The many faces of endometriosis

Endometriosis is a common disease; however, unusual findings may cause diagnostic difficulties. We present herein three cases illustrating different morphological appearances of endometriosis: 1) endometriosis with atypical hyperplasia associated with bilateral ovarian carcinoma (mixed clear cell/endometrioid in the left ovary and endometrioid in the right ovary); 2) deep infiltrating endometriosis with intravascular spread, polypoid configuration in peritoneal surfaces, and involvement of a lymph node; and 3) decidualized endometriosis with prominent myxoid/mucinous change and multivacuolated (pseudoxanthoma) cells. Awareness of uncommon morphological manifestations of endometriosis is important to avoid improper consideration of malignancy.

Keywords:
Endometriosis; Ovary; Pathology

Authorship

Marcelo Luis Pereira de Souza Filho

1 Imagepat, Laboratório de Patologia, Salvador, BA, BrasilImagepat, Laboratório de PatologiaBrasilSalvador, BA, Brasil1 Imagepat, Laboratório de Patologia, Salvador, BA, Brasil

http://orcid.org/0000-0003-4761-5961

Talita Porto da Costa

2 Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, BrasilUniversidade Federal da BahiaBrasilSalvador, BA, Brasil2 Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil

http://orcid.org/0000-0003-4581-3593

Nathanael Pinheiro de Freitas Junior

http://orcid.org/0000-0003-0691-3006

Maiara Ferreira de Souza

http://orcid.org/0000-0002-0233-1386

Daniel Abensur Athanazio

1 Imagepat, Laboratório de Patologia, Salvador, BA, BrasilImagepat, Laboratório de PatologiaBrasilSalvador, BA, Brasil1 Imagepat, Laboratório de Patologia, Salvador, BA, Brasil

http://orcid.org/0000-0002-5280-8517

Authors’ contributions: Daniel Abensur Athanazio and Marcelo Luis Pereira de Souza Filho¹ conceived the idea. Daniel Abensur Athanazio and Marcelo Luis Pereira de Souza Filho was the major contributor to the writing of the manuscript. Talita Porto da Costa, Maiara Ferreira de Souza, Nathanael Pinheiro de Freitas Junior and Daniel Abensur Athanazio diagnosed the cases. Talita Porto da Costa, Maiara Ferreira de Souza, Nathanael Pinheiro de Freitas Junior were major contributors for critically revising the manuscript for important intellectual content. The authors read and approved the final manuscript.

Conflict of interest: None.

CorrespondenceDaniel Abensur Athanazio Imagepat, Laboratório de Patologia Rua Lucaia, 209, 3º andar, Rio Vermelho, CEP 41940-660, Salvador, BA, Brasil Phone: 55 (71) 34965671dathanazio@gmail.com

SCIMAGO INSTITUTIONS RANKINGS

1 Imagepat, Laboratório de Patologia, Salvador, BA, BrasilImagepat, Laboratório de PatologiaBrasilSalvador, BA, Brasil1 Imagepat, Laboratório de Patologia, Salvador, BA, Brasil

Figures

Figures (4)

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Figure 1
Case 1. Solid and cystic tumor in the left ovary. Cut surface. (A - Gross appearance during intraoperative frozen section consultation). Photomicrographs of the clear cell carcinoma component of the mixed carcinoma of the left ovary (B - HE, 100×; C - HE, 400×). The right ovary showed an endometrioid carcinoma. Adjacent tissues showed atypical endometriosis (D and E - HE, 100×; F: HE, 400×).

Thumbnail

Figure 2
Case 2. Endometriosis within vessels and lymph nodes. Intravascular foci of both endometrial stroma and epithelium (A and B - HE, 40×). Weigert’s stain highlights the walls of large vessels (C and D - 40×; E and F - 100×). Intravascular endometriosis showing D2-40 labeling of both the inner surface of a lymphatic vessel and the external surface of the intravascular mass (G - D2-40 immunostain, 40×). An endometriosis focus within a lymph node from the sigmoid mesocolon (H - HE, 100×).

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Figure 3
Case 2. Polypoid endometriosis in a specimen removed as an epiploic appendix (A - External appearance with HE). The microscopic image is reminiscent of an ordinary endometrial polyp (B - HE, 40×; C - HE, 40×; D - HE, 100×).

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Figure 4
Case 3. Endometriosis in a cesarean section scar. Stromal decidualization and flat/atrophic epithelium (A - HE, 40×). Multifocal zones demonstrated a transition from typical areas to myxoid/mucinous changes (B - HE, 40×; C - HE, 100×). The latter areas showed numerous vacuolated cells (pseudoxanthoma cells) (D and E - HE, 400×). The Alcian Blue stain highlighted a striking accumulation of mucin (F - 40×; G - 100×; H - 400×).

Figure 1 Case 1. Solid and cystic tumor in the left ovary. Cut surface. (A - Gross appearance during intraoperative frozen section consultation). Photomicrographs of the clear cell carcinoma component of the mixed carcinoma of the left ovary (B - HE, 100×; C - HE, 400×). The right ovary showed an endometrioid carcinoma. Adjacent tissues showed atypical endometriosis (D and E - HE, 100×; F: HE, 400×).

Figure 2 Case 2. Endometriosis within vessels and lymph nodes. Intravascular foci of both endometrial stroma and epithelium (A and B - HE, 40×). Weigert’s stain highlights the walls of large vessels (C and D - 40×; E and F - 100×). Intravascular endometriosis showing D2-40 labeling of both the inner surface of a lymphatic vessel and the external surface of the intravascular mass (G - D2-40 immunostain, 40×). An endometriosis focus within a lymph node from the sigmoid mesocolon (H - HE, 100×).

Figure 3 Case 2. Polypoid endometriosis in a specimen removed as an epiploic appendix (A - External appearance with HE). The microscopic image is reminiscent of an ordinary endometrial polyp (B - HE, 40×; C - HE, 40×; D - HE, 100×).

Figure 4 Case 3. Endometriosis in a cesarean section scar. Stromal decidualization and flat/atrophic epithelium (A - HE, 40×). Multifocal zones demonstrated a transition from typical areas to myxoid/mucinous changes (B - HE, 40×; C - HE, 100×). The latter areas showed numerous vacuolated cells (pseudoxanthoma cells) (D and E - HE, 400×). The Alcian Blue stain highlighted a striking accumulation of mucin (F - 40×; G - 100×; H - 400×).

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The many faces of endometriosis

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[1] Authors’ contributions: Daniel Abensur Athanazio and Marcelo Luis Pereira de Souza Filho¹ conceived the idea. Daniel Abensur Athanazio and Marcelo Luis Pereira de Souza Filho was the major contributor to the writing of the manuscript. Talita Porto da Costa, Maiara Ferreira de Souza, Nathanael Pinheiro de Freitas Junior and Daniel Abensur Athanazio diagnosed the cases. Talita Porto da Costa, Maiara Ferreira de Souza, Nathanael Pinheiro de Freitas Junior were major contributors for critically revising the manuscript for important intellectual content. The authors read and approved the final manuscript.