Mucosal changes in the large bowel with endometriosis: a possible cause of misdiagnosis of colitis?

Colorectal endometriosis - a challenging, often overlooked cause of colorectal pathology: a clinicopathological review of 114 cases

The colon is the most common site for endometriosis outside the genital tract. It has a varied presentation and can mimic numerous other conditions, both clinically and pathologically. We investigated the clinicopathological features of a series of colorectal endometriosis with a particular emphasis on the features seen in cases with colonic mucosal involvement. A total of 114 consecutive cases of colorectal endometriosis were reviewed. Forty-eight percent did not have a prior diagnosis of endometriosis and in 34 patients (30%) the endometriosis was determined as the cause for the presentation. Mucosal involvement was present in 31 specimens. Features of chronic colitis were seen in the adjacent mucosa in 90% of cases whilst there were glandular changes mimicking adenocarcinoma in two cases (1.8%). Fifty percent of cases with mucosal involvement also showed glands with a hybrid intestinal-endometrial phenotype by morphology and/or by immunohistochemistry. Endometriosis is an important mimic of other conditions.

An Unusual Cause of Large Bowel Obstruction in a Patient With Ulcerative Colitis

Endometriosis is a rare cause of large bowel obstruction and has been infrequently reported in patients with inflammatory bowel disease. We present an unusual case of a young woman with ulcerative colitis, who presented with a large bowel obstruction with colonic stricture and peripancreatic mass concerning for malignancy. The evaluation revealed endometriosis, and her large bowel obstruction was successfully managed with leuprolide and colonic stenting.

Endometriosis of the Small Bowel: A Diagnostic Enigma

Endometriosis refers to the implantation and proliferation of endometrial tissue outside the uterus. Small bowel endometriosis is an uncommon location for endometrial deposits and when present, it can pose diagnostic difficulty. Here, we present a case of a 50-year-old female with small bowel endometriosis who suffered from recurrent attacks of colicky abdominal pain for few months. Her cross-sectional investigations remained largely inconclusive. Ultimately, she underwent diagnostic laparoscopy which was diagnostic and therapeutic.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

A case of unique endoscopic findings of intestinal endometriosis exposed to the mucosa: aggregation of papillary protruded bulges from the submucosal elevation of the rectum

Intestinal endometriosis exposed to the mucosa is relatively rare. Therefore, its endoscopic findings with pit pattern and magnifying endoscopy with narrow-band imaging and clinicopathological features of intestinal endometriosis exposed to the mucosa have not been well documented until now. A 44-year-old woman was suspected to have gastrointestinal bleeding by positive fecal occult blood test. Colonoscopy revealed a hemicircular submucosal tumor whose surface was covered with easy-bleeding papillary bulges in the rectum. Pit pattern analysis and magnifying endoscopy with narrow-band imaging revealed straight microvessels among the straight pits arranged in a radial manner, and the avascular area with no pit pattern of the top of the bulge. These findings were different from those of polyps or cancer. Biopsy specimens from the protruded lesions were diagnosed as rectal mucosal endometriosis by hematoxylin-eosin staining and immunohistochemical examination. Surgical resection was suggested to the patient, but the patient did not favor surgical treatment. After the diagnosis dienogest treatment started and successfully relieved her abdominal pain. Malignant transformation of the endometriotic lesion has not arisen to this date.

Bowel endometriosis

Bowel obstruction accounts for 20% of hospital admissions due to acute abdominal pain. We report a case of acute bowel obstruction in a 31-year-old woman with a history of endometriosis diagnosed on laparoscopy a year before this presentation. Her clinical and biochemical picture suggested peritonitis and CT revealed an irregular soft tissue mass compressing a dilated rectosigmoid. Pockets of intraperitoneal gas were also documented and presumed to be secondary to bowel perforation at the level of the mass. Exploratory laparotomy was performed and the affected bowel was resected. Histology revealed extensive stricturing and fibrosis secondary to intestinal endometriosis. General practitioners, gastroenterologists and general surgeons are likely to encounter endometriosis, need to be competent in its diagnosis and management and collaborate promptly with the gynaecologist. Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with any gastrointestinal or abdominal symptom.

Endometriosis involving the mucosa of the intestinal tract: a clinicopathologic study of 15 cases

Endometriosis involving the mucosa of the intestines is rare, but may lead to diagnostic pitfalls. We reviewed 15 cases (seven biopsies and eight resections) from 14 patients. The patients' mean age is 48 years (31-66 years). Presenting symptoms included lower gastrointestinal bleeding, pelvic pain, rectal urgency, abdominal mass, and bowel obstruction. In the majority of cases, the lesion was located in the rectum (73%) with the remainder in the sigmoid colon (20%) and ileum (7%). The most common indication for biopsy was a polypoid lesion seen endoscopically (eight cases). For patients who underwent resections, the most common clinical impression was colonic carcinoma (75%), due to mass lesions and stricture as the most common macroscopic findings. Histologically, one case had stromal endometriosis only, but the remaining 14 cases had both endometrial glands and stroma. Epithelial metaplasia was present in all cases, mostly tubal metaplasia (ciliated epithelium). Hybrid glands and replacement of the surface epithelium by endometrial epithelium were also seen. Crypt architectural distortion, cryptitis, and crypt abscesses were seen in some cases, mimicking chronic active colitis or enteritis. A panel of immunohistochemical stains (CK7, CK20, CDX2, and ER) was found to be useful in biopsies with suspected endometriosis demonstrating unusual histology or only containing endometrioid stroma tissue. Vascular involvement by endometriosis was identified in one case. Endometrial hyperplasia (n=2) and cancer (n=1) were also seen in the ectopic tissue. All patients were alive at follow-up (3-216 months, mean 67 months).

Endometriosis of the terminal ileum: a diagnostic dilemma

Endometriosis is characterized by the presence of endometrial tissue consisting of glands and/or stroma located outside the uterus. Involvement of the terminal ileum is extremely rare. Preoperative distinction of ileal endometriosis from other diseases of the ileocecal region is difficult in terms of clinical presentation, symptomatology, radiological appearance, and surgical and pathological findings. We report a case initially diagnosed as Crohn's disease due to a longstanding diarrhea with subsequent intestinal obstruction, but finally diagnosed as ileal endometriosis by histopathological evaluation after resection of the involved segment.

Endometriosis: a rare cause of small bowel obstruction

Although endometriosis is a common condition in young women, symptomatic involvement of the small bowel is rare. The authors report the case of a 44-year-old lady initially thought to have irritable bowel syndrome who presented 1 month later with acute small bowel obstruction. A CT scan showed small bowel dilatation with a transition point in the ileum, but no distinct lesion. The patient had an exploratory laparotomy where an obstructing lesion in the terminal ileum and several enlarged mesenteric lymph nodes were identified. Consequently, a right hemicolectomy was performed. Pathology specimens showed multiple endometriotic foci in the bowel with stricturing of terminal ileum and appendiceal intussusception. This likely resulted in subocclusive episodes and intestinal obstruction. This case highlights the difficulty in establishing a preoperative diagnosis of endometriosis. Small bowel endometriosis should, therefore, be considered in the differential diagnosis of women of childbearing age who present with symptoms of obstruction.

Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Acute small bowel obstruction caused by endometriosis: A case report and review of the literature

Gastrointestinal involvement of endometriosis has been found in 3%-37% of menstruating women and exclusive localization on the ileum is very rare (1%-7%). Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction, ranging from 7% to 23% of all cases with intestinal involvement. We report a case in which endometrial infiltration of the small bowel caused acute obstruction requiring emergency surgery, in a woman whose symptoms were not related to menses. Histology of the resected specimen showed that endometriosis was mainly prevalent in the muscularis propria and submucosa and that the mucosa was not ulcerated but had inflammation and glandular alteration. Endometrial lymph node involvement, with a cystic glandular pattern was also detected.

Experimental endometriosis in the rat is correlated with colonic motor function alterations but not with bacterial load

Endometriosis commonly presents with symptoms that mimic chronic gastrointestinal disorders. The authors used the autotransplantion model of endometriosis in rats to investigate the possible underlying mechanisms. After the rats were killed, the presence of endometriotic vesicles, colonic inflammation, and white blood cell (WBC) numbers in the peritoneal fluid was determined. Sections of colon and of jejunum were collected for measurement of myeloperoxidase (MPO) activity and bacterial counts, and isometric recording in response to acetylcholine was measured in segments of longitudinal and circular smooth muscle. Experimental animals had significantly more colonic damage, MPO activity, and WBC numbers than controls did. There was no significant difference in the total bacterial load; however, experimental animals demonstrated an increased tension in the longitudinal muscle, which correlated with WBC numbers and colonic damage. In summary, this study presents evidence for a significant effect of peritoneal endometriosis on colonic function and integrity, which may help explain the gastrointestinal symptoms associated with this disease.

Crohn’s disease complicated by multiple stenoses and internal fistulas clinically mimicking small bowel endometriosis

We report a 31-year-old woman with Crohn’s disease complicated by multiple stenoses and internal fistulas clinically misdiagnosed as small bowell endometriosis, due to the patient’s perimenstrual symptoms of mechanical subileus for 3 years; at first monthly, but later continuous, and gradually increasing in severity. We performed an exploratory laparotomy for small bowel obstruction, and found multiple ileal strictures and internal enteric fistulas. Because intraoperative findings were thought to indicate Crohn’s disease, a right hemicolectomy and partial distal ileum resection were performed for obstructive Crohn’s ileitis. Histopathology of the resected specimen revealed Crohn’s disease without endometrial tissue. The patient made an uneventful recovery from this procedure and was discharged home 10 d post-operatively. The differential diagnosis of Crohn’s diease with intestinal endometriosis may be difficult pre-operatively. The two entities share many overlapping clinical, radiological and pathological features. Nevertheless, when it is difficult to identify the cause of intestinal obstruction in a woman of child-bearing age with cyclical symptoms suggestive of small bowel endometriosis, Crohn’s disease should be included in the differential diagnosis.

The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects

Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia. Although the last 2 findings are often referred to collectively as "atypical endometriosis," they should be separately recognized as their premalignant potential likely differs. In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change. Occasional findings in endometriosis that may raise concern for a neoplasm include necrotic pseudoxanthomatous nodules, polypoid growth (polypoid endometriosis), bulky disease, and venous, lymphatic, or perineural invasion. Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings and include infection within endometriotic cysts, pseudoxanthomatous salpingitis, florid mesothelial hyperplasia, peritoneal inclusion cysts, and Liesegang rings. The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis, including the important distinction of an endometrioid carcinoma arising from colonic endometriosis from a primary colonic adenocarcinoma. Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance.

Bowel endometriosis: CT-enteroclysis

Although several radiological techniques have been used for the diagnosis of bowel endometriosis, no gold standard is currently established. We used multislice computerized tomography (CT) combined with the distention of the colon by rectal enteroclysis (MSCTe) for the diagnosis of bowel endometriosis. Following bowel preparation, pharmacological hypotonicity, retrograde colonic distention by water enteroclysis, and intravenous injection of iodinated contrast medium, a single volumetric acquisition of the abdomen is performed. MSCTe findings suggestive of bowel endometriosis are the presence of solid nodules with positive enhancement, contiguous or penetrating the colonic wall. When endometriotic lesions are detected, the degree of infiltration of the intestinal wall can be estimated; however, the depth infiltrated by nodules reaching the submucosa may be underestimated. MSCTe is well tolerated by the patients. The strength of MSCT consists in the high spatial resolution; volumetric data acquired by using thin slices provide isotropic voxels and multiplanar reconstructions have a quality comparable with that of the original axial scans. The potential of MSCTe for the diagnosis of bowel endometriosis relies on the fact that the serosal, muscular, and mucosal layers of the bowel wall can be evaluated.

Simultaneous Laparoscopic Treatment for Rectosigmoid and Ileal Endometriosis

Endometriosis is common in women of childbearing age, while severe intestinal endometriosis requiring bowel resection is relatively rare. Intestinal endometriosis has recently been managed laparoscopically. We report the case of a 38-year-old patient with rectosigmoid and ileal endometriosis who was successfully treated by laparoscopic bowel resections. The patient had first presented at age 34 years with a chief complaint of rectal bleeding and lower abdominal pain related to the menstrual cycle. She underwent laparoscopic surgery and was diagnosed with severe endometriosis involving the rectosigmoid colon. Although an additional laparoscopic surgery had been planned, she did not return to the hospital. When she was 38 years old, she presented again with the same symptoms. Magnetic resonance imaging revealed a low intensity mass between the uterus and the rectosigmoid colon. A barium enema showed a stenotic site in the rectosigmoid colon. After hormone therapy, she underwent laparoscopic surgery. The anterior wall of the rectosigmoid colon adhered firmly to the corpus of the uterus, and another stenotic site was identified at the terminal ileum. The rectosigmoid colon and ileum were partially resected under laparoscopy. The postoperative course was uneventful and she was freed of symptoms. Laparoscopic treatment for patients with severe endometriosis of the bowel has becomes feasible and safe.

An Unusual Rectosigmoid Mass: Endometrioid Adenocarcinoma Arising in Colonic Endometriosis: Case Report and Literature Review

Malignant transformation is an infrequent complication of endometriosis. The ovary is the primary site in 79 per cent of cases, and extragonadal sites are identified in 21 per cent. Primary involvement of these types of tumors with the colon and/or rectum is a rare clinical entity. Endometrioid carcinoma is a common histologic type that remains a diagnostic challenge–the main differential diagnosis includes colorectal carcinomas. We report a case of malignant transformation arising in colonic endometriosis. The patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy 10 years before she presented with hematochezia. The patient was ultimately treated by surgical resection. Immunohistochemical staining in addition to the usual histopathology was critical for accurate diagnosis of this endometriosis-associated intestinal tumor.

Preoperative double-contrast barium enema in patients with suspected intestinal endometriosis

STUDY OBJECTIVES

To assess the usefulness of double-contrast barium enema (DCBE) in the diagnosis of endometriotic lesions of the bowel and to define its potential value in preoperative decision making for intestinal surgery.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

General hospital with a specialized endometriosis unit.

PATIENTS

One hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery.

INTERVENTION

Laparoscopic complete excision of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Fifty-five patients were found to have an entirely normal colon on DCBE studies. Twenty-eight of these were found to have adhesions of the bowel at laparoscopy. Radiographic abnormalities suggestive of endometriosis were detected in 53 patients; 20 of these underwent laparoscopic bowel segmental resection, 10 laparoscopic full-thickness disc excision, 4 laparoscopic mucosal skinning, and 4 total laparoscopic hysterectomy with bilateral salpingo-oophorectomies. Fourteen patients refused intestinal surgery. One patient had no endometriosis but severe adhesions. In all cases but one, the radiographic findings on DCBE were confirmed by surgery and with histopathologic examination of the resected specimens (accuracy 99%). In these same cases, the preoperative choice of intestinal surgery remained unchanged during the procedure.

CONCLUSION

Our data show that, in expert hands, DCBE correlated with a patient's clinical history and clinical findings is capable of diagnosing bowel wall involvement due to endometriosis, which could require intestinal surgery. This allows for proper preoperative planning of surgical procedures and a thorough informed consent.

A case of sigmoid endometriosis difficult to differentiate from colon cancer

BACKGROUND

Although endometriosis with sigmoid serosal involvement is not uncommon in women of childbearing age, the mucosal involvement is rare and differential diagnosis from colon cancer may be difficult due to the lack of pathognomonic symptoms and the poor diagnostic yield of colonoscopy and colonic biopsies.

CASE PRESENTATION

We present a case of a young woman with sigmoid endometriosis, in which the initial diagnostic workup suggested colon cancer. Histologic evidence, obtained from a second colonoscopy, along with pelvic ultrasound findings led to the final diagnosis of intestinal endometriosis which was confirmed by laparoscopy.

CONCLUSION

Colonic endometriosis is often a diagnostic challenge and should be considered in young women with symptoms from the lower gastrointestinal tract.

A case of sigmoid endometriosis difficult to differentiate from colon cancer

BACKGROUND

Although endometriosis with sigmoid serosal involvement is not uncommon in women of childbearing age, the mucosal involvement is rare and differential diagnosis from colon cancer may be difficult due to the lack of pathognomonic symptoms and the poor diagnostic yield of colonoscopy and colonic biopsies.

CASE PRESENTATION

We present a case of a young woman with sigmoid endometriosis, in which the initial diagnostic workup suggested colon cancer. Histologic evidence, obtained from a second colonoscopy, along with pelvic ultrasound findings led to the final diagnosis of intestinal endometriosis which was confirmed by laparoscopy.

CONCLUSION

Colonic endometriosis is often a diagnostic challenge and should be considered in young women with symptoms from the lower gastrointestinal tract.

Colorectal mass lesions masquerading as chronic inflammatory bowel disease on mucosal biopsy

AIMS

We bring to the attention of diagnostic pathologists a further cause of mimicry of chronic inflammatory bowel disease on mucosal biopsy, namely intramural and subserosal colorectal mass lesions.

METHODS AND RESULTS

In a 10-year prospective study in one centre, we describe 26 cases in which the initial colonoscopic biopsies suggested a diagnosis of chronic inflammatory bowel disease, whereas subsequent information indicated that the mucosal changes were due to underlying mass lesions, without evidence of chronic inflammatory bowel disease. These mass lesions included underlying primary adenocarcinoma, metastatic carcinoma, pneumatosis, endometriosis and complicated diverticular disease.

CONCLUSIONS

In the colon and rectum, intramural and subserosal mass lesions are a significant cause of chronic inflammatory bowel disease mimicry. Possible pathogenic mechanisms include mechanical effects, lymphatic obstruction by underlying tumour, relative mucosal ischaemia and mucosal prolapse. Since the changes seen on mucosal biopsies are a secondary phenomenon, we tentatively suggest that 'secondary colitis' may be an appropriate appellation.

Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation

Endometriosis of the intestinal tract may mimic a number of diseases both clinically and pathologically. The authors evaluated 44 cases of intestinal endometriosis in which endometriosis was the primary pathologic diagnosis, and evaluated them for a variety of gross and histologic changes. Cases with preneoplastic or neoplastic changes were excluded specifically because they were the subject of a previous study. The patients ranged in age from 28 to 56 years (mean age, 44 years), and presenting complaints included abdominal pain (n = 15), an abdominal mass (n = 12), obstruction (n = 8), rectal bleeding (n = 2), infertility (n = 3), diarrhea (n = 2), and increasing urinary frequency (n = 1). The clinical differential diagnoses included diverticulitis, appendicitis, Crohn's disease, tubo-ovarian abscess, irritable bowel syndrome, carcinoma, and lymphoma. Forty-two patients underwent resection of the diseased intestine and two patients underwent endoscopic biopsies. In 13 patients there were predominantly mural masses, which were multiple in two patients (mean size, 2.6 cm). In addition, 11 cases had luminal stenosis or strictures, six had mucosal polyps, four had submucosal masses that ulcerated the mucosa (sometimes simulating carcinoma), three had serosal adhesions, one had deep fissures in the mucosa, and one was associated with appendiceal intussusception. Involvement of the lamina propria or submucosa was identified in 29 cases (66%) and, of these, 19 had features of chronic injury including architectural distortion (n = 19), dense lymphoplasmacytic infiltrates (n = 7), pyloric metaplasia of the ileum (n = 1), and fissures (n = 1). Three cases had features of mucosal prolapse (7%), ischemic changes were seen in four (9%), and segmental acute colitis and ulceration were seen in four and six cases (9% and 13%) respectively. In 14 patients, endometriosis formed irregular congeries of glands involving the intestinal surface epithelium, mimicking adenomatous changes. Mural changes included marked concentric smooth muscle hyperplasia and hypertrophy, neuronal hypertrophy and hyperplasia, and fibrosis of the muscularis propria with serositis. Follow-up of 20 patients (range, 1-30 years; mean, 7.8 years) revealed that only two patients had recurrent symptoms. None of the patients developed inflammatory bowel disease. Endometriosis can involve the intestinal tract extensively, causing a variety of clinical symptoms, and can result in a spectrum of mucosal alterations. Because the endometriotic foci may be inaccessible to endoscopic biopsy or may not be sampled because of their focality, clinicians and pathologists should be aware of the potential of this condition to mimic other intestinal diseases.

Hyperplastic-like mucosal change in Crohn's disease: an unusual form of dysplasia?

Patients with Crohn's disease are at increased risk of developing intestinal adenocarcinoma. Dysplasia is both a marker and a precursor of adenocarcinoma in this setting. In a review of our cases of Crohn's-related adenocarcinoma, we noted a peculiar hyperplastic-like mucosal change (HPC) in mucosa both adjacent to and distant from the adenocarcinoma in some cases. However, the significance of this change is unknown. We evaluated 30 cases of Crohn's-related adenocarcinoma and 30 age- and site-matched resection specimens with Crohn's disease without adenocarcinoma to determine the prevalence of this mucosal alteration in these groups. HPC was recognized by a diffuse expanse of flat mucosa with an architecture resembling that seen in colorectal hyperplastic polyps and composed of cells with cytologically bland basal nuclei and apical cytoplasmic mucin distention. The relationship of the HPC to the adenocarcinoma was noted in the Crohn's-related adenocarcinoma cases. An immunohistochemical stain for p53 (antibody DO7) was performed on all cases with HPC in both groups. HPC was identified in 10 of 30 (33%) cases of Crohn's-related adenocarcinoma compared with 3 of 30 (10%) cases in the control group (P = .03). In the 10 cases of Crohn's-related adenocarcinoma with HPC, this alteration was found adjacent to the adenocarcinoma in 3 cases, distant to the adenocarcinoma in 5 cases, and both adjacent to and distal from the adenocarcinoma in 2 cases. In two specimens, HPC was seen immediately adjacent to adenocarcinoma in the absence of adjacent dysplasia. p53 immunoreactivity was noted in HPC in 5 of 10 (50%) Crohn's-related adenocarcinomas. In contrast, p53 immunoreactivity was not seen in HPC in the three control cases with this mucosal alteration. In conclusion, HPC is found significantly more commonly in mucosa both adjacent to and distant from Crohn's-related adenocarcinoma when compared with age- and site-matched controls. In addition, p53 immunoreactivity is more commonly seen in HPC in cases of Crohn's-related adenocarcinoma compared with controls. These data suggest that this mucosal alteration may, in some cases, represent an unusual form of dysplasia in this setting.

Neoplastic and pre-neoplastic changes in gastrointestinal endometriosis: a study of 17 cases

The clinicopathologic features of neoplasms arising in gastrointestinal endometriosis have not been well characterized. In this series, we report 17 cases of gastrointestinal endometriosis complicated by neoplasms (14 cases) or precancerous changes (three cases). Four patients, one of whom also had hypermenorrhea, presented with chronic abdominal pain and five had obstructive symptoms; one of these also had rectal bleeding. One patient presented with an acute abdomen and fecal peritonitis, one had vaginal bleeding, and one had a progressive change in bowel habits. Nine patients had a long history of endometriosis, 11 patients had had hysterectomies, and eight of these had also received unopposed estrogen therapy. The lesions involved the rectum (6), sigmoid (6), colon, unspecified (2), and small intestine (3), and comprised 8 endometrioid adenocarcinomas (EA), 4 mullerian adenosarcomas (MAS), 1 endometrioid stromal sarcoma (ESS), 1 endometrioid adenofibroma of borderline malignancy (EBA) with carcinoma in situ, 2 atypical hyperplasias (AH), and one endometrioid adenocarcinoma in situ (ACIS). The tumors ranged in size from 2 to 15 cm and all involved the serosa and muscularis propria. Two tumors extended into the mucosa, with mucosal ulceration in one. Follow-up was available in 11 cases. One patient with EA was dead of disease at 1 year, one had two recurrences at 1 and 2 years, and three were alive with no evidence of disease (ANED) at 9 months to 13 years (mean, 68 mos). The patient with the EBA was ANED at 3 months. Two patients with MAS were ANED at 2 and 3 years. The patient with ESS had a recurrence at 3 years and was ANED 6 years after her original diagnosis. One woman with AH was ANED at 60 months and the patient with ACIS was ANED at 16 months. One of the carcinomas was originally misdiagnosed as a primary intestinal adenocarcinoma. The pathologist should be aware of the possibility of a tumor of genital tract type when evaluating intestinal neoplasms in females, particularly if they have a history of endometriosis and have received unopposed estrogen therapy.

Endometriosis of the bowel with lymph node involvement. A report of three cases and review of the literature

Three cases of endometriosis of the bowel with lymph node involvement were studied. Histologically, endometriotic glands with typical stroma were recognized throughout the intestinal wall, from the subserosal tissue to the mucosa. Foci of endometriosis were found in a number of pericolic lymph nodes occupying the subcapsular area or the cortex. The cytological smears were cellular, composed of large sheets of mucous columnar cells of intestinal origin, mixed with groups of recognizable endometrial cells and smaller spindly cells of endometrial stroma. Immunohistochemically, endometriotic cells showed positivity for cytokeratin and EMA, and they retained immunoreactivity for estrogen and progesteron in the intestinal lesions, as well as in the lymph nodes. Lymph nodal endometriosis was disclosed in two out of three cases only by multistep section examination of the pericolic lymph nodes, previously reported as negative for this feature.