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Letter to the Editor
Lymph node involvement in isolated rectal endometriosis
Afectación ganglionar en endometriosis rectal aislada
José Félix Fernández-Vala,
Corresponding author
, José María García-Gonzáleza, Jaime González de Tánagob, Alberto Colina-Alonsoa
a Servicio de Cirugía General, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain
b Servicio de Anatomía Patológica, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Endometriosis is the presence of endometrial tissue&#44; glands and stroma in sites outside the uterine cavity&#46; It is a frequent condition with a 6&#8211;10&#37; prevalence in women of childbearing age&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Generally divided into pelvic &#40;ovaries&#44; fallopian tubes and pelvic peritoneum&#41; and extrapelvic endometriosis&#46; Extrapelvic endometriosis can involve any part of the body&#44; being gastrointestinal tract the most frequent &#40;3&#8211;12&#37;&#41; site&#44; especially at the rectosigmoid junction&#44; followed in frequency by small intestine&#44; cecum and appendix&#46; Intestinal involvement usually coexists with its presence at other levels&#46; One location alone is very rare&#46; Isolated rectal endometriosis with involvement of regional lymph nodes is an exceptional circumstance and with little description in the medical literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 34-year-old woman who came to the emergency room for watery diarrhea accompanied by mucus and red blood&#44; rectal tenesmus and intense urge to defecate&#46; A hard and fixed mass was palpable on digital rectal examination&#46; Colonoscopy showed the presence of a large congestive submucosal lesion extending 4<span class="elsevierStyleHsp" style=""></span>cm from anal margin&#46; CT scan showed a rectal injury 10<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>cm collapsing the rectal ampulla&#46; Pelvic nuclear magnetic resonance imaging showed a pedunculated mass dependent on left posterolateral wall&#44; with implantation 6<span class="elsevierStyleHsp" style=""></span>cm long and 4<span class="elsevierStyleHsp" style=""></span>cm lateral-medial&#44; well defined with heterogeneous signal and significant blood component&#44; not presenting a marked enhancement after administration of gadolinium&#46; Surgical resection of the lesion was proposed&#44; performing anterior resection with mechanical colorectal anastomosis&#46; Histopathological examination of the surgical specimen revealed the presence of multiple foci of endometriosis consisting of cytogenic stroma and endometrial glands without atypia&#44; also observing nodes with endometriosis foci&#46; The patient improved with disappearance of symptoms&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The etiopathogenesis of endometriosis is uncertain&#44; and there are several theories intended to explain&#59; the most widely accepted is the dissemination of endometrial cells through the fallopian tubes with retrograde flow during menstruation&#44; and subsequent implantation into the peritoneum and pelvic structures&#46; Metaplasia theory suggests that the source is in metaplastic processes of peritoneal mesothelial cells&#46; Moreover&#44; the finding of endometrial tissue in vessels and lymph nodes&#44; and in remote sites led to the theory of lymphatic spread&#46; In recent years the hypothesis proposed has been the endometrial stem cells as the source&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Theories of retrograde menstruation and endometrial metaplasia of mesothelial cells remain the most accepted&#46; However&#44; recently the relevant role of the lymphatic system in endometriosis has been emphasized&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The presence of lymph nodes with endometriosis makes us consider the lymphatic spread as our patient most likely pathogenic theory&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The uniqueness of our case is that the intestinal endometriosis usually coexists with endometriosis in any other sites&#44; usually ovary or peritoneum&#46; The intestinal involvement alone is rare and the finding of regional lymph node involvement is extremely rare&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Therefore&#44; there are very few cases reported in the literature&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Standard treatment should be surgery in most cases&#44; since in certain cases the possibility of a neoplasm cannot be excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Moreover&#44; medical treatment is not effective to remove the tumor in the extrapelvic involvement&#44; and does not seem to improve the results of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In general terms&#44; we believe that surgery should be &#8220;complete&#8221;&#44; i&#46;e&#46; with the same approach as cancer surgery&#44; since more conservative strategies&#44; including curettage and limited excisions of injury&#44; are associated with high rates of recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The choice of the approach&#44; open laparotomy versus laparoscopy should be individualized for each patient&#46;</p></span>"
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Article information
ISSN: 23870206
Original language: English
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es en pt

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