{"paper_id":"d9acea66-2940-40b1-9e97-d3544fd4e19b","body_text":"Introduction\nEndometriosis is a common gynaecologic disorder,\naffecting 2% of the population and 10% of women in\nfourth decade (1, 2). It is characterized by the presence\nand proliferation of endometrial tissue in ectopic sites\n(2, 3). It may affect any of the abdominal or pelvic or-\ngans, but groin involvement is rare (1).\nThe first case of inguinal endometriosis was descri-\nbed by Cullen in 1896 (1, 4). Since then 40 cases have\nSUMMARY: Isolated inguinal endometriosis. Case report with ul-\ntrasonographic preoperative diagnosis. \nP. G .  CALÒ, F . ESU, A. TATTI, L. P ILLONI, F . MEDAS, G. P ISANO, \nA. NICOLOSI\nInguinal endometriosis is rare and accounts for 0.3-0.6% of pa-\ntients affected by endometriosis. A correct preoperative diagnosis is rare.\nDiagnosis is frequently made by histologic examination.\nA 36-year-old nulliparous woman presented with a painful mass\nin her right groin of 2 years duration. The pain fluctuated according to\nthe menstrual period. Physical examination revealed an elastic hard\nmobile mass measuring 2x2 cm in the right inguinal region. Ultra-\nsound examination confirmed a hypoechoic tumor in the right ingui-\nnal region with poorly defined boundaries and perilesional and intra-\nlesional vascular flow suspect for endometriosis. \nWide excision of the lump with a part of the round ligament was\ncarried out. Histology showed  endometrial glands and stroma within\nthe fibrous tissue. \nThe patient had an uneventful recovery and was discharged the\nnext day. After surgery, the pain disappeared completely. No signs of re-\ncurrence occurred at approximately 16 months after the surgery.\nAlthough rare, extrapelvic endometriosis should be considered in\nthe differential diagnosis in women of reproductive age presenting with\nan inguinal mass, especially if the groin mass is associated in size and\ntenderness with menstrual variability. US appearance is very useful in\ndiagnosis so ultrasonography can be considered the examination of choi-\nce.\nRIASSUNTO: Endometriosi inguinale isolata. Descrizione di un caso\nclinico con diagnosi preoperatoria ecografica.\nP. G .  CALÒ, F . ESU, A. TATTI, L. P ILLONI, F . MEDAS, G. P ISANO, \nA. NICOLOSI\nL ’endometriosi inguinale è rara e rappresenta lo 0.3-0.6% delle\nforme di endometriosi. Una diagnosi preoperatoria corretta è rara e la\ndiagnosi emerge frequentemente dall’esame istologico.\nUna donna nullipara di 36 anni si presentò all’osservazione con\nuna massa dolente in regione inguinale destra presente da 2 anni. Il do-\nlore si modificava di intensità in relazione al ciclo mestruale. L ’esame\nobiettivo mise in evidenza una tumefazione duro-elastica, mobile, in\nregione inguinale destra, delle dimensioni di 2 x 2 cm. L ’esame ecogra-\nfico evidenziò una tumefazione ipoecogena in regione inguinale destra\na limiti scarsamente definiti e vascolarizzazione peri e intralesionale,\nsospetta per endometriosi. \nFu praticata una ampia asportazione della massa insieme a una\nparte del legamento rotondo. L ’istologia confermò la presenza di tessuto\nendometriale misto a tessuto fibroso. La paziente ebbe un decorso po-\nstoperatorio regolare e fu dimessa il giorno successivo all’intervento. Do-\npo l’intervento il dolore scomparve completamente. Non vi sono segni\ndi recidiva 16 mesi circa dopo il trattamento chirurgico.\nSebbene rara, l’endometriosi extrapelvica deve essere considerata\nnella diagnosi differenziale nelle donne in età riproduttiva con una tu-\nmefazione inguinale, specialmente se varia nelle dimensioni e nella\nconsistenza durante il ciclo mestruale. L ’aspetto ecografico è molto uti-\nle nella diagnosi e di fatto rende l’ecografia l’indagine di scelta.\nKEY WORDS:  Endometriosis - Groin - Round ligament - Diagnosis.\nEndometriosi - Regione inguinale - Legamento rotondo - Diagnosi.\nIsolated inguinal endometriosis. Case report with ultrasonographic\npreoperative diagnosis\nP .G. CALÒ, F . ESU, A. TATTI, L. PILLONI1, F . MEDAS, G. PISANO, A. NICOLOSI\nG Chir Vol. 32 - n. 5 - pp. 263-265\nMay 2011\n263\nUniversity of Cagliari, Italy\n“Monserrato” Hospital\nDepartment of Surgery and Odontostomatological Sciences\n1 ”San Giovanni di Dio “ Hospital\nUnit of Pathology\n© Copyright 2011, CIC  Edizioni Internazionali, Roma\n0199 6 Isolated_Calo:-  14-04-2011  15:48  Pagina 263\n\n264\nP .G. Calò et al.\nbeen reported in the literature (4, 5). A correct preope-\nrative diagnosis is rare. Diagnosis is frequently made by\nhistologic examination (2, 6).\nWe report a case of a patient in which inguinal en-\ndometriosis was suspected by clinical presentation and\nultrasound.\nCase report\nA 36-year-old nulliparous woman presented with a painful mass\nin her right groin lasting 2 years. She denied dysmenorrhea. Her past\nmedical history was unremarkable. The pain fluctuated according to\nthe menstrual period.\nPhysical examination revealed an elastic hard mobile 2x2 cm mass\nin the right inguinal region. The swelling was not reducible and had\nno evident cough impulse. Skin over the mass was normal.\nUltrasound examination revealed a complex hypoechoic mass in\nthe right inguinal region with poorly defined boundaries and peri-\nlesional and intralesional vascular flow suspect for endometriosis (Fig.\n1). \nAt surgery a 5 cm longitudinal skin incision was made over the\nmass. The mass was attached to the extraperitoneal portion of the\nright round ligament. Wide excision of the lump with a part of the\nround ligament was carried out. No hernial sac was detected. Posterior\nabdominal wall and trasversalis fascia appeared solid. Histology showed\nendometrial glands and stroma within the fibrous tissue (Fig. 2). No\nmalignant cells were identified.\nThe patient had an uneventful recovery and was discharged the\nnext day. After surgery, the pain disappeared completely. A diagno-\nstic pelvic laparoscopy showed no intraperitoneal or pelvic endo-\nmetriosis. Patient was submitted to hormonal therapy.\nNo signs of recurrence occurred at 16 months after the surgery.\nDiscussion\nEndometriosis is a common gynaecological condition,\noccurring in 8-15% of fertile women (1, 4, 5, 7, 8). In-\nguinal endometriosis is rare and accounts for 0.3-0.6%\nof patients affected by endometriosis (1, 8). The right\nside is much more commonly involved than the left (90-\n94%), while bilateral involvement is exceptional (only\none case described) (1, 4, 8, 9, 10). The right-sided pre-\nponderance may be explained by the theory that the sig-\nmoid colon relatively protects the left groin (1, 4, 5, 10).\nIn our case, the patient also presented with the more com-\nmon right-sided inguinal endometriosis.\nThe most common complaint of patients with in-\nguinal endometriosis is an inguinal mass, followed by pain\nand enlargement of the mass near menses (4). In 30-37%\nof patients, inguinal endometriosis is associated with a\ngroin hernia (6, 8). Pelvic endometriosis is found in most\npatients with inguinal endometriosis (4). Though rare,\nmalignant degeneration is possible (8). Our patient did\nnot have any intraperitoneal or pelvic endometriosis, nor\na groin hernia.\nThe imaging appearance, particularly on CT , is non-\nspecific (4). Magnetic resonance imaging has been de-\nmonstrated as particularly useful in diagnosing extra-\nperitoneal localizations. T o evaluate the mass sonography\nis also a very handy and a beneficial tool (1). In many\nprior cases, patients had undergone surgery after a preo-\nperative diagnosis of inguinal hernia (4). In our case, ul-\ntrasonography detected an irregular solid hypoechoic no-\ndule in the groin region with perilesional and intralesional\nvascular flow. This picture contributed to confirm the\nsuspicion of endometriosis. We did not use magnetic re-\nsonance or computed tomography in our case. In our opi-\nnion CT and MR should be limited to the few cases in\nwhich other diseases (expecially malignant) are to be ex-\ncluded. Cytology also can aid in distinguish endometriosis\nfrom inflammatory, neoplastic, or lymphoproliferative\nprocesses (4). We have no experience in using citology\nin such cases.\nSurgical excision of inguinal endometriosis is repor-\nFig. 1 - Ultrasonographic finding: complex hypoechoic mass with poorly defi-\nned boundaries.\nFig. 2 - Histological finding: endometrial glands and stroma within the fibrous\ntissue.\n0199 6 Isolated_Calo:-  14-04-2011  15:48  Pagina 264\n\nted to be curative (11). Hormonal therapy has also been\nrecommended (5). In our case surgery was curative too\nand patient is currently disease free.\nConclusion\nWe present an unusual case of inguinal endometriosis\ninvolving the extraperitoneal portion of the round li-\ngament. The appearance on US supported the clinical\ndiagnosis of endometriosis.\nAlthough rare, extrapelvic endometriosis should be\nconsidered in the differential diagnosis in women of re-\nproductive age presenting with an inguinal mass, espe-\ncially if the groin mass is associated in size and tender-\nness with menstrual variability. US appearance is very use-\nful in diagnosis, so ultrasonography can be considered\nthe examination of choice.\n265\nIsolated inguinal endometriosis. Case report with ultrasonographic preoperative diagnosis\n1. Hagiwara Y, Hatori M, Moriya T , T erada Y, Yaegashi N, Ehara\nS, Kokubun S. Inguinal endometriosis attaching to the round\nligament. Australas Radiol 2007; 51: 91-4.\n2. Miranda L, Settembre A, Capasso P , Piccolboni D, De Rosa N,\nCorcione F . Inguinal endometriosis or irreducibile hernia? A dif-\nficult preoperative diagnosis. Hernia 2001; 5: 47-9.\n3. La Gamma A, Kunin N, Letoquart JP , Mambrini A. Endomé-\ntriose du ligament rond de l’utérus dans le canal inguinal: A pro-\npos d’une nouvelle observation. J Chir 1994; 131: 162.\n4. Freed KS, Granke DS, Tyre LL, Williams VL, Omert LA. En-\ndometriosis of the Extraperitoneal Portion of the Round Liga-\nment: US and CT Findings. J Clin Ultrasound 1996; 24: 540-\n2.\n5. Mashfiqul MAS, Tan YM, Chintana CW . Endometriosis of the\ninguinal canal mimicking a hernia. Singapore Med J 2007; 48:\n157-9.\n6. Baccoli A, Mais V , Pani C, Musu S, Milesi M, Farina GP . En-\ndometriosi del canale inguinale. Contributo clinico. Giorn It Ost\nGin 1999; 12: 579-82.\n7. Calò PG, Piludu M, Catani G, Piga G, Malloci A, Nicolosi A.\nEndometriosi ombelicale. Descrizione di un caso clinico. Chir\nItal 2005; 57: 535-7.\n8. Licheri S, Pisano G, Erdas E, Ledda S, Casu B, Cherchi MV , Po-\nmata M, Daniele GM. Endometriosis of the round ligament: de-\nscription of a clinical case and review of the literature. Hernia\n2005; 9: 294-7.\n9. Candiani GB, Vercellini P , Fedele L, Vendola N, Carinelli S, Sca-\nglione V . Inguinal Endometriosis: Pathogenetic and Clinical Im-\nplications. Obstet Gynecol 1991; 78: 191-4.\n10 Mascaretti G, Patacchiola F , Di Berardino C, Moscarini M. En-\ndometriosi inguinale isolata. Descrizione di un caso clinico. Mi-\nnerva Ginecol 2000; 52: 249-52.\n11. Kapan M, Kapan S, Durgun AV , Goksoy E. Inguinal endome-\ntriosis. Arch Gynecol Obstet 2005; 271: 76-8.\nReferences\n0199 6 Isolated_Calo:-  14-04-2011  15:48  Pagina 265","source_license":"CC0","license_restricted":false}