The Lymphatic System in Endometriosis: a Pilot Study of Endometrial-Like Cells and Immune Cell Populations in Lymph Nodes Associated with Deep Infiltrating Bowel Lesions

Reprod Sci. 2020 Apr;27(4):977-987. doi: 10.1007/s43032-020-00171-0. Epub 2020 Feb 19.


In endometriosis, the lymphatic and immune systems are implicated in disease establishment and progression. The objective of this pilot study was to examine endometrial-like, and for the first time, immune cell populations in lymph nodes associated with deep infiltrating endometriosis (DIE) bowel lesions. Premenopausal women undergoing excision of endometriosis and/or hysterectomy were included. DIE bowel lesion-associated (n = 10) and other pelvic (n = 15) lymph nodes were studied. Samples were immunohistochemically stained for endometrial-like cells (CD10), T cells (CD3, CD4, CD8, and FoxP3), dendritic cells (DC; DC-Lamp and DC-Sign), B cells (CD20, CD79 and plasma), macrophages (CD68), and natural killer cells (NK; CD57). Cell abundance (percentage positive area) and antigen expression (optical density; OD) were quantified. Endometrial-like cells and each immune cell population were present in all studied nodes. The DIE bowel lesion-associated nodes showed features of immune activation, with T cell proliferation (CD3+ area p = 0.007, CD4+ area p = 0.015 compared with other pelvic nodes); and a mixture of helper and regulatory T cells, B cells, DCs, macrophages, and plasma cells present in the paracortex. In DIE bowel lesion-associated compared with other pelvic nodes, CD10+ endometrial-like cells were reduced (percentage positive area p < 0.001, OD p = 0.004). This study provides new insight into lymphatic and immune system involvement in advanced endometriosis. In particular, we have shown evidence of immune activation in DIE lesion-associated nodes. This was despite lower endometrial-like cell numbers compared with other pelvic nodes. The observations contribute to a developing understanding of the local immune response to advanced disease.

Keywords: Deep infiltrating endometriosis; Endometriosis; Immune response; Lymph nodes; Lymphatic spread.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Endometriosis / complications
  • Endometriosis / immunology*
  • Endometriosis / pathology
  • Endometrium / immunology*
  • Female
  • Humans
  • Lymph Nodes / immunology*
  • Lymph Nodes / pathology
  • Lymphatic System / immunology*
  • Middle Aged
  • Pilot Projects
  • Rectal Neoplasms / complications
  • Rectal Neoplasms / immunology*
  • Rectal Neoplasms / pathology