Müllerian-type carcinosarcoma arising in gastric endometriosis: Case report and review of the literature

Although endometriosis is a common condition, both extrapelvic endometriosis and endometriosis associated malignancy (EAM) are rare. We describe the first reported case of a patient with Müllerian-type carcinosarcoma arising in gastric endometriosis.

Malignant transformation of rectal endometriosis: Preoperative diagnosis by endorectal ultrasound guided biopsy

The prevalence of malignant transformation of endometriotic lesions is estimated between 0.3% and 1%. Malignant transformations of endometriosis occur in the colorectum is rarer, accounting for 0.25%. Because the malignant transformation of colorectal endometriosis rarely involves mucosa, it is difficult to obtain abnormal tissue by routine endoscopic biopsy. In this case, we evaluated a patient with a rectal mass by endorectal ultrasound (ERUS) and performed endorectal ultrasound-guided biopsy (EGB). Malignant transformations of endometriosis were confirmed by histological result. For patients with rectal tumors but with negative findings on colonoscopy and biopsy, ERUS and EGB contribute to preoperative diagnosis.

Clinicopathologic Features of Gynecologic Malignancies Presenting Clinically as Colonic Malignancies

OBJECTIVES

To systematically evaluate gynecologic malignancies (adnexal or uterine) causing gastrointestinal (GI) signs (eg, mass on colonoscopy) or symptoms (eg, bloody stools) clinically mimicking a GI primary malignancy.

METHODS

The archives of 2 institutions were retrospectively reviewed for gynecologic malignancies clinically manifesting as colonic lesions. For each case, available radiologic, endoscopic, and histologic findings were recorded.

RESULTS

We identified 16 cases: 13 biopsies and 3 resections. The masses were localized in the rectosigmoid (14 cases [88%]), right (1 case [6%]), and transverse (1 case [6%]) colon. Gastrointestinal-type complaints included abdominal pain, weight loss, hematochezia, and obstruction; 1 case was asymptomatic and found during screening colonoscopy. Nine patients (56%) had no known prior gynecologic malignancy, and in only 2 of these patients was there some clinical suspicion of a noncolonic primary malignancy. Most cases (13 [81%]) were serous carcinoma, usually high-grade adnexal or primary peritoneal. Six cases (38%) directly extended into the colon, and 7 (44%) metastasized; route of spread was unclear in the others. Only 1 case (6%) showed mucosal involvement, and none showed desmoplasia or dirty necrosis. Four of the 13 serous carcinomas (31%) showed psammoma bodies.

CONCLUSIONS

Advanced gynecologic malignancies, most commonly serous carcinoma, can rarely manifest as GI lesions. Clues to noncolonic origin on biopsy include lack of colonic mucosal involvement/dysplasia, desmoplasia, or dirty necrosis.

Endometriosis-associated intestinal tumors: a new challenge in clinical practice

A 66-year-old female consulted due to headache associated with diaphoresis, constipation, and melena. A urinalysis revealed elevated metanephrines, and colonoscopy identified an extrinsic sigmoid stricture. CT and MRI showed a presacral mass infiltrating the sigma. Scintigraphy and SPECT ruled out a diagnosis of paraganglioma. Based on these findings, the patient was proposed to undergo surgery.

Intestinal endometriosis treated by laparoscopic surgery: case series of 5 patients

Background

Intestinal endometriosis is rare and most frequently involves the rectum and sigmoid colon.

Case presentation

Here, we report a case series of 5 patients who underwent laparoscopic resection for intestinal endometriosis. None of the patients developed postoperative complications, and all were discharged at 5–8 days after surgery. The diagnosis of intestinal endometriosis is difficult to obtain before surgery. Only 2 of 5 patients were diagnosed preoperatively. Among 1 of the 2 patients, the symptoms at the time of menstruation were obvious. In patients with submucosal tumors, the preoperative diagnosis can be difficult. Additional imaging examinations at the time of menstruation might be useful for obtaining a diagnosis. D2 dissections were performed for 3 patients, because malignancy could not be ruled out as a preoperative diagnosis. The surgical findings of 1 patient did not appear to be endometriosis. Surgery for intestinal endometriosis usually encounters advanced pelvic adhesions and fibrosis. For patients undergoing sigmoidectomy, the mean operative time was 152 min and mean blood loss was 10 mL. For patients undergoing rectal resection, the mean operative time was 282 min and mean blood loss was 17 mL. Two cases had severe pelvic adhesions, and the residual rectum could not be straightened. Therefore, side-to-side anastomosis was performed. For intestinal endometriosis surgery, flexible planning for the anastomosis method used for residual intestine should be undertaken.

Conclusion

Laparoscopic surgery for intestinal endometriosis was safe but technically difficult, because of fibrosis and adhesions. An accurate diagnosis should be attempted based on the clinical symptoms, imaging findings, and intraoperative findings. The method used for anastomosis should be decided on a case-by-case basis.

Unusual Presentation of Recurrent Early Stage Endometrial Carcinoma 28 Years after Primary Surgery

Endometrial carcinoma is the most common neoplasia of female genital tract. The prognosis of early stage disease (FIGO I and FIGO II) is excellent: recurrence after surgery is less than 15%, most of which are reported within 3 years after primary treatment. Herein we report a case of late rectal recurrence from FIGO Ib endometrial adenocarcinoma. Patient had also familiar and personal history of colonic adenocarcinoma and previous findings of microsatellite instability (MSI); molecular analysis evidenced heterozygotic somatic mutation in MLH1 gene. Twenty-eight years after hysterectomy and bilateral salpingoovariectomy, a rectal wall mass was detected during routine colonoscopy. Patients underwent CT scan, pelvic MRI, and rectal EUS with FNA: histopathological and immunohistochemical analysis revealed differentiated carcinoma cells of endometrial origin. No neoadjuvant treatment was planned and low rectal anterior resection with protective colostomy was performed; histology confirmed rectal lesion as metastasis from endometrial carcinoma. Recurrence of early stage endometrial carcinoma after a long period from primary surgery is possible. It is important to keep in mind this possibility in order to set a correct diagnostic and therapeutic algorithm, including preoperative immunohistochemical staining, and to plan a prolonged follow-up program.

Liver recurrence in early endometrial cancer with focal myometrial invasion

Endometrial cancer is the most common malignancy of the female genital tract. The cancer spreads by direct extension, transtubal dissemination, lymphatic dissemination, and/or by hematogenous spread, usually results in lung metastasis, but may less commonly involve liver, brain, and bone. Here, we describe a patient with stage IA endometrial cancer who developed liver recurrence 17 months after surgery.

Endometroid carcinoma developing in endometriosis over the symphysis pubis

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We present the case of a premenopausal woman, who developed an endometriosis based endometrial carcinoma at the mons pubis.

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After a three year follow-up period the patient remains disease free.

Carcinoma of müllerian origin presenting as colorectal cancer: a clinicopathologic study of 13 Cases

Carcinomas of müllerian origin involving colorectum in women with no concurrent or history of gynecologic malignancies are diagnostically challenging, and its histogenetic origin is uncertain. We reviewed 13 cases of carcinoma of müllerian origin with clinical presentation mimicking primary colorectal carcinoma. The patients' average age was 63.9 years. All except 2 patients presented with mass lesions in rectosigmoid colon or rectovaginal septum. The major presenting symptoms were rectal bleeding (4/13), rectosigmoid mass (6/13), vaginal mass (1/13), and abdominal pain or constipation (2/13). The average size of tumor was 4.2 cm (range, 2.4-15.0 cm). Among the 10 patients who underwent preoperative biopsy, 5 were diagnosed to have moderately and poorly differentiated colorectal carcinoma. All tumors were surgically resected with final diagnoses of moderately differentiated endometrioid carcinoma in 6 cases, mixed serous and endometrioid carcinoma in 4 cases, malignant mixed müllerian tumor in 2 cases, and undifferentiated carcinoma in 1 case. In 9 of 13 cases, foci of endometriosis were identified adjacent to or within the tumor. One case had endosalpingiosis. Immunohistochemical stains showed, after positive results, the following: cytokeratin 7 (CK7; 13/13), estrogen receptor (13/13), progesterone receptor (10/13), cytokeratin 20 (CK20; 0/13), and CDX-2 (0/13). In conclusion, carcinoma of müllerian origin often presents as bulky mass in rectosigmoid or rectovaginal septum clinically mimicking primary colorectal cancer. Endometriosis might be an important etiologic factor. Familiarities of this unusual clinicopathologic entity, careful morphologic evaluation, and immunohistochemical stain with a panel of markers (CK7, CK20, estrogen receptor, progesterone receptor, CDX-2) will be helpful for the correct diagnosis.

Endometrioid adenocarcinoma arising from endometriosis of the rectosigmoid

A case of endometrioid adenocarcinoma supposedly arising from endometriosis of the rectum is reported. Malignant transformation is uncommon but a well-known complication of endometriosis. In the present case, it was proved by histopathological findings and immunophenotype such as cytokeratin7+/cytokeratin20-/estrogen receptor+. The cause of rectal endometriosis in this case might have been related with previously received hormone replacement therapy for ovarian endometriosis. Following surgical removal of the lesion, this patient underwent adjuvant chemotherapy with paclitaxel and carboplatin, although this kind of therapy is still controversial as to its effectiveness.

Colonic endometriosis mimicking colon cancer on a virtual colonoscopy study: a potential pitfall in diagnosis

Colonic endometriosis has been reported in the literature to mimic colon cancer. Patients can present with symptoms almost identical to colon cancer. We present an exemplary case of a woman who was found to have a mass on conventional colonoscopy. Virtual colonoscopy was instrumental in characterizing the obstructive sigmoid mass. A biopsy of the mass revealed sigmoid endometriosis.

Stage IV endometrial cancer after failed conservative management: a case report

BACKGROUND

With younger women becoming increasingly overweight, endometrial cancer is becoming a concern in this group. These women are likely to desire fertility preservation. There are no randomized controlled data to guide conservative therapy.

CASE

A 24-year-old female with endometrial adenocarcinoma diagnosed in December 2003 was treated conservatively with Megace and levonorgestrel intrauterine device. She was lost to follow-up and represented in March 2006. Endometrial biopsy revealed grade 1 endometrial adenocarcinoma. Definitive surgical therapy was recommended, however, the patient declined surgery in the interest of preserving fertility until November 2006. Final pathology revealed a stage IV, grade 1 endometrioid endometrial cancer.

CONCLUSION

Women with endometrial cancer who desire fertility preservation should be counseled regarding the possible risk of advanced disease if surgical therapy is delayed.

[Gastrointestinal bleeding of obscure origin caused by a metastatic endometrial adenocarcinoma. Response to hormonal therapy]

BACKGROUND

Endometrial cancer (EC) is the most common gynecologic malignancy. Gastrointestinal tract involvement is unusual and is often limited to local invasion of the rectum in advanced disease.

CASE REPORT

We report the case of a 77-year-old woman who presented with intermittent gastrointestinal bleeding 2 years after treatment of stage IIb EC. Biopsy of a subcutaneus nodule showed fibroadipose tissue infiltrated by an EC. A computed tomography scan showed extensive lymphatic, abdominal and pelvic recurrence of the cancer. A source of bleeding in the small bowel was detected by scintigraphic study with 99mTc-marked red blood cells. Control of bleeding and a 22-month survival were obtained after treatment with oral medroxyprogesterone acetate.

DISCUSSION

We review digestive tract involvement in EC and previously published data on small bowel metastases. We also review the role of hormone therapy in the management of this disease.

[Intestinal endometriosis. Current status]

Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.