Endometriosis in para-aortic lymph nodes during pregnancy: case report and review of literature

OBJECTIVE: To report a case of endometriosis in para-aortic lymph nodes during pregnancy. DESIGN: Case report. SETTING: Tertiary care center. PATIENT(S): A 25-year-old multipara pregnant woman with a history of chronic pelvic pain and ovarian cystectomies for bilateral endometriomas. INTERVENTION(S): The patient was admitted with a placenta previa and a subchorionic hemorrhage at 24 weeks 5 days' gestation, and subsequently developed uterine contractions. Magnetic resonance imaging revealed a large complex adnexal mass adherent to the uterus and pelvic and para-aortic lymphadenopathy. Tocolysis could not be achieved and the patient underwent cesarean delivery at 26 weeks 3 days. An implant on the uterus and an enlarged para-aortic lymph node were removed surgically at that time. MAIN OUTCOME MEASURE(S): Involvement of lymph node by endometriosis and presence of a recurrent endometrioma. RESULT(S): Endometriosis was confirmed pathologically in para-aortic lymph nodes. Uterine serosal biopsy demonstrated endometriosis, and the large adnexal cyst was grossly consistent with endometrioma. The patient delivered a viable male infant at 26 weeks 3 days. CONCLUSION(S): To our knowledge, this is the first reported case of endometriosis in para-aortic lymph nodes. Its presence supports the hypothesis that endometriosis travels lymphatically, and not simply via locoregional spread. Lymphatic spread also further supports the theory that endometriosis is an aggressive chronic systemic disease.