Gastrointestinal deep infiltrative endometriosis with lymph node involvement

Dear Editor, A 37-year-old female presented with diffuse severe colicky abdominal pain for which she was evaluated radiologically and was detected to have vividly enhancing soft density lesion in the pelvis encasing the recto-sigmoid colon and causing eccentric focal luminal narrowing [Figure 1]. Due to acute presentation and nonrelieving of pain with medical management, she underwent exploratory laparotomy and low anterior resection with clinical and radiological impression of neoplasm. Intraoperatively, she was found to have a stricture at recto-sigmoid junction causing luminal narrowing and the specimen was sent for histopathological examination. On gross examination, there was an area of luminal narrowing with thickened bowel wall corresponding to the area of stricture [Figure 2]. No definite growth was identified; however, multiple sections from the thickened portion of bowel were subjected to histopathology. Microscopy revealed numerous foci of variably dilated and variable shaped endometrial gland surrounded by the endometrial type stroma extending through serosa, muscularis propria, and submucosal layer. The pericolonic lymph nodes showed mild reactive changes and isolated lymph node revealed dilated endometrial gland with adjacent scant stroma, which was highlighted with immunohistochemistry for CD10 and progesterone receptor [Figure 2]. Deep infiltrating pelvic endometriosis was first described by Cornillie et al.[1] in 1990s where they described the endometriotic foci at depth >5mm with glandular activity in sync with menstrual cycle. Gastrointestinal involvement is reported in up to 3.8%–37% of women diagnosed as endometriosis.[2] Rectum and sigmoid are the most common locations comprising GI involvement cases 52%–72% followed by terminal ileum and appendiceal involvement. Other rare locations reported are gallbladder, Meckel diverticulum, stomach, and endometriotic cyst in liver and pancreas.[3] Patients (with GI involvement) present with varying symptoms depending on the site or extent of bowel wall involvement and may include episodes of abdominal pain, abdominal distension, tenesmus, constipation, and diarrhea. These cases are difficult to diagnose preoperatively but possible hints may be related to cyclical nature of symptoms. Radiologic findings are not specific, however, may assist in preoperative diagnosis. The lymph node involvement in deep endometriosis is an uncommon but not rare event reported in 42.6% cases. Though endometriosis is considered to be a benign disease, it may share overlapping histological features with malignant neoplasm including abnormal morphology, cellular invasion, and neoangiogenesis. In addition, endometriosis can undergo malignant transformation as reported in few case reports of endometriosis being associated with endometrioid and clear cell carcinoma.[4] Presently, there are many controversies with regards to the therapeutic approach to the cases of deep infiltrative endometriosis. In our case, due to acute presentation with heavy symptoms and suspicion of malignancy, resection was necessary. In the published literature, it is proven that surgery with postoperative hormone therapy can provide better results than exclusive hormone therapy or surgical intervention alone.[5]Figure 1: Contrast CT image showing vividly enhancing soft density lesion in the pelvis encasing the recto-sigmoid colon and causing eccentric focal luminal narrowingFigure 2: Gross (left top) image showing cut opened anterior resection specimen with wall thickening corresponding to the area of stricture, and microscopic images (right top and bottom) showing submucosal dilated irregular endometrial glands with intraluminal secretions and surrounding stroma and Pericolonic lymphnode showed isolated endometrial gland with eosinophilic secretions and sparse adjacent stroma, highlighted with immunohistochemistry for progesterone receptorDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.[7]