{"paper_id":"5ec7d43f-8491-40d8-aad8-7dbf55eb473f","body_text":"Received\n 08/19/2020 \nReview began\n 08/24/2020 \nReview ended\n 08/26/2020 \nPublished\n 08/27/2020\n© Copyright \n2020\nMao et al. This is an open access article\ndistributed under the terms of the\nCreative Commons Attribution License\nCC-BY 4.0., which permits unrestricted\nuse, distribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nPost-Cesarean Section Abdominal Wall\nEndometrioma\nAllen Mao \n \n, \nHunaid N. Rana \n \n, \nBrad Steffler \n \n, \nSuzy Figarola \n1.\n Radiology, University of South Alabama College of Medicine/University of South Alabama Health University\nHospital, Mobile, USA \n2.\n Radiology, University of South Alabama Health University Hospital, Mobile, USA\nCorresponding author: \nAllen Mao, \nam1722@jagmail.southalabama.edu\nAbstract\nA 30-year-old female with a history of multiple cesarean sections presents to the emergency department\nwith several months of right lower quadrant abdominal pain only associated with her menstrual cycles. CT\nabdomen and pelvis with contrast was remarkable for an abdominal wall mass that likely represented an\nendometrioma, and she was subsequently discharged with pain medications and conservative treatment.\nHowever, three months later, she returned to the ED, because her pain was unbearable and refractory to\nmedical management. Interventional radiology was consulted for percutaneous biopsy of the soft tissue\nmass located in her rectus abdominus muscle. Following the procedure, the patient was started on\nORILISSA\n®\n (elagolix), the first FDA-approved oral treatment for the management of severe pain associated\nwith endometriosis. We highlight an interesting case of post-cesarean section abdominal wall endometrioma\nimplantation and describe the patient’s clinical course and disease management. The radiographic features\nof the mass are described and proposed mechanisms for the development of an abdominal wall\nendometrioma following a C-section is discussed.\nCategories:\n Medical Education, Obstetrics/Gynecology, Radiology\nKeywords:\n endometrioma, endometriosis, c-section, abdominal wall\nIntroduction\nEndometriosis is estrogen-sensitive endometrial tissue, such as endometrial glands and stroma, that\ndevelops outside of the uterine cavity. A more localized form of endometriosis is an endometrioma or\n“chocolate cyst”, which classically occurs in women of reproductive age. The most common location for an\nendometrioma is the ovary, followed by the anterior/posterior cul-de-sac and posterior broad ligament \n[1]\n.\nOther rare sites of extrauterine involvement that have been reported include the gastrointestinal tract,\nrespiratory tract, and abdominal wall. Although the most commonly accepted mechanism for the\ndevelopment of endometriomas is attributed to retrograde menstruation, an abdominal wall endometrioma\nis likely due to a combination of endocrine, immune, and inflammatory pathways. Of note, endometrial\nseeding of the abdominal wall can occur postoperatively after a C-section, which is enhanced by chronic\ninflammation and impaired immunity \n[2]\n. Due to the multifaceted and partially understood mechanism of\nabdominal wall endometrioma formation, the diagnosis can be delayed. Histological examination of\nspecimens is often required for diagnostic confirmation. Depending on the severity of the presentation,\npatients can be treated with non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief or with\nbiopsy and laparoscopic resection of implants for definitive diagnosis and treatment.\nCase Presentation\nA 30-year-old G4P3013 African American female with past medical history of morbid obesity, three cesarean\nsections, and bilateral tubal ligation presents to the emergency department with right lower quadrant\nabdominal pain, nausea, and vomiting. The patient reports that her pain has been periodically occurring\nover the last several months and interestingly is only associated with her menstrual cycles. The abdominal\npain is cramping in nature without radiation and localized to her right lower abdomen. She states that she\nfeels a “bulge and bump” in this region. On physical exam, there was tenderness to superficial palpation in\nthe right periumbilical region, without rebound tenderness, guarding, or any other signs of acute abdomen,\nin addition to an absent Rovsing’s sign. Due to her large body habitus and abdominal pannus, the mass was\nunable to be palpated.\nThe patient was given NSAID and anti-nausea medication, and a CT abdomen and pelvis with contrast was\nordered to determine the etiology of the abdominal pain. CT showed an irregular, ill-defined 5 x 4 cm soft\ntissue mass in the inferior right rectus abdominus muscle at the right lower abdominal wall that was\nconsistent with an endometrioma based on the patient’s past medical history (Figures \n1\n, \n2\n). After discussion\nwith the emergency physician, recommendation was made for obstetrics and gynecology (OBGYN) to follow\nup the case regarding operative removal of the endometrioma and subsequent fascial repair. The patient was\ndischarged with NSAIDs due to her hemodynamic stability.\n1\n2\n2\n2\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.10088\nHow to cite this article\nMao A, Rana H N, Steffler B, et al. (August 27, 2020) Post-Cesarean Section Abdominal Wall Endometrioma. Cureus 12(8): e10088. \nDOI\n10.7759/cureus.10088\n\nFIGURE\n 1: Initial emergency department CT axial demonstrates an ill-\ndefined hyperattenuating soft tissue mass in the inferior right rectus\nabdominis muscle measuring approximately 5 x 4 cm with surrounding\nfat stranding and soft tissue edema that is consistent with an\nabdominal wall endometrioma (yellow circle).\n2020 Mao et al. Cureus 12(8): e10088. DOI 10.7759/cureus.10088\n2\n of \n5\n\nFIGURE\n 2: CT sagittal again exhibits an endometrioma contained in the\nright inferior rectus abdominus muscle, marked by an \nill-defined\nhyperattenuating soft tissue mass (yellow circle).\nAfter three months, the patient returned back to the ED with complaints of severe dysmenorrhea that was\nnot alleviated with NSAIDs. OBGYN was consulted, but significant weight loss was recommended prior to\nsurgical management due to the risk of wound healing complication and potential hernia development.\nInstead, interventional radiology (IR) was consulted for ultrasound-guided percutaneous biopsy of soft\ntissue mass in the rectus abdominus muscle. There were no postoperative complications on postprocedure\nultrasound. Following the IR procedure, pathologic examination of three core biopsy soft tissue specimens\nconfirmed the diagnosis of endometrioma due to the presence of ectopic endometrial stroma. The patient\ncontinued to follow-up with OBGYN and was placed on ORILISSA\n®\n (elagolix), a gonadotropin-releasing\nhormone (GnRH) antagonist used to treat severe pain associated with endometriosis.\nDiscussion\nEndometriosis is defined as endometrial glands and stroma located at extrauterine sites that implant most\ncommonly in the pelvis, such as the ovaries and fallopian tubes. These estrogen-sensitive ectopic implants\ncan develop nearly anywhere in the body including infrequent locations such as the gastrointestinal tract,\nrespiratory tract, or abdominal wall. A more localized form of endometriosis is an endometrioma or\n“chocolate cyst” that classically occurs in women of reproductive age. While the etiology and\npathophysiology are not entirely understood, the most commonly accepted mechanism is due to retrograde\nmenstruation, where endometrial cells flow in reverse through the fallopian tubes and into the pelvic cavity\ncausing cyclical lower abdominal pain \n[1]\n. This produces proliferation and hemorrhage with each cycle that\ncan lead to the manifestation of clinical symptoms, such as dysmenorrhea, dyspareunia, dyschezia,\n2020 Mao et al. Cureus 12(8): e10088. DOI 10.7759/cureus.10088\n3\n of \n5\n\ninfertility, and cervical motion tenderness.\nInterestingly, surgical operations, such as a C-section, can induce endometrial seeding of the abdominal\nwall, which is enhanced by chronic inflammation and impaired immunity. The development of an abdominal\nwall endometrioma likely is due to a combination of endocrine, immune, and inflammatory pathways rather\nthan retrograde menses. Abdominal wall endometrioma is a relatively rare condition with a reported\nincidence of 0.03%-0.45% in women with previous C-section with a mean age at diagnosis of 35 years \n[3]\n.\nIt is important to have a thorough review of a patient's prior surgical history when assessing an anterior\nabdominal wall mass that may be an endometrioma. When evaluating an abdominal mass, although much\nless likely, the differential diagnosis should include desmoid tumors, hematomas, and soft tissue sarcomas\n[3,4]\n. In our case, the constellation of chronic pelvic pain, abdominal wall mass on imaging, and history of\nC-section is highly suggestive of the diagnosis of an abdominal wall endometrioma.\nPatients may initially present with chronic pain that is cyclical in nature with the menstrual cycle at the\ncesarean scar or incision site of the abdominal wall. Occasionally, an endometrioma located superficially\nunder the skin may be visualized and appear blue, purple, or brown \n[5]\n. Ultrasound, CT, and MRI can all be\nused to characterize the mass. Due to low cost and easy accessibility, ultrasound is the recommended\nimaging modality to start diagnostic workup. On ultrasound, an endometrioma should appear hypoechoic,\nsolid, and display vascularity \n[6]\n.\nCT commonly demonstrates non-specific findings of a solid, enhancing mass. Compared to CT, MRI is often\npreferred to suggest the diagnosis of endometrioma due to enhanced definition of soft tissues. There will be\nhyperintense, heterogeneous signal intensity of the affected area, often with high internal punctate signal\nintensity on both T1 and T2-weighted images, indicative of hemorrhage from the endometrial glands \n[7]\n.\nAnother diagnostic clue may be the presence of a dark spot sign on T2-weighted sequences, which is an\nindicator of chronic hemorrhage \n[8]\n. Furthermore, percutaneous needle biopsy can be performed for\ndiagnostic confirmation, often with IR guidance, in order to obtain pathologic tissue specimens with high\naccuracy. The definitive treatment of an abdominal wall endometrioma is via wide local excision with\nnegative margins, which has a low recurrence rate. For patients who desire non-invasive medical\nmanagement or are not surgical candidates, ORILISSA (elagolix) is a novel FDA-approved medication used\nto treat severe pain associated with endometriosis. This oral non-hormonal drug works by antagonizing\nGnRH receptors in the pituitary gland that leads to a dose-related reduction in estrogen production, the\ndriving factor in endometriomas \n[9]\n.\nConclusions\nWe highlight an interesting case of an abdominal wall endometrioma status post C-section. The diagnosis\nrequires heavily on a combination of history, presentation, and imaging for confirmation. This case\nemphasizes the need to have a high index of clinical suspicion when evaluating women with a prior surgical\nhistory of C-section who present with cyclical pain and an abdominal wall mass on imaging. Definitive\ntreatment is via operative resection; however, oral medications are preferred for patients with certain\ncomorbidities where surgery is unfavorable.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nAcknowledgements\nAll authors listed on the manuscript have approved the submission of this case study.\nReferences\n1\n. \nKoninckx PR, Ussia A, Adamyan L, Wattiez A, Gomel V, Martin DC: \nPathogenesis of endometriosis: the\ngenetic/epigenetic theory\n. 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J Clin\nUltrasound. 2009, 37:215-220.\n7\n. \nKocher M, Hardie A, Schaefer A, McLaren T, Kovacs M: \nCesarean-section scar endometrioma: a case report\nand review of the literature\n. J Radiol Case Rep. 2017, 11:16-26.\n8\n. \nCorwin MT, Gerscovich EO, Lamba R, Wilson M, McGahan JP: \nDifferentiation of ovarian endometriomas\nfrom hemorrhagic cysts at MR imaging: utility of the T2 dark spot sign\n. Radiology. 2014, 271:126-132.\n9\n. \nTaylor HS, Giudice LC, Lessey BA, et al.: \nTreatment of endometriosis-associated pain with Elagolix, an oral\nGnRH antagonist\n. N Engl J Med. 2017, 377:28-40.\n2020 Mao et al. Cureus 12(8): e10088. DOI 10.7759/cureus.10088\n5\n of \n5","source_license":"CC0","license_restricted":false}