{"paper_id":"c42a6b4d-1910-4c03-86b6-f9a890061b79","body_text":"11\nRadiology Section\nRole of MRI in Diagnosis of Uterine Caesarean \nScar Endometriosis: A Case Report\nCase ReportDOI: 10.7860/IJARS/2022/49623.2795\nInternational Journal of Anatomy, Radiology and Surgery. 2022 Jul, Vol-11(3): RC01-RC02\nCASE REPORT\nA 26-year-old female, P2L2, presented with the chief complaint of \nrecurrent pelvic pain since five months without history of bleeding or \ndischarge with history of previous Lower Segment Caesarean Section \n(LSCS) two years back. On clinical examination, the abdomen was \nsoft, lax, and non tender with a healthy LSCS scar. Vaginal examination \nshows the uterus was bulky, non tender with irregular outline.\nTransabdominal Ultrasonography (USG) revealed a mildly bulky \nuterus, and a well-defined predominantly echogenic complex mass \nwas seen posteriorly to the urinary bladder with size of approximately \n6×5 cm. The endometrial thickness was normal. Ovaries and adnexa \nappeared unremarkable. MRI was advised for characterization of the \nlesion. It showed a well-defined rounded/lobulated mass (6×5 cm), \nhyperintense on T2, and intermediate signal intensity on T1 projecting \noutward from the anterior lower uterine wall at LSCS scar's site into \nthe ureterovesical space [Table/Fig-1]. No invasion into the urinary \nbladder or any other adjacent pelvic wall was seen. Blooming on T2 \nWI was noted in the periphery of the lesion, suggesting haemorrhagic  \ncontents [Table/Fig-2]. The ovaries appeared normal and observed \nto be separate from the mass. On the basis of MRI, it was diagnosed \nas scar endometrioma in the uterine wall.\nleuprolide acetate 3.75 mg monthly injection, danazol (100 mg/oral) \nfor three months, after liver and renal function clearance. The patient \ncame for regular follow-up for every three months for ultrasound \nand medical management. During follow-up, there was no changes \nobserved in USG from initial presentation. \nDISCUSSION\nEndometriosis is a chronic, benign gyaecological condition with an \nincidence of 10% and is seen in young women with the mean age \nof diagnosis of 25-29 years. These lesions are hormone dependent \nand can have various clinical presentations ranging from chronic \npelvic pain that may or may not be cyclical, dyspareunia to infertility \n[1,2]. Scar endometriosis of the abdominal wall is an uncommon \nentity that is probably on the rise following various obstetrical and \ngyaecological procedures [3,4].\nScar endometriosis is caused by implantation of endometrial \nstem cell at surgical site during uterine surgery [5]. Abdominal \nscar endometriosis has a reported incidence of 1.08-2% after \nhysterectomy and 0.03-0.4% after caesarean section [6,7]. It has \nbeen reported to be between 0.03% and 1.7% [8]. The uterine wall \nscar endometriosis is very rare and less data available regarding its \nincidence.\nThe USG method is a good modality to detect the endometriosis \nof the ovary, urinary bladder, or rectum. Because of its high \nspatial resolution, MRI shows specificity and sensitivity of 91-98% \nand 90-92% [9]. It also provides essential information about the \nsurrounding structure’s infiltration and helps in providing a roadmap \nto the surgery.\nARuShi Gupt A1, M VenkA teSh 2\n \nKeywords: Implantation, Magnetic resonance imaging, Pelvic pain\nABSTRACT\nEndometriosis refers to the implantation and growth of functional endometrial tissue outside the uterus. The common sites include \novaries, pelvic peritoneum, deep pelvic subperitoneal spaces, intestinal system, and urinary system. Endometriosis of a uterine \nscar is extremely rare. Uterine scar endometriosis has been described in women of reproductive ages following an obstetrical or \ngynaecological surgery. Despite a varying range of clinical presentations, a probable diagnosis is possible with imaging modalities \nlike ultrasound and Magnetic Resonance Imaging (MRI). Herein the authors report a case of 26-year-old patient complaining of \nrecurrent pelvic pain since five months, MRI diagnosed the scar endometrioma in the uterine wall. The patient has not undergone \nthe advised surgical excision of lesion and has continued the medical management. \n[Table/Fig-2]: Large well-defined STIR hyperintense; a) (Black arrow), GRE \nhypointense foci (white  arrow) with peripheral hypointense rim; b) Noted anterior to \nuterus  suggesting blood products.\n[Table/Fig-1]: a) Large well-defined T2 hyperintense (black arrow); b) T1 hypoin-\ntense lesion (white arrow) with peripheral hyperintense rim is noted anterior to \nuterus and  small communication to uterine cavity (blue arrow).\nThe patient was advised for surgery but she refused it. Hence, is \ncurrently on medical management and regular follow-up. Medical \ntreatment such as oral contraceptives, progestogens, danazol and \nleuprolide acetate were used for relief of symptoms without any \nreduction in size of the lesion. Eethinyl estradiol (20 µg/day, oral), \n\n\nArushi Gupta and M Venkatesh, Uterine Caesarean Scar Endometriosis www.ijars.net\nInternational Journal of Anatomy, Radiology and Surgery. 2022 Jul, Vol-11(3): RC01-RC0222\nIn the present case report, using MRI, it was diagnosed as scar \nendometrioma of the uterine wall. MRI reported large well-defined T2 \nhyperintense, and T1 hypointense lesion with peripheral hyperintense \nrim observed anterior to uterus and small communication to \nthe uterine cavity. Kafkasli A et al., reviewed histopathology of \nhysterectomy samples duting seven years, and observed two cases \nof endometriosis in uterine wall [5]. Lahiri AK et al., reported a 42-\nyear woman with intermenstural bleeding and pelvic pain for six \nmonths after two previous LSCS. USG examination shows bulky \nuterus with heterogenous myometrial echotexture. Computed \nTomography (CT) scan shows heterogeneous enhanced nodular \nmasses of lower uterine region. Finally, histopathology diagnosed \nas endometriosis of the uterine scar [10].\nKhachani I et al., reported a 37-year-old with subcutaneous oval \nmass sized 80×35 mm, with 2 mm skin orifice at the center of \nthe mass. Surgical wide en bloc excision was performed, and no \nrecurrence observed during the 24 months follow-up [11]. Ramdani \nA et al., study reported two cases, in which a 41-year-old female \nultrasonography revealed a subcutaneous right paramedian mass \nof 7×3 cm was attached to the rectus abdominis muscle. The \npatient was diagnosed with parietal endometriosis and underwent \nomentoplasty procedure, and shows no recurrence after four year \nfollow-up. Another case of 31-year-old female MRI diagnosed \nsubcutaneous mass of the left lateral pelvic wall, with spiculated \ncontours of 28×23 mm [12].\nSharma HK and Prashar S reported a 28-years-old female with \nswelling at left angle with previous LSCS pfannenstiel scar. USG of \nlesion measured 2.6×1.5.×0.15 cm at the pfannenstiel scar which \npredominantly hypoechoic with areas of hyper echogenicity within. \nPatient underwent surgical excision of swelling with margins of 1 \ncm. Histopathology diagnosed it as scar endometriosis, and the \npatient came for a follow-up upto six months, and did not report any \nrecurrence of swelling [13].\nTo prevent recurrence, a surgical excision with 1 cm margin \nshould be performed, in addition to neighboring structures such \nas fascia or muscle, being excised. Hence, the transplantation of \nmicroscopic endometrial tissue residuals can prevent the recurrence \nof endometriosis in the wound area [14]. But in the present case, no \nsurgery was performed as patient’s self refusal to surgery. In a case \nseries of five patients, the mass was invaded the peritoneal surface, \nand the large defect area was formed on the abdominal wall after \nthe surgery supported with Prolene mesh [14,15].\nCONCLUSION(S)\nUterine scar endometriosis is a rare presentation in pelvic \nendometriosis. MRI played crucial role in diagnosing endometriosis \nwith specific signal characterization by detecting blood products \nwithin the lesion.\nREFERENCES\nPatil NJ, Kumar V, Gupta A. Scar endometriosis-a sequel of caesarean section. [1] \nJ Clin Diagn Res. 2014;8(4):FD09-FD10.\nGupta P , Gupta S. Scar Endometriosis: Case Report with Literature Review. [2] \nNepal J Obstet Gynaecol. 2014;9(2):55-7.\nVellido-Cotelo R, Muñoz-González JL, Oliver-Pérez MR, de la Hera-Lázaro [3] \nC, Almansa-González C, Pérez-Sagaseta C, et al. Endometriosis node in \ngynaecologic scars: a study of 17 patients and the diagnostic considerations \nin clinical experience in tertiary care center. BMC women's health. 2015 \nDec;15(1):1-0.\nVural B, Vural F, MüezzinOGlu B. An abdominal wall desmoid tumour mimicking [4] \ncesarean scar endometriomas: A case report and review of the literature. J Clin \nDiagn Res. 2015;9(9):QD14.\nKafkasli A, Franklin RR, Sauls D. Endometriosis in the uterine wall cesarean [5] \nsection scar. Gynecol Obstet Invest. 1996;42:211-13. \nTaff L, Jones S. Cesarean scar endometriosis. A report of two cases. J Reprod [6] \nMed. 2002;47(1):50-52.\nGoel P , Sood SS, Dalal A, Romilla Cesarean scar endometriosis: Report of two [7] \ncases. Indian J Med Sci. 2005;59:495-98.\nPhupong V, Triratanachat S. Cesarean section scar endometriosis: a case report [8] \nand review of the literature. Journal of the Medical Association of Thailand= \nChotmaihet Thangphaet. 2002;85(6):733-38.\nBalleyguier C, Chapron C, Chopin N, Helenon O, Menu Y. Abdominal wall and [9] \nsurgical scar endometriosis: results of magnetic resonance imaging. Gynecologic \nand obstetric investigation. 2003;55(4):220-4.\nLahiri AK, Sharma K, Busiri N. Endometriosis of the uterine cesarean section [10] \nscar: A case report. Indian J Radiol Imaging. 2008;18(1):66-68.\nKhachani I, Filali Adib A, Bezad R. Cesarean scar endometriosis: An uncommon [11] \nsurgical complication on the rise? Case report and literature review. Case reports \nin obstetrics and gynecology. 2017 Feb 23;2017.\nRamdani A, Rais K, Rockson O, Serji B, El Harroudi T. Parietal mass: Two case [12] \nreports of rare cesarean scar endometriosis. Cureus. 2020 Feb;12(2).\nSharma HK, Prashar S. Cesarean scar endometrioma: A rare case report with [13] \nliterature review. MOJ Clin Med Case Rep. 2019;9(4):92-94.\nYıldırım D, Tatar C, Dog ˘ an O, Hut A, Dönmez T, Akıncı M, Toptas ¸ M, Bayık RN. [14] \nPost-cesarean scar endometriosis. Turkish journal of obstetrics and gynecology. \n2018;15(1):33.\nUçar MG, S ¸ anlıkan F, Göçmen A. Surgical Treatment of Scar Endometriosis [15] \nFollowing Cesarean Section, a Series of 12 Cases. Indian J Surg. \n2015;77:682-3.\np ARtiCuLARS OF COntRiButORS:\n1. Postgraduate, Department of Radiodiagnosis, Maharaja Agrasen Hospital, New Delhi, India.\n2. Assistant Professor, Department of Radiodiagnosis, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India.\npLAGiARiSM CheCkinG MethODS: [Jain H et al.]\n•  Plagiarism X-checker: Mar 27, 2021\n•  Manual Googling: Feb 10, 2022\n•  iThenticate Software: Apr 02, 2022 (5%)\netyMOLOGy:  Author OriginnAMe, ADDReSS, e-MAiL iD OF the CORReSpOnDinG AuthOR:\nM Venkatesh,\nProfessor, Department of Radio-Diagnosis, Narayana Medical College Hospital, \nNellore-524002, Andhra Pradesh, India.\nE-mail: drvenki143@gmail.com\nDate of Submission: Mar 25, 2021\nDate of Peer Review: Jun 26, 2021\nDate of Acceptance: Feb 16, 2022\nDate of Publishing: Jul 01, 2022\nAuthOR DeCLARA tiOn:\n•  Financial or Other Competing Interests:  None\n•  Was informed consent obtained from the subjects involved in the study?  No\n•  For any images presented appropriate consent has been obtained from the subjects.  Yes","source_license":"CC0","license_restricted":false}