Thursday, May 1, 2014

Histology (what the path report shows) and Endometriosis

When your doctor sends specimens from your surgery to the pathologist for confirmation, the pathologist will be looking for glands and/or stroma ("Histologic demonstration of a combination of endometrial glands and stroma in biopsy specimens obtained from outside the uterine cavity is required to make the diagnosis of endometriosis."

When they find those glands and/or stroma, then endometriosis is confirmed. If they do not find them, then it is inconclusive (meaning it may be endo but they could not positively identify in the specimen sent). It can be inconclusive for several reasons:

"Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia... In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change....Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings...The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis... Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance."

"Positive histology for endometriosis was confirmed in 75% of cases, the histology was negative in 18.7% and in 6.3% was non-diagnostic. The study confirmed that correlation between laparoscopic findings and positive histology was dependant on the site of lesion and the stage of endometriosis. As more information was provided to the laboratory and as the pathologists became accustomed to looking for the disease, there was a higher detection of endometriosis."

"Positive histology confirms the diagnosis of endometriosis; negative histology does not exclude it. Whether histology should be obtained if peritoneal disease alone is present is controversial: visual inspection is usually adequate but histological confirmation of at least one lesion is ideal. In cases of ovarian endometrioma (> 4 cms in diameter), and in deeply infiltrating disease, histology should be obtained to identify endometriosis and to exclude rare instances of malignancy."

"Stromal endometriosis, characterised histologically by small microscopic nodules or plaques of endometrioid-type stroma, sometimes with a whorled pattern and prominent vascularity and erythrocyte extravasation, was identified in 44.9% of the biopsies. In 6.6% of the biopsies, stromal endometriosis occurred without typical endometriosis. The foci of stromal endometriosis usually had a superficial location just beneath the mesothelial surface or protruding above this. Associated histological features present in some cases included reactive mesothelial proliferation, inflammation, giant cell or granuloma formation, haemosiderin pigment deposition, microcalcification and decidualisation and myxoid change.


Stromal endometriosis, usually in the form of superficial nodules or plaques, is a relatively common form of endometriosis which typically occurs in association with typical endometriosis but occasionally on its own. Pathologists should be aware of the existence of this form of endometriosis, the morphological features of which may be subtle. The typical location, intimately associated with surface mesothelium, may suggest that stromal endometriosis derives from mesothelial or submesothelial cells via a metaplastic process."

More details (and pictures!) if you are curious:

“Although the histological diagnosis of endometriosis is usually easy to make, there are diagnostic problems in relation to certain aspects such as the atypias and neoplastic alterations of the endometriotic glandular and stromal components and in cases of endometriosis in unusual places the small size of specimens available for histological examination does not aid the correct diagnosis….

Usually both, glands and stroma are observed but occasionally the diagnosis can be

made when only one component is present. Endometriosis is distinct from adenomyosis or

endometriosis interna which is defined by the presence of endometrial components in the

myometrium. These two entities were linked in the past by common terminology but

present different clinical presentation, epidemiologic and etiologic patterns….

The location and the age of the endometriotic lesion and the patients’ age affect the

morphological appearance of endometriosis and may lead to diagnostic difficulties….

Typically endometriosis in women of reproductive age presents histologically as one or

more endometrioid glands surrounded by stromal cells, resembling the endometrial stromal

cells of the proliferative phase. The glandular epithelium is one layer thick with cuboidal or

tall cells and eosinophilic cytoplasm. Nuclei are ovoid with vertical orientation and very

rare mitoses. The whole picture is usually consistent with inactive or irregular proliferative

endometrium, although typical proliferative or secretory changes may be observed. Cilia

may be observed as well. Stromal cells are supported by a delicate reticulin network in

which hyperemic small vessels may be observed. In the case of exogenous administration of

progestins, cyclically functionic endometriosis or pregnancy, a stromal decidual reaction

may be observed. A diffuse infiltration of histiocytes is usually observed. The histiocytes

convert the red blood cells into glucolipid and brown pigment (pseudoxanthoma cells) .The

pigment is usual a ceroid such as lipofuscin and to a lesser extend hemosiderin .The amount

of the pigment increases with the age of the lesion. Inflammatory cells may be present and a

small component of smooth muscle cells especially in the wall of endometrioid cysts may be

observed. Not all the above described elements are easily identified in endometriosis.”