Skin Endometriosis at the Caesarean Section Scar: A Case Report and Review of the Literature

Characterising umbilical abdominal wall endometriosis as a distinct subgroup of abdominal wall endometriosis - retrospective cohort study

Abdominal wall endometriosis (AWE) is one of the rarest forms of endometriosis. Little is known about differences between umbilical AWE (U-AWE) and non-umbilical AWE (non-U-AWE) patients. This retrospective cohort study included patients treated for AWE at tertiary endometriosis centre between 2012 and 2020. Patients were divided into two groups - umbilical AWE and non-umbilical AWE.We identified 14 U-AWE and 45 non-U-AWE patients who mostly had lesions in caesarean section scar (38, 64.4%), rarely at other locations (7, 11.9%). Infertility rates for U-AWE patients and non-U-AWE patients were 57.1% and 17.8%, respectively. Concurrent or previous peritoneal endometriosis was noted in 85.7% of U-AWE and 24.4% of non-U- AWE patients. In addition, U-AWE patients and non-UAWE patients significantly differed in following: parity, number of previous caesarean sections, lesion size, prevalence of concurrent or previous deep infiltrating endometriosis, bleeding from abdominal wall, cyclic pain, continuous pain.Infertility and pelvic endometriosis were more prevalent in U-AWE patients. Our data suggests that U-AWE may be a specific marker for a patient highly prone to pelvic endometriosis and subsequent infertility. Findings suggests that clinician should consider comprehensive evaluation of U-AWE patients.

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.

Eyes, menstruation and endometriosis

Vicarious menstruation refers to cyclical bleeding outside the uterine cavity during the menstrual cycle. Haemolacria, or blood in tears, is a rare medical phenomenon that can occur with menstruation or in association with endometriosis. Endometriosis, defined by the presence of endometrial-like tissue in extra-uterine sites, affects around 10% of fertile women; the ocular system is one of the rarest sites it can be present in. Endometriosis usually requires a biopsy for diagnosis, and the anatomic difficulty of obtaining a biopsy of the ocular system makes ocular endometriosis diagnosis more obscure. However, few cases have been described in the literature and due to the psychological, physical, and social implications of haemolacria on the patient, treatment is of utmost importance. We reviewed the literature on ocular endometriosis and ocular vicarious menstruation with the aim to discuss the clinical presentation, necessary workup and various treatment modalities, while also shedding light on the connection between the eyes and endometriosis in general. It is hypothesised that uterine endometrial cells can travel lymphatically or haematogenously and deposit extra-uterine endometriotic lesions that bleed in response to hormonal changes in the menstrual cycle. Additionally, the conjunctival vasculature has been found to be responsive to hormonal changes due to the presence of oestrogen and progesterone receptors, causing bleeding at the corresponding sites, even without endometriotic lesions. Clinical correlation of the haemolacria with the menstrual cycle can suffice for a diagnosis of vicarious menstruation, and thus opens the possibility of treatment to provide symptomatic treatment for the patient.

The clinical features and long-term surgical outcomes of different types of abdominal wall endometriosis

PURPOSE

To classify abdominal wall endometriosis (AWE) according to the invasive levels of tissue mass, and to compare the differences in clinical characteristics between different types of AWE.

METHODS

In this study, we retrospectively analyzed the clinical data of 367 patients who had undergone resection of abdominal-wall endometriotic lesions at the Peking Union Medical College Hospital from January 2008 to December 2018, and we divided the patients into three types according to their deepest level of lesion invasion. Type I designated invasion of skin and subcutaneous tissue; type II, of fascia and rectus abdominis; and type III, of peritoneum. We classified, compared, and analyzed the general conditions, clinical manifestations, auxiliary examinations, surgical conditions, postoperative conditions, and recurrence status of patients.

RESULTS

Of the 367 patients, type I patients accounted for 13.62%, type II patients for 56.68%, and type III for 29.7%. With respect to group comparisons, we observed that as the location of the mass deepened, the rate of concurrent pelvic endometriosis increased (P = 0.007), recurrent AWE was augmented (P = 0.02), the size of the mass increased (P < 0.001), the rate of multiple lesions became elevated (P < 0.001), the rate of mesh implantation increased (P < 0.001), the length of postoperative hospital stay (P < 0.001) was lengthened, the number of postoperative fever cases (P = 0.006) increased, and the risk of drainage placement (P < 0.001) was enhanced. The 5-year cumulative recurrence rate was 3.3%, and there was no significant difference in the recurrence rate among various types of AWE.

CONCLUSION

Type III AWE carries more severe clinical manifestations, larger lesion size, longer operative time, greater intraoperative surgical difficulty, higher necessity of mesh implantation, and longer postoperative recovery process. Complete resection of AWE lesion is the main therapeutically approach and shows relatively low long-term recurrency rate.

Scar Endometriosis: A Rare Cause of Abdominal Pain

Scar endometriosis or incisional endometriosis is the presence of endometrial tissues with glands in the previous incision or scar. Its overall estimated incidence after post-cesarean and post-hysterectomy is 0.03–0.4% and 1.08–2%, respectively. The patient presents with non-specific symptoms such as cyclical abdominal pain at the site of a previous surgical incision and scar and an abdominal lump with a cyclical increment in size, which is tender. The diagnosis is made only after the surgical excision with confirmation by histopathological analysis. We present the case of a 31-year-old female complaining of cyclical abdominal pain and a lump on the right side of a Pfannenstiel incision for five months. She had undergone two Lower Segment Caesarean Sections (LSCSs); the last surgery was eight months prior. Surgical excision was planned with the corresponding clinical features and radiological data. After the surgical excision, the sample was sent for histopathological examination, and scar endometriosis was diagnosed.

Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section

Endometriosis is a gynecological condition caused by the development of endometrial tissue outside the uterine cavity. Naturally, it commonly occurs at locations such as the ovaries and pelvic peritoneum. However, ectopic endometrial tissue may be discovered outside of the typical sites, suggesting the possibility of iatrogenic seeding after gynecological operations. Based on this hypothesis, we developed a study aiming to establish the root cause of atypical implantation of endometrial foci, as the main end point, and to determine diagnostic features and risk factors for this condition, as a secondary target. The research followed a retrospective design, including a total of 126 patients with endometriosis who met the inclusion criteria. A group of 71 patients with a history of c-section was compared with a control group of patients with endometriosis and no history of c-section. Endometriosis that developed inside or in close proximity to surgical incisions of asymptomatic patients before surgical intervention was defined as iatrogenic endometriosis. Compared with patients who did not have a c-section, the c-section group had significantly more minimally invasive pelvic procedures and multiple adhesions and endometriosis foci at intraoperative look (52.1% vs. 34.5%, respectively 52.1% vs. 29.1%). The most common location for endometriosis lesions in patients with prior c-section was the abdominal wall (42.2% vs. 5.4%), although the size of foci was significantly smaller by size and weight (32.2 mm vs. 34.8 mm, respectively 48.6 g vs. 53.1 g). The abdominal wall endometriosis was significantly associated with minimally invasive pelvic procedures (correlation coefficient = 0.469, p-value = 0.001) and c-section (correlation coefficient = 0.523, p-value = 0.001). A multivariate regression analysis identified prior c-section as an independent risk factor for abdominal wall endometriosis (OR = 1.85, p-value < 0.001). We advocate for strict protocols to be implemented and followed during c-section and minimally invasive procedures involving the pelvic region to ensure minimum spillage of endometrial cells. Further research should be developed to determine the method of abdominal and surgical site irrigation that can significantly reduce the risk of implantation of viable endometrial cells. Understanding all details of iatrogenic endometriosis will lead to the development of non-invasive disease diagnosis and minimally invasive procedures that have the potential to reduce postoperative complications.

Cutaneous Metastasis in a Previously Known Case of Ovarian Dysgerminoma: A Case Report

Introduction: Cutaneous metastasis is an uncommon manifestation that mostly occurs in patients with previous gastrointestinal or gynecological malignancies. Local recurrence usually can be seen in surgical incisions. Dysgerminomas are rare ovarian tumors that usually have local invasions, but metastases are infrequent. Here, we described a case of dysgerminoma and cutaneous metastasis in the surgical incision. Case Presentation: The patient was a 39-year-old woman previously known as ovarian dysgerminoma, who had undergone surgery one year ago. Ultrasound examination a year after surgery showed a 35 × 33 millimeters hypoechoic solid tumor in the left ovary and another 3 masses with similar echo pattern and vascularity were found in the surgical incision. Magnetic resonance imaging (MRI) findings were compatible with cutaneous metastasis of pervious dysgerminoma. Pathologic evaluation and Immunohistochemistry (IHC) confirmed dysgerminoma's skin metastasis. She received chemotherapy due to the recurrence of malignancy. Conclusions: Local recurrence and metastases (even in the skin) should be kept in mind and the clinician must examine the surgical site skin in patients with a history of malignancy.

Cesarean Section: A Potential and Forgotten Risk for Abdominal Wall Endometriosis

Cesarean section endometriosis (CSE) can be caused by the iatrogenic deposition of endometrial cells, glands, and stroma during any time of the surgical procedure. It can be asymptomatic or, more frequently, resulting in chronic pain. Our article intends to provide more clinical information on CSE symptomatology, diagnosis, and preventive methods available in the literature, and discuss the malignancy transformation risk.

We performed a systematic review based on the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. We included all types of study designs and selected only English articles from 2016 and forward. A total of 268 patients with abdominal wall endometriosis (AWE) were included in the final review; 260 women had CSE and eight women had endometriosis related to another gynecologic procedure.

Attention for suggestive symptoms during anamnesis and the presence of abdominal nodules close to the cesarean scar should raise suspicions of scar endometriosis. In addition, abdominal ultrasonography (USG), computed tomography (CT), magnetic resonance imaging (MRI), and fine-needle aspiration (FNA) biopsy can be helpful to differentiate from other conditions such as incisional hernias, suture granulomas, or malignant tumors. However, the final diagnosis and treatment is still the complete excision of the tumor. Therefore, additional studies on pathophysiology would help with new preventive methods and less invasive therapeutic options.

Ultrasound Imaging of Abdominal Wall Endometriosis: A Pictorial Review

Endometriosis is a debilitating disease characterized by endometrial glands and stroma outside the endometrial cavity. Abdominal wall endometriosis (AWE) indicates the presence of ectopic endometrium between the peritoneum and the skin, including subcutaneous adipose tissue and muscle layers, often following obstetric and gynecological surgical procedures. AWE is a not infrequent gynecological surgical complication, due to the increasing number of cesarean sections worldwide. In this pictorial review, we discuss the importance of medical history and physical examination, including the main ultrasound features in the diagnosis of AWE.

Focused ultrasound for the diagnosis of non-palpable endometriotic lesions of the abdominal wall: a not-uncommon surgical complication

Endometriosis is a benign disease characterized by endometrial glands and stroma outside the endometrial cavity. We reported two cases of endometriosis of the abdominal wall, with subcutaneous and intramuscular localization, that became symptomatic a few years after a cesarean intervention. These cases have a clinical pattern quite similar to cutaneous endometriosis, but they are more difficult to diagnose through physical examination because they are barely palpable. In this sense, coupled with suggestive symptoms, ultrasound examination can confirm the clinical suspicion of endometriosis without the use of computed tomography and/or magnetic resonance imaging.

Abdominal wall endometriosis (a narrative review)

One of the rarest forms of endometriosis is abdominal wall endometriosis (AWE), which includes caesarean scar endometriosis. AWE remains a challenging condition because some issues related to this topic are still under debate. The increasing number of caesarean sections and laparotomies will expect to increase the rate of AWE. The current incidence in obstetrical and gynaecological procedures is still unknown. The disease is probably underestimated. The pathogenic mechanism involves local environment at the implant site including local inflammation and metalloproteinases activation due to local growth factors, estrogen stimulation through estrogen receptors and potential epigenetic changes. However, the underlying mechanisms are not fully explained, and we need more experimental models to understand them. The clinical presentation is heterogeneous; the patient may be seen by a gynaecologist, an endocrinologist, a general surgeon, an imaging specialist, or even an oncologist. No particular constellation of clinical risk factors has been identified, and the histological report is the major diagnostic tool for confirmation. Surgery is the first line of therapy. Further on we need protocols for multidisciplinary investigations and approaches.

A Rare Cause of Abdominal Pain: Scar Endometriosis

Introduction. Scar endometriosis (SE) is a rare pathology that develops in the scar tissue formed on the anterior abdominal wall usually after a cesarean section. There have been instances of women presenting to emergency or general surgery clinics with abdominal pain due to SE. Materials and Methods. This study retrospectively reviews 19 patients who were operated on in our clinic between January 2010 and January 2017 with a prediagnosis of SE and were reported to have SE based on their pathology results. Results. The mean age of the patients was 30.8 years (range: 20-49 years). The body mass indexes of 12 (63.2%) patients were ≥ 25. All patients had a history of cesarean section and 9 (47.4%) patients had undergone cesarean section once. With the exception of one patient who had her SE localized in her inguinal region, all patients had a mass localized on their anterior abdominal wall neighboring the incision and complained about cyclic pain starting in their premenstrual periods. The complaints began 2 years after their cesarean section in 10 (52.6%) patients. Mostly abdominal ultrasonography was used for diagnostic purposes. The lesions were totally excised and the SE diagnosis was made through a histopathological examination in all patients. No postoperative complications or recurrences were seen in any of the patients. Conclusion. Suspicion of SE is essential in women of reproductive age who have a history of cesarean section and complaints of an anterior abdominal wall mass and a pain at the scar site that is associated with their menstrual cycle. An accurate and early diagnosis can be established in such patients through a careful history and a good physical examination and possible morbidities can be prevented with an appropriate surgical intervention.