{"paper_id":"8b4e6532-af98-477a-ade2-687101aa7032","body_text":"Our Dermatology Online\n© Our Dermatol Online 2.2018 176\n INTRODUCTION\nSampson 1927,postulated that retrograde flow of \nendometrium during the menstrual cycle, seeded the \nFallopian tube and pelvic and abdominal organs causing \nendometriosis to occur in these sites under favorable \nconditions. This he referred to as implantation \nendometriosis. In recent times another form of \nimplantation endometriosis has been reported post \ncaesarian section, and following surgery on the uterus. \nImplantation often occurs within the Pfannenstiel scar \nand also within the pelvis and peritoneum. The case \nin question presents a 30-year-old female who suffered \npain and discomfort within her pelvis and abdominal \nscar for four years following caesarian section. Her \npain and discomfort continues for she most likely has \nimplantation endometriosis within her pelvic organs \nas a result of implantation during caesarian section. \nThe article focuses on the malignant transformation \nof endometriosis a phenomenon that is often forgotten \nas part of the natural sequel of endometriosis. In \nrecent times cases of caesarian scar endometriosis \nwith malignant transformation [1-4] have been \nreported in the literature indicating that malignant \ntransformation of endometriosis can occurs at every site \nwhere it is deposited. The true incidence of malignant \ntransformation of endometriosis is unknown.\nEfforts should be made to avoid implantation \nendometriosis during surgical procedures of the uterus, \nand also to diagnose and treat this entity promptly to \navoid the risk of its malignant transformation.\nCASE REPORT\nA 30 years old female, G2P1+1 who had a LSCS in \nthe year 2009, presented to the Gynecology Outpatient \nClinic in March 2013 with complaints of a lump on the \nright end of the LSCS scar. The lump had been present \nfor over one year. She also complained of severe pain \nand swelling on the same side of the lesion, and in her \npelvis, during and after her menstrual period.\nShe had her menarche at age 15years. She admitted to \nusing oral contraceptive for 2years. She had no history \nABSTRACT\nImplantation endometriosis following caesarian hysterectomy is not an uncommon entity. Seeding of endometrium \nwithin the peritoneum and pelvic organs and the Pfannenstiel incision commonly occur. Post caesarean implantation \nendometriosis occurrence is determined by several factors. While endometriosis is a morbid disease, which causes \npain, dysfunctional uterine bleeding and infertility, it is also a precancerous condition, and efforts should be made to \navoid implantation endometriosis during uterine surgery. The object of this article is to present a 30 year old female \nwith implantation endometriosis in a Pfannenstiel abdominal scar and to review the diagnostic facilities available and \nhighlight the premalignant potential of endometriosis.\nKey words: Endometriosis; Caesarean scar; Malignant transformation\nCase Report\nCaesarean section scar endometriosis: A case report Caesarean section scar endometriosis: A case report \nand review of the literature with special emphasis on and review of the literature with special emphasis on \nmalignant transformationmalignant transformation\nHubert Daisley Jr.1, Stacey Trim2, Alicia R. Daisley1\n1General Hospital San Fernando, Trinidad, West Indies, 2General Hospital Scarborough, Tobago, West Indies\nCorresponding author: Prof. Hubert Daisley Jr., E-mail: profhdjr@yahoo.com \nHow to cite this article: Daisley Jr. D, Trim S, Daisley AR. Caesarean section scar endometriosis: A case report and review of the literature with special \nemphasis on malignant transformation. Our Dermatol Online. 2018;9(2):176-179.\nSubmission: 02.08.2017; Acceptance: 28.10.2017\nDOI: 10.7241/ourd.20182.19\n\nwww.odermatol.com\n© Our Dermatol Online 2.2018 177\nof inter-menstrual bleeding, dyspareunia, post-coital \nbleeding or sexually transmitted disease.\nShe had an excision biopsy of the lump under general \nanesthesia.\nThe tissue received in pathology was a 4 x 2.5 cm 2 \nfibroadiopose mass admixed with old hemorrhages. \nHistological examination of the scar revealed \nendometriosis (Fig. 1).\nDISCUSSION\nEndometriosis is classically defined as the presence of \nendometrial glands and stroma in ectopic locations, \nprimarily the pelvic peritoneum, ovaries, and recto-\nvaginal septum. The manifestation of endometriosis \nis not straightforward and does not occur in each \nindividual during retrograde menstrual flow, for \nthere seems to be interplay between immune, \nhormonal, genetic and environmental factors in its \npathogenesis [3,4].\nSampson’s implantation theory of endometriosis is \nthe most accepted [5]. Here retrograde menstrual \nflow seeds the Fallopian tube, the ovaries and the \nperitoneum and pelvic organs with endometrial \ntissue, and with the right milieu, endometriosis is \ngenerated. This mechanism of endometriosis has \nbeen demonstrated both in humans and in laboratory \nanimals [6].\nSampson 1927, proposed a second theory of \nendometriosis. He postulated that endometriosis \noccurred as a result of dissemination of endometrial \ntissue to other organs via the blood stream and \nlymphatic [7].\nA third hypothesis is the coelomic metaplastic theory, \nwhich postulates that undifferentiated coelomic cells \nare transformed into endometrium-like tissue under \nfavorable conditions [8].\nThe case in question is one of implantation \nendometriosis, namely Caesarean section scar \nimplantation endometriosis [9,10] and is another \nmechanism for the pathogenesis of endometriosis. \nThe abdominal incision was seeded with endometrial \ntissue during the caesarian section and it is also \npossible that the peritoneum and other pelvic organs \nwere similarly implanted at surgery, for her abdominal \npains and discomfort continued after excision of the \nendometrial deposit in the surgical scar. The frequency \nwith which endometriosis post-uterine surgery takes \nplace is yet unknown and may very well be the major \ncontributing factor to the causation of present day \nendometriosis.\nEndometriosis is an inflammatory estrogen dependent \ncondition associated with pelvic pain and infertility. \nClassically it is diagnosed by identifying endometrial \ntissue that is glands and stromal in extra uterine sites; \nthe primary sites being the rest of the internal genital \nlike the Fallopian tubes and ovaries, other pelvic \norgans, the peritoneum, the gastrointestinal tract. \nEndometriosis has been reported to involve even the \nmouth [11], probably as a result of the metaplastic \ntheory or Sampson’s or dissemination theory via \nlymphatic or bloodstream.\nEndometriosis affects approximately 10% of women \nin their reproductive lives [12]. The diagnosis is not \noften readily made. Many biochemical markers have \nbeen investigated for the diagnosis of endometriosis \nbut they lack specificity [13], although the evaluation \nof CA125 might me a useful marker in some forms \nof endometriosis and might be used to monitor \nimprovement in endometriosis when therapy is \ninstituted. Maiorana et al 2007 [14], found CA \n125 serum levels were related to endometriosis \nand R-AFS score, in their study of patients with \nendometriosis. Because of the alarming statistical bias \nof endometriosis transforming into adenocarcinoma \n(79%)within the ovary, it would be useful to do early \nscreening for ovarian cancer in patients with proven \nendometriosis [15].\nFigure 1: Endometrial glands and stromal cells within scar tissue. The \nglands are non-secretory.\n\nwww.odermatol.com\n© Our Dermatol Online 2.2018 178\nEndometriosis is not only to be considered as a benign \npainful, morbid, condition but; a disease entity which \nundergoes malignant transformation [16].\nFunction and dysfunction of the female immune \nsystem play important roles in the initiation \nand progression of the disease and its relation to \ninfertility and cancer [17]. In 79% of cases, the ovary \nhas been recorded as the most common site where \nmalignant transformation of endometriosis has taken \nplace [18,19]. Melin et al [20] found an increased risk \nof some types of malignancy, above all ovarian cancer, \nin women with endometriosis, and postulates that \nthe risk of transformation of endometriosis deposits \nin the ovary has been underestimated. Given the \nfact that ovarian cancers represents gynecological \ncancers with the worst prognosis [21], and that 79% \nof malignant transformation of endometriosis takes \nplace in the ovaries, it would be prudent to avoid \novarian implantation endometriosis during uterine \nsurgery.\nAdenocarcinoma developing in extra-ovarian \nendometriotic sites have been recorded namely \nin the colon [22], symphysis pubis [23], the \nurethro-vaginal septum [24] and many other sites \nincluding the caesarian scar (1,2,9). The evidence \nsupports the fact that endometriosis is yet another \nhyperestrogenic condition that has a propensity \nfor the development of carcinoma, and should be \nconsidered to be a precancerous condition. Melin \net al [20] states that approximately 1.0% of women \nwith endometriosis have lesions that undergo \nmalignant transformation.\nBecause of its troublesome clinical features of pain \nand infertility, its impact on the quality of life of \nthe patient [25] and its propensity for malignant \ntransformation [9], implantation endometriosis \nduring gynecological surgery and caesarian sections \nshould be avoided and early detection and treatment \nof endometriosis with a view to its eradication should \nbe the goal.\nCONCLUSION\nImplantation endometriosis within Caesarean section \nis not an uncommon occurrence.\nThis malady needs to be diagnosed and treated early \nfor endometriosis is a premalignant condition.\nREFERENCES\n1. Li X, Yang J, Cao D, Lang J, Chen J, Shen K. Clear-cell carcinoma \nof  the abdominal wall after cesarean delivery. Obstet Gynecol. \n2012;120:445-8.\n2. Matter M, Schneider N, McKee T. Cystadenocarcinoma of  the \nabdominal wall following caesarean section: case report and review \nof  the literature. Gynecol Oncol. 2003;91:438-43.\n3. Laganà AS, Sturlese E, Retto G, Sofo V , Triolo O. Interplay between \nMisplaced Müllerian-Derived Stem Cells and Peritoneal Immune \nDysregulation in the Pathogenesis of  Endometriosis. Obstet \nGynecol Int. 2013;2013:527041.\n4. Richard OB, Linda CG. Pathogenesis and Pathophysiology of  \nEndometriosis. Fert and Steri. 2012;98;511-19.\n5. Sampson JA. Peritoneal endometriosis due to menstrual \ndissemination of  endometrial tissue into the peritoneal cavity. Am \nJ Obst Gyn. 1927;14:442–69.\n6. Yamanaka A, Kimura F, Takebayashi A, Kita N, Takahashi K, \nMurakami T. Primate model research for endometriosis. Tohoku J \nExp Med. 2012;226:95-9.\n7. Sampson. J.A. Metastatic or Embolic Endometriosis, due to the \nMenstrual Dissemination of  Endometrial Tissue into the Venous \nCirculation: Am J Pathol. 1927;3:93–110.\n8. Ferguson BR, Bennington JL, Haber SL. Histochemistry of \nmucosubstances and histology of  mixed mullerian pelvic \nlymph node glandular inclusions. Evidence for histogenesis by \nmullerian metaplasia of  coelomic epithelium. Obstet. Gynecol. \n1969;33:617-25.\n9. Leng J Lang J, Guo L, Li H, Liu Z. Carcinosarcoma arising from \natypical endometriosis in a cesarean section scar. Int J Gynecol \nCancer. 2006;16:432-5.\n10. Biswas BK, Gupta N, Magon N. Incisional endometriosis: A rare \ncause for a painful scar - A report and commentary. Niger Med J. \n2012;53:257-9.\n11. Akre DP , Konan KE, Seka SJ, Dasse SR, Kof fi  KA, Abauleth R. \n[Immunological aspects of  a case of  extragenital endometriosis \nlocalized in the mouth]. Odontostomatol Trop. 2010;33:15-20.\n12 Wheeler JM. Epidemiology of  endometriosis-associated infertility. \nJ Reprod Med. 1989;34:41–6.\n13. May KE, Conduit-Hulbert SA, Villar J, Kirtley S, Kennedy SH, \nBecker CM. Peripheral biomarkers of  endometriosis: a systematic \nreview. Hum Reprod Update. 2010;16:651-74.\n14. Maiorana A, Cicerone C, Niceta M, Alio L. Evaluation of  serum CA \n125 levels in patients with pelvic pain related to endometriosis. Int \nJ Biol Markers. 2007;22:200-2.\n15. Shapira I. Oswald M, Lovecchio J, Khalili H, Menzin A, Whyte J, \net al. Circulating biomarkers for detection of  ovarian cancer and \npredicting cancer outcomes. Br J Cancer. 2014;110:976-83.\n16. Baskakov VP , Tsvelëv IuV . Endometriosis and cancer Vopr Onkol. \n1982;28:45-51.\n17. Olovsson M. Immunological aspects of  endometriosis: an update. \nAm J Reprod Immunol. 2011;66 Suppl 1:101-4.\n18. Worley MJ1, Welch WR, Berkowitz RS, Ng SW . Endometriosis-\nassociated ovarian cancer: a review of  pathogenesis Int J Mol Sci. \n2013;14:5367-79.\n19. Heidemann LN, Hartwell D, Heidemann.CH, Jochumsen KM. The \nrelation between endometriosis an ovarian cancer-a review. Acta \nObstet Gynecol Scand. 2014;93:20-31.\n20. 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Nnoaham KE, Hummelshoj L, Webster P , d’Hooghe T, de Cicco \nNardone F, de Cicco Nardone C, et al. World Endometriosis Research \nFoundation Global Study of  Women’s Health consortiumFertil \nSteril. Impact of  endometriosis on quality of  life and work \nproductivity: a multicenter study across ten countries. Fertil Steril. \n2011;96:366-73.\nCopyright by Hubert Daisley Jr., et al. This is an open-access article \ndistributed under the terms of the Creative Commons Attribution License, \nwhich permits unrestricted use, distribution, and reproduction in any \nmedium, provided the original author and source are credited.\nSource of Support: Nil, Confl ict of Interest: None declared.","source_license":"CC0","license_restricted":false}