Ultrasound and MR-imaging in preoperative evaluation of two rare cases of scar endometriosis

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Caesarean-section scar endometriosis (CSSE): clinical and imaging fundamentals of an underestimated entity

Caesarean-section scar endometriosis (CSSE) is a form of extra-pelvic endometriosis developing through endometrial cell implantation anywhere along the route of a previous caesarean section (CS) surgery, including the skin, subcutaneous tissue, abdominal wall muscles, intraperitoneally, and the uterine scar itself. Synchronous intra-abdominal endometriosis is not a prerequisite. Given the rising prevalence of CS, CSSE may be underrepresented in the literature and occur more frequently than previously thought. Locating a painful soft-tissue mass-like lesion along the path of a previous CS scar is the most indicative sign that should initially alarm physicians towards suggesting CSSE, especially if symptoms are typical (cyclically reoccurring with menstruation). The detection of hyperintense (haemorrhagic) foci on T1 fat-saturated sequences will strongly support the diagnosis on magnetic resonance imaging (MRI), the most sensitive imaging method for CSSE assessment. A non-specific, contrast-enhancing, hypodense nodule with spiculate edges may be suggestive if the lesion was originally detected on computed tomography (CT). Although ultrasound is frequently the first imaging method used, the findings are non-specific; therefore, making it more useful for ruling out other differentials and for image-guided biopsy. In any case, histopathology provides the definitive diagnosis. Surgical excision is the mainstay of treatment; however, minimally invasive, percutaneous techniques have also been implemented successfully.

Abdominal wall endometriosis: a case report

Abdominal wall endometriosis has an incidence of 0.3–1% of extrapelvic disease. Α 48-year-old female appeared in the emergency department with cellulitis in a lower midline incision. She had an endometrioma of the anterior abdominal wall removed 2 years ago. After 5 months, she underwent an open repair of an incisional hernia with a propylene mesh, which was unfortunately infected and removed 1 month later. Finally, in July 2019, she had her incisional hernia repaired with a biological mesh. Imaging modalities revealed a large mass below the umbilicus. Mass was punctured under ultrasound guidance. Cytology reported the recurrence of endometriosis. Pain and abdominal mass associating with menses were the two most typical symptoms. Wide local excision of the mass with at least 1 cm negative margins is the preferred treatment. Surgeons should maintain a high suspicion of the disease in reproductive women with circular pain, palpable abdominal mass and history of uterine-relating surgery.

Multimodality imaging and clinicopathologic assessment of abdominal wall endometriosis: knocking down the enigma

PURPOSE

To review the clinical, multimodality imaging, and pathologic characteristics of abdominal wall endometriosis (AWE), the most common type of extra-pelvic endometriosis.

METHODS

116 women with histopathologically confirmed extragenital endometriosis diagnosed between 2/2014 and 6/2017 were evaluated retrospectively. Of these, 26 (22.4%) were found to have AWE and 18/26 met inclusion criteria for imaging. Available imaging studies were re-reviewed by two expert radiologists. Data regarding clinical features, histopathologic findings, and management were collected through medical record review.

RESULTS

21 pathology-proven AWE deposits were identified by imaging in 18 women [mean age at diagnosis of 38.5 years (range 31-48)]. Prior C-section was present in 15/18 (83.3%) and pelvic endometriosis in 3/18 (16.7%) patients. Patients presented with abdominal pain in 14/18 (77.8%) cases, which was cyclical in 8/14; palpable mass in 12/18 (66.7%); fluid discharge in 2/18 (11.1%); and local skin discoloration in 2/18 (11.1%). Of the 21 lesions, 15 were evaluated with US, 10 with CT, and 5 with MRI. Mean lesion dimensions were 2.5 × 2.2 × 2.6 cm, and deposits were predominantly located at midline or left hemiabdomen [22/30 (73.3%)], were either stellate [15/30 (50%)] or round [15/30 (50%)] in shape, had ill-defined margins [21/30 (70%)], were heterogenous in appearance [27/30 (90%)], and involved both deep and superficial abdominal wall layers [17/30 (56.7%)]. On US, lesions were mainly isoechoic/hyperechoic [7/15 (46.7%)], and scarcely vascular [8/15 (53.3%)] with a peripheral vascular pattern [8/13 (61.5%)]. On CT, AWEs were hypervascular and homogeneous [8/10 (80%)], superiorly located to scar tissue, and on MRI lesions appeared hyperintense [4/5 (80%)] to muscle with T2 cystic and T1 hemorrhagic foci [4/5 (80%)]. In 23/27 (85.1%) original reports, there was at least one known mass prior to imaging; AWE was correctly diagnosed in only 7/23 (30.4%) cases. In those with no prior knowledge of a mass, the lesion was detected in 3/4 (75%), but AWE was only diagnosed in a single case. Median time between onset of symptoms and histopathology was 24.41 moths (IQR 15.18-47.33).

CONCLUSIONS

AWE is a challenging clinical entity frequently diagnosed with a significant delay and easily misinterpreted despite multimodality imaging. Familiarity with its radiologic features holds the potential for positively impacting diagnosis.

Mullerian tissue in the rectus abdominis muscle forming an endometrioma: a case report

Endometriosis is defined as the presence of endometrial tissue at the sites other than the uterine lining and responds to the cyclical ovarian hormonal activity. It is a multidimensional and a complex disease which has an impact on physical, mental, sexual, and social aspects of the life of a woman. Here is a case report of a patient, presented to the department with pain and swelling in her left side of the previous cesarean scar. It was surgically removed and was diagnosed to be an endometrioma of rectus sheath and rectus abdominis muscle on histopathology.

Surgical scar endometriosis: a series of 14 patients and brief review of literature

Background and aims

Endometriosis is a commonly encountered disorder in women of reproductive age, consisting of the presence of active ectopic endometrial tissue outside the endometrial cavity. Surgical scar endometriosis is a rare condition representing about 2% of all endometriosis cases. The purpose of this study was to assess the main characteristics, diagnostic tools and therapeutic options in abdominal wall endometriosis (AWE).

Methods

We have reviewed a series of fourteen cases with histopathological confirmation of AWE that were managed in our institution.

Results

The main characteristic of AWE were emphasized, showing that 78.57% of the patients had at least one previous caesarian section and that in only 57.14% of all cases an accurate diagnosis of AWE was established preoperatively.

Conclusion

A direct relationship between gynecological and obstetrical surgery and AWE is well established and as the caesarian section rates increase constantly, the awareness regarding AWE should also be increased.

Mid-term outcomes after percutaneous cryoablation of symptomatic abdominal wall endometriosis: comparison with surgery alone in a single institution

OBJECTIVES

To compare the outcomes of percutaneous image-guided cryoablation of symptomatic abdominal wall endometriosis (AWE) versus surgery alone.

METHODS

From 2004 to 2016, cryoablation or surgery alone was performed under local (n = 5) or general anaesthesia (n = 15) for AWE in a single institution in 7 (mean age, 36.1 years) and 13 (mean age, 31.9 years) patients, respectively. Fifteen lesions were treated by cryoablation (mean size, 2.3 cm; range, 0.5-7 cm) and 16 by surgery (2.5 cm; 1.1-3.4 cm). Tolerance, efficacy and patient and procedural characteristics were compared.

RESULTS

Median follow-up was 22.5 (range, 6-42) months after cryoablation and 54 (14-149) after surgery. The median procedure and hospitalisation durations were 41.5 min (24-66) and 0.8 days (0-1) after cryoablation, and 73.5 min (35-160) and 2.8 days (1-12 days) after surgery (both P = 0.01). Three patients (23.1%) had severe complications and nine aesthetic sequels (69.2%) after surgery, none after cryoablation (P = 0.05). The median 12- and 24-month symptom free-survival rates were 100% and 66.7% (95% CI, 5.4; 94.5) after cryoablation and 92% (55.3; 98.9) after surgery at both time points (P = 0.45).

CONCLUSIONS

Cryoablation presents similar effectiveness to surgery alone for local control of AWE while reducing hospitalisation duration and complications. Any aesthetic sequels were associated with the cryoablation treatment.

KEY POINTS

• Hospitalisation is shorter after cryoablation than after surgery of abdominal wall endometriosis. • A significantly lower rate of complications is observed after cryoablation compared to surgery. • Cryoablation of abdominal wall endometriosis presents similar effectiveness to surgery alone. • A significant reduction of pain is observed 6 months after treatment. • A significant reduction of abdominal wall endometriosis is observed at 6 months.

Diagnosis and Management of Abdominal Wall Endometriosis: A Systematic Review and Clinical Recommendations

Importance

Abdominal wall endometriosis (AWE) is a rare but easily treated cause of pain in women, especially those who have undergone cesarean deliveries.

Objective

This article reviews the diagnosis and management of AWE, a condition that generally develops after surgery but may arise spontaneously. We present a systematic review of the existing literature on AWE, as well as our clinical recommendations for medical and surgical management.

Evidence Acquisition

We searched PubMed and other databases using the search criteria "abdominal wall endometriosis," "abdominal wall endometriomas," and "abdominal wall mass." The references of those articles were then reviewed, and additional publications were evaluated.

Results

Many case reports and case series have been published describing AWE. The overall quality of evidence is poor due to the lack of prospective studies and heterogeneous descriptions of AWE lesions and treatment options. Based on the available literature, it appears that AWE may arise spontaneously but is generally associated with prior pelvic surgery. Abdominal wall endometriosis can be diagnosed with a careful history and physical examination. Imaging including ultrasound and magnetic resonance imaging can assist with localization of the lesions, and aid in surgical excision and management. Lesions that have been removed in their entirety are unlikely to reoccur.

Conclusions and Relevance

Although limited, the body of literature describing management of AWE suggests that it can be successfully treated in most patients with careful surgical planning.

Intramuscular abdominal wall endometriosis treated by ultrasound-guided ethanol injection

Abdominal wall endometriosis (AWE) is a rare condition that usually develops in a surgical scar resulting from a Caesarean section. While commonly seen in the cutaneous and subcutaneous fat tissue at the Caesarean scar level, its intramuscular localization is quite rare. Its treatment options consist of the excision of the lesion and/or hormonal therapies, although wide surgical excision is the treatment of choice in the literature. Wide surgical excision may create a defect in the abdominal wall and may increase the risk of hernia formation and mesh complications. This case report describes the clinical and radiological findings and treatment modalities of endometriosis that have appeared in the rectus abdominis muscle of a 25-year-old patient at the Caesarean scar level. Sclerotherapy may be used for endometrioma. We present a new and alternative treatment method using ultrasound-guided intralesional ethanol injection for AWE. Compared with the complications of surgical excision, the complications of sclerotherapy by ethanol are at a more acceptable level. Sclerotherapy by ethanol injection may be an alternative treatment to surgery for AWE.

Ultrasound of musculoskeletal soft-tissue tumors superficial to the investing fascia

OBJECTIVE

The objective of our study was to evaluate the diagnostic accuracy of ultrasound in assessing musculoskeletal soft-tissue tumors superficial to the investing fascia.

MATERIALS AND METHODS

Seven hundred fourteen superficial soft-tissue tumors evaluated with ultrasound by two musculoskeletal radiologists were retrospectively reviewed. In all ultrasound reports, the reporting radiologists provided one, two, or three diagnoses depending on their perceived level of diagnostic certainty. Two hundred forty-seven tumors had subsequent histologic correlation, thus allowing the accuracy of the ultrasound diagnosis to be determined. Images of the lesions with a discordant ultrasound diagnosis and histologic diagnosis were reviewed, and the ultrasound features were further classified as concordant with the known histologic diagnosis, concordant with the known histologic diagnosis with atypical features present, or discordant with the known histologic diagnosis. Four hundred sixty-seven tumors without pathologic confirmation were followed up clinically.

RESULTS

Overall the accuracy of ultrasound examination for assessing superficial soft-tissue masses was 79.0% when all differential diagnoses were considered and 77.0% when only the first differential diagnosis was considered. The sensitivity and specificity of the first ultrasound diagnosis were 95.2% and 94.3%, respectively, for lipoma; 73.0% and 97.7% for vascular malformation; 80.0% and 95.4% for epidermoid cyst; and 68.8% and 95.2% for nerve sheath tumor. Reduced observer awareness of specific tumor entities tended to contribute to underdiagnosis more than poor specificity of ultrasound findings. Most tumors (236/247, 96%) were benign. The sensitivity and specificity of ultrasound for identifying malignant superficial soft-tissue tumors was 94.1% and 99.7%, respectively.

CONCLUSION

The diagnostic accuracy of ultrasound in the assessment of superficial musculoskeletal soft-tissue tumors is high and can be improved through increased radiologist awareness of less frequently encountered tumors. Ultrasound is accurate for differentiating benign from malignant superficial soft-tissue tumors.

Endometriosis and ovarian cancer risk: a systematic review of epidemiological studies

Background: A possible etiological association between endometriosis and ovarian cancer has been repeatedly reported in the literature.

Objective: Our aim was to evaluate published epidemiological data on this issue.

Review Methods: We conducted an extensive search of the literature in MEDLINE, of articles ever published until February 2014, using the key-words “endometriosis” and “ovarian” and one of the following terms in the title: “cancer” or “malignancy” or “malignant” or “tumor” or “neoplasia” or “neoplasm” or “transformation.” Retrieved papers were checked for further relevant publications.

Results: Overall, our search yielded 1 prospective cohort study, 10 retrospective cohort, and 5 case–control studies. A meta-analysis of these studies was not considered to be appropriate, due to differences in data reporting, study design, and adjustment for confounding factors.

Limitations: The main limitation of studies found, with one exception, was the lack of operative confirmation of endometriosis.

Conclusion: An association of endometriosis with clear-cell and endometrioid ovarian cancer was a consistent finding in most studies. On the other hand, existing epidemiological evidence linking endometriosis with ovarian cancer is insufficient to change current clinical practice. Prospective cohort studies, with prior laparoscopic confirmation, localization, and staging of endometriosis are needed, in order to further clarify this issue.

Appearance of abdominal wall endometriosis on MR imaging

OBJECTIVE

Abdominal wall endometriosis (AWE) is defined as endometrial tissue that is superficial to the peritoneum. AWE is often difficult to diagnose, mimicking a broad spectrum of diseases. The aim of this study was to describe the appearance of AWE on magnetic resonance (MR) imaging.

METHODS

We present ten patients with AWE (12 lesions) in which MR imaging was used for diagnosis. MR imaging included T2-weighted imaging and T1-weighted imaging with fat suppression. To assess the value of diffusion-weighted imaging (DWI) in endometriosis, four patients underwent additional DWI. The apparent diffusion coefficient (ADC) was calculated using b values of 50, 400, 800 and 1,200 s/mm(2).

RESULTS

In most cases, the lesion was located ventral or dorsal to the aponeurosis of the rectus oblique muscle (n = 6) or in the rectus abdominis (n = 5). MR of AWE lesions showed isointense or slightly hyperintense signal compared with muscle on T2-weighted images and showed isointense or slightly hyperintense signal compared with muscle on T1-weighted images with foci of high signal intensity, indicative of haemorrhage. The mean ADC value of AWE was 0.93 x 10(-3)/mm(2)/s.

CONCLUSION

MR imaging seems to be useful in determining the location and depth of infiltration in surrounding tissue preoperatively.