1.
Problem Based Learning
24 yrs female with Rectal mass
Dr Usha Kiran Pandey
2nd year Resident
Department of Pathology
NAIHS
Moderator: Lt col. Dr Kavita Karmacharya

2.
History
• 24 years female
• Married for 3 years and nulligravida
• Lower abdominal pain for 2 years
• Irregular cycles, heavy menstrual bleeding,
dysmenorrhoea for 7 months
• Anorexia and weight loss of aprox.14 kg within
2 years period
• No family history of cancer

3.
Radiological investigations
• USG report of Abdomen and Pelvis
– Bulky cervix measuring 5.3 x 4.3 cm with
irregularitis, thickened endometrium measuring
upto 1.5cm with polypoid lesion and fluid filled
endometrial cavity at lower uterine segment
suggestive of Carcinoma cervix.
– Moderate left sided hydroureteronephrosis

4.
• MRI of Pelvis; Impression (04- jan-2023)
– A large heterogenous enhancing ill-defined mass in the left
side of pelvis with epicenter in between the cervix and
rectum and showing mixed signal intensity in T2 weighted
images with cystic areas. Some of the cysts show blood
products. Only subtle restriction of diffusion is seen.
– Mass is infiltrating into the (i)cervix and upper third of
vagina, (ii)mid and upper rectum and (iii)encasing lest
distal ureter with moderate proximal
hydroureteronephrosis.
– Posteriorly mass is extending up to the fascia of left
piriformis muscle and encasing the distal branches of left
internal iliac artery.

5.
• D/D: (i) pelvic endometriosis
• Other possibilities are malignancy (Ca rectovaginal
septum) and ca rectum
• Minimal free fluid in POD.
• Small lymph nodes in right lateral pelvic wall-likely
reactive.
• Small cyst in right ovary containing blood products-
likely tiny endometrioma/hemorrhagic cyst.
• No other mass in b/l ovaries.
• Normal rest of the upper abdominal organs.

6.
• Colonoscopic report (05 jan-2023)
– Rectum: Semicircimferential ulcero proliferative
growth seen at the rectum approx. 6-8cm from
the anal verge.
– Ileum, Caecum, Ascending colon, Descending
colon, Sigmoid, Anal canal: Normal
– Impression: Ca Rectum

7.
Fig: Colonoscopic image of ulceroproliferative
growth at Rectum

8.
Lab investigations
• CA125: 109.50 U/ml (RR: <35)
• CA19-9: 14.29 U/ml (RR: <39)
• CEA: 1.14ng/ml (RR: <3.8)
• HPV qualitative RT PCR: Undetected

9.
• Cervical PAP smear: NILM
• Cervical biopsy done on 2023-01-10:
– Cervical polyp with squamous metaplasia with acute
on chronic cervicitis.
• Rectal biopsy done on 2023-01-08:
– Chronic Active colitis with reparative changes. No
evidence of malignancy seen in the submitted biopsy.
Advice: Rebiopsy from representative site

10.
• Rebiopsy from rectal mass was done.
• Multiple tissue bits were received , altogether
measuring 1 x 0.8cm. AE(B1)

11.
Microscopic findings

12.
• Section from rectal mass shows multiple fragmented
tissues focally lined by simple columnar epithelium with
mucin depletion along with area of erosions showing
granulation tissues comprising of proliferation of blood
vessels lined by plumped endothelium and dense
inflammatory infiltrates predominantly neutrophils. Lamina
propria shows glands lined by simple columnar epithelium
with pseudostratification and hyperchromatic nuclei. On
foci shows few scattered atypical cells with moderate
eosinophilic cytoplasm, iregular nuclear border with
hyperchromatic nuclei. No granuloma seen. No cryptitis
and crypt abscess. No parasites seen. No mitosis seen.

13.
Differential diagnosis
• Rectal Endometriosis
• Tubular adenoma. Carcinoma cannot be ruled
out
• Infective colitis likely CMV

14.
Endometriosis
Favouring points
• Reproductive age
• History of irregular and heavy
menstruation with pain
abdomen
• CA-125 raised, CEA negative
• Can present with rectal mass
• Histologically: presence of
glands lined by simple
columnar epithelium with
pseudostratification similar to
endometrial glands.
Non favouring points
• Absence of hemosiderin
laden macropahges
• Presence of atypical cells

15.
• Further confirmation can be done by
• IHC: CK7 +, CD10+, ER +ve, CK20-ve,
CDX2 –ve,
• Deeper biopsy or resection specimen

16.
Tubular Adenoma
Favouring points
• Pseudostratified lining of
glands
• Hyperchromatic nuclei
• Mucin loss

17.
Infective colitis Likely CMV
Favouring points
• May present with pain
abdomen
• Enlarged nucleus typically in
endothelial cells
• Neutrophilic inflammation
Non favouring points
• Common in
immunocompromised
patient
• Rarely present with rectal
mass
• Absence of intanuclear and
intracytoplasmic inclusions,

18.
Infective colitis
IHC for CMV can be done for confirmation

19.
• 36 yrs female , postcoital bleeding for 6
months
• CT pelvus show vaginal ocupying lesion
invading the rectum
• Increased CA125 and normal CEA and CA19-9.
• Colonoscopy: Mass at rectum
• Biopsy: Rectal endometriosis supported by
IHC.

20.
• Multidisciplinary team, including oncologists,
surgical specialists, gynecologists and
pathologists, was established to discuss the
complex condition.
• The pathologist supported the diagnosis of
rectal endometriosis according to the
immunohistochemical result.
.

21.
• If a radical operation was performed,treating it as a
malignant tumor, considering that the rectal mass was
only 4 cm away from the anal verge, the patient could
not save the anal function, and colostomy wouldbe
existentpermanently, reducing thequality of life.
• After a heated discussion, a consensus that partial
resection should be operated to confirm the
histopathological diagnosis and then to determine the
further treatment was achieved.
• Eventually, the final diagnosis was confirmed as rectal
endometriosis and gynecological management was
suggested

22.
• Diagnosing intestinal endometriosis in the bowel
wall, involving the serosa, muscularis propria,
and/ or submucosa, is usually straightforward in
resection specimens.
• The presence of endometrial glands,
endometrial stroma, and hemosiderin deposition,
often referred to as ‘diagnostic triad’, is present in
most cases.
• When endometriosis involves the intestinal
mucosa, it may cause diagnostic difficulty,
especially in endoscopic biopsies.

23.
• Sometimes may present with Crypt architectural
distortion, cryptitis, and crypt abscesses were
seen in some cases, mimicking chronic active
colitis or enteritis.
• A panel of immunohistochemical stains (CK7,
CK20, CDX2, and ER) was found to be useful in
biopsies with suspected endometriosis
demonstrating unusual histology or only
containing endometrioid stroma tissue.

24.
• A woman age 37 was referred for investigation of
bright red rectal bleeding of seven months'
duration and usually coinciding with
menstruation.
• Abdominal MRI scans suggested endometriotic
cysts arising from both ovaries. Colonoscopy
revealed mild mucosal inflammation at 35 cm
from the anal verge, and a polypoid lesion 3 cm in
diameter was seen within the ascending colon 65
cm from the anal verge.

25.
• On histological examination, biopsies from the
‘inflamed’ area of distal colon showed
‘inflammatory changes’, while two separate
biopsies from the polypoid lesion in the
ascending colon showed fragments with
mixed features of an inflammatory polyp and
adenomatous glands: areas of low-grade
dysplasia were surrounded by inflamed
fibrotic stroma with focal surface ulceration
and granulation tissue.

26.
• Immunohistochemical staining clearly
differentiated between colonic glands
(cytokeratin 20 positive, cytokeratin 7 negative)
and endometrial glands (cytokeratin 7 positive,
cytokeratin 20 negative,
• The present case suggests that colonic mucosal
endometriosis can produce reactive changes in
colonic glands, with cellular atypia and glandular
hyperplasia mimicking dysplasia, thus making the
lesions harder to discriminate from a neoplastic
adenoma.

27.
• Final impression:
– Tubular adenoma. Carcinoma cannot be ruled out.
– In view if clinical and radiological findings
endometriosis should be ruled out.
Advice:
• IHC: CK7 +, CD10+, ER +ve, CK20-ve,
CDX2 –ve,
• Deeper biopsy or resection specimen

28.
• Thank you.