Images in Gynecologic Surgery

Lymphatic Spread of Endometriosis to Para-Aortic Nodes

Pedro F. Escobar, MD*From the Division of Gynecologic Oncology, Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio, and HIMA Health, Caguas, Puerto Rico.

DISCUSS

Fig. 1

Paraaortic noda

The author decla

Corresponding au

Oncology, Clevel

OH 44118.

E-mail: escobarp

Submitted Februa

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l involvement with endometriosis.

res no conflict of interest.

thor: Pedro F. Escobar, MD, Department of Gynecologic

and Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland,

@mac.com

ry 10, 2013. Accepted for publication February 11, 2013.

.sciencedirect.com and www.jmig.org

e front matter � 2013 AAGL. All rights reserved.

0.1016/j.jmig.2013.02.014

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Endometriosis, ‘‘the abnormal growth of endometrialcells,’’ is a benign, chronic estrogen-dependent gynecologicdisease that affects women of reproductive age worldwide[1]. In patients diagnosed with deep infiltrating endometri-osis, foci of endometriosis have been detected in mesorectallymph nodes after bowel resection [2,3].

A 23-year-old woman was admitted with an adnexal massand pelvic pain. Further evaluation showed an elevated can-

cer antigen 125 level, a left adnexal complex mass, and anenlarged para-aortic lymph node. After a discussion withthe patient about the rationale, risk, benefits, and alterna-tives, a minimally invasive approach, ‘‘laparoscopic resec-tion,’’ was attempted. After the laparoscopic findings(Fig. 1), the case was converted to exploratory laparotomy,left ovarian cystectomy with frozen section confirming anendometrioma, and resection of the enlarged para-aorticnode involved with endometriosis.

Mechsner et al [4] described endometriotic cells in pelvicsentinel lymph nodes of patients with deep infiltrating endo-metriosis. However, there is a paucity of data about lym-phangiogenesis in endometriotic lesions. Moreover, theprognostic significance of such findings and its role in thedisease process are unknown. The presence of aortic nodalinvolvement with endometriotic cells may perhaps point to-ward a systemic aspect of this disease.

References

1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;9447:1789–1799.

2. Lorente Poyatos R, Palacios Perez A, Bravo Bravo F, et al. Rectosigmoid

endometriosis with lymph node involvement. Gastroenterol Hepatol.

2003;I:23–25.

3. Abrao MS, Podgaec S, Dias JA Jr, et al. Deeply infiltrating endmetriosis

affecting the rectum and lymph nodes. Fertil Steril. 2006;3:543–547.

4. Mechsner S, Weichbrodt M, Riedlinger WF, et al. Estrogen and pro-

gestogen receptor positive endometriotic lesions and disseminated

cells in pelvic sentinel lymph nodes of patients with deep infiltrating

rectovaginal endometriosis: a pilot study. Hum Reprod. 2008;23:

2202–2209.