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JAMA Surgery Clinical Challenge
February 2016

Nodules in the Pouch of Douglas

Author Affiliations
  • 1Department of Surgical Oncology, HCG-MSR Cancer Centre, M. S. Ramaiah Medical College, Bangalore, India
JAMA Surg. 2016;151(2):189-190. doi:10.1001/jamasurg.2015.4437

A pregnant woman in her 30s in the first trimester was evaluated for incidentally detected anemia. At colonoscopy, she was found to have a 3 × 4-cm ulceroproliferative lesion in the rectum 7 cm from the anal verge. A biopsy specimen was reported as moderately differentiated adenocarcinoma. No other lesion was found in the rest of colon. The pregnancy was medically terminated. Further evaluation showed that the disease was limited to the rectal wall, with no nodal involvement, and there was no liver metastasis. Her carcinoembryonic antigen level was 4.3 ng/mL (to convert to micrograms per liter, multiply by 1.0). A definitive resection was planned. On laparotomy, no ascites was observed. However, the pelvic peritoneum in the pouch of Douglas showed dark brown-black nodules (Figure, A). The rest of the peritoneal cavity was normal. The rectal growth was mobile and was palpable below the peritoneal reflection. The nodule was biopsied, and the specimen was sent for frozen section analysis. The histopathological findings are shown in Figure, B.