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Lymph node involvement in isolated rectal endometriosis
Med Clin (Barc). 2016;146(2):e9
www.elsevier.es/medicinaclinica
Letter to the Editor Lymph node involvement in isolated rectal endometriosis夽 Afectación ganglionar en endometriosis rectal aislada Dear Editor, Endometriosis is the presence of endometrial tissue, glands and stroma in sites outside the uterine cavity. It is a frequent condition with a 6–10% prevalence in women of childbearing age.1 Generally divided into pelvic (ovaries, fallopian tubes and pelvic peritoneum) and extrapelvic endometriosis. Extrapelvic endometriosis can involve any part of the body, being gastrointestinal tract the most frequent (3–12%) site, especially at the rectosigmoid junction, followed in frequency by small intestine, cecum and appendix. Intestinal involvement usually coexists with its presence at other levels. One location alone is very rare. Isolated rectal endometriosis with involvement of regional lymph nodes is an exceptional circumstance and with little description in the medical literature.2 We report the case of a 34-year-old woman who came to the emergency room for watery diarrhea accompanied by mucus and red blood, rectal tenesmus and intense urge to defecate. A hard and fixed mass was palpable on digital rectal examination. Colonoscopy showed the presence of a large congestive submucosal lesion extending 4 cm from anal margin. CT scan showed a rectal injury 10 × 5 × 6 cm collapsing the rectal ampulla. Pelvic nuclear magnetic resonance imaging showed a pedunculated mass dependent on left posterolateral wall, with implantation 6 cm long and 4 cm lateral-medial, well defined with heterogeneous signal and significant blood component, not presenting a marked enhancement after administration of gadolinium. Surgical resection of the lesion was proposed, performing anterior resection with mechanical colorectal anastomosis. Histopathological examination of the surgical specimen revealed the presence of multiple foci of endometriosis consisting of cytogenic stroma and endometrial glands without atypia, also observing nodes with endometriosis foci. The patient improved with disappearance of symptoms. The etiopathogenesis of endometriosis is uncertain, and there are several theories intended to explain; the most widely accepted is the dissemination of endometrial cells through the fallopian tubes with retrograde flow during menstruation, and subsequent implantation into the peritoneum and pelvic structures. Metaplasia theory suggests that the source is in metaplastic processes of peritoneal mesothelial cells. Moreover, the finding of endometrial tissue in vessels and lymph nodes, and in remote sites led to the theory of lymphatic spread. In recent years the hypothesis proposed has been the endometrial stem cells as the source.
夽 Please cite this article as: Fernández-Val JF, García-González JM, González de Tánago J, Colina-Alonso A. Afectación ganglionar en endometriosis rectal aislada. Med Clin (Barc). 2016;146:e9. ˜ S.L.U. All rights reserved. 2387-0206/© 2015 Elsevier Espana,
Theories of retrograde menstruation and endometrial metaplasia of mesothelial cells remain the most accepted. However, recently the relevant role of the lymphatic system in endometriosis has been emphasized.3 The presence of lymph nodes with endometriosis makes us consider the lymphatic spread as our patient most likely pathogenic theory. The uniqueness of our case is that the intestinal endometriosis usually coexists with endometriosis in any other sites, usually ovary or peritoneum. The intestinal involvement alone is rare and the finding of regional lymph node involvement is extremely rare.2 Therefore, there are very few cases reported in the literature. Standard treatment should be surgery in most cases, since in certain cases the possibility of a neoplasm cannot be excluded.4 Moreover, medical treatment is not effective to remove the tumor in the extrapelvic involvement, and does not seem to improve the results of surgery.5 In general terms, we believe that surgery should be “complete”, i.e. with the same approach as cancer surgery, since more conservative strategies, including curettage and limited excisions of injury, are associated with high rates of recurrence.6 The choice of the approach, open laparotomy versus laparoscopy should be individualized for each patient. References 1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364:1789–99. 2. Lorente R, Palacios A, Bravo F, López FJ, Bouhmidi A, Huertas C, et al. Endometriosis de rectosigma con afección de los ganglios linfáticos. Gastroenterol Hepatol. 2003;26:23–5. 3. Jerman LF, Hey-Cunningham AJ. The role of the lymphatic system in endometriosis: a comprehensive review of the literature. Biol Reprod. 2015;92:1–10. 4. Stern RC, Dash R, Bentley RC, Snyder MJ, Haney AF, Robboy SJ. Malignancy in endometriosis: frequency and comparison of ovarian and extraovarian types. Int Gynecol Pathol. 2001;20:133–9. 5. Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. Cochrane Datab Syst Rev. 2014. Art. N.◦ : CD009590. 6. Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, et al. Complete surgery for low rectal endometriosis. Ann Surg. 2010;251:887–95.
José Félix Fernández-Val a,∗ , José María García-González a , Jaime González de Tánago b , Alberto Colina-Alonso a a
Servicio de Cirugía General, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain b Servicio de Anatomía Patológica, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain ∗ Corresponding author. E-mail address: [email protected] (J.F. Fernández-Val).
www.elsevier.es/medicinaclinica
Letter to the Editor Lymph node involvement in isolated rectal endometriosis夽 Afectación ganglionar en endometriosis rectal aislada Dear Editor, Endometriosis is the presence of endometrial tissue, glands and stroma in sites outside the uterine cavity. It is a frequent condition with a 6–10% prevalence in women of childbearing age.1 Generally divided into pelvic (ovaries, fallopian tubes and pelvic peritoneum) and extrapelvic endometriosis. Extrapelvic endometriosis can involve any part of the body, being gastrointestinal tract the most frequent (3–12%) site, especially at the rectosigmoid junction, followed in frequency by small intestine, cecum and appendix. Intestinal involvement usually coexists with its presence at other levels. One location alone is very rare. Isolated rectal endometriosis with involvement of regional lymph nodes is an exceptional circumstance and with little description in the medical literature.2 We report the case of a 34-year-old woman who came to the emergency room for watery diarrhea accompanied by mucus and red blood, rectal tenesmus and intense urge to defecate. A hard and fixed mass was palpable on digital rectal examination. Colonoscopy showed the presence of a large congestive submucosal lesion extending 4 cm from anal margin. CT scan showed a rectal injury 10 × 5 × 6 cm collapsing the rectal ampulla. Pelvic nuclear magnetic resonance imaging showed a pedunculated mass dependent on left posterolateral wall, with implantation 6 cm long and 4 cm lateral-medial, well defined with heterogeneous signal and significant blood component, not presenting a marked enhancement after administration of gadolinium. Surgical resection of the lesion was proposed, performing anterior resection with mechanical colorectal anastomosis. Histopathological examination of the surgical specimen revealed the presence of multiple foci of endometriosis consisting of cytogenic stroma and endometrial glands without atypia, also observing nodes with endometriosis foci. The patient improved with disappearance of symptoms. The etiopathogenesis of endometriosis is uncertain, and there are several theories intended to explain; the most widely accepted is the dissemination of endometrial cells through the fallopian tubes with retrograde flow during menstruation, and subsequent implantation into the peritoneum and pelvic structures. Metaplasia theory suggests that the source is in metaplastic processes of peritoneal mesothelial cells. Moreover, the finding of endometrial tissue in vessels and lymph nodes, and in remote sites led to the theory of lymphatic spread. In recent years the hypothesis proposed has been the endometrial stem cells as the source.
夽 Please cite this article as: Fernández-Val JF, García-González JM, González de Tánago J, Colina-Alonso A. Afectación ganglionar en endometriosis rectal aislada. Med Clin (Barc). 2016;146:e9. ˜ S.L.U. All rights reserved. 2387-0206/© 2015 Elsevier Espana,
Theories of retrograde menstruation and endometrial metaplasia of mesothelial cells remain the most accepted. However, recently the relevant role of the lymphatic system in endometriosis has been emphasized.3 The presence of lymph nodes with endometriosis makes us consider the lymphatic spread as our patient most likely pathogenic theory. The uniqueness of our case is that the intestinal endometriosis usually coexists with endometriosis in any other sites, usually ovary or peritoneum. The intestinal involvement alone is rare and the finding of regional lymph node involvement is extremely rare.2 Therefore, there are very few cases reported in the literature. Standard treatment should be surgery in most cases, since in certain cases the possibility of a neoplasm cannot be excluded.4 Moreover, medical treatment is not effective to remove the tumor in the extrapelvic involvement, and does not seem to improve the results of surgery.5 In general terms, we believe that surgery should be “complete”, i.e. with the same approach as cancer surgery, since more conservative strategies, including curettage and limited excisions of injury, are associated with high rates of recurrence.6 The choice of the approach, open laparotomy versus laparoscopy should be individualized for each patient. References 1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364:1789–99. 2. Lorente R, Palacios A, Bravo F, López FJ, Bouhmidi A, Huertas C, et al. Endometriosis de rectosigma con afección de los ganglios linfáticos. Gastroenterol Hepatol. 2003;26:23–5. 3. Jerman LF, Hey-Cunningham AJ. The role of the lymphatic system in endometriosis: a comprehensive review of the literature. Biol Reprod. 2015;92:1–10. 4. Stern RC, Dash R, Bentley RC, Snyder MJ, Haney AF, Robboy SJ. Malignancy in endometriosis: frequency and comparison of ovarian and extraovarian types. Int Gynecol Pathol. 2001;20:133–9. 5. Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. Cochrane Datab Syst Rev. 2014. Art. N.◦ : CD009590. 6. Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, et al. Complete surgery for low rectal endometriosis. Ann Surg. 2010;251:887–95.
José Félix Fernández-Val a,∗ , José María García-González a , Jaime González de Tánago b , Alberto Colina-Alonso a a
Servicio de Cirugía General, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain b Servicio de Anatomía Patológica, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain ∗ Corresponding author. E-mail address: [email protected] (J.F. Fernández-Val).