{"paper_id":"9f88844b-65bd-4360-883c-8870ecdc552f","body_text":"Our Dermatology Online\n© Our Dermatol Online 1.2021 62\nHow to cite this article: Di Martino Ortiz B, Cuenca Torres OM. Skin endometriosis at the caesarean section scar: A case report. Our Dermatol Online. \n2021;12(1):62-65.\nSubmission: 20.01.2020; Acceptance: 27.03.2020\nDOI: 10.7241/ourd.20211.16\nSkin endometriosis at the caesarean section scar: A case Skin endometriosis at the caesarean section scar: A case \nreportreport\nBeatriz Di Martino Ortiz1, Osmar Manuel Cuenca Torres2 \n1Dermatology Department, Clinicas Hospital, Faculty of Medical Sciences, National University of Ausunción-Paraguay, \n2Surgical Department, Clinicas Hospital, Faculty of Medical Sciences, National University of Ausunción-Paraguay\nCorresponding author: Prof. Dr. Beatriz Di Martino Ortiz, E-mail: beatrizdimartino@gmail.com\n INTRODUCTION\nEndometriosis represents the presence of non-\nneoplastic endometrial tissue outside the uterus. The \ndisease is relatively common and typically affects the \novaries and presents with deep pelvic pain, dyspareunia, \nand dysmenorrhea.\nThe usually presentation location is usually the \nintrapelvic location and among them the most frequent \novarian form. However, extra-pelvic location may occur \nin more than 12% of women with endometriosis [1,2] \nand affect any part of the body, even the skin [3].\nCutaneous endometriosis is relatively uncommon and \noccurs when endometrial glands and stroma reside in \nthe skin.\nCutaneous endometriosis can be divided into primary \nand secondary endometriosis.\nEndometriosis usually occurs in the form of diffuse \ninvolvement, in plaques, although sometimes it does \nso by adopting cystic or tumor morphology. When \nendometriosis occurs as a well-defined mass, it called \nendometrioma [4].\nThe pathogenesis for primary cutaneous endometriosis \nremains unclear, but secondary cutaneous endometriosis \nis believed to occur due to seeding after abdominal or \npelvic surgery.\nBecause the condition is rare and can mimic \npresentations of other diseases, such as keloid or \ndermatofibroma, cutaneous endometriosis can be \ndifficult to diagnose.\nPunch biopsy can be performed to obtain tissue for \nhistopathologic testing, but physicians must take care \nto obtain abdominal ultrasound if there is potential \nfor uterocutaneous fistula. Once the diagnosis has \nbeen established, treatment options include hormonal \nagents and surgical excision with wide margins.\nCASE REPORT\nA 39-year-old patient with no family or personal history \nof interest, with a gynecological history of cesarean \nABSTRACT\nEndometriosis is a pathology little referenced in the dermatological literature and is defined as the presence of \nendometrial tissue outside the uterus. When it is a well-defined mass of endometriosis it is called endometrioma. \nCutaneous endometriosis is one of the rare gynecological conditions. Cutaneous endometriosis is a disorder that primarily \naffects women of reproductive age. The disorder is most commonly associated with cyclical pain during menses, but \nit can be difficult to diagnose in the absence of these symptoms and requires biopsy testing for a definitive diagnosis. \nWe report on a case of a 39-year-old patient who presented with pain at the cearean section scar. She was ultimately \ndiagnosed with cutaneous endometriosis and underwent surgical excision.\nKey words: Scar endometriosis; Cutaneous endometriosis\nCase Report\n\nwww.odermatol.com\n© Our Dermatol Online 1.2021 63\ndelivery 7 years ago without complications, without \nother valuable gynecological records.\nThree years after the surgical history, she noticed a \ntumor of approximately 10 mm in diameter in the left \nlateral third of Pfannenstiel’s scar. This tumor 1 year \nago undergoes progressive growth, accompanied by \nstabbing pain related to the menstrual cycle, with local \ncolor change.\nPhysical Examination\nA tumor of 50 mm in diameter, of elastic solid \nconsistency, mobile that does not impress being \nadhered to deep planes, is observed.\nAccording to the patient’s clinic, the presumptive \ndiagnosis of soft tissue endometriosis is made and it is \ndecided to perform surgical excision with loco regional \nanesthesia.\nLosangic incision is made on the tumor with a \n20 mm window, being removed in block, it reaches an \naponeurotic plane without exceeding it, a piece is sent \nto a pathological anatomy. There was a satisfactory \nevolution in the postoperative period.\nPathological Anatomy\nA surgical piece that measures 55 x 25 x 45 mm of \nmajor axes, upholstered by a skin losange, is remitted.\nThe cut shows a poorly defined and non-encapsulated \nnodular formation of 20 mm of major axes. On the \nperiphery of the same, multiple small cystic cavities \nfull of hematic material are observed and in the center \na yellow white tissue, of solid elastic consistency.\nSerial cuts are made and the sample is processed \nroutinely (Fig. 1).\nAt the histopathological examine there are multiple \nendometrial glands with surrounding endometrial \nstroma (Fig. 2). Decidualization of the stroma is not. \nSmooth muscle metaplasia is found. The glands show \nvariable cystic dilatation and may contain blood and \ndebris. There is not hemosiderin pigment There is \ndense fibrosis between the endometriotic foci.\nFinal Diagnosis\nCutaneous endometriosis.\nDISCUSSION\nEndometriosis is a chronic inflammatory reaction \ncharacterized by the presence of endometriomas \noutside the uterine cavity. It mainly causes painful \nsymptoms and infertility while some women don’t \nexperience symptoms at all. The prevalence in the \ngeneral female population is 2% to 10% but reaches \nup to 50% in infertile women [5].\nThe main etiology of endometriosis is not clear, but \nmany studies suggest the hematogenous or lymphatic \nspread of stem cells from bone marrow or coelomic \nmetaplasia [6].\nClassically presents as a firm subcutaneous papule or \nnodule that averages 2 cm in diameter [7]. Its color \ncan range from blue or violaceous to brown or skin-\nFigure 1: Gross pathology. The surface cut shows a poorly de fi ned \nand non-encapsulated nodular formation of 20 mm of major axes with \nmultiple small cystic cavities full of hematic material at the perifery.\nFigure 2:  Histopathology. Endometrial glands with surrounding \nendometrial stroma (HE4X; HE20X).\n\nwww.odermatol.com\n© Our Dermatol Online 1.2021 64\ncolored. Patients frequently experience cyclical pain, \nswelling, and even bleeding that corresponds with their \nmenstrual cycle [8].\nA diagnosis of cutaneous endometriosis can be made \nonce the presence of endometrial glands and stroma in \nthe skin is established. Notably, an ultrasound should \nbe completed prior to performing a punch biopsy of \nthe lesion to rule out the presence of uterocutaneous \nfistula.\nThe skin is an uncommon location for endometriosis, \nand cutaneous endometriosis cases comprise <1% of all \ncases in large series (8). One review demonstrated that \nonly 109 cases of cutaneous endometriosis had been \ndescribed in the literature up to that point in time [9].\nCutaneous endometriosis is subdivided into two \ncategories depending on patients’ surgical history. \nPrimary cutaneous endometriosis refers to cases in \nwhich the endometriosis develops spontaneously \nwithout any history of local surgery. It is the less \ncommon of the two (only 30% of patients present \nwithout a surgical history that could explain their \ncutaneous manifestations). Secondary cutaneous \nendometriosis, also called scar endometriosis, is \nassociated with prior abdominal or pelvic surgery [7].\nOur patient was diagnosed with cutaneous \nendometriosis based on the cyclical nature of her pain \nand the dermatopathologist diagnosis is in bad order. \nIdentifying the patient’s surgical history was crucial to \nsubclassifying our patient’s involvement as most likely \nbeing secondary in nature.\nThe most common location for both primary and \nsecondary cutaneous endometriosis is the umbilicus. \nUmbilical cutaneous endometriosis comprises 30% to \n40% of all cutaneous endometriosis cases, but other \nlocations such as the groin, arm, episiotomy wounds, \nappendectomy scars, and cesarean scars have also been \ndescribed [7].\nSecondary cutaneous endometriosis is perhaps easier to \nconceptualize, and the prevailing hypothesis remains \nthat endometrial cells dislodged during surgery seed the \nwound within and adjacent to the incision sites. In cases \nof primary cutaneous endometriosis, some postulate that \nseeding occurs hematogenously or via lymphatics [7].\nCutaneous endometriosis can mimic variable number \nof pathologies and also can mimic malignancy.\nThe most effective treatment of cutaneous \nendometriosis It is the surgical one. In the exeresis \nthe focus of endometriosis with wide margins of \n5-10 mm may be done with the intention of avoiding \nrecurrence [3,10,11].\n The incidence of cancer on an ovarian endometriosis \nsite is 1%. The incidence of cancer in a focus of \nextrapelvic endometriosis is unknown [12]. Few cases \nof cancers of endometriosis on the abdominal wall have \nbeen described [13].\nConsent\nThe examination of the patient was conducted according to the \nDeclaration of Helsinki principles.\nThe authors certify that they have obtained all appropriate \npatient consent forms. In the form the patient(s) has/have given \nhis/her/their consent for his/her/their images and other clinical \ninformation to be reported in the journal. The patients understand \nthat their names and initials will not be published and due efforts \nwill be made to conceal their identity, but anonymity cannot be \nguaranteed.\nREFERENCES\n1. Daisley Jr. D, Trim S, Daisley AR. Caesarean section scar \nendometriosis: A case report and review of  the literature with \nspecial emphasis on malignant transformation. Our Dermatol \nOnline. 2018;9:176-9.\n2. Nellihela L, Al-Adnani M, Kufeji D. Primary umbilical endometriosis \nin an adolescent girl: unsuspected pathology. European J Pediatr \nSurg Rep. 2020;8:e10-e13.\n3. Kocher M, Hardie A, Schaefer A, McLaren T, Kovacs M. Cesarean-\nsection scar endometrioma: a case report and review of  the \nliterature. J Radiol Case Rep. 2017;11:16-26.\n4. Ozturk A, Kaya C, Bozkurtoglu H, Tan N, Yananli ZD, Ucmakli \nE. Scar endometrioma: an uncommon yet easily treated condition. \nJ Reprod Med. 2016 May-Jun;61(5-6):249-53.\n5. Dunselman GAJ, Vermeulen N, Becker C, Calhaz-Jorge C, \nD’Hooghe T, De Bie B, et al. ESHRE guideline: management \nof  women with endometriosis. Hum Reprod. 2014;29:400–\n12.\n6. Mansouri S, Mai S, Hassam B, Meziane M. Omphalolith: a rare \numbilical concretion. Our Dermatol Online. 2019;10:411-2.\n7. Loh SH, Lew BL, Sim WY . Primary cutaneous endometriosis of  \numbilicus. Ann Dermatol. 2017;29:621–5.\n8. Ao X, Xiong W , Tan SQ. Laparoscopic umbilical trocar port site \nendometriosis: A case report. World J Clin Cases. 2020;8:1532-7.\n9. Lopez-Soto A, Sanchez-Zapata MI, Martinez-Cendan JP , Ortiz \nReina S, Bernal Mañas CM, Remezal Solano M. Cutaneous \nendometriosis: Presentation of  33 cases and literature review. Eur \nJ Obstet Gynecol Reprod Biol. 2018;221:58–63.\n10. Batista M, Alves F, Cardoso J, Gonçalo M. Cutaneous endometriosis: \na differential diagnosis of  umbilical nodule. Acta Med Port. \n2020;33:282-4.\n11. Carsote M, Terzea DC, Valea A, Gheorghisan-Galateanu AA. \nAbdominal wall endometriosis (a narrative review). Int J Med \nSci. 2020;17:536-42.\n\nwww.odermatol.com\n© Our Dermatol Online 1.2021 65\n12. Lin KY , Chang CY , Lin WC, Wan L. Increased risk of  endometriosis \nin patients with endometritis - a nationwide cohort study involving \n84,150 individuals. Ginekol Pol. 2020;91:193-200.\n13. Guo SW . Cancer-associated mutations in endometriosis: shedding \nlight on the pathogenesis and pathophysiology. Hum Reprod \nUpdate. 2020;26:423-49.\nCopyright by Beatriz Di Martino Ortiz, 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:\n Nil, Confl ict of Interest: None declared.","source_license":"CC0","license_restricted":false}