{"paper_id":"945237d2-cac2-45de-aa47-fd7191109ae1","body_text":"Yonsei Med J   http://www.eymj.org    Volume 50   Number 5   October 2009732\nEndometriosis is defined as the presence of endometrial glands and stroma\noutside the uterine cavity and musculature.1 It is a common benign disease among\nwomen of reproductive age, and affects the intestinal tract in 3-37% of all patients\nwith pelvic endometriosis.\n2 The sigmoid colon and rectum are the most commonly\ninvolved areas in women with intestinal endometriosis. 3 Sometimes, the\ndifferential diagnosis of colorectal endometriosis from other malignancies of the\ncolon and rectum is difficult due to similar colonoscopic and radiologic findings.\nIn this report, we present five cases involving patients with intestinal endo-\nmetriosis, in which the initial diagnostic work-up suggested carcinoma of rectum\nand sigmoid colon [i.e., rectal cancer, sigmoid colon cancer or gastrointestinal\nstromal tumor (GIST)].\nFrom October 2002 to September 2007, five patients were admitted for the surgical\nresection of rectal and sigmoid colon tumors, which were subsequently revealed\nto be intestinal endometriosis. The average age of the patients was 39.8 years\n(range, 27-47 years). There was one nullipara who had been explored for inferti-\nlity. Two patients were asymptomatic, two patients complained of hematochezia,\nand one patient had obstipation revealed by colonoscopy. None of the sympto-\nmatic patients had symptoms related to menstruation. Colonoscopy was performed\nCase Report\nDOI 10.3349/ymj.2009.50.5.732\npISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 50(5): 732-735, 2009\nIntestinal Endometriosis Mimicking Carcinoma \nof Rectum and Sigmoid Colon: A Report of Five Cases\nJin Soo Kim,1 Hyuk Hur,1 Byung Soh Min,1 Hoguen Kim,2\nSeung-Kook Sohn,1 Chang Hwan Cho,1 and Nam Kyu Kim1\nDepartments of 1Surgery, 2Pathology, Yonsei University College of Medicine, Seoul, Korea.\nAmong women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas.\nSometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is\ndifficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed\nfive operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis.\nColonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal\ncancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two\npatients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in\ntwo patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with\ngastrointestinal symptoms and an intestinal mass of unknown origin.\nKey Words :Intestinal endometriosis, endometriosis, colorectal neoplasm\nReceived: November 7, 2008\nReceived: June 2, 2009\nAccepted: June 2, 2009\nCorresponding author: Dr. Nam Kyu Kim,\nDepartment of Surgery, Yonsei University\nCollege of Medicine, 250 Seongsan-ro,\nSeodaemun-gu, Seoul 120-752, Korea.\nTel: 82-2-2228-2117, Fax: 82-2-313-8289 \nE-mail: namkyuk@yuhs.ac  \n∙The authors have no financial conflicts of\ninterest.\n© Copyright:\nYonsei University College of Medicine 2009\nINTRODUCTION\nCASE REPORT\n\nin all five patients and revealed an ulcerofungating mass in\ntwo cases (Fig. 1), mucosal protrusion without mucosal\nabnormality in one case, luminal narrowing with extrinsic\ncompression in one case and a polypoid mass in one case.\nColonoscopic biopsy was performed in three out of the five\npatients. The biopsies showed chronic inflammation in two\ncases and a normal finding in one case. A computed tomo-\ngraphy (CT) scan was also performed in all patients, and\nrevealed colonic and rectal wall thickening in two cases\nand submucosal tumor suggesting GIST in one case. How-\never, no masses were identified in two cases (Table 1).\nMagnetic resonance imaging (MRI) was performed in\ncases with rectal involvement, and the findings were not\ndifferent from those of CT. PET scan was performed in\ncase 5 and suggested malignant uptake in the rectum (not\ndocumented in Table 1).\nAll patients underwent dissection of paracolic and\nintermediate lymph nodes, as well as lymph nodes in the\nroot of the inferior mesenteric artery. The laparotomy was\ndone by low midline incision in three patients and by\nlaparoscopic surgery in two patients. Two anterior resec-\ntions and three low anterior resections were performed.\nWe did not perform a frozen section at the time of the\noperation because the operative finding seemed to be a\nmalignant tumor, even though a previous colonoscopic\nbiopsy did not reveal malignancy. However, all surgical\nspecimens were indicated endometriosis according to final\npathology reports (Fig. 2).\nThe symptoms of intestinal endometriosis vary according\nto the site of involvement.\n4 Rectosigmoid endometriosis\ncan cause alterations in bowel habit and bleeding that\nresemble symptoms of colorectal cancer. Colonic endome-\ntriosis may manifest as an acute abdomen resulting from\nperforation and associated peritonitis. Small bowel\ninvolvement may produce non-specific symptoms such as\nrecurrent abdominal pain and bloating, but terminal ileal\ninvolvement frequently results in the development of acute\nor chronic small bowel obstruction.\nThe gold standard diagnostic procedure for intestinal\nendometriosis is laparoscopy or laparotomy. The laparos-\ncopic procedure is more useful for a complete and accurate\nevaluation of both the genital and intestinal tracts. More-\nIntestinal Endometriosis Mimicking Carcinoma\nYonsei Med J   http://www.eymj.org    Volume 50   Number 5   October 2009733\nFig. 1. (A) Colonoscopic finding. Ulcerofungating mass 8 cm above the anal\nverge is suspicious for rectal cancer. (B) CT scan of the pelvis shows rectal\nmass with perirectal tumor infiltration (Case 2).\nA\nB\nFig. 2.(A) Gross specimen. The polypoid mass is seen on the laparoscopically\nresected rectum. (B) The mass was revealed as endometriosis, which is\ncomposed of stroma and glands of endometrium, upon microscopic analysis\n(Hematoxylin Eosin\n×100) (Case 5).\nA\nB\nDISCUSSION\n\nover, surgical intervention of genital endometriosis may be\nperformed during laparoscopy. Thus, diagnostic laparos-\ncopy is indicated in patients with suspicion of intestinal\nendometriosis.\nIntestinal endometriosis often presents as a submucosal\ntumor or luminal stenosis because it mainly involves the\nmuscularis propria and subserosa or mesentery.\n5 In the\ncase of mucosal involvement, a bleeding, polypoid mass\nmay be present. These clinical manifestations are some-\ntimes difficult to distinguish from malignancy, inflam-\nmatory bowel disease, or ischemic colitis.\n5,6 Radiologic and\nendoscopic examinations are essential for the diagnosis of\nintestinal endometriosis, which may be confused with\nmalignancy, based on colonoscopy and CT scan, particu-\nlarly in patients with mucosal involvement.\n7 MRI seems to\nbe the most sensitive imaging technique for intestinal\nendometriosis.\n8 However, these evaluations are not diag-\nnostic.\nThe purpose of treatment of intestinal endometriosis is\nelimination of symptoms, removal of as much endometrial\ntissue as possible and cessation of disease progression.\nPhysicians should consider the patient’s age and desire to\nmaintain fertility and the severity and complications of the\ndisease.\n7 Treatment options consist of medical and surgical\ntreatment. In severe cases, combined treatment may be\nconsidered. The medications used in the treatment of\nendometriosis are danazol, high-dose progestins, and\nGnRH agonists, all of which have equivalent efficacy.\n9\nMost decisions for surgical intervention depend on the\nseverity of symptoms and response to medical treatment.\nInfertility is one of the most important symptoms to consi-\nder for operative intervention. Intestinal endometriosis\nmay be encountered unexpectedly during abdominal\nexploration. If the diagnosis of endometriosis can be\nconfirmed by frozen biopsy and there is no significant\nobstruction, the optimal treatment choice is to close the\nabdomen and consider definitive treatment of the patient\nafter bowel preparation and possible medical therapy.\nRecently, treatment outcomes for endometriosis have\nimproved with the development of laparoscopic surgical\nskills and medical hormonal therapy.\n10\nWe report five cases of intestinal endometriosis misdia-\ngnosed as colorectal cancer. The symptoms of hematochezia\nand abdominal pain in combination with colonoscopic and\nradiologic findings were suggestive of malignancy alth-\nough the colonoscopic biopsies were not confirmative. We\nadmit that preoperative evaluations were not fully examined,\nand close follow-up may be helpful to avoid false positives.\nThe addition of diagnostic laparoscopy may be a reasonable\noption. However, surgical treatment should be considered\nwhen the differential diagnosis of malignancy is not\ndetermined or medically intractable symptoms are present.\nIn the current case report, gastrointestinal symptoms or\ncolonoscopic and radiologic findings resulted in the\ndecision for surgery, and subsequent surgical specimens\nrevealed intestinal endometriosis.\nJin Soo Kim, et al.\nYonsei Med J   http://www.eymj.org    Volume 50   Number 5   October 2009734\nTable 1.Clinical Characteristics of Five Patients with Intestinal Endometriosis Mimicking Carcinoma of Rectum and Sigmoid\nColon\nPresenting Colonoscopic Involved Preoperative Operative Pelvic organCase Age symptom Parity finding/biopsy CT finding intestine impression treatment involvement& sign\nUlcero-fungating Colonic Sigmoid Sigmoid colon1 41 Hematochezia G3P2 mass / chronic wall colon cancer AR Lt. ovary\ninflammation thickening\nUlcero-fungating Rectal \n2 27 Hematochezia G1P0 mass / within wall Rectum Rectal cancer LAR None\nnormal thickening\nMucosal Submucosal Laparoscopic 3 46 None G2P1 protrusion / not tumor Rectum GIST LAR None\nperformed\nAbdominal pain, Luminal Sigmoid Sigmoid colon44 7 obstipation G2P2 narrowing / NED colon cancer AR None\nnot performed\nPolypoid mass Rectal Laparoscopic5 38 None G0 / chronic NED Rectum cancer LAR None\ninflammation\nAR, anterior resection; LAR, low anterior resection; GIST, gastrointestinal stromal tumor; NED, no evidence of disease.\n\nIn conclusion, intestinal endometriosis is a relatively rare\ndisease and is difficult to differentiate from malignancy,\nwhen based on clinical symptoms, endoscopic procedure,\nand radiologic findings. We suggest to consider also intes-\ntinal endometriosis in reproductive women presenting with\ngastrointestinal symptoms and an intestinal mass of unkn-\nown origin.\nThis study was supported by grants of the Korea Healthcare\ntechnology R&D project, Ministry for Health, Welfare &\nFamily Affairs, Republic of Korea (A040001, A040151).\n1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;\n328:1759-69.\n2. Croom RD 3rd, Donovan ML, Schwesinger WH. Intestinal\nendometriosis. Am J Surg 1984;148:660-7.\n3. Miller LS, Barbarevech C, Friedman LS. Less frequent causes of\nlower gastrointestinal bleeding. Gastroenterol Clin North Am\n1994;23:21-52.\n4. Giudice LC, Kao LC. Endometriosis. Lancet 2004;364:1789-99.\n5. Barclay RL, Simon JB, Vanner SJ, Hurlbut DJ, Jeffrey JF. Rectal\npassage of intestinal endometriosis. Dig Dis Sci 2001;46:1963-7.\n6. Langlois NE, Park KG, Keenan RA. Mucosal changes in the\nlarge bowel with endometriosis: a possible cause of misdiagnosis\nof colitis? Hum Pathol 1994;25:1030-4.\n7. Dimoulios P, Koutroubakis IE, Tzardi M, Antoniou P, Matal-\nliotakis IM, Kouroumalis EA. A case of sigmoid endometriosis\ndifficult to differentiate from colon cancer. BMC Gastroenterol\n2003;3:18.\n8. Brosens I, Puttemans P, Campo R, Gordts S, Brosens J. Non-\ninvasive methods of diagnosis of endometriosis. Curr Opin\nObstet Gynecol 2003;15:519-22.\n9. Mahutte NG, Arici A. Medical management of endometriosis-\nassociated pain. Obstet Gynecol Clin North Am 2003;30:133-50.\n10. Emmanuel KR, Davis C. Outcomes and treatment options in\nrectovaginal endometriosis. Curr Opin Obstet Gynecol 2005;\n17:399-402.\nIntestinal Endometriosis Mimicking Carcinoma\nYonsei Med J   http://www.eymj.org    Volume 50   Number 5   October 2009735\nREFERENCES\nACKNOWLEDGEMENTS","source_license":"CC0","license_restricted":false}