[Endometriosis in retroperitoneal lymph nodes]

Endometriosis with an aberrant immunophenotype: Challenging differential diagnosis of glandular lesions in the pelvic lymph nodes

CASE REPORT

We describe an unusual case of pelvic lymph node endometriosis with an aberrant immunophenotype mimicking metastasis of adenocarcinoma. A 37-year-old patient with a history of invasive cervical adenocarcinoma stage pT1a2 is presented. Due to insufficient loop electrosurgical excision procedure (LEEP) conization, total laparoscopic hysterectomy with pelvic lymphadenectomy was indicated. Intraoperatively, the diagnosis of deep infiltrating endometriosis of parametrial ligament and vesicouterine pouch, endometrioma of the left ovary and Allen Master's syndrome was suspected; the patient had no history or clinical symptoms of endometriosis. A PubMed search of similar cases was followed by a comparison to this case and discussion of the differential diagnosis of glandular lesions in the pelvic lymph nodes is reported.

RESULTS

Histological investigation showed no residual neoplasia; the diagnosis of endometriosis was confirmed. An interesting microscopic finding was represented by a solitary glandular lesion in one pelvic lymph node. Using immunohistochemistry, it was demonstrated that there was a complete loss of oestrogen and progesterone receptor expression (unlike parametrial ligament endometriosis). The diagnosis of endometriosis was based on the presence of endometrial stroma; malignancy was excluded by bland cytomorphologic features and results of immunohistochemical examination.

CONCLUSIONS

This type of aberrant of the endometriotic gland immunophenotype has never been presented in the scientific literature before. This finding plays a significant role from the pathology standpoint and, perhaps more importantly, from the clinical standpoint. An asymptomatic patient with a correct diagnosis of lymph node endometriosis did not undergo excessive treatment for false positive diagnosis of metastatic cervical adenocarcinoma.

Lymph node involvement and lymphovascular invasion in deep infiltrating rectosigmoid endometriosis

OBJECTIVE

To analyze the lymph node involvement by endometriotic foci in rectosigmoid endometriosis and to correlate it with clinical and histological parameters including the presence of lymphovascular invasions, which could explain this lymph node involvement.

DESIGN

A prospective study of 26 consecutive cases of rectosigmoid endometriosis between January 2005 and January 2007.

SETTING

A multidisciplinary study including clinical and pathological data.

PATIENT(S)

Twenty-six patients with symptomatic rectosigmoid endometriosis.

INTERVENTION(S)

Laparoscopic surgery with pathological analysis of each specimen.

MAIN OUTCOME MEASURE(S)

Involvement of lymph nodes by endometriotic foci was correlated with the size and the wall layers affected by endometriotic lesions, the number of lymph nodes retrieved, and the presence of lymphovascular invasions demonstrated by D2-40, a specific antibody to lymphatic vessels.

RESULT(S)

Lymph node involvement by endometriosis was observed in 11 of the 26 patients (42.3%) and correlated with the size of the lesions, the number of lymph nodes retrieved, and the presence of lymphovascular invasions, which were observed in 36.3% of cases.

CONCLUSION(S)

Our data confirm that lymph node involvement by endometriotic foci is a frequent event in rectosigmoid endometriosis and may result at least partially from a lymphatic spread of the disease.

Some mullerian inclusion cysts in lymph nodes may sometimes be metastases from serous borderline tumors of the ovary

Glandular inclusions that appear morphologically benign are occasionally found in lymph nodes as well as in peritoneal and omental biopsies. In patients with gynecologic malignancies, the nature and significance of these mullerian inclusion cysts (MIC) present a diagnostic challenge with regard to whether they are benign and incidental or are related to the coincident tumor for which surgery is being performed. Sixty-two cases of MIC were prospectively identified during a 6-year period. The frequencies were calculated and stratified by lymph node chain distribution, primary tumor site, and primary tumor type. MIC appeared as small cysts lined by a serous (mullerian)-type, cytologically bland, cuboidal to columnar epithelium with a simple architecture. Among 62 women, MIC was found in lymph nodes (27 cases), pelvic peritoneum (19 cases), omentum (16 cases), bowel serosa (9 cases), uterine serosa (8 cases), and parametrial connective tissues (4 cases). Among a set of 417 consecutive cases in which lymphadenectomy was performed, 46 (11%) women had MIC. The MIC involved multiple sites (26 cases in the peritoneum/omentum and 27 in lymph nodes). The primary tumor was in the ovary in 32 of the 46 women with MIC (70%) and of these, 17 were borderline serous (53%). Sixty-two of 6,154 lymph nodes examined contained MIC (1.0%). 3.2% of nodes contained MIC in which the primary tumor arose in the ovary, but only 0.1% with either endometrial or cervical tumors (chi2, p <0.00001). The lymph nodes most often involved by MIC were from para-aortic sites (40%), which reflect the primary drainage route from the ovary. Not uncommonly, neighboring areas in the same lymph node group with MIC disclosed separate foci of obvious metastatic borderline tumor (4 of 10; 40%). In summary, the increased frequency of MIC in lymph nodes sampled for primary ovarian malignancies suggests that MIC in some cases, rather than being benign, incidental inclusions, are more likely bland-appearing forms of metastatic tumor. The preponderance of inclusions occurs with serous ovarian tumors of borderline malignancy, and the inclusions are overrepresented in the lymph nodes that primarily receive drainage from the ovary.

Frequency and histogenesis of pelvic retroperitoneal lymph node inclusions of the female genital tract. An immunohistochemical study of 34 cases

Heterotopic tissue in lymph nodes is rare. Benign glandular lymph node inclusions (BGI) occur in 11.4% on average. Their histogenesis is still obscure. We studied 34 out of 1,039 cases of retroperitoneal lymph nodes with BGI (3.35%) of women who were treated by radical hysterectomy by Wertheim-Meigs of a cervical carcinoma. The nodes were reexamined by light microscopy and in 19 cases the antibodies MAK 6 (cytokeratine cocktail), HEA 125, Ber EP-4 (for differentiation between mesothelium and glandular differentiation), vimentin and CEA were additionally used. All BGI showed a strong expression of MAK 6 and in 57.9% and 73.7% to HEA 125 and Ber EP-4, respectively. Positive reaction against vimentin occured in 47.3%, but often only single cells were positive. None but one metastasis of an endometrioid adenocarcinoma of the cervix uteri of BGI expressed CEA. The BGI showed a capsular, trabecular or interfollicular location in more than 80% and in 44.1% an admixture of several cells at the lining epithelium was noted. No features usually associated with endometriosis, such as periglandular stroma or evidence of recent or old hemorrhage were seen. The results suggest that the BGI represent an endosalpingiosis and is therefore of secondary Müllerian origin. Some light microscopic features favoring the benign origin (location in the nodes, lining cells of multiple types, lack of mitoses and cellular atypism, no desmoplastic stroma reaction, presence of periglandular basement membrane) may be helpful in distinguishing metastasis of serous ovarian borderline tumors. Negative reaction against CEA and the cellular morphology can preclude metastases of an endometrioid adenocarcinoma of the cervix uteri as well as of a mucinous ovarian borderline tumor.