{"paper_id":"8cec6158-531a-4e7c-86d6-6e5c8b0c5a19","body_text":"~ 174 ~ \nInternational Journal of Clinical and Diagnostic Pathology 2021; 4(1): 174-175 \n \nISSN (P): 2617-7226 \nISSN (E): 2617-7234 \nwww.patholjournal.com  \n2021; 4(1): 174-175 \nReceived: 28-12-2020 \nAccepted: 30-01-2021 \n \nKute KV \nResident, Department of \nPathology, Swami Ramanand \nTeerth Rural Government \nMedical College, Ambajogai, \nBeed, Maharashtra, India\n \n \nSwami SY \nAssociate Professor, \nDepartment of Pathology, \nSwami Ramanand Teerth \nRural Government Medical \nCollege, Ambajogai, Beed, \nMaharashtra, India\n \n \nNarwade SB \nAssistant Professor, \nDepartment of Pathology, \nSwami Ramanand Teerth \nRural Government Medical \nCollege, Ambajogai, Beed, \nMaharashtra, India\n \n \nBadlani KS \nAssistant Professor, \nDepartment of Pathology, \nSwami Ramanand Teerth \nRural Government Medical \nCollege, Ambajogai, Beed, \nMaharashtra, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nKute KV \nResident, Department of \nPathology, Swami Ramanand \nTeerth Rural Government \nMedical College, Ambajogai, \nBeed, Maharashtra, India \n \nDeciduosis in a caesarean scar: A case report \n \nKute KV, Swami SY, Narwade SB and Badlani KS \n \nDOI: https://doi.org/10.33545/pathol.2021.v4.i1c.345 \n \nAbstract \nCutaneous deciduosis is an exceedingly rare manifestation of endometriosis pote ntially mistaken for \nmalignancy and thus far documented solely within surgical scars. In the sc ars, the prevalence of \nsurgically proven endometriosis is around 1.6% and is often difficult to  diagnose due to its rarity. It is \noften confused with stitch granuloma, hernia, lipoma, cysts, desmoids tumor,  sarcoma etc. Areas of \nmyxoid change or marked decidual change in the stroma can m ake the recognition difficult. Here we \npresent a case of caesarian scar deciduosis in a 37-year-old female. \n \nKeywords: caesarian scar, deciduosis, endometriosis \n \nIntroduction  \nEndometriosis is the term used to describe the presence of endometrial tissue at s ites other \nthan the uterus. It may rarely arise from scar tissue due to previous ab dominal surgery such \nas caesarean section or episiotomy and may present with some histological features  of \ndecidual change, fibrosis, hyperplasia, metaplasia and calcifications [1]. In the scars, the \nprevalence of surgically proven endometriosis is around 1.6% and is o ften difficult to \ndiagnose due to its rarity [2]. \nEndometriosis is most commonly found in the pelvis including ovaries, u terine ligaments, \nrectovaginal septum, and peritoneum. Unusual sites of endometriosis have also been reported \nsuch as intestine, appendix, bladder and skin from scars, umbilicus, per ineum and inguinal \nregion. In most of the cases, it consists of both the endometrial glands and stroma but may \nalso consist only of endometrial stroma [1].  \nDecidual cells outside the endometrium are named “deciduosis” or “ectopic decidua”.  This \nbenign entity is the result of the metaplasia of sub-coelomic pluripotent mesenchymal cells to  \nprogesterone [2].  \n \nCase report \nA 37-years old female, second gravida with a history of previous caesarean  section 6 years \nago underwent another caesarean section. LSCS [Lower segment caesarean section] was \nuneventful and a single live male baby was delivered. Intraoperatively the previous caesar ean \nscar tissue showed focal nodular thickening. Scar tissue was excised and referre d to \nhistopathological examination. Specimen received in 10% formalin fixative measured 3x 2x2 \ncm, externally firm in consistency and was attached with adipose tissue. Cut surface showed \npinkish white areas along with adipose tissue. Representative sections microscopically \nrevealed [Fig.1 & Fig.2] scar tissue composed of fibroblasts and collagen admixed with \nhypertrophic decidualized stromal tissue surrounding slit like endometrial glands.  Individual \nstromal cells were polygonal with large nuclei and abundant eosinophilic cytoplasm at places  \nshowing hydropic changes. \n \n \n \n \n \n \n \n \n\n\nInternational Journal of Clinical and Diagnostic Pathology  http://www.patholjournal.com \n \n~ 175 ~ \n \n \nFig 1: Scar deciduosis: shows hypertrophy of decidualized stromal \ntissue surrounding slit like endometrial glands. Scar tissue \ncomposed of fibroblasts is seen at the periphery. [H&E: 10X] \n \n \n \nFig 2[A, B]: Scar deciduosis: shows large polygonal decidual cells with \nhomogenous eosinophilic cytoplasm and vacuolar degeneration \nsurrounding the endometrial glands. [H&E: 40X] \n \nDiscussion \nDecidualization is a pregnancy induced change in which \nthere is conversion of the normal endometrium into a \nspecialized uterine lining adequate for optimal \naccommodation of the gestation. In this condition there is \nhypertrophy of endometrial stromal cells and this leads to \nthickening of the normal endometrium and giving rise to the \ndecidua. In rare cases there can be presence of ectopic \ndecidua’s during pregnancy due to hormonal effects on the \nectopic endometrium and this phenomenon is called as \ndeciduosis [1]. \nEndometriosis that responds to hormonal stimulation \n(deciduosis) is extremely rare in a surgical scar and is \npresent in 0.1% women who have undergone caesarean \nsection. Whenever endometriosis is present at a cutaneous \nsite, there is nearly always associated with surgical scar [1]. \nCutaneous deciduosis is an exceedingly rare manifestation \nof endometriosis potentially mistaken for malignancy and \nthus far documented solely within surgical scars [3]. \nEctopic decidua was first described in 1864 by Walker von \nSolothurn during the observation of two ectopic \npregnancies. The pathogenesis of ectopic decidua is not \ncompletely understood, but it is believed that it develops as \na result of the metaplasia of subserosal stromal cells affected \nby progesterone during pregnancy. Deciduosis is a \nclinicopathological process distinct from endometriosis [4].  \nDecidualization is the hypertrophy of endometrial stromal \ncells by the effect of progesterone. Similarly, in pregnancy, \nectopic stromal endometrial cells in endometriosis can also \nbe transformed by the same mechanism and ectopic decidua \n(deciduosis) may occur [5]. In the absence of pregnancy, \nectopic decidual changes have been attributed to the \nstimulation of appropriate cells by progesterone and \nprogesterone like substances from the corpous luteum or the \nadrenal cortex [6]. \nDeciduosis occurring in the caesarean scar may be \nsecondary to iatrogenic transplantation of endometrium or \nextra-uterine decidual tissue into the incision during the \ncaesarean section. The symptoms of scar endometriosis are \nrelated to the cutaneous mass or nodule that appears weeks \nto years after the surgery and in one study the average \npostoperative interval was 30 months.  \nChaterjee reported that 71% cases of scar deciduosis \nfollowed abdominal hysterectomy over a study period of 5 \nyears and the incidence of scar endometriosis in the patients \nwho underwent hysterotomy during this period was 1.08%. \nKoger et al . reported 24 patients with surgical scar \ndeciduosis in which majority of cases had cesarean section \nscar [1]. \nDecidual cells are generally large polygonal, with \nhomogenous, eosinophilic cytoplasm and vacuolar \ndegeneration at various rates can be seen in these cells as \nseen in the present case [7]. These cells are vimentin and \nprogesterone-receptor-positive and focally positive for \ndesmin and smooth muscle actin [8].  \nThe treatment of deciduosis may be surgical or hormonal \ndepending upon the circumstances, but usually surgical \nexcision is sufficient for the treatment of non-decidualized \nand decidualized endometriosis of the abdominal wall or \nscar after Cesarean section [1].  \n \nConclusion \nAlthough the histologic diagnosis of endometriosis is \nusually easy, diagnostic problems can occur as a result of \nsecondary changes such as decidual change as seen in the \npresent case. It can be confused with neoplasm clinically \nand histologically. Histopathologist should be aware of this \nphenomenon to avoid erroneous diagnosis. \n \nReferences  \n1. Saeed Alam, Huma Mushtaq, Salma Kafeel. Deciduosis \nin a cesarean scar. JIMDC 2013;2:32-34. \n2. Lingegowda JB, Muddegowda PH, Koteswary P, \nThamilselvi R. Scar endometriosis with decidual \nchange. National Journal of Basic Medical Sciences \n2016;7:52-54. \n3. Kevaghn PF, James WP, Richard JM, Rebecca JR. \nCutaneous deciduosis. J Am Acad Dermatol \n2000;43:102-7. \n4. Baroni Cruz D, Dhamer T, da Rocha VW et al . BMJ \nCase Rep 2014. doi:10.1136/bcr-2013-202480:1-2. \n5. Barbieri M, Somigliana E, Oneda S, Ossola MW, Acaia \nB, Fedele L. Decidualized ovarian endometriosis in \npregnancy: a challenging diagnostic entity. Hum \nReprod 2009;24:1818-1824. \n6. Kinra P, Sen A, Sharma JC. Ectopic decidual Reaction: \nA case report. MJAFI 2006;62:280-281.  \n7. Bolat F, Canpolat T, Tarim E. Pregnancy related \nperitoneal ectopic decidua [deciduosis]: Morphological \nand clinical evaluation. Turk J Pathol 2012;28:56-60. \n8. Shukla S, Pujani M, Singh SK. Ectopic decidual \nreaction mimicking peritoneal tubercles: A report of 3 \ncases. Indian J Pathol Microbiol 2008;51:519-20.","source_license":"CC0","license_restricted":false}