the variation in length and thickness was <20% was considered as ‘stable’. Patients were divided into three groups based on evidence of progression, regression or stability of deep endometriotic nodules between their two MRI examinations. The total length of any period of amenorrhoea between the two MRI examinations, due to pregnancy, breastfeeding or hormonal treatment, was recorded. The total proportion of the time between MRIs where amenorrhoea occurred was compared between groups. MAIN RESULTS AND THE ROLE OF CHANCE Eighty-six patients underwent at least two MRIs for deep endometriosis infiltrating the sigmoid or rectum between September 2016 and March 2018. Of these, we excluded 10 patients with an interval of <12 months between MRIs, 10 patients who underwent surgery between MRIs, 17 patients for whom at least 1 MRI was considered to be of poor quality and 6 patients for whom no deep colorectal lesion was found on repeat review of either MRI. This resulted in a total of 43 patients eligible for enrolment in the final analysis. Mean time (SD) between MRIs was 38.3 (22.1) months. About 60.5% of patients demonstrated stability of their colorectal lesions between the two MRIs, 27.9% of patients met the criteria for ‘progression’ of lesions and 11.6% met the criteria for ‘regression’ of lesions. There was no significant difference in time interval between MRIs for the three groups (P = 0.76). Median duration of amenorrhoea was significantly lower in women with progression of lesions (7.5 months) when compared to those with stability of lesions (8.5 months) or regression of lesions (21 months) (P < 0.001). Median duration of amenorrhoea (expressed as percentage of total time between two MRIs) was also found to be significantly lower in the group demonstrating progression (15.1%) when compared to the group demonstrating stability (19.2%) and the group demonstrating regression (94.1%; P = 0.006). Progression of rectosigmoid nodules was observed in 34% of patients without continuous amenorrhoea, in 39% who had never had amenorrhoea and in no patients with continuous amenorrhoea. LIMITATIONS, REASONS FOR CAUTION Due to a lack of universally accepted criteria for defining the progression or regression of deep endometriotic nodules on MRI, the values used in our study may be disputed. Due to the retrospective design of the study, there may be heterogeneity of interval between MRIs, MRI techniques used, reason for amenorrhoea and duration of amenorrhoea. The mean inter-MRI interval was of short duration and varied between patients. Our findings are reported for only deep endometriosis infiltrating the rectosigmoid and cannot be extrapolated, without caution, to nodules of other locations. WIDER IMPLICATIONS OF THE FINDINGS Patients with deeply infiltrating rectosigmoid endometriotic nodules, for which surgical management has not been performed, should undergo surveillance to allow detection of growth of nodules, particularly when continuous amenorrhoea has not been achieved. This recommendation is of importance to young patients with rectosigmoid nodules who wish to conceive, in whom first line ART is planned. There is a very low risk of progression of deep endometriotic nodules infiltrating the rectosigmoid in women with amenorrhoea induced by medical therapy, lactation or pregnancy. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for this study. The authors declare no competing interests related to this study.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases

“…However, medical therapy should be taken continuously, is contraceptive and may have side effects ( Vercellini et al , 2011 ). Expectant management may be followed by an increase in nodule size in 39% of cases after as little as 3 years ( Netter et al , 2019 ). For these reasons, surgical management may be considered to allow removal of endometriosis lesions and provide relief from symptoms.…”

Dose-dependent pro- or anti-fibrotic responses of endometriotic stromal cells to interleukin-1β and tumor necrosis factor α

“…Progression of the disease and appearance of specific symptoms rarely occurs in patients with asymptomatic rectovaginal endometriosis 64 . However, progression of the disease occurs in some symptomatic patients 65 and to date, we do not know how to predict who will and will not progress 63 . Recent animal experiments showed that the stress-induced activation of hypothalamo-pituitary-adrenocortical (HPA) axis promoted the progression of endometriotic lesions 66,67 .…”

Advances in the medical management of bowel endometriosis

“…Netter et al [32] assessed rectosigmoid nodule measures variation in 43 women who underwent two MRIs at least 12 months apart. Nodule progression or regression was defined as, respectively, ³20% increase or ³20% decrease in length or in thickness.…”

“…Barra et al [33] [32] reported persistence of pain symptoms in the vast majority of women in whom the nodule regressed or remained stable. On the other hand, Egekvist et al [29] observed that progression of nodule volume dimensions occurred without worsening of symptoms or healthrelated quality of life.…”

“…No changes in BMD were identified. Weight gain (32) Decreased libido (18) Bloating (16) Vaginal dryness (16) Headache ( Significant reduction of endometriotic nodules volume.…”