{"paper_id":"0d34d716-099f-4e7b-a979-88aa049a5e8b","body_text":"CLINICAL ASPECTS \n \nAMT, vol. 26, no. 1, 2021, p. 41 \n ACTA MEDICA TRANSILVANICA March 26(1):41-43 \nDOI: 10.2478/amtsb-2021-0012 \nOnline ISSN 2285-7079 \n    \n \nINTRAMUSCULAR ABDOMINAL WALL ENDOMETRIOSIS, AN \nUNUSUAL FINDING FOR GENERAL SURGEON \n \n \nALIN MIHEŢIU1, DAN BRATU2, OANA POPESCU3 \n \n1,2,3 “Lucian Blaga” University of Sibiu,1,2 Sibiu County Emergency Clinical Hospital \n \nKeywords: endometriosis, \nabdominal wall, cesarean \nsection, recurrence \nAbstract: Defined as the ectopic development of uterine tissue outside the uterine cavity, \nendometriosis is an increasingly common condition that can lead to various complications from \nchronic pain syndrome, infertility, obstruction due extrinsic compression to malignancy of \nendometriosis foci. Extrapelvic positioning  of endometriosis is rare, diagnosis can be difficult both \nclinically and imaging, and treatment does not always ensure the absence of recurrences. \n \n                                                           \n1Corresponding author: Alin Miheţiu, B-dul Corneliu Coposu, Nr. 2-4, Sibiu, România, E-mail: alin_mihetiu@yahoo.com, Phone: +40751 619292 \nArticle received on 22.10.2020 and accepted for publication on 26.02.2021 \n \nINTRODUCTION \nEndometriosis was first described by Karl Freiherr \nvon Rokitansky in 1860. \nIt is most common  in the pelvis, ovaries, Douglas \npouch, uterine ligaments, or posterior cul -de-sac, but it may also \nhave extrapelvic locations in the abdominal wall, umbilical cord, \nileum, colon, vulvar, or sacs of inguinal or femoral hernia. \nThe incidence of this conditi on in childbearing age \nwomen is between 5 -15%, localizations in the abdominal wall \nbeing rare. \nThe appearance of endometriosis implants in the \nabdominal wall is related to surgery, most commonly with \ncesarean section, the tumours usually appear in the postoperative \nscars. \nThe appearance of a tumour in the abdominal wall, in \nthe proximity of a scar, in the lower abdomen and especially the \npainful manifestations in relation to the menstrual cycle, \nindicates the suspicion an outbreak of endometriosis. \nThe trea tment is a multimodal one, but surgical \nexcision remains the main choice as therapy, especially since \nthere is also the risk of malignant transformation.(1,2,3,4) \n \nCASE REPORT \nA 34 -year-old patient presents a left paramedian \ntumour in the lower abdomen, fi rst discovered two years ago. \nThe patient is known to have epilepsy, cesarean section \n(Pfannenstiel incision) 8 years ago. \nFor about a year and a half, the patient complains of \npain related to the menstrual cycle in the newly formed nodule, \npain that for a bout 3 months is no longer cyclical but \ncontinuous. \nOn clinical examination, in left paramedian lower \nabdomen, in the lower third of the left rectus abdominal muscle \nand at about 8 cm from the post -cesarean scar, a tumour located \ndeep in the thickness of the muscular structures was highlighted. \nThe formation was sensitive to palpation with relatively regular \nedges, hard consistency with the size around of 4/3 cm. No other \nchanges were found at clinical examination of the abdomen.   \nLab tests were without pa thological values, in normal \nlimits. \nAbdominal ultrasound shows in the thickness of the \nleft side of rectus abdominal muscle a hypoechoic formation, \ninhomogeneous with microcalcifications, well vascularized, well \ndelimited with dimensions of 3/1.1/ 2.2 cm,  without exceeding \nthe muscle fascia. \nAnamnestic and clinical examination raises the \nsuspicion of parietal endometriosis. \n \nFigure no. 1. Ultrasound appearance - tumour in the \nthickness of the rectus abdominal muscle \n \nSurgery was performed under spinal ane sthesia, \nposterior to the anterior sheath of the left rectus abdominal \nmuscle, medial to the epigastric vessels (that are intercepted and \npreserved) in muscle thickness, adherent to muscle fibers a \ntumour of about 4/3/3cm, was highlighted.  \nThe tumour was completely removed with safety \nlimits included.    \nMyoraphy, rectus abdominal aponeurosis closure and \nskin suture were performed.  \nOn the section, yellow-grey looking piece \nThe evolution was favourable, the patient being \ndischarged the next day.  \n\n\nCLINICAL ASPECTS \n \nAMT, vol. 26, no. 1, 2021, p. 42 \nFigures no. 2, 3. Resection piece and sectioned specimen \n \n   \n \nFigures no. 4, 5. Postoperative aspect in evolution (the dotted \nline coincides with the post-cesarean scar) \n  \nThe anatomopathological result showed fragments of \nconnective tissue and striated muscle with chronic inflammatory \nchanges (gigantocellular reaction, macrophage and histiocytic \nreaction) around some endometriotic foci (glands and \nendometrial stroma), hematological infiltrates with the presence \nof hemosiderin pigment. The histological diagnosis was parietal \nendometriosis. \nSubsequent surgical checks showed no signs of local \nrecurrence. \n                         \nDISCUSSIONS \n Endometriosis is defined as the ectopic spread of \nfunctional endometrial glans and stroma.(5)  \nIn 1 860, von Rokitansky described the first case of \nendometriosis as “sarcoma”. In 1899, Russel first identified and \ndescribed the existence of endometrial tissue in the ovary.(5) \nIt affects between 5 -15% of women of reproductive \nage. The distribution of endom etriosis can be pelvic or \nextrapelvic. At the pelvic level, foci of endometriosis are found \nin the bottom of the Douglas pouch, ovaries, in the reflection of \nthe peritoneum on the pelvic organs and in the uterine ligaments. \nExtrapelvic localizations are ra re and may involve the \nabdominal wall, umbilicus, small intestine, appendix, large \nintestine, kidneys, pleura, lungs, or central nervous system. (5) \nEndometriosis of the abdominal wall with functional \nendometrial tissue was first described in 1950. \nFrequently this localization associates surgical \ninterventions in the background with an incidence between 0.03-\n1.08%.(6,7) \nThe vast majority of cases of parietal endometriosis \nhave a history of gynecological surgery, usually after \nhysterectomy, cesarean section or hysteroscopy. \nThus, it is considered that the risk of endometriosis in \nthe scar abdominal wall is 2.7% after obstetric interventions, \n1.5% after gynecological interventions and 0.6% after \nlaparoscopic interventions. \nThe location of endometrial tumours i n the abdominal \nwall is common in the postoperative scar (especially in their \nextremities) or in their vicinity. \nParietal locations distant from postoperative scars are \na rare finding. Also, parietal endometriosis has as favourite \nplace of development the subcutaneous cellular tissue, the \nplacement strictly intramuscularly or without the involvement of \nthe peritoneum is not frequently encountered.(1,2,8,9,10) \nAs a preventive measure, before abdominal closure it \nis recommended to isolate the incision with st erile fields and \nabundant lavage with saline solutions to limit the risk of \nintraoperative contamination.(8) \nSurgery is not the only way to develop parietal \nendometriosis, the literature also describes cases of de novo \nabdominal wall damage. Also, not only  gynecological surgeries \nhave the potential for parietal endometriosis, cases being \ndescribed after laparoscopic treatment of inguinal hernia, \nappendicitis or colorectal surgery.(11,12,13) \nThe etiopathogenesis of this condition is still unclear \nand controv ersial, there are several theories that try to explain \nhow the outbreaks of endometriosis appear, spread and \nproliferate. \nThe implantation theory - considered basically a \nsecondary implantation either by retrograde menstruation or \niatrogenic, surgical. However, menstrual reflux or gynecological \nsurgery does not always progress to endometriosis, the \nexplanation being that the immune system recognizes and \ndestroys endometrial cells outside the uterus.  A dysfunction of \nthe immune system (with the genetic compo nent) explains why \nyet ectopic endometrial tissue implants develop.(9) \nThe theory of metaplasia (Meyer) describes the spread \nof endometrial cells in the embryonic stage and their migration \nalong the coelomic cavity.(6) \nLymphatic (metastatic) theory explains the appearance \nof endometrial structures in atypical places: brain, lung, lymph \nnodes, myocardial tissue, etc.(14) \nAlcohol consumption, heavy menstrual cycle, \nobstructions in the evacuation of the menstrual cycle (Müllerian \nabnormalities), prolonged expo sure to estrogen and dioxin are \nincriminating factors in the occurrence of endometriosis. \nClinically, parietal endometriosis may have \nnonspecific symptoms, with suspicion of endometriosis rising \nwhen the triad described by Esquivel is present: tumor, \ncatamenial pain, and history of cesarean section.(15) \nIf they are associated with dysmenorrhea or heavy \nmenstrual or intermenstrual bleeding, then the diagnosis can be \noriented from the clinical-anamnestic examination phase. \nSuperimposed pain on the menstrual c ycle is the main \nsymptom that guides the clinician, but it is not always cyclical, \nsometimes having a permanent character and making the \ndiagnosis more difficult. \nThe differential diagnosis is made with desmoid \ntumors, granulomas, fetal necrosis, lipomas, hernias, metastatic \nsecondary determinations. \nImaging diagnosis is usually performed by ultrasound, \nCT or MRI. \nIn ultrasound, the vast majority of nodules appear as \ndecrete solid masses, with a lower echogenicity than adipose \ntissue or compared to the neig hboring musculoskeletal planes. \nThe proximity to a postoperative scar or history of \nendometriosis guides the diagnosis.(16,17,18) \nMRI provides superior data to CT examination, \ndetecting smaller formations, periendometrial vascularization \nand the boundary b etween the muscular, aponeurotic planes or \nthe degree of infiltration of deep structures. \nFine needle aspiration cytology (FNAC) increases the \nrisk of implantation of endometrial tissue on the puncture site. \nThe post -excision or post -FNAC histopathological  \ndiagnosis is positive for endometriosis if two of the following \nthree elements are detected: endometrial glands, endometrial \nstroma and hemosiderin laden macrophages.(1,18) \nThe treatment is a multidisciplinary one, the most used \nbeing the hormonal treatment as an association with the surgical \nor analgesic treatment. For abdominal wall endometriosis, \nsurgery is the only curative treatment. \nPreoperatively, intra -femoral injection of \nradioisotopes can be used to guide the excision of small foci of \n\n\nCLINICAL ASPECTS \n \nAMT, vol. 26, no. 1, 2021, p. 43 \nendometriosis. \nSclerotherapy with ultrasound guided injection into \nthe lesion and high intensity focused ultrasound ablation used \npreoperatively appear to reduce bleeding and limit the size of \nthe resection and decrease the risk of recurrence.(19) \nEndometriosis has a 1% risk of malignancy. \n80% of malignancies occur in the ovary and 20% in \nother locations (including the abdominal wall). The most \ncommon types of malignancies are endometrial carcinoma \n(70%), sarcoma (25%) and clear cell carcinoma (5%). Clear cell \ncarcinoma and endometrial carcinoma have the lowest survival \nrate (44% mortality in the months immediately following \ndiagnosis).(20,21) \nGeneral surgeons often misdiagnose parietal \nenometriosis due to its rarity interpreting it as a tumour of \nanother nature. Thus in a study that considered cases of \nendometriosis of the abdominal wall, treated by a general \nsurgeon 55.55% of them they didn’t suspected endometriosis \npreoperatively.(22,23) \nAlthough it is a rare entity, general surgeons must also \nconsider this type of t umour, so that the surgical strategy to be \nsuch as to avoid the implantation of endometrial cells, thus \navoiding local recurrence. \n \nCONCLUSIONS \nEndometriosis of the abdominal wall is an \nincreasingly common condition in the context of the \nproliferation of gynecological and obstetric procedures. \nThe diagnosis can be guided by clinical and imaging \nexamination but is established by histologic exam. \nSurgical removal of the endometrial implant remains \nthe best therapeutic option, reducing the risk of recurrence o r \nprogression to malignancy. \n \nREFERENCES \n1. Song H, Lee S, Kim MJ, Shin JE, Lee DW, Lee HN. \nAbdominal wall mass suspected of endometriosis: clinical \nand pathologic features. 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