Immunology and Immunotherapy of Endometriosis

Endometriosis is one of the most common gynecological and systemic diseases, with a remarkable immune background. Patients suffer from pain and fertility reduction. Due to the distinct immune component, an immunotherapeutic approach may gain importance in the future. In endometriosis, shifts in the cell fractions of the immune system are well known. Moreover, hypoxia concomitant with inflammation causes a disturbed immune response. The removal of endometriosis has a therapeutic effect, normalizes the immune disorders, and remains the most effective causative treatment in terms of pain and infertility. A key issue is whether a similar effect can be achieved for fertility with non-invasive immunotherapy where surgery is inadvisable or cannot be performed for various reasons. Numerous immunotherapy trials, including vaccines, were conducted on animals only, although the research is encouraging. Among the promising methods of non-specific immunotherapy is the administration of an ethiodized oil contrast. Moreover, due to the significant successes of immunotherapy in oncology, the possibility of immunotherapy affecting NK cells has been postulated. NK cells are responsible for the surveillance and apoptosis of ectopic cells. Expanding the arsenal of endometriosis treatment by immunotherapy is promising due to the significant contribution of immunological factors and the limitations of current treatment methods.

Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax

Objective: To preliminarily explore the safety and effectiveness of transpedal lymphangiography (TL) with high-dose ethiodized oil application (>20 ml) in the treatment of high-output postoperative chylothorax.Methods: From 1 July 2020 to 1 July 2021, a total of 7 patients with high-flow postoperative chylothorax (> 1,000 ml/d) were retrospectively reviewed in a single center. Clinical data, including surgery types, technical and treatment success of TL, and adverse events of TL, were collected and analyzed.Results: Seven patients (5 cases of non-small cell lung cancer; 2 cases of esophageal carcinoma) with a median age of 62 years (range: 30–70 years) occurred postoperative chylothorax after tumor resection with mediastinal lymphadenectomy. All patients received conservative treatment including total parenteral nutrition and somatostatin administration for a median of 20 days (range: 15–31 days) that failed to cure the chylothorax, so TL was performed as a salvage. Before TL, the median daily chyle output was 1,500 ml/day (range: 1,100–2,000 ml/day). The technical success rate of TL was 100% (7/7), with the median volume of ethiodized oil of 27.6 ml (range: 21.2–30.0 ml) injected in TL. Ruptured thoracic duct was identified in 5 patients (5/7, 71%) in fluoroscopy and chest CT after TL. The treatment success rate of TL was 86% (6/7). In 6 patients, the thoracic drainage was removed after a median of 7 days (range: 4–13 days) from TL performance. No adverse event of TL was reported.Conclusion: Transpedal lymphangiography with high-dose ethiodized oil application (>20 ml) is a feasible, safe, and effective modality for the treatment of high-flow (> 1,000 ml/day) postoperative chylothorax.

Implementation of ethiodized oil for treatment of endometriosis-associated infertility.

One of the leading health conditions associated with female infertility is endometriosis, which is the presence of endometrial-like tissue outside the uterine cavity. It is estimated that endometriosis can be demonstrated in up to half of infertile patients, but this does not mean that in all cases, it is the only cause that reduces fertility. Apart from the relatively rare case of endometriosis-induced anatomical changes that mechanically impede fertilization, the main effect is to modify the immune system by the secretion of soluble signaling factors by ectopic endometriotic lesions. The primary treatment of endometriosis in patients trying to become pregnant is radical excision of foci outside the uterus, which is associated with the normalization of immune system disorders and often leads to pregnancy. However, the significant technical complexity and the possibility of complications make the surgery a good solution, mainly for patients who, apart from infertility, pain is also an important factor. An important medical problem remains the development of methods that could eliminate disorders caused by endometriosis and, at the same time, could be used in patients with minor or moderate ailments and in patients with contraindications to surgery. At present, despite many approaches, there are no specific immunotherapy methods. It is interesting that for several decades, it has been reported that the examination of the patency of the Fallopian tubes has a beneficial effect on the possibility of pregnancy. Detailed analyzes have shown that this is not a common effect, but it mainly concerns patients with endometriosis and the use of etiodized oil contrast. In this group, there is a significant, five-fold increase in infertility. Therefore, every second previously infertile patient becomes pregnant within six months. A smaller but also distinct effect is observed in the case of idiopathic infertility. The impact is so significant that it can be used both for the practical treatment of patients as well as to understand the mechanisms underlying fertility disorders occurring in endometriosis. The data so far show that the immunotherapeutic effect of etiodized oil contrast is overwhelming. However, it is not entirely clear why the improvement is not achieved using other currently more popular water contrasts. The dissemination of perfusion of the uterine cavity and Fallopian tubes with the use of oil contrast seems to be a simple, safe and effective strategy that allows patients to offer patients alternative treatment methods and improve the final effectiveness and increase the pharmacoeconomics of treatment of endometriosis-related infertility.

Endovascular Use of Cyanoacrylate-Lipiodol Mixture for Peripheral Embolization: Properties, Techniques, Pitfalls, and Applications

Endovascular embolization agents are particles and fluids that can be released into the bloodstream through a catheter to mechanically and/or biologically occlude a target vessel, either temporarily or permanently. Vascular embolization agents are available as solids, liquids, and suspensions. Although liquid adhesives (glues) have been used as embolic agents for decades, experience with them for peripheral applications is generally limited. Cyanoacrylates are the main liquid adhesives used for endovascular interventions and have a major role in managing vascular abnormalities, bleeding, and many vascular diseases. They can only be injected as a mixture with ethiodized oil, which provides radiopacity and modulates the polymerization rate. This review describes the characteristics, properties, mechanisms of action, modalities of use, and indications of the cyanoacrylate-Lipiodol® combination for peripheral embolization.