Endometriosis and the Surgeon: A New Profiling of the Disease
A Major | JM Ayoubi
Seance of wednesday 14 march 2018 (Communications libres)
DOI number : 10.26299/knm4-a470/emem.2017.4.019
Abstract
Endometriosis is a curious pathology that has been the source of many international publications. Its etiology remains mysterious but seems to have multiple causes. Endometriosis is a complex disease whose lesions are very heterogeneous on the part:
• Their location (deep endometriosis, superficial, ovarian cyst).
• Their extent.
• associated symptoms.
• The evolution or aggressiveness of the disease.
• Response to treatments.
It evolves in pushes, remains autonomous and is responsible for superficial and deep lesions that explain its two challenges: pain and infertility. It has always been classified by the size of its anatomical lesions (Acosta classification, revised AFS, ASRM classification with a description of the disease at different stage: minimal (score of 1 to 5), mild (6-15), moderate (16 to 40) and severe (>40).
But if this classification provides a complete repertoire of implants (anatomic), the attribution of points is arbitrary: In fact the size of the lesions is not synonymous with the difficulty to treat them surgically. Their location if deep is larger than the size of ovarian endometriomas.
In addition small anatomical but evolutive lesions will have more impact than big fibrous and stable lesions.
So, attempts to explain its inflammatory side effect have been proposed. The FOATI classification has had the merit of taking the phenomenon into account.
But we think that we must go much further and propose an amendment in this classification to take account of the evolution of the lesions, of their deep molecular biology whereas in reality the lesions are not at the same stage.
We have begun to demonstrate an embryological origin, chromosomal instability, genomic and proteomic abnormalities problems related to pharmacologic testing during a wild hormone therapy that does not take into account the phenotype of lesions. Indeed, it is possible using a common model: breast cancer. An endometriosis profile is necessary to know its phenotype such as hormone receptors, the proliferation of rank, Mib-1 (Ki 67%), its growth factors and oncogenic factors.
The peritoneal fluid is one of the factors of diffusion of the endometriosis in the rest of the organism: ovaries, deep forms under and peritoneal. In order to address the need of improving endometriosis diagnosis and management, we have developed EndoGram®, a prognostic test based on a signature of 14 biomarkers, validated in a first prospective study and allowing each patient to determine:
1. The risk of recurrence of the disease at two years in order to identify the patients with a high risk of recurrence from the first diagnostic surgery and to adapt their follow-up to better detect the recurrence of the disease.
2. The presence or absence of the receptors targeted by the hormone treatments used at the present time. This information on hormonal sensitivity will serve as a decision-making aid for the surgeon to prescribe the most appropriate and effective therapeutic strategy.
3. The best fertility strategy if desire for pregnancy. Depending on the age of the patient and the profile of her lesion as defined by the EndoGram® test, the surgeon will be able to optimize the patient's fertility strategy and reduce the number of In Vitro Fecundation destined to fail. Thus, some minimal anatomical forms are very aggressive with infertility, medication ineffectiveness, and persistence / recurrence despite surgery, whereas large ovarian cysts accessible to laparoscopic surgery and do not reoffend. This makes the surgical diagnosis of the disease and its management difficult and still too dependent on the experience and dexterity of the surgeon.
To meet this clearly identified need, EndoGram® program has the aim of identifying specific markers of this heterogeneity and giving a unique and personal photograph of the stage of endometriosis for each patient through an innovative analysis of the biopsies Taken during diagnostic surgery. This information can then be used by the surgeon to adjust its therapeutic approach and in particular. This article reveals all the characteristics of the disease for each patient. It allows defining a therapeutic attitude whose primary goal is not to let the time of the PMA pass in young patients, to respect the recommendations of the ESHRE on a single, non-aggressive surgery that respects the ovaries and their follicular count. It should also be noted that this proliferative side explains that pregnancy and menopause do not cure the disease, can only improve it. New molecules can be used according to this profile.
• Their location (deep endometriosis, superficial, ovarian cyst).
• Their extent.
• associated symptoms.
• The evolution or aggressiveness of the disease.
• Response to treatments.
It evolves in pushes, remains autonomous and is responsible for superficial and deep lesions that explain its two challenges: pain and infertility. It has always been classified by the size of its anatomical lesions (Acosta classification, revised AFS, ASRM classification with a description of the disease at different stage: minimal (score of 1 to 5), mild (6-15), moderate (16 to 40) and severe (>40).
But if this classification provides a complete repertoire of implants (anatomic), the attribution of points is arbitrary: In fact the size of the lesions is not synonymous with the difficulty to treat them surgically. Their location if deep is larger than the size of ovarian endometriomas.
In addition small anatomical but evolutive lesions will have more impact than big fibrous and stable lesions.
So, attempts to explain its inflammatory side effect have been proposed. The FOATI classification has had the merit of taking the phenomenon into account.
But we think that we must go much further and propose an amendment in this classification to take account of the evolution of the lesions, of their deep molecular biology whereas in reality the lesions are not at the same stage.
We have begun to demonstrate an embryological origin, chromosomal instability, genomic and proteomic abnormalities problems related to pharmacologic testing during a wild hormone therapy that does not take into account the phenotype of lesions. Indeed, it is possible using a common model: breast cancer. An endometriosis profile is necessary to know its phenotype such as hormone receptors, the proliferation of rank, Mib-1 (Ki 67%), its growth factors and oncogenic factors.
The peritoneal fluid is one of the factors of diffusion of the endometriosis in the rest of the organism: ovaries, deep forms under and peritoneal. In order to address the need of improving endometriosis diagnosis and management, we have developed EndoGram®, a prognostic test based on a signature of 14 biomarkers, validated in a first prospective study and allowing each patient to determine:
1. The risk of recurrence of the disease at two years in order to identify the patients with a high risk of recurrence from the first diagnostic surgery and to adapt their follow-up to better detect the recurrence of the disease.
2. The presence or absence of the receptors targeted by the hormone treatments used at the present time. This information on hormonal sensitivity will serve as a decision-making aid for the surgeon to prescribe the most appropriate and effective therapeutic strategy.
3. The best fertility strategy if desire for pregnancy. Depending on the age of the patient and the profile of her lesion as defined by the EndoGram® test, the surgeon will be able to optimize the patient's fertility strategy and reduce the number of In Vitro Fecundation destined to fail. Thus, some minimal anatomical forms are very aggressive with infertility, medication ineffectiveness, and persistence / recurrence despite surgery, whereas large ovarian cysts accessible to laparoscopic surgery and do not reoffend. This makes the surgical diagnosis of the disease and its management difficult and still too dependent on the experience and dexterity of the surgeon.
To meet this clearly identified need, EndoGram® program has the aim of identifying specific markers of this heterogeneity and giving a unique and personal photograph of the stage of endometriosis for each patient through an innovative analysis of the biopsies Taken during diagnostic surgery. This information can then be used by the surgeon to adjust its therapeutic approach and in particular. This article reveals all the characteristics of the disease for each patient. It allows defining a therapeutic attitude whose primary goal is not to let the time of the PMA pass in young patients, to respect the recommendations of the ESHRE on a single, non-aggressive surgery that respects the ovaries and their follicular count. It should also be noted that this proliferative side explains that pregnancy and menopause do not cure the disease, can only improve it. New molecules can be used according to this profile.