6.  A scarred black lesion of 7 mm in diameter is seen in the right broad ligament over the right ureter.  Additional white satellite lesions of 1 to 2 mm are along the line of the ureter.

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7.  This section demonstrates the histologic characteristics of the scarred black lesion.  The dilated glands contain red cell debris and phagocytic macrophages with ingested red cells and hemosiderin.  These are surrounded by glandular epithelium and endometrial stroma.  Intermixed through this is a fibromuscular scar (myofibroblastic cicatrix). 

8.  Black and scarred lesions are not the only presentation.  John Sampson published a series of articles between 1921 and 1927 which described a multitude of appearances associated with endometriosis.  These included hemorrhagic cyst, chocolate cyst, adenomyomata, adhesions, pockets, purple raspberries, red raspberries, blueberries and blebs.  Cancer was found associated with endometriosis.

9.  Sampson published many of his appearances in color.  This plate from 1924 appears to have both dark lesions which have been labeled as endometriosis and more subtle lesions adjacent to them. (With permission  SURGERY,  GYNECOLOGY AND  OBSTETRICS)

10.  The difficulties associated with a diagnosis of subtle appearances of endometriosis were published in 1950 by John Fallon.  He described the clear colorless implants as amenorrheic lesions.  He did not feel it was reasonable to call any given lesion incidental or quiescent.

11.  Karl Karnaky described a progression of appearances from water blister appearing lesions to a scarred blue-domed cyst over 10 years.  This change may be due to progression in all patients, to random observation in different patient groups or to factors to be discovered in future research.  In any of these situations, different lesion types can be predicted at varying ages.  However, other studies demonstrate there is significant overlap and age is not the only factor in the appearance.

13.  Near-contact and contact endoscopy has greater resolution than the naked eye.  The 40 micron particles can be seen with a laparoscope and red blood cells circulating through the vascular fields have been seen using a Microview® hysteroscope.

14.  However, the increased limits of resolution of tissue specimens of high contrast, such as carbon, does not  mean that all endometriosis can be recognized.  At present, red lesions as small as 400 micron and clear lesions as small as 180 micron have been recognized and documented.  On the other hand, 120 micron lesions have been found after sectioning specimens which appeared to be normal using near-contact laparoscopy.

15.  Detection of lesions requires a combination of history, examination, visualization and palpation.  Patients' histories can frequently lead to areas of the pelvis where endometriosis can be anticipated.

16.  Patients can use body mapping at home in order to help guide the clinical and operative examination.

17.  Mapping the pelvis following clinical examination has aided in finding lesions at laparoscopy and at laparotomy.  This adds to the standard bimanual and rectovaginal exam by using a preliminary exam with one finger only.  This "one finger gynecologist" approach emphasizes charting of focal findings in exam of the bladder, round ligaments, adnexa, broad ligaments, uterosacrals, mid cul-de-sac, deep cul-de-sac, rectum, perirectal spaces, boney pelvis and pelvic floor.

18.  This is a panoramic view of the pelvis in a patient who has deep right uterosacral tenderness near the sacrum.  Although this view of the pelvis appears to be adequate for many purposes, it only shows the upper halves of the uterosacral ligaments and cul-de-sac.

19.  With the patient tilted to the left and using three punctures, the bowel has been pulled to the left so that the sacral margin of the uterosacral ligament is seen.  The 1 cm lesion that was easily palpated in the office is seen at the margin of the uterosacral immediately anterior to the sacrum.

20.  Near contact laparoscopy has a better chance of seeing small lesions than distant viewing.  Double puncture techniques may be needed to lift the ovaries in order to visualize the broad ligament, to move the sigmoid colon away from the posterior pelvic brim above the sacrum and to move the bowel off the appendix.  Videoendoscopy appears to be best at viewing the upper abdomen and the anterior peritoneal compartments.  In addition, videoendoscopy makes difficult mobilization easier on the operator.  Although some newer camera systems have resolution and detection that may approach or exceed direct visualization, this may not be true for older camera systems.  Furthermore, palpation is still needed for certain lesions.  Large lesions in the bowel, bowel mesenteric lesions and many appendiceal lesions have been missed at laparoscopy but found at laparotomy by palpation.

21.  In order for the pathologist to confirm a small polypoid or vesicular lesion, a small biopsy must be taken.  Sending a 1 mm lesion on a 1 cm specimen decreases the chance of confirmation.  The 200 micron lesion which is demonstrated in this slide set was sent on a 1.2 mm specimen.  However, large scarred lesions may require excision as these are often predominantly scar with few intermixed areas of endometriosis.  Random biopsy through the scar has a significant chance of missing the glands and stroma.  Tissue documentation is used to exclude other pathology more than to confirm endometriosis.  When the tissue is nondiagnostic, the clinical diagnosis is used.  The advantages of documentation are weighed against the risks.  This is particularly true near the tube, ureter and colon.

22.  With a tissue confirmation of 98%, there were no lesions that were always endometriosis and no lesions that were never endometriosis.  Endometriosis was documented in 94% of black lesions, 80% of white lesions and 26% of adhesions when no specific lesions had been noted.  In addition, when red lesions were broken into different types, polypoid lesions were commonly endometriosis while vascular and flat lesions were less commonly endometriosis.  There were a total of 20 different descriptive types during this study.  Grain-like lesions (psammoma bodies) and carbon where the least commonly found to be adjacent to associated endometriosis at 20% and 16%.

23.  In addition to endometriosis, other clear and white vesicular lesions include psammoma bodies, endosalpingosis, inflammatory inclusions and Walthard rests.

24.  This picture is of the right pelvic brim lateral to the right tube.
 

25.  Clear vesicles of 2 and 4 mm are seen.
 

26.  Histology of a clear vesicle showed a dilated endometrial gland associated with endometrial stroma and hemosiderin.

27.  An alternate histologic finding in similar cases is a polypoid area of endometriosis with edema.

28.  A light reflection obscures the lesions in this picture is of the right uterosacral ligament and broad ligament.  However, changing the angle of light changes the appearance as seen in the next slide.
 

29.  The second view increases the ability to see the tissue.  In addition to the angle of illumination, the intensity of light can also hide lesions.
 

30.  White nodules of 3 to 5 mm, some with clear vesicles of 1 to
2 mm on the surface, are marked in this picture.

31.  Dilated glands and stroma are contained within a fibromuscular scar in the white nodules.

32.  This picture is of the anterior peritoneum in a 19-year-old patient with diffuse pelvic pain.

33.  The red polyp is 400 microns wide and the clear vesicles appear as scattered areas of light reflection.  These are 200 microns in diameter.
 

34.  This is a 200 micron wide area of glands and is near other areas of the same epithelium associated with endometrial stroma.

35.  This is the 400 micron red polyp of endometriosis with both endometrial epithelium and stroma.

36.  This picture is of the anterior peritoneum in a patient undergoing laparoscopy for Stein-Leventhal syndrome.

37.  These discrete lesions are psammoma bodies.  These are generally easier to see at high magnification and have the appearance of grains of salt.  They are usually 0.5 to 1 mm in size.  Although these are frequently associated with high chlamydia titers, this patient had a negative chlamydia titer.

38.  Psammoma bodies are the areas of calcium shown on the surface of this peritoneum.  Psammoma bodies have been associated with endosalpingosis, chlamydia, adhesions and pelvic cancer.  Peritoneal washings, close observation of the ovaries and biopsy of any suspicious lesions appear reasonable when psammoma bodies are seen.
 

39.  This picture is of the left broad ligament in a patient with a chlamydia titer of 1 to 256.

40.  This patient has psammoma bodies associated with endosalpingosis.  The lesions are 1 to 3 mm in diameter.  Several but not all of these are circled.
 

41.  Resection of this area shows scattered endosalpingeal glands and psammoma bodies.

42.  This is a picture of the right tube and right pelvis.
 

43.  Clear and opaque vesicles on the surface of the tube are noted.  These are 1 to 3 mm in diameter.

44.  Walthard rests are dilated cystic structures often containing nests of squamous epithelium and lined by an mesothelium or any upper genital canal epithelium such as tubal.  These lesions are not commonly biopsied as the risk of tubal damage appears greater than the benefit to the patient since these tubal lesions have not been endometriosis in any of the cases studied.
 

45.  Red lesions have included endometriosis, granulation tissue, hemangiomas, and ectopic gestations.

46.  Polypoid red lesions appear to have active stroma and have been associated with an increased synthesis of prostaglandin F.

47.  The location of a lesion with respect to a peritonealized or scarred surface may theoretically predict the clinical sequelae.  Surface lesions can bleed, secrete and exfoliate directly into the peritoneal cavity.  Surface lesions are commonly clear or red.  Superficial retroperitoneal lesions can rupture and act as surface lesions.  Deep retroperitoneal lesions appear predisposed to focal expansion, nerve entrapment, focal tenderness, and deep pressure.  These deep lesions are dark and/or scarred.  Systemic metastasis and immunologic effect may be related to any of these.

48.   This picture is of the right pelvic brim lateral to the tube.  The right round ligament is seen in front of these lesions.

49.  Red polypoid lesions look like normal endometrium and are easy to document by biopsy or excision.  Superficial biopsy of these 7 to 12 mm lesions will contain only glands and stroma and, if the pathologist is not accustomed to seeing these type biopsies, may be interpreted as floaters from a D&C.  However, when excised, there is frequently an associated deep scarring which is seen clinically as a white scarred rim beneath the lesion.

50.  With the lesion excised in its entirety, the red area has glands and stroma and the white scarred area beneath it is fibromuscular scar (myofibroblastic cicatrix) which is larger than the lesion itself.
 

51.  With H&E stain, the scar appears to be muscular.  Other cases have shown varying degrees of collagen and muscular component.
 

52.  Trichrome strain suggest that this lesion is predominantly muscular with intermittent collagen component.

53.  This picture is of the right uterine cornua and right tube.
 

54.  These 3 mm red lesions at the cornua of the tube are associated with deep fibrotic scar in the tube and cornua.

55.  These areas have trapped blood within the endometrial glands and have endometrial stroma at the base.

56.  These lesions are seen in the cul-de-sac.  The left ovary and right uterosacral ligament are seen as landmarks.

57.  These 5 mm lesions are red but have no associated fibrosis at the base.

58.  These lesions are peritoneal hemangiomas.  These blood-filled lesions are lined by endothelium.
 

59.  This is the left side of the cul-de-sac in a 14-year-old patient with pelvic pain.

60.  One pink 4 mm lesion is seen on the left uterosacral ligament.
 

61.  Histology demonstrates the glands and stroma of endometriosis.

62.  Patients similar to this 14-year-old were followed by Thomas in a randomized prospective study.  In that study, 47% of patients on placebo had a progression of their disease while none of those on gestrinone (a progestational agent) therapy progressed.  Theory suggests that this progression may be from retrograde menstruation or from growth of lesions too small to be seen at the first surgery.  Plans must consider both possibilities.

63.  This is the right cul-de-sac in the same 14-year-old patient who has the pink polypoid endometriosis in slide 59.
 

64.  There is an area of diffuse red in the right cul-de-sac medial to the uterosacral.  However, no specific lesions were noted.  An initial attempt at oral contraceptive suppression resulted in significant side effects and was discontinued.
 

65.  This is the right cul-de-sac of the same 14-year-old one year following the initial laparoscopy.  She has been off birth control pills for six months and her pain has recurred.
 

66.  At this time, multiple pockets and red endometriotic polyps of up to 6 mm are noted.  The area in the right lower quadrant of the picture is a vein and does not represent a black lesion.  There were no scarred or black lesions present.

67.  In a study by Goldstein in adolescents with pelvic pain, 53% had endometriosis noted at laparoscopy.  Of these, 20% had only red lesions.
 

68.  Several studies have shown that endometriosis changes appearance with age.  Sampson noted the change from a red raspberry appearance to a blueberry appearance as lesions aged.  Karnaky stated that it required 4 to 10 years for water blister lesions to progress to scarred blue-domed cysts.  Redwine quantitated these changes and demonstrated a change from red to scarred black lesions over 7 to 10 years.  Koninckx showed 40% increase in the occurrence of scarred black lesions over a 20 year age change.  Koninckx also documented a decreasing occurrence of red lesions and an increasing occurrence of deep infiltrating lesions.  These changes may be due to progression in all patients, to random observation in different patient groups or to factors to be discovered in future research.  In any of these situations, different lesion types can be predicted at varying ages.  However, other studies demonstrate there is significant overlap and age is not the only factor in the appearance.

69.  This summary from Redwine's article demonstrates both the mean age and age range in patients in whom isolated lesion of a uniform appearance were seen.  Although the 10 year change between the mean age of patients with clear papules and those with black lesions may have research implications, the range overlap suggests this is not useful for all patients.

70.  When Redwine studied the appearances by occurrence with or without other lesion types, the age range expands and there is more overlap.  In spite of this expansion, clear lesions still appear to be a disease of younger women.

71.  Koninckx studied several characteristics.  Over a 20 year age span, red lesions decreased by 27%, "typical" lesions increased by 18% and deep infiltrating lesions increased by 27%.
 

72.  Martin, Stripling and others in a series of studies from Memphis noted an increasing documentation of the various appearances of endometriosis.  Subtle lesions were not an issue in 1984.  However, second look laparoscopies were being used to evaluate the residual tissue following laser laparoscopy.  A search for malignant and premalignant changes related to previous laser surgery showed only foreign body giant cell reaction to carbon.  This was similar to reaction to suture remnants.  However, many abnormal areas which were resected looking for these changes were diagnosed as endometriosis on histologic exam.  This was at the time of Jansen's publication of nonpigmented lesions.  By 1988, "subtle" lesions were the most common and "typical" lesions appeared to be least representative of the two.

73.  In 1950, John Fallon noted that experience increased uncertainty and concern regarding the exact nature of a lesion.

74.  In agreement with Fallon, a study of 55 gynecologists and 492 patients demonstrated that 14% to 59% of endometriotic lesions which were histologically diagnosed by pathologists were not documented by the operating gynecologist.  This supports the concept that endometriosis can be hard to recognize.
 

75.  Endometriosis has been histologically confirmed in lesions of up to 20 different descriptive types.  In addition, endometriosis has been found unseen in the specimens of adhesions, fibrosis, hemorrhagic corpus luteum cysts, myomata, tubal ligation reversals and bowel resections for bowel cancer.

76.  Furthermore, there is no appearance which is always endometriosis.  Thus far, the only exception to this has been scarred black lesions in patients who have had no previous surgery.  When patients have had previous surgery, these lesions have frequently represented foreign body within scar.

77.  Small lesions of 120 µ have been missed using near contact laparoscopy and deep lesions of the uterosacrals and bowel may be more palpable than visual.
 

78.  Tissue confirmation is needed to exclude other pathology more than to confirm endometriosis.  When a biopsy demonstrates pathology other than endometriosis, this will often change the long term management of the patient.  If a specific abnormality other than endometriosis is not demonstrated, then the laparoscopic diagnosis of endometriosis is used for management.

79.   Long-term management of endometriosis may be for persistent as well as recurrent disease.  Patient who have a rapid return of tenderness may have lesions which were smaller or deeper than seen.  In addition, there may be pathology other than endometriosis.  Data is not adequate to determine if lesions seen at second operation were too small to be seen at the first operation or if these are new lesions.  At present, therapy must be oriented towards both of these possibilities.  Planning for management needs to consider the possibilities of both persistent and recurrent disease.