{"paper_id":"847d359c-8409-4cd8-92f2-99126a403289","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: SE, Scar endometrisois; LSCS, lower segment \ncesarean section \nIntroduction\nEndometriosis, first described by German pathologist Carl \nvon Rokitansky as cystosarcoma adenoids uterinum, is defined as \npresence of endometrial glands and stroma outside uterine cavity \nwith a prevalence of 5-10% in women during reproductive age. 1,2 \nPelvic endometriosis is more common and seen in Uterine ligaments, \nFallopian tubes, Pouch of Douglas, Ovaries and Pelvic peritoneum. \nOn the contrary, extra pelvic endometriosis is rare entity with frequent \nlocalization in abdominal wall(most common), bladder, kidney, \nbowel, omentum, lymph nodes, lungs, pleura, extremities, umbilicus \nand hernia sacs sites. 3 Scar endometrisois (SE), an extremely \nrare site (incidence 0.03-3.5%) of extra pelvic endometriosis, is \npresence of endometriosis at or near previous surgery scar site as a \npainful discreet tumoral mass known as Endometrioma or admixed \nwith native tissue. 2,4 SE usually develops after General surgery \nand Obstetrics and Gynecological surgeries ,most commonly after \nhysterectomy (1.08-2% cases) cesarean delivery (0.03-0.04% cases) \nand rarely after Appendicitis, Tubal ligation, Ectopic pregnancy, \nInguinal herniorrhapy, in laparoscopic trocar tract and needle tract \nafter diagnostic amniocentesis and in perineal episiotomy incision. 1 \nHowever, few cases of Endometriosis of abdominal wall have been \nreported without any association with previous surgery. 5 Most \nof the cases of SE are referred to Surgeons because its clinical \nsimilarity to incisional and inguinal hernias, abdominal wall tumor, \nInfective granuloma , lipoma, rectus sheath hematoma, keloid \nand other miscellaneous anterior abdominal wall masses and can \ncause unnecessary surgical interventions, inadvertent delayed or \nmisdiagnosis and emotional and physical distress to the patient. 4 We \nare reporting a rare case of scar endometriosis diagnosed 6 years after \nendometrioma developed in lower segment cesarean section (LSCS) \nscar to increase awareness about this benign treatable entity for correct \ntimely diagnosis.\nCase details\n28 years old P2L2female patient reported to Gynecology \ndepartment with a painful swelling at left angle of previous LSCS \npfannenstiel scar for 6 years. She delivered her first Full term Alive \nand Healthy baby by LSCS 6 years back. She first felt pain at operated \nsite 3 months after the surgery. It was cyclic and used to subside \nwithout any treatment. About 3 years back, she again conceived \nand delivered Full term, Alive and Healthy baby by LSCS. Now she \npresents with a tender swelling measuring 4x3x2cm at left angle of \nhealed pfannenstiel scar. It was well circumscribed, firm and situated \nin subcutaneous plane. Rest of her systemic examination, vital \nparameters, laboratory investigations and sonographic examination \nwere unremarkable without any evidence of pelvic endometriosios \n(Figure 1). \nFigure 1 Photomicrograph showing benign endometrial glands and stroma \nsurrounded by fibrous scar tissue consistent with Endometriosis (Hematoxylin \nand eosin x100).\n Ultrasonogram (USG) of swelling showed well defined lesion \nmeasuring 2.6x1.5.x.15cm in left pelvic region at the pfannenstiel \nscar site which was predominantly hypoechoic with areas of \nhyeprechogenecity within. Based on USG findings along with clinical \nhistory, a diagnosis of Scar endomerisois was made. Patient was taken \nup for wide local excision of swelling with surrounding margins of 1 \ncm. Gross examination of excised tissue revealed irregular, grayish \nblack fibro fatty mass with areas of congestion and hemorrhage. \nMOJ Clin Med Case Rep. 2019;9(4):92‒94. 92\n© 2019 Sharma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nCesarean scar endometrioma: A rare case report \nwith literature review\nVolume 9 Issue 4 - 2019\nHemant Kumar Sharma,1 Shivani Prashar2\n1Pathologist, Government Hospital, India\n2Medical Officer, Government Hospital, India\nCorrespondence: Hemant Sharma, Department of Pathology, \nGovernment Hospital, Danapur Cantt, H.No.167/1,MAP Quarters, \nIndia, 801503, T el 8968865923, Email  \nReceived: June 13, 2019 | Published: August 07, 2019\nAbstract\nEndometriosis is presence of endometrial glands and stroma outside uterine cavity. Scar \nendometriosis is an uncommon variant of extra pelvic endometriosis developing at scar \nsite of previous abdominopelvic surgery. Pre-operative Diagnosis of scar endometriosis is \noften delayed due to its clinical similarity with other surgical conditions. We present a case \nof Pfannenstiel scar endometriosis diagnosed 6 years after cesarean section delivery and \nhighlight pathogenesis, clinical and imaging features and various treatment options with an \naim to increase awareness about this rare entity. \nKeywords: endometriosis, scar endometrioma, extra pelvic endometriosis, casearean \nsection\nMOJ Clinical & Medical Case Reports\nCase Report\n Open Access\n\n\nCesarean scar endometrioma: A rare case report with literature review\n93\nCopyright:\n©2019 Sharma et al.\nCitation: Sharma HK, Prashar S. Cesarean scar endometrioma: A rare case report with literature review. MOJ Clin Med Case Rep. 2019;9(4):92-94. \nDOI: 10.15406/mojcr.2019.09.00312\nHistopathology examination revealed endometrial glands surrounded \nby endometrial stroma, embedded in fibro collagenous tissue and \nhemosiderin pigment at places without any evidence of malignancy \n(Figure 2). All histopathology findings were consistent with Scar \nendometriosis. On follow up period for 6 months, she did not report \nfor any recurrence of swelling and was completely relived of her \ncyclic symptoms.\nFigure 2 Photomicrograph showing benign endometrial glands and stroma \nsurrounded by fibrous scar tissue consistent with Endometriosis (Hematoxylin \nand eosin x200). \nDiscussion\nVarious theories like Metaplasia theory suggesting differentiation \nof primitive pluripotent mesenchymal cells in to endometrial tissues \nat sites other then uterine cavity and Transport theory suggesting \ntransportation of endometrial cells to extra uterine sites have been \npostulated about development of endometriosis. 1,6 Another theory \npostulates ability of endometrial cells to regulate cytotoxic immune \nactivity by diminishing natural killer cell activity in clearing endometrial \ncells and their capability to resist immune-mediated apoptosis \nenabling survival of ectopic endometrial cells in peritoneum. 3,7 \nAs proliferating capacity of end differentiated endometrial cells is \nlimited, Most Plausible hypothesis favoring development of scar site \nEndometrioma appears to be transportation and inadvertent inoculation \nof endometrial cells during surgical procedures followed by cyclical \nhormonal stimulation by estrogen similar to normal endometrium. 6 \nEndometrioma usually develops 3 months to 10years (average \n3.6years) after the surgeries but time between surgery and diagnosis \nvaries.2 Our patient underwent LSCS 6 years ago. Although rare \nentity, Endometrioma develops more commonly post-hysterotomy \nbecause of increased cellular replication and regenerative capacity \nof early decidua due to higher capability for pluripotency. 1 As in our \ncase, Pfannenstiel incision post LSCS is the most common site for \ndevelopment of SE possibly because wider dissection of tissue planes \ncompared to vertical midline incisions. Usually patients presents \nwith symptoms of severe dysmenorrhea, dyspareunia, menstrual \nirregularities and infertility. Clinically, endomtrioma presents as \ndiscoloured tender swelling responding in cyclic hormonal changes \nlocated in a surgical scar area. 4 Thorough clinical and sonographic \nevaluation of all SE patients is necessary to rule out concomitant \npelvic endomteriosis seen 24% of all SE patients. 1,3 Our patient did \nnot show any evidence of pelvic endometriosis. Due to variable \npresentation, lack of awareness and clinical similarity to other lesions \nspecific to scar site, preoperative diagnosis of scar endometrioma is \nvery difficult leading to unnecessary delays in correct diagnosis and \nunwarranted surgeries. In fact, most of the cases of scar endometrioma \nare diagnosed post-operatively during histopathological examination. \nVarious imaging diagnostic modalities like USG, CT(Computed \ntomography) and Magnetic resonance (MR) imaging have been \nused for establishing pre-operative diagnosis of scar endometriosis \ndepending on the phase of the patient’s menstrual cycle, the chronicity \nof the process, the number of stromal and glandular elements, and \nthe amount of bleeding and associated inflammation. 6 USG shows \nnon-specific findings of solid, hypoechoic and vascularized mass with \nspeculated margins infiltrating the surrounding tissue with scattered \ninternal echoes representing fibrotic strands. Francicsa et al. made \naccurate pre-operative diagnosis in 12 patients by using USG with \nColour Doppler findings along with clinical examination. 8 However, \nabdominal wall endometriosis can easily be missed in obese patients \nif appropriate USG probe is not used. 5 CT scan of swelling shows a \nsolid, well-circumscribed soft tissue mass directly associated with an \narea of surgical scarring while MR Imaging shows a hyper intense \nheterogeneous nodule associated with anterior abdominal or pelvic \nwall surgical scarring. MR Imaging is more useful in young patients \ndue to its improved tissue characterization and lack of ionizing \nradiation. Also, MR imaging is superior compared to CT scan \nparticularly in patients who are symptomatic or have extensive lesions \nwith deep infiltration by depicting the delineation between muscles \nand abdominal subcutaneous tissues and infiltration of abdominal \nand pelvic wall structures, to identify hemorrhage associated with \nendometriotic lesions and to accurately and safely plan surgical \nresection and can be more helpful when diagnosing small lesions \ndue to its high spatial resolution due to its ability to detect detecting \nthe planes between muscles and abdominal subcutaneous tissue. 2,4,6 \nRecently various studies like Veda et al stressed on the importance of \nFNAC in early diagnosis of SE and excluding other mimicking entities \nlike metastatic deposit, desmoid tumor, lipomas, cysts, fat necrosis \n,hematoma or abscess. FNAC of SE shows sheets of epithelial cells, \nspindled stromal cells and variable number of hemosiderin laden \nmacrophages and confirmation of diagnosis requires presence of \nany two out of there features. 9 FNAC, CT and MRI were not done \nin our patient to save cost and time as she was feeling severe pain \nand above all, these investigations would not have contributed much \nwith working clinical diagnosis of scar endometriosis and choice \nof treatment of wide local excision in all suspected cases of scar \nendometriosis. Although Various Medical and Surgical treatment \nmodalities have been tried, treatment of choice remains wide excision \nof the lesion with/without mesh placement depending upon size of the \nlesion along with histologically proven, surgical-free margin of 1cm to \nprevent recurrence.3 In symptomatic patients, Diagnostic laparoscopy \ncan be combined with excision to assess pelvic localization and \nexclude intraperitoneal spread. Medical treatment used for relief of \nsymptoms includes Progestogens, Oral contraceptive pills, Danazol \nand Gonadotropin agonist like leuprolide acetate have yielded only \npartial relief without any reduction in size. 2,3 Follow up and re-\nexcision is required in recurrent cases(incidence 4.3% after surgery) \nwith thorough evaluation to rule out any malignancy. 3 Malignant \ntransformation of endometriosis is a rare(seen in 0.3-1% of cases), \nrapidly progressive complication with 20-month survival rate is only \n57% and can be attributed to combination of oxidative stress from \nrecurrent hemorrhage, inflammation, and hyperestrinism.3,4 Till 2017, \n22 cases of carcinoma arising in scar endometroisois reported, out of \nwhich clear cell carcinoma was approximately (77.3%,17/22) followed \nby endometrioid carcinoma (13.6%, 3/22) and serous carcinoma \n(0.09%, 2/22). 10 If there is frequent recurrence or endometrioma is \nfast-growing, large and ulcerating, malignancy should be suspected. \nIncidence of scar endometriosis can be reduced by thorough cleaning \nand irrigation of surgical wound with high jet solution before closure \nin all abdominopelvic procedures.2,7\n\n\nCesarean scar endometrioma: A rare case report with literature review\n94\nCopyright:\n©2019 Sharma et al.\nCitation: Sharma HK, Prashar S. Cesarean scar endometrioma: A rare case report with literature review. MOJ Clin Med Case Rep. 2019;9(4):92-94. \nDOI: 10.15406/mojcr.2019.09.00312\nConclusion\nScar endomteriosis should be suspected in any women in \nreproductive age group presenting with a painful swelling in the \nabdominal scar especially with a history of previous gynecological \nor obstetrical surgery. Clinical similarity with various surgical \nlesions of anterior abdominal wall and vague symptoms often delay \ndiagnosis and casue physical and emotional stress to the patient. \nImaging modalities like MRI and FNAC should be used for accurate \npre-operative diagnosis. Treatment of choice is wide local excision \nwith 1 cm margin with regular follow-up to detect recurrence. Stress \nmust be laid on thorough cleaning and washing of surgical wound \nall abdominopelvic surgeries to avoid iatrogenic implantation of \nendometrium.\nAcknowledgements\nNone.\nFunding \nNone.\nConflicts of interest\nThe authors declare that there is no conflict of interest.\nReferences\n1. Chatterjee SK. Scar endometriosis: A clinicopathological study of 17 \ncases. Obstet Gynecol. 1980;56(1):81–84.\n2. Gupta P, Gupta S. Scar Endometriosis: a case report with Literature \nreview. Acta Medica Iranica. 2015;53(12):793–795.\n3. Mistrangelo M, Gilbo N, Cassoni P, et al. Surgical scar endometriosis. \nSurg Today. 2014;44(4):767–772.\n4. Leite GK, Carvalho LF, Korkes H, et al. Scar endometrioma following \nobstetric surgical incisions: retrospective study on 33 cases and review of \nthe literature. Sao Paulo Med J. 2009;127(5):270–277.\n5. Tomás E, Martín A, Garfia C, et al. Abdominal wall endometriosis in \nabsence of previous surgery. J Ultrasound Med. 1999;18(5):373–374.\n6. Gidwaney R, Badler RL, Yam BL, et al. Endometriosis of abdominal and \npelvic wall scars: multimodality imaging findings, pathologic correlation, \nand radiologic mimics. Radiographics. 2012;32(7):2031–2043.\n7. Ding DC, Hsu S. Scar endometriosis at the site of cesarean section. \nTaiwan J Obstet Gynecol. 2006;459(3):247–249.\n8. Francica G, Giardiello C, Angelone G, et al. Abdominal wall \nendometriomas near cesarean delivery scars: sonographic and \ncolor doppler findings in a series of 12 patients. J Ultrasound Med . \n2000;22(10):1041–1047.\n9. Veda P, Srinivasaiah M. Incisional endometriosis: diagnosis by fine \nneedle aspiration cytology. J Lab Physicians. 2010;2(2):117–120.\n10. Wei CJ, Huang SH. Clear cell carcinoma arising from scar endometriosis: \nA case report and literature review. Tzu Chi Med J. 2017;29(1):55–58.","source_license":"CC0","license_restricted":false}