Individualized management of umbilical endometriosis: A report of seven cases

Umbilical Endometriosis: A Systematic Literature Review and Pathogenic Theory Proposal

Umbilical endometriosis represents 30–40% of abdominal wall endometriosis and around 0.5–1.0% of all cases of endometriosis. The aim of this systematic review is to revisit the epidemiology, signs, and symptoms and to formulate a pathogenic theory based on literature data. We performed a systematic literature review using the PubMed and Embase databases from 1 January 1950 to 7 February 2021, according to the PRISMA guidelines. The review was registered at PROSPERO (CRD42021239670). Studies were selected if they reported original data on umbilical endometriosis nodule defined at histopathological examination and described as the presence of endometrial glands and/or stromal cells in the connective tissue. A total of 11 studies (10 retrospective and one prospective), and 14 case series were included in the present review. Overall, 232 umbilical endometriosis cases were reported, with the number per study ranging from 1 to 96. Umbilical endometriosis was observed in 76 (20.9%; 95% CI 17.1–25.4) of the women included in studies reporting information on the total number of cases of abdominal wall endometriosis. Umbilical endometriosis was considered a primary form in 68.4% (158/231, 95% CI 62.1–74.1) of cases. A history of endometriosis and previous abdominal surgery were reported in 37.9% (25/66, 95% CI 27.2–49.9) and 31.0% (72/232, 95% CI 25.4–37.3) of cases, respectively. Pain was described in 83% of the women (137/165, 95% CI 76.6–88.0), followed by catamenial symptoms in 83.5% (142/170, 95% CI, 77.2–88.4) and bleeding in 50.9% (89/175, 95% CI 43.5–58.2). In the 148 women followed for a period ranging from three to 92.5 months, seven (4.7%, 95% CI 2.3–9.4) recurrences were observed. The results of this analysis show that umbilical endometriosis represents about 20% of all the abdominal wall endometriotic lesions and that over two thirds of cases are primary umbilical endometriosis forms. Pain and catamenial symptoms are the most common complaints that suggest the diagnosis. Primary umbilical endometriosis may originate from implantation of regurgitated endometrial cells conveyed by the clockwise peritoneal circulation up to the right hemidiaphragm and funneled toward the umbilicus by the falciform and round liver ligaments.

Umbilical Endometriosis Disguised by Seborrheic Keratosis on Punch Biopsy

ABSTRACT

Endometriosis is a benign condition of the female genital system, characterized by endometrial tissue external to the uterine cavity. Of all cases with endometriosis, the incidence of umbilical endometriosis is only 0.29%. Umbilical endometriosis typical presents with symptoms including cyclical pain, bleeding, and swelling of the nodule. Morphological changes in the epidermis, as in this case, simulating a seborrheic keratosis both clinically and microscopically, can initially mask the underlying endometriosis and prolong the course of treatment. A thorough anamnesis and examination revealing the characteristic symptoms and findings coupled with a representative biopsy is essential to correctly diagnose umbilical endometriosis.

IFITM1 is a Novel, Highly Sensitive Marker for Endometriotic Stromal Cells in Ovarian and Extragenital Endometriosis

When the presence of endometriotic lesions are not evident by hematoxylin and eosin staining, CD10 is used to highlight and confirm the presence of endometriotic stroma. However, CD10 is not specific only to the endometrial stroma but is also expressed in many other cells. Recently, interferon-inducible transmembrane protein 1 (IFITM1) was reported as a highly specific immunohistochemical marker of normal endometrial stroma and endometrial stromal neoplasm. In this study, we examined the expression of IFITM1 and CD10 in 18 cases of ovarian endometriosis and 44 cases of extragenital endometriosis. Among the 62 patients, 62 (100.0%) were positive for IFITM1 and 60 (96.8%) for CD10, and CD10 was negative in 2 cases that were positive for IFITM1. Additionally, we found that IFITM1 sensitivity was unaffected by the presence or absence of hormonal therapy. To the best of our knowledge, this represents the first demonstration of IFITM1 as a highly sensitive stromal marker of ovarian and extragenital endometriosis.

Clinical practice guidelines for the treatment of extragenital endometriosis in Japan, 2018

The aim of this publication is to disseminate the clinical practice guidelines for the treatment of intestinal, bladder/ureteral, thoracic and umbilical endometriosis, already published in Japanese, to non-Japanese speakers. For developing the original Japanese guidelines, the clinical practice guideline committee was formed by the research team for extragenital endometriosis, which is part of the research program of intractable disease of the Japanese Ministry of Health, Labor and Welfare. The clinical practice guideline committee formulated eight clinical questions for the treatment of extragenital endometriosis, which were intestinal, bladder/ureteral, thoracic and umbilical endometriosis. The committee performed a systematic review of the literature to provide responses to clinical questions and developed clinical guidelines for extragenital endometriosis, according to the process proposed by the Medical Information Network Distribution Service. The recommendation level was determined using modified Delphi methods. The clinical practice guidelines were officially approved by the Japan Society of Obstetrics and Gynecology and the Japan Society of Endometriosis. This English version was translated from the Japanese version.

Extra-pelvic endometriosis: A review

BACKGROUND

Extra-pelvic endometriosis is a rare type of endometriosis, which occurs in a distant site from gynecological organs. The diagnosis of extra-pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis. The main objective of this review was to characterize abdominal wall endometriosis (AWE) and thoracic endometriosis (TE).

METHODS

The authors performed a literature search to provide an overview of AWE and TE, which are the major types of extra-pelvic endometriosis.

MAIN FINDINGS

Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin. Surgical treatment appeared to be effective for AWE. Case reports indicated that the diagnosis and treatment of catamenial pneumothorax or endometriosis-related pneumothorax (CP/ERP) are challenging, and a combination of surgery and postoperative hormonal therapy is essential. Further, catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.

CONCLUSION

Evidence-based approaches to diagnosis and treatment of extra-pelvic endometriosis remain immature given the low prevalence and limited quality of research available in the literature. To gain a better understanding of extra-pelvic endometriosis, it would be advisable to develop a registry involving a multidisciplinary collaboration with gynecologists, general surgeons, and thoracic surgeons.

Clinical aspects and management of inguinal endometriosis: A case series of 20 patients

AIM

This study aimed to describe the clinical presentation, diagnostic evaluation, and operative or medical management of inguinal endometriosis.

METHODS

In this study, we retrospectively reviewed 20 cases of inguinal endometriosis in our facility, particularly on the clinical characteristics, diagnosis, and surgical and medical treatment.

RESULTS

We retrospectively investigated the following items for each patient: age at diagnosis, surgical history, presence of extragenital endometriosis, symptoms, imaging modalities, surgical therapy, hormonal therapy, follow-up period, postoperative recurrence and time to recurrence. We identified 20 cases of inguinal endometriosis in our facility. First, 75% of the patients had right inguinal endometriosis. Second, T1-weighted or fat-saturated T1-weighted images showed hyperintensity in the lesions in 17 patients (17/18 patients, 94.4%). Third, in 5 of 6 patients who underwent surgical therapy, we performed radical surgery to excise the inguinal lesion including the round ligament. One patient had disease relapse. Fourth, in 6 of 7 cases, dienogest effectively improved pain without significant adverse effects, but oral contraceptive was effective in 1 of 4 patients without significant adverse effects.

CONCLUSION

We retrospectively reviewed 20 patients with inguinal endometriosis in our facility. We have shown that magnetic resonance imaging can be a useful imaging modality to obtain a specific diagnosis of this disease. In addition, inguinal endometriosis can be managed with radical surgery to resect lesions including the round ligament and with hormonal treatment. In particular, dienogest ameliorated symptoms, which can be an option for patients who do not want surgery.

IFITM1 is a Novel, Highly Sensitive Marker for Endometriotic Stromal Cells in Ovarian and Extragenital Endometriosis

When the presence of endometriotic lesions are not evident by hematoxylin and eosin staining, CD10 is used to highlight and confirm the presence of endometriotic stroma. However, CD10 is not specific only to the endometrial stroma but is also expressed in many other cells. Recently, interferon-inducible transmembrane protein 1 (IFITM1) was reported as a highly specific immunohistochemical marker of normal endometrial stroma and endometrial stromal neoplasm. In this study, we examined the expression of IFITM1 and CD10 in 18 cases of ovarian endometriosis and 44 cases of extragenital endometriosis. Among the 62 patients, 62 (100.0%) were positive for IFITM1 and 60 (96.8%) for CD10, and CD10 was negative in 2 cases that were positive for IFITM1. Additionally, we found that IFITM1 sensitivity was unaffected by the presence or absence of hormonal therapy. To the best of our knowledge, this represents the first demonstration of IFITM1 as a highly sensitive stromal marker of ovarian and extragenital endometriosis.

Primary umbilical endometriosis with cyclic bleeding

Umbilical endometriosis is a rare clinical entity with unclear pathogenesis. A 36-year-old woman who presented with painless umbilical bleeding during the menstrual period for 9 months, history of dysmenorrhea for 10 years ago without medial used for relieving pain. A painless, 2-cm superficial hyperpigmented dark nodule with an orifice located in an umbilicus had been revealed during physical examination. The ultrasonography showed a 2.6-cm right hypoechogenic ovarian cyst and a 2.37-cm umbilical mass. The operation was umbilical lesion excision, laparoscopic enucleation of right endometrioma and surgical excision of endometriosis at the uterosacral ligament which revealed endometriosis on microscopic examination. The umbilicus had performed for neo-umbilicus suturing. Postoperative was uneventful. The concomitant endometriosis of the umbilicus, right endometrioma and the uterosacral ligament is rarely reported in the literature.

Umbilical Nodule with Cyclical Bleeding: A Case Report and Literature Review of Atypical Endometriosis

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. It affects 3 to 10 percent of women of reproductive age. Umbilical endometriosis is rare, with an estimated incidence of 0.5–1.0% among all cases of endometriosis, and is usually secondary to prior laparoscopic surgery involving the umbilicus. In this report, we described a case of umbilical endometriosis treated with surgical resection and highlight the great importance of medical history compared to complementary diagnostic tests that can be sometimes inconclusive.

Primary umbilical endometrioma: Analyzing the pathogenesis of endometriosis from an unusual localization

OBJECTIVE

This report presents a rare case of symptomatic primary umbilical endometriosis and reviews the literature on the topic with the aim to clarify some questions on the origin of endometriosis.

CASE REPORT

A 33-year-old woman with cyclic umbilical bleeding was found to have umbilical endometriosis. She had no history of pelvic or abdominal surgery. There was no past history of endometriosis or endometriosis-associated symptoms. An omphalectomy was performed after explorative laparoscopy to carefully inspect the abdominopelvic cavity and assess any coexisting pelvic endometriotic lesions. Histological examination confirmed the diagnosis of umbilical endometriosis.

CONCLUSION

Umbilical endometriosis is a rare but under-recognized phenomenon. Primary lesions are difficult to recognize, but probably represent an independent nosological entity. The possibility of endometriosis must be considered during the evaluation of an umbilical mass despite the absence of previous surgery. Complete excision and successive histology are highly recommended.

An unusual case of asymptomatic spontaneous umbilical endometriosis treated with skin-sparing excision

Spontaneous umbilical endometriosis is a rare extrapelvic manifestation of endometriosis. Very few such cases have been previously reported, almost always associated with a variety of symptoms, usually during menstruation. We present a case of asymptomatic umbilical endometriosis treated with skin-sparing excision. Differential diagnoses relevant to the clinician, as well as treatment options, are also presented. Surgeons should always consider umbilical endometriosis in their diagnostic approach when confronted with atypical umbilical nodules, regardless of whether they are symptomatic or not.

Dienogest reduces proliferation, aromatase expression and angiogenesis, and increases apoptosis in human endometriosis

Dienogest is a novel progestin that is highly selective for progesterone receptors and inhibits endometriosis. However, it remains unknown how the administration of dienogest to patients with endometriosis impacts on their lesion tissues. The aim of this study was to evaluate the in vivo effect of dienogest on endometriosis tissue. We collected endometrioma tissues from patients treated with dienogest (N = 7) or not treated (N = 11, controls). Cell proliferation, aromatase expression and blood vessel density were evaluated by staining for Ki67, aromatase and the von Willebrand factor, respectively. Apoptosis was detected using the TUNEL assay. The proportion of Ki67 and aromatase positive epithelial cells was significantly lower in the dienogest group than in controls (p < 0.05, respectively). The number of TUNEL positive cells was significantly higher in the dienogest group (p < 0.05). The density of blood vessels in endometrioma was marginally lower in the dienogest group compared with controls (p = 0.20). Our study demonstrates that endometrioma taken from patients treated with dienogest show remarkable histological features such as reduction of proliferation, aromatase expression and angiogenesis, and increase of apoptosis. This study clarified the impact of dienogest on local histological events that explain its therapeutic effect on endometriosis.