Arch Gynecol Obstet (2001) 265:165–167
© Springer-Verlag 2001
C A S E R E P O RT
L. Roncoroni · R. Costi · V. Violi · R. Nunziata
Endometriosis on laparotomy scar A three-case report
Received: 3 November 2000 / Accepted: 30 November 2000
Abstract Endometriosis of surgical scar is a rare late complication of cesarean section. 3 cases of endometriosis after Pfannenstiel-type laparotomy are reported. The typical surgical presentation, present in all 3 cases, is a nodule on laparotomy scar after cesaren section, spontanously painful during the menstrual period. Ultrasound, performed in two cases, and cytological examination, performed in one, proved to be ineffective in establishing the diagnosis. The histopathological analysis of surgical specimens revealed in all cases multiple foci of well developed endometrial tissue scattered in a sclerotic stroma. Both stromal and glandular components of the endometrial mucosa were present showing the typical changes of the various phases of the menstrual cycle. In our opinion, an accurate clinical history should directly lead the surgeon to the excision with inclusion of the needle tract, whenever biopsy is performed. Surgical excision is at present the most appropriate diagnostic and therapeutic procedure. Keywords Endometriosis · Scar · Cesarean section
Introduction Laparoceles, granulomas from surgical stitches and keloids are the most frequently observed pathologies on surgical scars. Endometriosis is a very rare eventuality. In fact, endometriosis, the lesion defined by the presence of endometrial tissue outside the endometrium or myometrium, is mostly an endopelvic pathology, usually complaining of abdominal pain, uncomplete bowel obL. Roncoroni (✉) · R. Costi · V. Violi Department of Surgery, Institute of General Surgery and Surgical Therapy, Parma University, School of Medicine, Via Gramsci 14, 43100 Parma, Italy e-mail:
[email protected] Tel.: ++39-0521-991157, Fax: ++39-0521-940125 R. Nunziata Department of Pathology and Laboratory Medicine, Section of Anatomic Pathology, Parma University, Parma
struction or sterility; more rarely, it is found at the extrapelvic site, appearing at widely varying sites, such as the umbilicus, the appendix, the omentum and inguinal hernia sacs. The observation of 3 cases of endometriosis on surgical scars has induced us to revise the literature and to make various clinical observations.
Case report Case 1 (ML, 33 years old) 5 years after cesarean section, a 33-year-old white woman presented with an 18-month history of pain in the lower right quadrant. On physical examination she had a 4-cm nodule on the cesarean scar, causing pain during menstruation. Ultrasound showed the presence of hypoecogenous trilobate. A cytological examination indicated a cystic neoformation removed under local anesthesia. The neoformation was firmly attached to the fascia of the oblique external muscle. Histological examination showed numerous endometriotic foci spread in an abundant fibrous sclerohyaline tissue. They were characterized by glands in frequent cystic dilation, sometimes associated with glands with scalloped profile with secretory epithelium. The glands were surrounded by a variable amount of endometrial stroma with extensive decidual changes (Fig. 1). This pattern was consistent with a secretory phase of the menstrual cycle. Case 2 (OE, 33 years old) The patient, who had undergone two cesarean sections, 11 and 7 years previously, presented with a nodule of about 5 cm diameter, painful in the menstrual period, in the suprapubic region at the site of a Pfannenstiel-type laparotomy; ultrasound revealed the presence of an oval-shaped hypoecogenous neoformation. On the basis of the preceding observation, endometriosis was suspected. At surgery, the neoformation was seen to be firmly attached to the rectal muscle. Histological examination of the resected tissue revealed fasciae of fibrous connective tissue intercalated with endometriotic foci, some of these featured endometrial stroma predominantly composed of elongated cells, whereas in others the predominant feature were glands of medium size, rounded and elongated, sometimes in cystic dilation. The glandular epithelium was cylindrical, with a low number of mitoses (Fig. 2). This pattern was consistent with a proliferative phase of the menstrual cycle.
166 Fig. 1 Case 1. Histologic survey of an endometriosic area showing cystic cavities lined by endometrial epithelium. The stroma in the centre of the field shows decidual changes and surrounds glands with typical secretive pattern. Haematoxylin-Eosin, X 40
Fig. 2 Case 2. Several endometriotic foci scattered in a dense fibrous tissue. The foci are composed of both endometrial stroma and glands partly dilated. Haematoxylin-Eosin, X 40
Fig. 3 Case 3. Endometriotic foci mostly composed of dilated cystic glands surrounded by fibrous tissue together with more typical endometrial glands with the appropriate stroma
167 Case 3 (FE, 27 years old) The patient, 2 years after a cesarean section, presented with a nodule of about 2 cm diameter, painful in the menstrual period, 3 cm higher than a Pfannenstiel-type laparotomy and endometriosis was suspected. ; no ultrasound was performed. At surgery, a 1,5 cm, sub-fascial nodule was extirped. Histologically, the nodule was composed of dense fibrous tissue in which scattered foci of endometrial glands and stroma were embedded. The glands showed frequent and, sometimes, conspicuous cystic dilatations of the lumen lined by flattened epithelium. The stroma showed focal hemorrhage and accumulation of hemosiderin-laden macrophages (Fig. 3).
Discussion Endometriosis in a surgical wound is always iatrogenic; it is observed after cesarean sections [1, 6]) with a frequency of 0.03–0.4% [1], and in an even lower percentage at the perianal site after episiotomy [2]. With the recent diffusion of laparoscopic surgery, it has also been described at the trocar site [7]. Concomitant pelvic endometriosis is found in 26% of women who present with endometriosis of the wound [8]. The etiopathogenetic mechanism by which endometriosis develops at the site of a surgical wound is evidently that of an endometrial tissue dissemination in the course of cesarean section or gynecological surgery. Subsequently, under the stimulus of estrogen, such tissue tends to grow until it becomes symptomatic; Koger et al. [3], in a study of 24 cases, defines the interval between surgery and onset of endometriosis as being from 1 to 20 years (mean 4.8). An increase in the dimensions of the tumefaction, accompanied by intensification of pain during the menstrual period, leads to suspect endometriosis. Ultrasound examination of the abdominal wall does not reveal pathognomonic aspects, but may be useful in the differential diagnosis of the mass and to rule out the possibility of a laparocele in the viscera. Despite the doubts associated with the possible dissemination of the endometriosis along the biopsy tract [5], in the first case cytological examination was performed: endometriosis was not diagnosed. The histopathological diagnosis of endometriosis was in all cases easy to perform because of the consistent association of endometriotic glands and stroma
showing the typical changes of the various phases of the menstrual cycle. Sometimes, however, cystic dilatations of the glands with flattening of the lining epithelium and disappearance of the endometriotic stroma were present. After histopathological diagnosis, a further cytological evaluation posteriorly revealed elements characteristic of endometriosis. Danazol or GnRh secretion inhibitor therapy reduces the symptoms and paves the way for the ex iuvantibus diagnosis of the neoformation and the treatment of endopelvic endometriosis, if present. The increased dimensions of the lesion, the radicality of the therapy and the possible onset of an endometrioid carcinoma in the context of an endometriosis [4] make surgical excision, inclusive of the needle tract, whenever biopsy is performed, the most appropriate diagnostic and therapeutic procedure. The use of cesarean sections and of the laparoscopic procedure in the treatment of numerous gynecological pelvic conditions, including endometriosis, is constantly increasing over time; hence, the surgeon must utilize every procedure to protect the surgical wound and the trocar sites, in order to prevent the dissemination of endometrial cells; in his turn, the physician should bear in mind this possible pathology of the abdominal wall.
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