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Sigmoid endometriosis in a postmenopausal woman
Sigmoid endometriosis in a postmenopausal woman Bruno Deval, MD,a Arash Rafii, MD,a Michele Felce Dachez, MD,c Reza Kermanash, MD,b and Michel Levardon, MDa Clichy, France Bowel obstruction resulting from endometriosis is an infrequently observed phenomenon in postmenopausal women. A 69-year-old woman without hormone replacement had clinical and radiologic findings consistent with a pelvic tumor invasive into the wall of the sigmoid colon. The patient underwent resection of the sigmoid colon and total hysterectomy. Histologic examination revealed endometrioma. This case documents the possible occurrence of symptomatic bowel endometriosis after years of a hormonally castrated state. (Am J Obstet Gynecol 2002;187:1723-5.)
Key words: Bowel obstruction, endometriosis, postmenopausal
Mechanical bowel obstruction in the elderly, presenting as an abdominal mass, is usually oncologic or inflammatory in etiology. A 69-year-old woman was seen for an abdominal tumor and bowel obstruction. She underwent colectomy, Hartmann’s pouch, and radical hysterectomy for a suspected pelvic carcinoma. The histologic diagnosis was endometriosis. The frequency of bowel endometriosis ranges between 3% and 34%,1 depending on the definition (symptomatic or pathologic). However, the rate of colonic resection is lower than 1%. In addition, colonic involvement by endometriosis typically occurs in women of menstruating age. We will therefore discuss the possible pathologic features of bowel endometriosis in the elderly and the reason of the colon resection. This case report illustrates the need for considering endometrioma in the differential diagnosis of pelvic mass in the elderly. Case report A 69-year-old postmenopausal woman, 1.61 m tall, weighing 52 kg, without hormone replacement or other medication was admitted with the chief complaints of pelvic pain, vaginal discharge, constipation, and a weight loss of 30 kg progressing over a 6-month period (initial weight 82 kg, body mass index 31.6). Physical examination revealed mild left lower quadrant (LLQ) tenderness and an LLQ abdominal mass. The pelvic examination revealed a normal cervix and paracervix, and uterine size and mobility were normal.
From the Departments of Gynecology,a Surgery,b and Pathology,c Hôpital Beaujon. Received for publication February 21, 2002; revised June 26, 2002; accepted July 12, 2002. Reprints not available from the authors. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002 $35.00 + 0 6/1/128394 doi:10.1067/mob.2002.128394
Routine hematology, chemistry, and tumor markers (CA 125, ACE) were within the normal range. An abdominal ultrasound, a pelvic magnetic resonance imaging, and a barium enema were performed (Fig 1). The endometrium was normal, and the ovaries were not seen. The findings were consistent with an extrinsic lesion of 12 cm compressing the sigmoid area. The colonoscopy results were normal. The differential diagnoses considered were sigmoid carcinoma, sigmoiditis, carcinoma of the left ovary, and pelvic actinomycosis. The patient underwent a laparotomy, revealing a pelvic mass that was attached to the bladder, the uterus, and the sigmoid colon; the liver was normal. Colonic resection with sigmoid end-colostomy, Hartmann’s pouch, and a radical hysterectomy were performed. Frozen sections were not contributive to any of the differential diagnoses. The patient’s postoperative course was uneventful, and she was discharged on day 18. Final pathologic findings was colon endometrioma with involvement of the submucosa and muscularis by endometrial-type glands (Fig 2) and pseudocystic endometrium hyperplasia; there was no ovarian lesion. Immunohistochemical assessment of hormonal receptors was rated semiquantitatively by use of a scoring system that incorporates the intensity of nuclear straining (from 0 to 3) and percentage of positive cells (from 0% to 100%, with a cutoff value of 10%). The immunostaining was positive for estrogen receptors in 50% of nuclei in glandular cells, but at a low intensity. More than 50% of nuclei were moderately positive for progesterone receptors in stroma cells. The histologic diagnosis of the endometrium was pseudocystic hyperplasia. However, there was no sign of estrogen stimulation on the ovaries (no stromal hyperplasia). Comment The frequency of segmental colectomy in bowel endometriosis ranges from 0.1% to 0.7%.1 1723
1724 Deval et al
December 2002 Am J Obstet Gynecol
Fig 1. A, Barium enema showing an extramucosal defect causing compression of the sigmoid colon. B, Enhanced computed tomography with oral contrast. Frontal view, 15-cm lesion with a cystic and tissular component. An encasement of the left sigmoid wall is present.
Fig 2. A, Macroscopic view of the resected lesion. 1, Inflammatory pseudotumor lesion with endometriotic nodules of the mesosigmoid; 2, sigmoidal lumen; 3, cystic lesion with abscess formation. B, Endometriotic tubes in inflammatory pseudotumor lesion.
In this case, the combination of two mechanisms can explain the occurrence of this colon endometrioma. In this case, the histologic features were concordant with a residual estrogen stimulation of the endometrium. The persistence of circulating estrogen, enhanced in obese women as in our case (estrogen secretion by the adrenal gland, or peripheral conversion of androstenedione to estrone) induces the accumulation of blood in the endometrioma located within the sigmoid wall.2 This phenomenon is the cause of a severe inflammatory reaction leading to fibrosis of the bowel wall; therefore, bowel wall en-
dometrioma is more autonomous than endometriosis located in the reproductive organs. In this case, the preoperative tissue diagnosis of bowel endometriosis was not made, and the suspicion of a pelvic carcinoma led to nonconservative surgery. First, the diagnosis requires pathologic examination of the tumor. A mucosal invasion by endometrioma is quite rare; therefore, an acute diagnosis is often difficult to make without surgery. Second, hormonal therapy transforms endometrial tissue in fibrous tissue, increasing the bowel symptoms. Endometrioma must be resected to treat
Deval et al 1725
Volume 187, Number 6 Am J Obstet Gynecol
the obstruction. Finally, other lesions, such as sarcomas, lymphomas, and carcinoids, that may have intact mucosa, cannot be differentiated from endometriosis, and the possible occurrence of a carcinoma either within or near the lesion justify our therapeutic procedure. In conclusion, occlusive bowel endometriosis is rare and the diagnosis cannot be made preoperatively because
malignancy cannot be excluded. Laparotomy with resection should be the method of choice. REFERENCES
1. Collin GR, Russel JC. Endometriosis of the colon its diagnosis and management. Am Surg 1990;56:275-9. 2. Redwine DB. Endometriosis persisting after castration: clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.
Key words: Bowel obstruction, endometriosis, postmenopausal
Mechanical bowel obstruction in the elderly, presenting as an abdominal mass, is usually oncologic or inflammatory in etiology. A 69-year-old woman was seen for an abdominal tumor and bowel obstruction. She underwent colectomy, Hartmann’s pouch, and radical hysterectomy for a suspected pelvic carcinoma. The histologic diagnosis was endometriosis. The frequency of bowel endometriosis ranges between 3% and 34%,1 depending on the definition (symptomatic or pathologic). However, the rate of colonic resection is lower than 1%. In addition, colonic involvement by endometriosis typically occurs in women of menstruating age. We will therefore discuss the possible pathologic features of bowel endometriosis in the elderly and the reason of the colon resection. This case report illustrates the need for considering endometrioma in the differential diagnosis of pelvic mass in the elderly. Case report A 69-year-old postmenopausal woman, 1.61 m tall, weighing 52 kg, without hormone replacement or other medication was admitted with the chief complaints of pelvic pain, vaginal discharge, constipation, and a weight loss of 30 kg progressing over a 6-month period (initial weight 82 kg, body mass index 31.6). Physical examination revealed mild left lower quadrant (LLQ) tenderness and an LLQ abdominal mass. The pelvic examination revealed a normal cervix and paracervix, and uterine size and mobility were normal.
From the Departments of Gynecology,a Surgery,b and Pathology,c Hôpital Beaujon. Received for publication February 21, 2002; revised June 26, 2002; accepted July 12, 2002. Reprints not available from the authors. © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002 $35.00 + 0 6/1/128394 doi:10.1067/mob.2002.128394
Routine hematology, chemistry, and tumor markers (CA 125, ACE) were within the normal range. An abdominal ultrasound, a pelvic magnetic resonance imaging, and a barium enema were performed (Fig 1). The endometrium was normal, and the ovaries were not seen. The findings were consistent with an extrinsic lesion of 12 cm compressing the sigmoid area. The colonoscopy results were normal. The differential diagnoses considered were sigmoid carcinoma, sigmoiditis, carcinoma of the left ovary, and pelvic actinomycosis. The patient underwent a laparotomy, revealing a pelvic mass that was attached to the bladder, the uterus, and the sigmoid colon; the liver was normal. Colonic resection with sigmoid end-colostomy, Hartmann’s pouch, and a radical hysterectomy were performed. Frozen sections were not contributive to any of the differential diagnoses. The patient’s postoperative course was uneventful, and she was discharged on day 18. Final pathologic findings was colon endometrioma with involvement of the submucosa and muscularis by endometrial-type glands (Fig 2) and pseudocystic endometrium hyperplasia; there was no ovarian lesion. Immunohistochemical assessment of hormonal receptors was rated semiquantitatively by use of a scoring system that incorporates the intensity of nuclear straining (from 0 to 3) and percentage of positive cells (from 0% to 100%, with a cutoff value of 10%). The immunostaining was positive for estrogen receptors in 50% of nuclei in glandular cells, but at a low intensity. More than 50% of nuclei were moderately positive for progesterone receptors in stroma cells. The histologic diagnosis of the endometrium was pseudocystic hyperplasia. However, there was no sign of estrogen stimulation on the ovaries (no stromal hyperplasia). Comment The frequency of segmental colectomy in bowel endometriosis ranges from 0.1% to 0.7%.1 1723
1724 Deval et al
December 2002 Am J Obstet Gynecol
Fig 1. A, Barium enema showing an extramucosal defect causing compression of the sigmoid colon. B, Enhanced computed tomography with oral contrast. Frontal view, 15-cm lesion with a cystic and tissular component. An encasement of the left sigmoid wall is present.
Fig 2. A, Macroscopic view of the resected lesion. 1, Inflammatory pseudotumor lesion with endometriotic nodules of the mesosigmoid; 2, sigmoidal lumen; 3, cystic lesion with abscess formation. B, Endometriotic tubes in inflammatory pseudotumor lesion.
In this case, the combination of two mechanisms can explain the occurrence of this colon endometrioma. In this case, the histologic features were concordant with a residual estrogen stimulation of the endometrium. The persistence of circulating estrogen, enhanced in obese women as in our case (estrogen secretion by the adrenal gland, or peripheral conversion of androstenedione to estrone) induces the accumulation of blood in the endometrioma located within the sigmoid wall.2 This phenomenon is the cause of a severe inflammatory reaction leading to fibrosis of the bowel wall; therefore, bowel wall en-
dometrioma is more autonomous than endometriosis located in the reproductive organs. In this case, the preoperative tissue diagnosis of bowel endometriosis was not made, and the suspicion of a pelvic carcinoma led to nonconservative surgery. First, the diagnosis requires pathologic examination of the tumor. A mucosal invasion by endometrioma is quite rare; therefore, an acute diagnosis is often difficult to make without surgery. Second, hormonal therapy transforms endometrial tissue in fibrous tissue, increasing the bowel symptoms. Endometrioma must be resected to treat
Deval et al 1725
Volume 187, Number 6 Am J Obstet Gynecol
the obstruction. Finally, other lesions, such as sarcomas, lymphomas, and carcinoids, that may have intact mucosa, cannot be differentiated from endometriosis, and the possible occurrence of a carcinoma either within or near the lesion justify our therapeutic procedure. In conclusion, occlusive bowel endometriosis is rare and the diagnosis cannot be made preoperatively because
malignancy cannot be excluded. Laparotomy with resection should be the method of choice. REFERENCES
1. Collin GR, Russel JC. Endometriosis of the colon its diagnosis and management. Am Surg 1990;56:275-9. 2. Redwine DB. Endometriosis persisting after castration: clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.