{"paper_id":"0d476019-02ba-4c4f-bb59-08bc4b8c2149","body_text":"22 © 2020 Clinical Cancer Investigation Journal | Published by W olters Kluwer - Medknow\nAddress for correspondence: \nProf. Rashmi Patnayak, \nDepartment of Pathology, \nInstitute of Medical \nSciences and SUM Hospital, \nBhubaneswar, Odisha, India. \nE‑mail: rashmipatnayak2002@\nyahoo.co.in\nAbstract\nEndometriosis usually affects premenopausal females. Its pathogenesis is not completely understood. \nThe presence of functioning endometrial glands and stroma outside the uterine cavity is known \nas endometriosis. Endometriosis can be found in both ovaries, the pouch of Douglas, pelvic \nperitoneum, and uterosacral ligaments. Cystic forms of endometriosis can occasionally present as a \nhuge abdominal mass, mimicking ovarian malignancy. Hereby, we present one such case of a large \nendometriotic cyst in a pre‑menopausal female. She underwent surgery, and the histopathology, along \nwith immunohistochemical examination, proved it to be a case of endometriotic cyst. Although this \ndiagnosis is relatively rare, this should be considered as a differential diagnosis in the case of cystic \nlesions in premenopausal females.\nKeywords: Endometriosis, endometriotic cyst, immunohistochemistry\nLarge Endometriotic Cyst -Masquerading as Ovarian Malignancy\nCase Report\nRashmi Patnayak, \nAjit Surya \nMohapatra,  \nNibedita Sahoo, \nAdya Kinkara \nPanda,  \nPendyala Sujata\n1, \nAmitabh Jena2, \nDebahuti Mahapatra\nDepartments of Pathology, \n1Obstetrics and Gynaecology \nand 2Surgical Oncology, Institute \nof Medical Sciences and SUM \nHospital, Bhubaneswar, \nOdisha, India\nHow to cite this article:  Patnayak R,  \nMohapatra AS, Sahoo N, Panda AK, Sujata P, \nJena A, \net al. Large endometriotic cyst‑masquerading \nas ovarian malignancy. Clin Cancer Investig J \n2020;9:22‑4.\nThis is an open access journal, and articles are \ndistributed under the terms of the Creative Commons \nAttribution‑NonCommercial‑ShareAlike 4.0 License, which allows \nothers to remix, tweak, and build upon the work non‑commercially, \nas long as appropriate credit is given and the new creations are \nlicensed under the identical terms.\nFor reprints contact: reprints@medknow.com\nIntroduction\nEndometriosis is a common and benign \ncondition. It affects approximately 10% of \npremenopausal women.\n[1] The pathogenesis \nof endometriosis is complicated and has not \nyet been fully explained.\n[2] The various sites \nof endometriosis include both ovaries, the \npouch of Douglas, pelvic peritoneum, and \nuterosacral ligaments. This phenomenon \ncomplies with the theory of menstruation \nback‑flow and implantation of endometrial \ntissue.\n[3]\nEndometriotic cysts are cystic form of \nendometriosis. These cysts may or may \nnot be associated with endometriosis in \nother sites. Usually, this condition is seen \nin females in their 4\nth–5th decades of life. \nClinically, they present with pain abdomen. \nThe endometriotic cyst can be large in \nsize with irregular lining and with areas of \nhemorrhage.\n[4]\nCase Report\nA 37‑year‑old female, P2 L2 presented with \nthe clinical history of gradual swelling of \nabdomen and loss of appetite for 5  months. \nShe had no history of surgery, including \ncesarean section. Ultrasonography was \nreported as left ovarian malignancy. Her \nCA‑125 level was 116 U/ml  (<35 U/ml). \nComputed tomography imaging showed \na large abdominopelvic cystic lesion with \nmultiple internal enhancing septations. The \ncyst was displacing the uterus posteriorly \nand bowel loops superiorly. Bilateral ovaries \nwere seen separately  [Figure 1a and b]. She \nunderwent laparoscopic debulking of the \ntumor along with hysterectomy and bilateral \nsalpingo‑oophorectomy. Intraoperatively, \nthere was a large cystic lesion covering \nthe whole of the abdominal cavity, densely \nadhered to mesentery. Grossly, the cyst \nwas measuring 20  cm  ×  17  cm and was \nattached to the left ovary, left fallopian \ntube, and posterior aspect of the uterine \nwall [Figure 1c].\nHistopathology of the cyst showed many \nendometrial glands lined by cuboidal \nepithelium surrounded by a rim of the \ncompact endometrial stroma  [Figure 1d]. \nThe rest of the stroma was edematous. \nImmunohistochemistry done with CD10 and \nprogesterone receptor  (PR) highlighted the \nendometrial stroma. The glandular lining \nwas positive for CK7 [Figure\n 1e and f]. \nThe final diagnosis given was endometriotic \ncyst. There were no areas of necrosis or \nincreased mitotic activity.\nShe had an uneventful postoperative period.\nDiscussion\nBy definition, the presence of functioning \nendometrial glands and stroma outside the \nuterine cavity is known as endometriosis. \nThe diagnostic criteria of endometriosis \nSubmitted: 13‑Aug‑2019 \nRevised: 18‑Oct‑2019 \nAccepted: 21‑Dec‑2019 \nPublished: 11‑Apr‑2020\nAccess this article online\nWebsite: www.ccij‑online.org\nDOI: 10.4103/ccij.ccij_74_19\nQuick Response Code:\n\n\nPatnayak, et al.: Endometriotic cyst\nClinical Cancer Investigation Journal | Volume 9 | Issue 1 | January-February 2020 23\ninclude the presence of two of the following three \nfeatures outside of the uterus: endometrial glands, \nendometrial stroma, and hemosiderin‑laden macrophages. \nEndometriosis is a fairly common condition. It is estimated \nto affect approximately 6%–10% of the reproductive \nage group females. [1] The macroscopic indicators of \nthe endometriosis can manifest themselves in various \nways such as a few petechial, vesicular, hemorrhagic, \npowder‑like implants or serous or clear vesicular structures \nor intraperitoneal adhesions attached to both ovaries, the \npouch of Douglas, and uterosacral ligaments. In 40%–60% \nof the patients, endometriosis is accompanied by ovarian \nendometrioma.[2]\nThe exact cause and pathogenesis of endometriosis are not \nclear. There are several theories regarding the pathogenesis \nof endometriosis. One theory suggests that through \nretrograde menstruation, viable endometrial cells are \ntransported to the peritoneal cavity. Another theory is that \nof transtubal dissemination of endometrial tissue, which is \nalso considered as the most common route of spread. One \nmore theory is the iatrogenic deposition of endometrial \ntissue following any gynecological surgery and cesarean \nsections.[1] Our patient did not have any such history.\nGoumenou et al . have described a case of \nendometriosis‑associated with massive ascites, pleural \neffusion, and extremely elevated CA‑125 mimicking \nadvanced ovarian cancer. [5] The patient did not have \nascites or pleural effusion. In the case of endometriosis, \nthe frozen‑section analysis should be performed during the \nsurgery to rule out the possibility of malignancy associated \nwith endometriosis. [3] However, in the present case, the \nintraoperative frozen section was not performed.\nIn our case, the findings suggestive of malignancy were \nthe size, which was huge, measuring 20 cm. The level of \nCA‑125 was elevated. It was attached to the left ovary, \nleft fallopian tube, and posterior aspect of the uterine wall. \nThe presence of endometrial glands and stroma along with \nimmunochemistry, which showed CD10 and PR positivity in \nthe endometrial stroma and CK7 positivity in the endometrial \ngland, established the diagnosis of the endometriotic cyst.\nEndometriotic cyst in retroperitoneal location is rare, \nand only a few cases have been reported in the English \nliterature.[6‑9] Recently, Pang et al . have described a case \nof mass‑like endometriosis on the surface of the uterus \nmimicking ovarian malignancy.[3]\nVery rarely endometrioid adenocarcinoma can arise from \nendometriosis.[10] The present case is a benign one of the \nendometriotic cyst.\nConclusion\nAlthough relatively rare in retroperitoneal location, a \ndiagnosis of endometriotic cyst should be considered \nin the differential diagnosis of cysts in premenopausal \nwomen. In our case, the histopathological diagnosis \nof the endometriotic cyst was confirmed with the \nimmunohistochemical staining.\nDeclaration of patient consent\nThe authors certify that they have obtained all appropriate \npatient consent forms. In the form the patient(s) has/have \ngiven his/her/their consent for his/her/their images and \nother clinical information to be reported in the journal. The \npatients understand that their names and initials will not \nbe published and due efforts will be made to conceal their \nidentity, but anonymity cannot be guaranteed.\nFinancial support and sponsorship\nNil.\nConflicts of interest\nThere are no conflicts of interest.\nReferences\n1. Raffi F, Amer S. Endometriosis. Obstet Gynaecol Reprod Med \n2011;21:112‑7.\nFigure 1: (a and b) Computed tomography imaging of a large abdomino-pelvic \ncystic lesion with multiple internal enhancing septations. (c) Gross of \nhuge cyst attached to left ovary, left fallopian tube and posterior aspect \nof the uterine wall. (d) Histopathology showing endometrial glands and \nstroma (H and E, ×200). (e) Immunohistochemistry showing cytoplasmic \npositivity for CD10 in endometrial stroma (immunohistochemistry, ×400). \n(f) Immunohistochemistry showing nuclear positivity for progesterone \nreceptor in endometrial glands and stroma (immunohistochemistry, ×100)\nd\nc\nb\nf\na\ne\n\nPatnayak, et al.: Endometriotic cyst\n24 Clinical Cancer Investigation Journal | Volume 9 | Issue 1 | January-February 2020\n2. Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, \nCrosignani PG. Reproductive performance, pain recurrence \nand disease relapse after conservative surgical treatment for \nendometriosis: The predictive value of the current classification \nsystem. Hum Reprod 2006;21:2679‑85.\n3. Pang L, Shi H, Wang T, Zhu L, Lang J, Fan Q, et al. \nEndometriosis on the surface of the uterus mimicking a malignant \ntumor: A case report with literature review. Medicine (Baltimore) \n2019;98:e15741.\n4. Kurman RJ, Ellenson LH, Ronnett BM. Blaustein’s Pathology \nof the Female Genital Tract. 6 th ed. Switzerland: Springer \nInternational Publishing; 2011.\n5. Goumenou A, Matalliotakis I, Mahutte N, Koumantakis E. \nEndometriosis mimicking advanced ovarian cancer. Fertil Steril \n2006;86:219.e23‑5.\n6. Rana S, Stanhope RC, Gaffey T, Morrey BF, Dumesic DA. \nRetroperitoneal endometriosis causing unilateral hip pain. Obstet \nGynecol 2001;98:970‑2.\n7. Lolis ED, Carvounis EE, Vasilikostas G, V oros D. Subhepatic \nretroperitoneal endometrioma: Report of a case. Gynecol \nEndocrinol 2007;23:479‑81.\n8. Lorente Poyatos R, Palacios Pérez A, Bravo Bravo F, \nLópez Caballero FJ, Bouhmidi A, Huertas Nadal C, et al . \nRectosigmoid endometriosis with lymph node involvement. \nGastroenterol Hepatol 2003;26:23‑5.\n9. Gouthaman S, Kaundinya K. Retroperitoneal endometriotic cyst \nmimicking a tumor. Gynecol Obstet 2015;5: 293.\n10. Kawate S, Takeyoshi I, Ikota H, Numaga Y , Sunose Y , Morishita Y . \nEndometrioid adenocarcinoma arising from endometriosis of the \nmesenterium of the sigmoid colon. Jpn J Clin Oncol 2005;35:154‑7.","source_license":"CC0","license_restricted":false}