title: Occult microscopic endometriosis: undetectable by laparoscopy in normal peritoneum.
abstract: OBJECTIVE
  Is there any occurrence of hidden (occult) endometriotic lesions in normal peritoneum of women with and without visible endometriosis?
  
  
  CONCLUSIONS
  We detected a slightly higher occurrence of occult microscopic endometriosis (OME) in normal peritoneum of women with visible endometriosis than in control women.
  
  
  BACKGROUND
  Based on a small number of cases, the concept of invisible microscopic endometriosis in visually normal peritoneum has been reported for more than a decade but there is controversy regarding their tissue activity and clinical significance.
  
  
  METHODS
  This case-controlled research study was conducted with prospectively collected normal peritoneal samples from 151 women with and 62 women without visible endometriosis.
  
  
  METHODS
  Normal peritoneal biopsy specimens from different pelvic sites of were collected during laparoscopy. A histological search of all peritoneal biopsy specimens for the detection of invisible endometriosis was done by immunoreaction to Ber-EP4 (epithelial cell marker), CD10 (stromal cell marker) and Calretinin (mesothelial cell marker). Tissue expression of estrogen/progesterone receptors (ER/PR) and cell proliferation marker, Ki-67, was performed by immunohistochemistry to identify tissue activity.
  
  
  RESULTS
  Three different patterns of OME were detected based on (I) the presence of typical gland/stroma, (II) reactive hyperplastic change of endometrioid epithelial cells with surrounding stroma and (III) single-layered epithelium-lined cystic lesions with surrounding stroma. A higher tendency toward the occurrence of OME was found in women with visible endometriosis (15.2%, 23/151) compared with control women (6.4%, 4/62) (P = 0.06, χ(2) test). The epithelial cells and/or stromal cells of OME lesions were immunoreactive to Ber-EP4 and CD10 but not reactive to Calretinin. ER and PR expression was observed in all patterns of OME lesions. Ki-67 index was significantly higher in pattern I/II OME lesions than in pattern III OME lesions (P< 0.05 for each).
  
  
  CONCLUSIONS
  Bias in the incidence rate of OME lesions in this study cannot be ignored, because we could not analyze biopsy specimens from the Pouch of Douglas of women with revised classification of the American Society of Reproductive Medicine Stage III-IV endometriosis due to the presence of adhesions in the pelvis.
  
  
  CONCLUSIONS
  We re-confirmed a decade long old concept of invisible (occult) endometriosis in visually normal peritoneum of women with visible endometriosis. The existence of a variable amount of tissue activity in these occult lesions may contribute to the recurrence/occurrence of endometriosis or persistence/recurrence of pain manifestation in women even after successful ablation or excision of visible lesions by laparoscopy.
  
  
  BACKGROUND
  This work was supported in part by Grants-in-aid for Scientific Research from the Japan Society for the Promotion of Science. There is no conflict of interest related to this study.
  
  
  BACKGROUND
  Not applicable.
authors.affiliation: Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
authors.forename: Khaleque Newaz
authors.initials: KN
authors.lastname: Khan
authors.forename: Akira
authors.initials: A
authors.lastname: Fujishita
authors.forename: Michio
authors.initials: M
authors.lastname: Kitajima
authors.forename: Koichi
authors.initials: K
authors.lastname: Hiraki
authors.forename: Masahiro
authors.initials: M
authors.lastname: Nakashima
authors.forename: Hideaki
authors.initials: H
authors.lastname: Masuzaki
mesh_terms: D015415:Biomarkers / Q000032:analysis*; D014408:Biomarkers, Tumor / Q000032:analysis; D064032:Calbindin 2 / Q000032:analysis; D016022:Case-Control Studies; D049109:Cell Proliferation; D004715:Endometriosis / Q000175:diagnosis / Q000473:pathology*; D005260:Female; D006801:Humans; D019394:Ki-67 Antigen / Q000096:biosynthesis; D010535:Laparoscopy; D015260:Neprilysin / Q000032:analysis; D010537:Peritoneum / Q000473:pathology*; D011960:Receptors, Estrogen / Q000096:biosynthesis; D011980:Receptors, Progesterone / Q000096:biosynthesis; D000951:Antigens, Neoplasm
chemical_list: D015415:Biomarkers; D014408:Biomarkers, Tumor; D064032:Calbindin 2; D019394:Ki-67 Antigen; D015260:Neprilysin; D011960:Receptors, Estrogen; D011980:Receptors, Progesterone; C576764:CALB2 protein, human; C115012:human epithelial antigen-125; D000951:Antigens, Neoplasm
keywords: Ki-67; estrogen receptor; occult endometriosis; progesterone receptor; visible endometriosis