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Laparoscopic view of the surface of the right lobe of the liver showing a 6 x 5 cm irregular rounded hemorrhagic
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... Other surgical techniques included ultrasonic cyst manipulation. In the two nonsurgical cases, those patients were treated with danazol alone [9,10]. Tumor size ranged from 1 to 30cm, with mean tumor size 9.8 cm. ...
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.
Hepatic endometriosis is a very rare form of endometriosis first described by Rokitansky in 1986. To our knowledge, 42 cases of hepatic endometriosis have been reported in the literature till date. The condition offers a diagnostic challenge owing to its variable presentation on imaging and the need for histological and immunohistochemical evidence for a definite diagnosis. We hereby present the 43rd case of ectopic endometrium in the liver of a 30 years old, multiparous female who presented with fever and pain in the right hypochondrium. Radiological imaging suggested a cystic lesion which was managed laparoscopically. Histopathology and immunohistochemistry findings came out to be consistent with endometriosis. The case highlighted the importance of considering endometriosis as a differential in all women irrespective of age and previous history of endometriosis.
Objective:
To conduct a systematic review of the literature for patients with extra-pelvic deep endometriosis.
Data source:
A thorough search was performed through PubMed/MEDLINE, EMBASE and Cochrane databases.
Methods of study selection:
Following PRISMA guidelines, in the last 20 years that reported on primary extra-pelvic endometriosis were included (PROSPERO registration number CRD42019125370).
Tabulation and integration:
Initial search identified 5.465 studies and 179 studies, mostly case reports and series, were included. A total of 230 parietal (PE), 43 visceral (VE), 628 thoracic (TE), 6 central nerve system (CNS), 12 extra-pelvic muscle or nerves, and one nasal endometriosis papers were identified.
Results:
Abdominal endometriosis was divided into PE and VE. PE lesions involved primary lesions of the abdominal wall, groin and perineum where presenting symptoms were palpable mass (99%), cyclic pain (71%) and cyclic bleeding (48%). Pre-operative clinical suspicion was low and use of tissue diagnosis was indeterminate (25%), and a few (8%) malignancy suspected. Surgical treatment for PE included wide local excision (97%) with 5% recurrence and no complications. Patients with VE involving the abdominal organs - kidneys, liver, pancreas, biliary tract - were treated surgically (86%) with both conservative (51%) and radical resection (49%), with 15% recurrence and 2 major complications reported. In patients with TE involving the diaphragm, pleura and lung, isolated and concomitant lesions occurred and favored the right side (80%). Patients with TE presented with triad of catamenial pain, pneumothorax and hemoptysis. Thoracoscopic with resection followed by pleurodesis were the most common procedures performed with 29% recurrence. Adjuvant medical therapy with GnRH was used in 15% of cases. Preoperative imaging with MRI was used in all cases of non-thoracic and non-abdominal endometriosis. Common symptoms were paresthesia and cyclic pain with radiation. Surgical resection was reported in 84% with improvement of symptoms.
Conclusions:
Extra-pelvic endometriosis, traditionally thought to be rare, have been reported in a considerable number of cases. Heightened awareness and clinical suspicion of the disease, and multi-disciplinary approach is recommended to achieve prompt diagnosis and optimize patient outcomes. At this time, there are no comparative studies to provide recommendations regarding optimal diagnostic methods, treatment options and outcomes for endometriosis involving extra-pelvic sites.
Introduction and objectives:
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.
Materials and methods:
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.
Results:
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.
Conclusions:
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.
Numerous types of ectopias and heterotopias located to the liver can result in tumor-like lesions. The presence of ectopic splenic tissue in various abdominal organs, including the liver, is termed splenosis. The liver can also contain various types of ectopic pancreatic tissue, ranging from exocrine lobules to small clusters of intrahepatic acinar cells. Adrenal cortex can ectopically adhere to the inferior-posterior capsule of the liver, a condition called adrenohepatic fusion. Other rare ectopic tissue components include thyroid gland ectopia, hepatogonadal fusion, hepatic endometriosis and endometrioma, and hepatic pregnancy.
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.
Numerous types of ectopias and heterotopias located to the liver can result in tumor-like lesions. The presence of ectopic splenic tissue in various abdominal organs, including the liver, is termed splenosis. The liver can also contain various types of ectopic pancreatic tissue, ranging from exocrine lobules to small clusters of intrahepatic acinar cells. Adrenal cortex can ectopically adhere to the inferior-posterior capsule of the liver, a condition called adrenohepatic fusion. Other rare ectopic tissue components include thyroid gland ectopia, hepatogonadal fusion, hepatic endometriosis and endometrioma, and hepatic pregnancy.
Endometriosis is an estrogen-dependent chronic inflammatory condition in which endometrial glands and stroma are found outside of the endometrium, causing pelvic pain and infertility. The majority of cases are confined to the pelvis, and can be treated either medically or surgically. Video-assisted laparoscopy is the preferred surgical approach, with the goal of restoring normal anatomy and alleviating pelvic pain. Although endometriosis is usually confined to the pelvis, it is also found in the GI tract, urinary tract and thoracic cavity. When endometriosis has spread beyond the genital tract, a high index of suspicion is necessary for diagnosis, and a multidisciplinary approach is often required to treat the disease adequately.
Background:
Hepatic endometriosis/uterus-like mass is rare and may be overlooked during hepatic cyst workups. We report a case of uterus-like mass, misdiagnosed as hepatic abscess.
Case report:
A 47-year-old woman developed abdominal pain and vomiting. Infectious colitis with hepatic abscess was diagnosed, and remained antibiotic-refractory. Fine-needle aspiration and core biopsies showed benign contents. The patient presented to our institution with symptoms and normal blood work. Laparoscopic excision demonstrated a 1.4-cm cyst composed of endometrial glands (estrogen receptor+ and progesterone receptor+) and stroma (CD10+) with smooth muscle actin (SMA+), arranged in an organoid fashion. The patient, status-post hysterectomy, had no history or symptoms of endometriosis.
Conclusion:
This rare case illustrates the merit of considering uterus-like mass/endometriosis in the differential diagnosis of antibiotic-refractory hepatic cysts. Cyst heterogeneity may confound needle biopsy. We report the first instance of a hepatic uterus-like mass, with a review of related entities, postulated histogenesis, and important clinical associations.
Endometrial cysts within the liver are rare but can present as diagnostic challenges on small biopsies or frozen sections and may mimic mucinous cystic neoplasms (MCN) of the liver. Five cases of endometrial cysts and 6 cases of MCNs within the liver were collected. The clinicopathological, imaging, and immunohistochemical features were systematically reviewed and compared. The average size of the endometrial cysts was 8.3 cm. Four patients had a prior pelvic operation and coexisting endometriosis at other sites. All 5 cases of endometrial cysts had positive ER staining within both the epithelium and the stroma. PR was also positive in both epithelial and stromal cells in 4 cases. Four cases had additional immunostains performed, which all showed cytokeratin 19 and cytokeratin 7 positivity (only in epithelium) and CD10 positivity (only in stroma). α-Inhibin and calretinin were negative for both the epithelium and the stroma in all 4 cases. All 6 MCN cases (mean size, 11.1 cm) had positive ER, PR, and α-inhibin staining only in the stroma. ER and PR were positive in both the epithelium and stromal cells in endometrial cysts, whereas they were positive only in the stromal cells of MCNs. The stromal cells were CD10 positive and α-inhibin negative in endometrial cysts as opposed to the opposite staining pattern in MCNs. Awareness of this distinct staining pattern and the possibility of endometrial cysts in the liver can lead to accurate diagnoses and appropriate treatment modalities.
