Pseudotumoral Endometriotic Nodule

Study Objective: To demonstrate a rare case of a pediculated endometriotic nodule that was initially diagnosed as a solid adnexal mass. Design: We present a stepwise narrated demonstration of our laparoscopic technique. Setting: We present a case report of a patient aged 44 years, gravida 2 para 2, who was diagnosed with a solid (adnexal) mass during a gynecologic examination. She presented symptoms of dyspareunia. During a bimanual examination, 2 fixed nodules were palpated in both the uterosacral ligaments, and a mobile solid mass of 5 cm could be palpated on the right adnex. A transvaginal ultrasound showed a solid (adnexal) mass of 50 mm in diameter. The tumor marker cancer antigen 125 was normal, and after application of the International Ovarian Tumor Analysis score, the risk of malignancy was up to 39%. A complementary magnetic resonance image showed a heterogeneous solid mass of 47 × 47 × 29 mm with a differential diagnosis of a pediculated fibroma in (myxoid) degeneration vs an adnexal solid mass. A laparoscopic unilateral adnexectomy was scheduled, and the patient was informed about the risk of malignancy. The laparoscopy revealed bilateral normal adnexa, the presence of a solid pediculated mass originating from the right uterosacral ligament and 2 endometriotic nodules originating from the left and right uterosacral ligaments. The rectovaginal space was dissected, and a third deep infiltrating endometriotic nodule was revealed. The operation proceeded by the sectioning of the left uterosacral ligament below the endometriotic nodule. The posterior vaginal wall was separated from the endometriotic nodule, and after further dissection of the rectovaginal space, we arrived in a disease-free area. After opening of the right medial division of the pararectal space, the right hypogastric nerve was dissected and preserved. The solid mass was separated from the uterus, the right uterosacral ligament was excised at a distance from the nodule, and the pediculated mass was removed intact en block with the right ligament. The patient was discharged 24 hours after surgery. The postoperative period was uneventful. The definitive histology report confirmed the presence of endometriotic nodules and a solid tumor classified as a pseudotumoral endometriotic mass. This was justified by the presence of conjunctival vascular stroma including multiple endometriotic foci, the presence of cytogenic stroma of variable abundance including glands lined with a columnar epithelium, and, most important, the fact that the epithelium had no cytologic atypias. Interventions: Laparoscopic excision of the pseudotumoral endometriotic nodule en block with the right and left uterosacral ligaments. Conclusion: Endometriosis is a complex multifactorial pathology in which several factors are involved: genetics, environmental factors, immunologic reactions, hormonal effects, and anatomic anomalies. All these factors may contribute to the creation of an inflammatory response related to immune cells, adhesion molecules, extracellular matrix metalloproteinase, and proinflammatory cytokines enhancing the formation of fibrotic tissue [1,2]. These changes may sometimes have an unusual presentation, as we are showing in this case report of a pseudotumoral endometriotic mass. This rare case should be included in the differential diagnosis of solid tumors before surgery for symptomatic patients and those who have a medical history of endometriosis.