Transcoelomic and Lympho-Hematogenous Dissemination of Endometrioid Heterotopias – the Mechanism of Extragenital Endometriosis Formation

Р. В. Украинец, Yu. S. Korneva
In: Journal of Anatomy and Histopathology · 2021 · vol. 10(1) , pp. 85–91 · doi:10.18499/2225-7357-2021-10-1-85-91 · W3160390249
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This article demonstrates how endometrioid cells spread via lymphatic, hematogenous, and transcoelomic routes, supporting the theory of utero-peritoneal reflux as a primary mechanism for extragenital endometriosis formation.

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The paper discusses the proposed mechanisms for dissemination of endometrioid heterotopias that lead to extragenital endometriosis, emphasizing transcoelomic spread and lympho-hematogenous dissemination in the body. It argues that endometriotic lesions have more developed lymphatic networks than normal endometrium due to active lymphangiogenesis, and that invasive growth allows dissemination along lymphatic outflow pathways from typical pelvic locations to affect inguinal and pelvic lymph nodes. The authors explicitly note that adenomyosis-associated lymphatic dissemination is reported in one-quarter of patients and claim that this may require changes to surgical protocols involving regional lymph node excision, while also pointing to pulmonary and hepatic endometriosis as support for hematogenous spread; however, the text is largely explanatory and does not describe a specific original study design. This paper is centrally about endometriosis — it focuses on mechanisms of extragenital endometriosis formation via transcoelomic and lympho-hematogenous dissemination and discusses adenomyosis-associated lymphatic spread as part of the proposed model.

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Abstract

Endometriosis nowadays still a disease with an undisclosed pathogenesis. This article demonstrates and explains the possibility of different variants of dissemination of endometrioid cells in the body with the formation of foci of extragenital endometriosis in organs and tissues remote from the pelvis, complementing and confirming the theory of utero-peritoneal reflux in the development of endometriosis as the most reasonable. Endometrioid heterotopias have a more developed lymphatic network compared to the normal endometrium due to active lymphangiogenesis, and, having a tendency to invasive growth, endometrioid heterotopia is a source of endometrioid cells spreading along the direction of lymph outflow from the most typical locations (pelvic organs) with damage to the inguinal and pelvic lymph nodes. Lymphatic dissemination in adenomyosis is observed in every fourth patient, which requires revision of the surgery protocol with excision of regional lymph nodes to prevent relapses. The presence of cases of pulmonary endometriosis and endometrioid liver cysts makes hematogenic dissemination of endometriosis from the primary source in the pelvic region obvious. The most frequent localizations of endometrioid heterotopias are located near the corresponding venous plexuses of the small pelvis, the outflow from which occurs mainly through the inferior vena cava, without anatomical obstacles for hematogenic dissemination of endometrioid cells with subsequent lung damage. For liver involment, it is likely that endometriosis in the distal parts of the colon is important, the venous outflow from which is directed to the portal vein system. Endometriosis of the diaphragm – is an example transcoelomic spread with predominant location on the right dome of the diaphragm, as the right subphrenic space communicates with the pelvic cavity through the right lateral channel, which justifies the possibility of such involments of the diaphragme in context of the theory of uteroperitoneal reflux.Thus, the theory of menstrual regurgitation and the theory of hemato-lymphatic dissemination are components of a single pathogenetic model of the distribution of endometrioid cells in the body.
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Трансцеломическая и лимфо-гематогенная диссеминация эдометриоидных гетеротопий – механизм формирования экстрагенитальных форм эндометриоза https://doi.org/10.18499/2225-7357-2021-10-1-85-91 Аннотация Эндометриоз в настоящее время продолжает оставаться заболеванием с нераскрытым патогенезом. Данная статья демонстрирует и обьясняет возможность различных вариантов диссеминации эндометриоидных клеток в организме с формированием очагов экстрагенитального эндометриоза в отдаленных от малого таза органах и тканях, дополняя и подтверждая теорию маточно-перитонеального рефлюкса в развитии эндометриоза как наиболее обоснованную. Эндометриоидные гетеротопии имеют более развитую лимфатическую сеть по сравнению с нормальным эндометрием за счет активного лимфангиогенеза. Обладая склонностью к инвазивному росту, эндометриоидная гетеротопия является источником распространения эндометриоидных клеток по ходу оттока лимфы из наиболее типичных локализаций (органов малого таза) с поражением паховых лимфатических узлов и малого таза. Лимфатическая диссеминация при аденомиозе наблюдается у каждой четвертой пациентки, что требует пересмотра протокола операции с иссечением регионарных лимфатических узлов для предотвращения рецидивов. Наличие случаев легочного эндометриоза и эндометриоидных кист печени делает гематогенную диссеминацию эндометриоза из первоисточника в области малого таза очевидной. Наиболее частые локализации эндометриоидных гетеротопий располагаются возле соответствующих венозных сплетений малого таза, отток от которых происходит преимущественно через нижнюю полую вену, не имея анатомических препятствий для гематогенной диссеминации эндометриоидных клеток с последующим поражением легких. Для поражения печени, вероятно, имеет значение эндометриоидное поражение дистальных отделов толстой кишки, венозный отток от которых направляется в систему воротной вены. Эндометриоз диафрагмы – пример трансцеломического распространения данной патологии с примущественным поражением правого купола диафрагмы, поскольку правое поддиафрагмальное пространство сообщается с полостью малого таза посредством правого бокового канала, что оправдывает возможность подобного поражения в рамках теории маточно-перитонеального рефлюкса. Таким образом, теория менструальной регургитации и теория гемато-лимфатической диссеминации являются составными элементами единой патогенетичексой модели распространения эндометриоидных клеток в организме. Об авторах Р. В. УкраинецРоссия Смоленск Ю. С. Корнева Россия Корнева Юлия Сергеевна ул. Крупской, 28, Смоленск, 214019 Список литературы 1. Аничков Н.М., Печеникова В.А., Костючек Д.Ф. 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Endometrial cyst of the liver: case report and review. Fertility and Sterility. 2003 May;79(5):1234–6. doi: 10.1016/s0015-0282(03)00178-x 44. Tulandi T, Sirois C, Sabban H, Cohen A, Murji A, Singh SS, et al. Relationship between Catamenial Pneumothorax or Non-catamenial Pneumothorax and Endometriosis. Journal of Minimally Invasive Gynecology. 2018 Mar;25(3):480–3. doi: 10.1016/j.jmig.2017.10.012 45. Ueki M. Histologic study of endometriosis and examination of lymphatic drainage in and from the uterus. American Journal of Obstetrics and Gynecology. 1991 Jul;165(1):201–9. doi: 10.1016/0002-9378(91)90252-m 46. Verbeke C, Hàrle M, Sturm J. Cystic Endometriosis of the Upper Abdominal Organs. Pathology - Research and Practice. 1996 Jan;192(3):300–4. doi: 10.1016/S0344-0338(96)80235-4 Рецензия Для цитирования: Украинец Р.В., Корнева Ю.С. Трансцеломическая и лимфо-гематогенная диссеминация эдометриоидных гетеротопий – механизм формирования экстрагенитальных форм эндометриоза. Журнал анатомии и гистопатологии. 2021;10(1):85-91. https://doi.org/10.18499/2225-7357-2021-10-1-85-91 For citation: Ukrainets R.V., Korneva Yu.S. Transcoelomic and Lympho-Hematogenous Dissemination of Endometrioid Heterotopias – the Mechanism of Extragenital Endometriosis Formation. Journal of Anatomy and Histopathology. 2021;10(1):85-91. (In Russ.) https://doi.org/10.18499/2225-7357-2021-10-1-85-91 JATS XML

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