ADENOACANTHOMA OF RECTAL ENDOMETRIOSIS

by K. S. GuoE, * M.B.,B.S. (Born.), F.R.C.S. (Ed.), F.R.C.S. (Eng.)

Malignancy arising in endometriosis is good and abdominal examination was nor­ unusually rare and such a change in mal. On rectal examination there was a hard, extramucosal, tender mass on the right bowel endometriosis is rarer still. The side and anteriorly. Pressure on this mass earliest reference to the occurrel!lce oi produced pain she had recently experienced. malignancy in bowel endometriosis is that Her routine blood tests, urinalysis, and of Hosoi and Meeker (1929) who describ­ barium enema were normal. ed! an adenocarcinoma in endometriosis of A laparotomy was performed on lOth October 1966. A hard mass was seen under the transverse colon. Nylander as quoted the pelvic peritonium. Her remaining left by Jenkinson and Brown (1943) reported ovary was atrophic. Histological examina­ a spindle cell sarcoma of the rectum con­ tion of the biopsy from this mass revealed taining endometrial tissue. Weinrod, et a poorly differentiated squamous carci­ noma. Further exploration at the second al (1956) have recorded an adenoacan­ laparotomy on 15th October 1966 showed thoma of sigmoid endometriosis. There this mass to be in the anterior rectal wall. have been isolated case reports of adeno­ It was adherent to the vaginal vault and carci.qomas arising in endometriosis of the the base of the bladder. There were no rectovaginal septum which have inffitrat­ visible liver or lymph node metastases. Ab­ domino-perineal resection of the rectum ed the rectum. (Docherty, et al 1954; and left iliac colostomy were performed. Ferreira and Clayton 1958; Lash and Postoperative recovery was uneventful. Rubenstone 1959). The following case, Pathology: Examination of the speci­ therefore, appeared! worthy of record. men showed a tumour in the anterior wall of the rectum on the right side, 10 em. Case Report above the anus. The mucosa overlying the A married woman aged 51 years was ad­ tumour was largely intact with several mitted to Harrow hospital on the 13th of ulcers, the largest about 5 mm. An irre­ September 1966. She complained of con­ gular piece of vagina 3 x 2 em in size was stipation alternating with diarrhoea for adherent to the anterior surface of the about 15 years. For most of this time she tumour. passed mucus in her stools and for the last Histology showed a poorly differentiated few years had frequent episodes of bleeding adenocarcinoma with areas of squamous per rectum. She also complained of con­ metaplasia invading the rectal wall from siderable pain in the rectum and perineum without (Fig. 1 and 2). Between vaginal for a few months before admission. For vault and the tumour lay an area of endo­ about 12 years she suffered from recurrent metriosis, possibly the origin of this tumour. bouts of pyrexia. She had a ruptured (Fig. 3 and 4). Ail glands were involved. ectopic pregnancy 12 years previously and The patient died about a year later but 2 years later underwent hysterectomy and details regarding the cause of her death right oophorectomy for endometriosis. were not available. On admission her general condition was Discussion *Late Regi8trar General Surgery, Harrow Hospital, Harrow, Middlesex. It is not safe to assume that a malignant Received for pubLication on 20-11-1970 . tumour has arisen in an endometrial

.I ADENOACANTHOMA OF RECTAL ENDOMETRIOSIS .523 tissue merely because endometriosis is Other authors have been more critical. also present or because the tumour Healey and Cutler (1930) showed acantho­ morphologically resembles endometrial sis in only 3 out of 100 endometrial car­ carcinoma. The clinical evidence for the cinomas while Novak and Nalley (1957) view that this growth arose in endo­ state a still lower incidence. Squamous metriosis seems however satisfactory. metaplasia is also a well recognised fea­ Exploration of the abdomen at the time ture of ovarian tumours arising in endo­ of resection showed no other intra-abdo­ metriosis. Although epidermoid trans­ minal pathology. Gross and microscopic formation is seen in ovarian cystadenoma, study of the specimen failed to show the its malignant counterpart, and some other origin of this tumour from the rectal ovarian tumours, in Thompson's opinion mucosa. Endometriosis and-- cancer can be (1957) most primary ovarian adenoacan­ seen in one histological block in adjacent thomas arise in endometriosis. Freed­ parts although direct transition between man, et al (1964) observed that 25 of 57 the two is not seen. Docherty et al (1954) ovarian adenoacanthomas had their origin felt that insistance on this criterion would in endometriosis. Ferreira and Clayton only serve to discourage the reporting of (1958) found 23 cases in which conditions bona fide cases. for malignant change in endometriosis Squamous metaplasia seen in this were fulfilled. Of these, 13 were adena­ tumour deserves some comment. Since the acanthomas or of epidermoid type and 10 first description of an adenoacanthoma in were adenocarcinomas. Assuming that the caecum by Herxheimer in 1907 this other criteria are fulfilled it does not seem histogenetically interesting neoplasm has unreasonable to consider squamous meta­ occasionally been described at intraepi­ plasia in an adenocarcinoma as additional thelial junctions, such as cervix (Hamperi evidence of the origin of a tumour in endo­ and Hellung 1957), ano-rectal region metriosis. (Key, 1954), oesophago-gastric junction Endometriosis is essentially a benign (Dodge 1961) and at various other sites condition and various authors have em­ in the body (Nicholson (1923). Never­ phasized the need to avoid unnecessary theless, acanthosis in an adenocarcinoma radical surgery. Surgical treatment of is not common in tumours other than this condition is almost never dictated by those of endometrial origin. The rarity any concern over possible malignant com­ of adenoacanthoma of the rectum is illus plication. Considering the frequency of trated by the fact that all the 1,000 cases endometrial carcinoma in the uterus it of rectal cancer reviewed by Dukes seems curious that malignancy in endo­ (1940) were adenocarcinomas. Ther@ metriosis should be so rare. The true in­ seems to be a considerable stimulus to cidence of such a change is extremely dif­ squamous metaplasia in endometrial car­ ficult to determine since the evolution of cino.mas the reason for which is of inte­ cancer from foci of endometriosis is often rest but unknown. It was observed in 9 difficult to verify. Such cancers ate fre­ of 50 cases of endometrial carcinomas by quently symptomless in early stages and Willis (1967) a proportion closely similar when detected! the. tissue of their origin to Miller's figure of 15% (1950). may be obscured. Also, there is consider­ Nicholson (1923) found squamous meta­ able divergence of opinion among patho­ plasia in 14 of 36 endometrial carcinomas logists regarding the criteria for accepting and Charles (1965) in 55 of 148 cases. the origin of malignancy in endometriosis. 524 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

In a study of 889 cases of ovarian endo~ Malignant change in endometriosis is metriosis and 265 cases of ovarian malig­ very rare. Incidence however seems to nancies Corner, et al (1950) found only 3 vary according to the criteria adopted and undoubted and 3 probable cases of malig­ is probably a little more than the paucity nant change in endometriosis. Thompson of case reports suggests. (1957) could demonstrate such a change I wish to thank Mr. J. P. Bentley for in only 1 of 181 cases of endometriosis permission to publish this case. I am also subjected to thorough histological study. indebted to Dr. M. H. Bennet for his help Fathala (1967) reported 4 cases of endo­ in the preparation of photomicrographs. metrial carcinomas in a survey of 592 cases of ovarian endometriosis and 418 References cases of primary malignant ovarian tum­ 1 . Charles, D.: Cancer. 18: 737, 1965. ours. However, in the same series malig­ 2 . Corner, J. W ., Chi-Yuan Hu and nant tumours histologically similar to Herting, A. T.: Am. J . Obst. & Gynec. endometrial growths were encountered in 59: 760, 1950. 52 cases. Long and Taylor (1964) have 3 . Docherty, M. B. , Pratt, J . H. and questioned the assumption that malig­ Decker, D. D.: Cancer. 7, 893, 1954. nancy in endometriosis is so rare. They 4 . Docherty, M. B.: Surg. Gynec. & studied 120 cases of malignant ovarian Obst. 99: 392, 1954. tumours and found 20 had structural re­ 5 . Dodge, 0 . G. : Brit. J. Surg. 49: 122, 1961. semblance to endometrial carcinoma sug­ gesting an origin in endometriosis. Kot­ 6 . Dukes, C. E. : J. Path. & Bact. 50: 527, 1940. tmeir (1952) and Docherty (1954) have 7 . Fathala, M. F.: J . Obst. & Gynec. also commented on the frequency with Brit. Cwlth. 74: 85, 1967. which endometrioid carcinomas are seen 8 . Ferreira, H. P. and Clayton, S. G.: in the ovary. The low incidence of re~ J. Obst. & Gynec. Brit. Emp. 65: 41, ported! cases may be partly due to strict 1958. compliance with the requirements dictat~ 9 . Freedman, H. H., Tellem, M. and ed by Sampson (1925) . It is fair to state Meranze, D. R. : Obst. & Gynec. 23: that malignant change in endometriosis is 237, 1964. such an unlikely possibility considering 10 . Hamperi, H. and Hellung, G. : Cancer. the frequency of this condition that we are 10: 1187, 1957. not justified in allowing this considera~ 11 . Healey, W . P. and Cutler, M.: Am. J . Obst. & Gynec. 19: 457, 1930. tion to alter our surgical judgement re­ garding the treatment of this condition. 12 . Herxheimer, G.: Bietr. Path. Anat. V . AUg. 4: 348, 1907. The importance of recognising such a 13 . Hosoi, K. and Meeker, L. H .: Arch. change as a rare occurrence in an indivi­ Surg. 18: 63 , 1929. dual case is however obvious. 14 . Jenkinson, E. L. and Brown, W. H.: J. A.M.A. 122: 349, 1943. Summary 15 . Kay, S.: Cancer. 7: 359, 1954. A rare case of adenoacanthoma arising 16 . Kottmeir, H. L .: Acta. Obst. & in rectal endometriosis is described. Gynec. Scand. 31: 313, 1952. Adenoacanthoma, while rare in other 17 . Lash, S. R. and Rubenstone, A. I. : sites, is a relatively frequent form of tum­ Am. J. Obst. & Gynec. 78: 299, 1959. our arising in tissues of endometrial 18 . Long, M. E. and Taylor, H. E.: Am. origin. Relevant literature is reviewed. J . Obst. & Gynec. 90: 313, 1964 .

.. ADENOACANTHOMA OF RECTAL END:)METRIOSIS 525

19. Miller, N. F.: Am. J. Obst. & Gynec. 23 . Thompson, J. D.: Obst. & Gynec. 9: 40: 791, 1950. 403, 1957. 20. Nicholson, G. W.: Guy's Hospital 24. Weinrod, N. M., Baggs, J. F. and Reports. 73: 298, 1923. Shanoff, J. G.: Obst. & Gynec. 7: 161, 21. Novak. E . R. and Nalley, W . B.: Obst. 1956. . & G yn ec. 9: 936, 1957. 25 . Willis, R. A.: Pathology of Tumours, 22 . Sampson, J . A. : Arch. Surg. 10: 1, ed. 4, London, 1967, Butterworth. p . 1925. 544. '

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