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Problem Based Learning.pptx

  1. 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. 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. 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. 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. 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. 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. 7. Fig: Colonoscopic image of ulceroproliferative growth at Rectum
  8. 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. 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. 10. • Rebiopsy from rectal mass was done. • Multiple tissue bits were received , altogether measuring 1 x 0.8cm. AE(B1)
  11. 11. Microscopic findings
  12. 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. 13. Differential diagnosis • Rectal Endometriosis • Tubular adenoma. Carcinoma cannot be ruled out • Infective colitis likely CMV
  14. 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. 15. • Further confirmation can be done by • IHC: CK7 +, CD10+, ER +ve, CK20-ve, CDX2 –ve, • Deeper biopsy or resection specimen
  16. 16. Tubular Adenoma Favouring points • Pseudostratified lining of glands • Hyperchromatic nuclei • Mucin loss
  17. 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. 18. Infective colitis IHC for CMV can be done for confirmation
  19. 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. 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. 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. 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. 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. 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. 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. 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. 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. 28. • Thank you.