Hepatic endometriosis: a rare case and review of the literature

A rare case report: Bladder endometriosis at the urachus

Endometriosis is an uncommon condition, and its occurrence in the urachus is exceptionally rare. This case report highlights the extreme rarity of bladder endometriosis involving the urachal area. To the best of our knowledge, no such cases have been previously reported in the literature. The clinical presentation and imaging findings of this condition are extremely similar to those of urachal carcinoma, which makes the differential diagnosis particularly challenging. In this case, a 34-year-old woman presented with significant bladder irritative symptoms during menstruation. Imaging revealed a mass in the urachal region, but its characteristics remained uncertain. Cystoscopy showed only bladder compression, and the patient ultimately underwent robot-assisted laparoscopic partial cystectomy. Postoperative pathology confirmed the diagnosis of bladder endometriosis. This case underscores the importance of considering bladder endometriosis in the differential diagnosis of masses in the urachal area, particularly when they resemble urachal cancer. Early surgical intervention and histopathological confirmation are essential to prevent disease progression.

Intestinal and liver involvement by endometrial stromal sarcoma: Expanding the differential diagnosis of mesenchymal tumors involving the GI tract

Endometrial stromal sarcoma (ESS) is a mesenchymal tumor known for infiltrative growth and lymphovascular invasion. Most examples arise in the endometrium, but some occur in the abdominal cavity without a primary uterine lesion, likely originating from endometriosis. ESS involving the gastrointestinal (GI) tract and liver is rare. We reviewed 15 examples from 13 women between 2010 and 2023. The mean age was 51 (range 16-81); just over half of the patients (7/13, 54 %) had a history of uterine ESS. Twelve tumors involved the intestines and three the liver; rectosigmoid colon was the most affected site. Tumors averaged 4.6 cm (range 0.3-10 cm) and involved all bowel layers with two showing transmural involvement. Predominantly low-grade features were observed, including uniform round to spindle cells in fibrous or myxoid stroma, permeative growth, hyaline plaques, and spiral arterioles. Endometriosis was seen in 4 (27 %) cases. Immunohistochemical analysis revealed positivity for ER (93 %), PR (92 %), CD10 (91 %), and focal cyclin D1 (80 %). A minority of cases showed staining with smooth muscle markers, CD117, DOG1, and keratins. High-grade features were suggested but not diagnostic in three cases. Follow-up data for three patients showed one death at 16 months, one patient disease-free at 94 months, and another alive at 16 months. ESS involving the GI tract is rare, may lack a uterine primary, and can mimic other neoplasms due to keratin, smooth muscle, and CD117/DOG1 expression. Recognizing ESS-associated features-such as a permeative pattern, hyaline plaques, and spiral arterioles-is key to avoiding misdiagnosis.

Role of computed tomography in imaging of endometriosis

Endometriosis is a chronic systemic disease characterized by the presence of endometrium-like glands and/or stroma outside the uterus, usually with an associated inflammatory process. It affects around 5-10% of women worldwide, with chronic pelvic pain and infertility being the predominant symptoms. Although suspected clinically, transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) are the primary imaging tools for diagnosing pelvic endometriosis, as well as helping in pre-surgical mapping. Computed tomography (CT) is not the preferred imaging modality for detection or depiction of disease extent. However, CT of the abdomen and pelvis is often performed as the initial imaging test in women presenting with acute or non-specific abdominal/ pelvic pain. CT features of endometriosis can vary depending on the organ affected, and the correct diagnosis is often not suspected due to its nonspecific CT appearance and overlap with other pathologies. Ovarian endometriomas (OMAs), the most recognized phenotype of endometriosis, may appear as hyperdense adnexal masses either in the expected location of the ovaries or positioned posterior to the uterus. Endometriomas may rupture, presenting with hemoperitoneum. The uterus may be distorted and acutely retroflexed from deep endometriosis along the posterior uterine surface. The bowel can be affected by endometriosis, especially the rectosigmoid colon, presenting as enhancing soft tissue bridging from the posterior uterine surface to the anterior rectal wall. Small bowel involvement may present with recurrent small bowel obstructions. Involvement of the urinary system may present with ureteral obstruction or a bladder wall mass. Given such varied appearances, a high degree of clinical suspicion and knowledge of CT features suggestive of endometriosis is required to facilitate an early diagnosis. This review paper therefore describes the imaging findings of endometriosis that can be recognized on an abdominopelvic CT, with the goal of decreasing the existing delay to accurate diagnosis and improving long term patient outcomes.

Quantification of Free Circulating DNA and Differential Methylation Profiling of Selected Genes as Novel Non-Invasive Biomarkers for Endometriosis Diagnosis

Endometriosis is a chronic, estrogen-dependent disorder associated with the presence of endometrial cells mainly in the pelvic cavity, causing systemic immune inflammation, infertility, epigenetic dysregulation of differential DNA methylation, coelomic metaplasia, and pain. It affects approximately 10-12% of women. Despite decades of research, full pathophysiology, a diagnostic roadmap, and clinical management strategies for endometriosis are not yet fully elucidated. Cell-free DNA (Cf-DNA) in the peripheral blood of diseased and healthy individuals was discovered in the 1950s. Quantifying peripheral Cf-DNA and the specific differential methylation of a group of genes have been proposed as potential non-invasive diagnostic biomarkers for somatic and constitutional genetics and for various other pathological disorders. In this study, we investigated the Cf-DNA levels of 78 young women, 38 of whom had endometriosis confirmed via laparoscopy and 40 of whom were healthy. We found a significant difference between the two groups when Cf-DNA was quantified, with 3.9 times more Cf-DNA in the serum of women with endometriosis. We also identified nine target genes potentially involved in the pathogenesis of endometriosis, with a different methylation profile between the two groups. Our data suggest that the combination of cell-free DNA quantification and the assessment of the epigenetic signature of differential methylation of nine genes can be proposed as a non-invasive predictive and diagnostic test for endometriosis.

Diagnosis and treatment of patients with suspected mucinous cystic neoplasms of the liver: a retrospective cohort study

PURPOSE

Mucinous cystic neoplasms of the liver (MCN-L) are hepatic cysts with a low malignant potential. The recent European Association for the Study of the Liver (EASL) guidelines provide guidance on the imaging features and surgical management of MCN-L, yet are hampered by a lack of studies adhering to the revised World Health Organization (WHO) criteria. This study attempted to validate the new 2022 EASL-guidelines in a retrospective cohort study of patients who underwent surgery for suspected MCN-L.

METHODS

Patients undergoing surgery for suspected MCN-L in a single center between 2010 and 2020 were included. Imaging features were assessed according to the EASL guidelines and were compared to final pathological diagnoses, according to the WHO criteria.

RESULTS

In total, 35 patients were included. In three patients, there were no worrisome imaging features, yet final pathological diagnosis showed MCN-L. Contrarily, six patients with worrisome imaging features did not have MCN-L. Five patients were diagnosed with MCN-L on final pathology. The sensitivity of the EASL-guidelines for the diagnosis of MCN-L was 40% (95%CI: 5.3-85%) and the specificity was 80% (95% CI: 61-92%).

CONCLUSION

Although the new EASL-guidelines provide some guidance, they could not reliably distinguish MCN-L from other cysts in our series. Thus, preoperative diagnosis of MCN-L remains challenging and we should be careful in selecting surgical strategies based on these criteria.

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

BACKGROUND

Endometriosis involves the intestine, and its clinical manifestations are nonspecific and lack of etiological manifestations. The diagnosis is difficult, which often leads to misdiagnosis. We report a case of endometriosis which was misdiagnosed as intestinal malignant tumor after colonoscopy and three biopsies.

CASE PRESENTATION

We reported a 42-year-old woman who went to see a doctor because of anal distension. She was examined by three gastrointestinal endoscopists at different levels in different hospitals and underwent biopsy at the same time. Combined with clinical manifestations, imaging examination, endoscopic examination and pathological examination, she was misdiagnosed as intestinal malignant tumor, and partial intestinal resection was performed according to the surgical principle of malignant tumor.

CONCLUSION

Although there are advanced gastrointestinal endoscopy and imaging techniques, intestinal endometriosis is still easy to be misdiagnosed. As our case report shows, after three colonoscopy and biopsy, it is still misdiagnosed as intestinal malignant tumor. Further research is needed to improve the ability of preoperative diagnosis, which deserves the attention of gastroenterologists and obstetricians and gynecologists.

Secondary Cutaneous Endometriosis of the Umbilicus in Tanzania: A Case Report

Introduction

Endometriosis is characterised by endometrial tissue outside the endometrial cavity. The implantation sites may be pelvic or extrapelvic in nature. Umbilical endometriosis is a rare type of cutaneous endometriosis, accounting for 0.5-1% of extrapelvic endometriosis cases. Current literature on umbilical endometriosis is absent in the Tanzanian population.

Case Report

A 30-year-old woman with prior caesarean deliveries presented with a 3-year history of umbilical swelling, cyclical pain, and menses-related bleeding. Examination revealed a firm brown umbilical lesion measuring 5×4 centimetres (cm). Wide excisional biopsy was performed. Histopathological examination confirmed endometriosis and ruled out malignancy. The postoperative follow-up revealed no signs of recurrence.

Conclusions

This case report highlights the need for high clinical vigilance and comprehensive differential diagnosis, especially for recurring and cyclical abdominal symptoms. Despite resource limitations, accurate diagnosis and appropriate treatment can result in the successful management of this rare condition. The report emphasises the urgency for clinicians to boost awareness, promote research, and advocate for better resources to ensure optimal patient outcomes.

Endometriosis in para-aortic lymph node resembling a malignancy: a case report and literature review

BACKGROUND

Endometriosis is a common benign gynecological disease characterized by growing-functioning endometrial tissue outside the uterus. Extra-pelvic endometriosis, which accounts for approximately 12% of endometriosis, is more challenging to diagnose because of its distance from the pelvic organs. Halban's theory of benign metastasis indicates that endometrial cells can appear in extra-pelvic organs via lymphatic and blood vessels, but endometrial lymph node metastasis cases are still rare. We report a case of endometriosis in a para-aortic lymph node whose clinical behavior mimicked a malignancy.

CASE PRESENTATION

A 52-year-old perimenopausal woman underwent laparoscopic hysterectomy plus bilateral salpingectomy (the patient insisted on the preservation of her ovaries) at a local hospital 2 years earlier because of adenomyosis. The patient presented with a complaint of low back pain to the gastrointestinal outpatient department of our hospital. The carbohydrate antigen 125 (CA125) was abnormally elevated at 5280.20 U/ml, human epididymis 4 (HE4) was 86.0 pmol/L, while other tumor markers were normal. Serum female hormone results were in the postmenopausal range, and her gastroenteroscopy showed no abnormalities. Moreover, both enhanced magnetic resonance imaging and positron emission tomography-computed tomography showed a high possibility of a retroperitoneal malignant lymph node (metastasis possible, primary site unknown). One week after admission, she underwent laparoscopic exploratory surgery, during which we observed normal shape and size of both ovaries while the left ovary was cystic-solid. After opening the retroperitoneal space, an enlarged lymph node-like tissue measuring 8 × 4 × 3 cm3 was found near the abdominal aorta. When the surrounding adhesions were separated, lymph node-like tissue was poorly demarcated from the abdominal aorta and renal artery. Some lymph node samples and left ovary were sent for intraoperative frozen section, which revealed benign lesions, similar to endometrial tissue. The lymph node tissue was then excised as much as possible, and the second set of intraoperative frozen sections showed high probability of endometrial tissue. The final histopathology and immunohistochemistry staining reached a diagnosis of para-aortic lymph node endometriosis. Gonadotropin-releasing hormone antigen treatment was recommended every 28 days because of the high preoperative CA125 and imaging-based suspicion of malignancy. The serum CA125 subsequently decreased to normal levels, and no para-aortic lesions were detected on abdominal enhancement CT. She is being followed up regularly.

CONCLUSION

It is known that the incidence of lymph node metastasis in pelvic endometriosis is relatively rare. Our report shows that endometriotic tissue can metastasize via the lymphatic route and suggests that endometriotic tissue has the characteristics of invasion and metastasis.

Malignant transformation of hepatic endometriosis: a case report and literature review

Background

Extrapelvic endometriosis is defined as the presence of ectopic endometrial tissue in structures outside the pelvis. Although extra-pelvic endometriosis is generally considered benign conditions, malignant potential within endometriotic foci occurs even after definitive surgery. Malignant transformation of hepatic endometriosis is extremely rare. Preoperative diagnosis of this cancer is difficult, and no guidelines on the optimal management currently exist. Here, we present a case report of malignant transformation of hepatic endometriosis and a brief literature review to highlight the current knowledge of the prevalence, clinical features, diagnosis, and management of this condition.

Case presentation

A 50-year-old woman with a 2-year duration of progressive right upper quadrant abdominal pain was admitted to the hospital. She underwent hysterectomy and bilateral salpingo-oophorectomy for benign conditions 4 years prior. Tumor markers demonstrated elevated carbohydrate antigen (CA)-199 112U/mL (normal range: 0–35U/mL) only. Radiological imaging suggested the presence of a 10.7 × 7.7-cm mass in the right lobe of the liver extending to the diaphragm. The intraoperative frozen sections suggested malignant tumor. Right hepatectomy with infiltrating diaphragm resection was performed. The final pathology with immunohistochemistry staining confirmed endometrioid adenocarcinoma in the liver originating from preexisting hepatic endometriosis. After the multidisciplinary team meeting, the consensus was surgery followed by adjuvant chemotherapy. To our knowledge, this is the first case of Chinese woman of a malignant liver tumor originating from endometriosis ever reported by reviewing the current English medical literature.

Conclusion

Though rare, extrapelvic endometriosis-associated cancers should be considered as differentiated diagnosis even after hysterectomy and bilateral salpingo-oophorectomy. This case highlights the importance of collaborative efforts across multiple disciplines for accurate diagnosis and appropriate treatment of malignant transformation of hepatic endometriosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01366-6.

Diagnosis, surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment. Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion. A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively. Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.

Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Cardiometabolic Risk Factors and Benign Gynecologic Disorders

Importance

While it has long been known that polycystic ovarian syndrome is associated with cardiometabolic risk factors (CMRFs), there is emerging evidence that other benign gynecologic conditions, such as uterine leiomyomas, endometriosis, and even hysterectomy without oophorectomy, can be associated with CMRFs. Understanding the evidence and mechanisms of these associations can lead to novel preventive and therapeutic interventions.

Objective

This article discusses the evidence and the potential mechanisms mediating the association between CMRFs and benign gynecologic disorders.

Evidence Acquisition

We reviewed PubMed, EMBASE, Scopus, and Google Scholar databases to obtain plausible clinical and biological evidence, including hormonal, immunologic, inflammatory, growth factor-related, genetic, epigenetic, atherogenic, vitamin D-related, and dietary factors.

Results

Cardiometabolic risk factors appear to contribute to uterine leiomyoma pathogenesis. For example, obesity can modulate leiomyomatous cellular proliferation and extracellular matrix deposition through hyperestrogenic states, chronic inflammation, insulin resistance, and adipokines. On the other hand, endometriosis has been shown to induce systemic inflammation, thereby increasing cardiometabolic risks, for example, through inducing atherosclerotic changes.

Conclusion and Relevance

Clinical implications of these associations are 2-fold. First, screening and early modification of CMRFs can be part of a preventive strategy for uterine leiomyomas and hysterectomy. Second, patients diagnosed with uterine leiomyomas or endometriosis can be screened and closely followed for CMRFs and cardiovascular disease.

Primary biliary adenosarcoma of the liver-a special and new entity

Primary sarcoma of the liver (PSL) is a rare entity accounting for less than 1% of all liver cancers, with unknown aetiology. Several subtypes have been recognized, with histology playing an essential role in patient tailoring and management. We are about to report a case of an unusual PSL, with peculiar morphologic and immunohistochemical properties. A 65-year-old female with a multicystic hepatic lesion underwent surgery due to spontaneous rupture. Pathology revealed dilated bile duct-like structures lined by benign cuboidal/columnar epithelium surrounded by neoplastic proliferation of spindle and epithelioid cells with interspersed osteoclast-like multinucleated giant cells, loosely arranged in a storiform pattern, positive for CD10. The conjugation of morphology and immunohistochemistry results provided the diagnosis of primary biliary adenosarcoma of the liver, biliary type. The patient experienced tumour relapse and died of disease 2 years and 7 months later.

Endometrioma of the Liver: A Case Report and Review of the Literature

Hepatic endometriosis is a rare form of endometriosis first described by Finkel in 1986. A thorough review of the literature revealed 28 cases of hepatic endometriosis. This unusual condition offers several diagnostic challenges due to its variable appearance on imaging and need for histologic analysis to establish a definitive diagnosis. We present a 42-year-old female initially treated for presumed hydatid cyst that was later found to be endometriosis in the liver. The case highlights the importance of considering endometriosis in the differential for a patient presenting with a solitary liver mass regardless of age and previous history of endometriosis.

A case report: Rectal endometriosis mimicking rectal cancer

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Rectal endometriosis and rectal cancer share many common Imaging characteristics.

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Small specimen is sometimes insufficient to make a correct diagnosis.

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Doctors should always pay attention on differential diagnoses.

Introduction: Rectal endometriosis is rare in women and imaging characteristics are similar with that of rectal cancer, which is one of the most common malignancies.

Presentation of case: A 36 years old woman with a suspicious diagnosis of cervical carcinoma in a tertiary hospital visited our hospital, complaining about vaginal bleeding after copulation for six months, accompanying with constipation and diameter-thinning stool. Vaginal and cervical biopsy only showed chronic inflammation. Colonoscopy found a mass at the rectum 4 cm from the anus, but the biopsy showed different diagnoses. Partial resection was eventually operated and the final diagnosis was confirmed as rectal endometriosis.

Discussion: Rectal endometriosis is prone to be misdiagnosed as rectal cancer. Small specimen is sometimes insufficient to make a correct diagnosis. Extensive examination should be done to confirm the diagnosis and rash decision should never be encouraging.

Conclusion: Rectal endometriosis should always be considered as one of the differential diagnoses in female who have a mass at the rectum. An adequate specimen should be obtained to confirm the histopathological diagnosis.

An Unusual Case of Gullo’s Syndrome Concomitant with Serious Endometriosis Disease in a Postmenopausal Woman

Gullo's syndrome is a singular physiological phenomenon defined by an abnormal increase in serum pancreatic enzyme levels that may occur in healthy subjects in the absence of pancreatic disorders. During routine health examination in a 54-year-old postmenopausal woman with severe endometriosis, elevated values of serum amylase and lipase were fortuitously observed (198 and 1461 U/L, resp.). Over five years of regular pancreas surveillance, all clinical, biological, and imaging investigations were normal. However, the pancreatic enzyme levels have shown considerable fluctuations including some episodic transient normalization. The description of this benign pancreatic hyperenzymemia case incidentally associated with endometriosis disease is a very rare clinical situation. More in-depth documentation of this phenomenon may help clinicians to avoid unnecessary diagnostic management approaches and reassure the concerned patients that this affection would not be so worrying.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Biomarkers in endometriosis: challenges and opportunities

Endometriosis is a debilitating gynecologic disease affecting millions of women across the world, with symptoms including dysmenorrhea, chronic pelvic pain, and infertility. Theorized to stem from the phenomenon of retrograde menstruation, the diagnosis of endometriosis is typically delayed by 8-10 years owing to misinterpretation of symptoms as common menstrual cramps in adolescent girls and young women. With increased incidence of endometriosis in young girls correlated with earlier menarche, the development of diagnostic biomarkers is imperative for diagnosing and treating women afflicted with endometriosis as early as we can. In the past few years, multiple reviews highlighted the list of potential diagnostic candidates in peritoneal fluid, blood, urine, and endometrial biopsies from endometriosis patients in different stages of disease and menstrual cycle. In this review, we explore the opportunities and challenges facing the field of diagnostic biomarkers for endometriosis. We highlight the importance of eutopic endometrium as a source of potential diagnostic biomarkers by looking at the expression levels of noncoding RNA in tissue as well as in blood. Finally, we discuss some of the challenges that hinder our efforts in validating candidate diagnostic biomarkers for endometriosis.

Giant endometrial cyst of the liver: a case report and review of the literature

Endometriosis is a benign condition described as the presence of endometrial- like tissue found outside the uterine cavity. Hepatic endometriosis is one of the rarest localization of extrapelvic endometriosis, only 22 cases have been reported in the literature. The preoperative diagnosis of hepatic endometriosis is rather difficult because in about the half of the patient affected they had no history of endometriosis. Moreover radiological images reveal no characteristic findings for hepatic endometriosis. It is often described as cystic mass with or without solid component, difficult to distinguish from hepatic abscess, hematoma, cystoadenoma or malignant neoplasia. We report a case of a 27-year-old female with a large cystic mass involving the left lobe of the liver. The patient underwent laparoscopic exploration and converted to laparotomy for resection of giant hepatic endometriosis.

Low Body Mass Index in Endometriosis Is Promoted by Hepatic Metabolic Gene Dysregulation in Mice

The gynecological disease endometriosis is characterized by the deposition and proliferation of endometrial cells outside the uterus and clinically is linked to low body mass index (BMI). Gene expression in the liver of these women has not been reported. We hypothesized that endometriosis may impact hepatic gene expression, promoting a low BMI. To determine the effect of endometriosis on liver gene expression, we induced endometriosis in female mice by suturing donor mouse endometrium into the peritoneal cavity and measuring the weight of these mice. Dual-energy X-ray absorptiometry (DEXA) scanning of these mice showed lower body weight and lower total body fat than controls. Microarray analysis identified 26 genes differentially regulated in the livers of mice with endometriosis. Six of 26 genes were involved in metabolism. Four of six genes were upregulated and were related to weight loss, whereas two genes were downregulated and linked to obesity. Expression levels of Cyp2r1, Fabp4, Mrc1, and Rock2 were increased, whereas Igfbp1 and Mmd2 expression levels were decreased. Lep and Pparg, key metabolic genes in the pathways of the six genes identified from the microarray, were also upregulated. This dysregulation was specific to metabolic pathways. Here we demonstrate that endometriosis causes reduced body weight and body fat and disrupts expression of liver genes. We suggest that altered metabolism mediated by the liver contributes to the clinically observed low BMI that is characteristic of women with endometriosis. These findings reveal the systemic and multiorgan nature of endometriosis.

Subcapsular hepatic endometriosis: case report and review of the literature

Hepatic endometriosis is a very rare medical condition characterized by the implantation of ectopic endometrial tissue within the hepatic parenchyma. Preoperative diagnosis is difficult via cross-sectional imaging and histopathologic evaluation remains the gold standard for diagnosis. We report a case of hepatic endometrioma in a 44-year-old woman with history of endometriosis. The literature is reviewed, and magnetic resonance imaging findings together with differential diagnosis of hepatic endometriosis are highlighted.

Focal Liver Lesion Secondary to Endometriosis: Case Report and Literature Review

Introduction

Hepatic endometriosis is a rare disorder, without preoperative imaging findings are unclear. A diagnosis of endometriosis in a heterogeneous cystic liver mass should be considered, especially in patients with known endometriosis.

Case Report

A 40-year-old female patient complaining of sporadic abdominal and pelvic pain, not related to the menstrual cycle and without previous history of endometriosis, underwent routine sonographic evaluation, which indicated a lesion in the right hepatic lobe, apparently solid-cystic to ultrasonography. Upon further investigation using computed tomography (CT) and magnetic resonance imaging (MRI), image patterns consistent with hemorrhagic spots were also found; however, without the characteristics compatible with the most common focal hepatic lesions. It was suggested a possible diagnosis of metastasis by tumor of unknown site, due to the presence of a heterogeneous and hypodense nodule in the paracolic gutter, right to the CT, and then established the correlation with the clinical condition. The histological analysis has found a liver endometriosis, and the patient was referred surgical treatment.

Conclusions

Based on the analysis of this case, the authors present a review of the cases of liver endometriosis described so far, exposing and comparing the most common clinical and image findings.