{"paper_id":"daeda52a-7465-429d-9fe9-7c973f0a7c07","body_text":"UC Davis\nDermatology Online Journal\nTitle\nPainful nodule in the caesarean section scar of a young woman\nPermalink\nhttps://escholarship.org/uc/item/4rn7q88d\nJournal\nDermatology Online Journal, 21(11)\nAuthors\nRusso, Veronica A\nAlikhan, Ali\nPublication Date\n2015\nDOI\n10.5070/D32111029301\nCopyright Information\nCopyright 2015 by the author(s).This work is made available under the terms of a Creative \nCommons Attribution-NonCommercial-NoDerivatives License, available at \nhttps://creativecommons.org/licenses/by-nc-nd/4.0/\n \nPeer reviewed\neScholarship.org Powered by the California Digital Library\nUniversity of California\n\nFigure 1.  Dark brown, firm, smooth mobile tender nodule with a \n0.5 cm, light blue, translucent papule located in the superomedial \nportion of the nodule embedded in caesarean section scar. \n \nVolume 21 Number 11  \nNovember 2015 \n \nPhoto vignette \nPainful nodule in the caesarean section scar of a young woman \nVeronica A Russo MD MPH and Ali Alikhan MD \nDermatology Online Journal 21 (11): 13 \nUniversity of Cincinnati Department of Dermatology, Cincinnati, OH \nCorrespondence:  \nVeronica A. Russo, MD \nUniversity of Cincinnati \nrussova@ucmail.uc.edu \n \n \n \n \n \n \nAbstract \nEndometriosis is the presence of ectopic endometrial tissue outside the uterus and cutaneous endometriosis is a rare manifestation \nof this disease that may be found at the sites of surgical scars as a result of iatrogenic implantation. Herein we present a case of \nscar endometriosis in a 35-year-old woman. The scar was sustained following a remote caesarean section. \nKeywords: cutaneous endometriosis \nCase synopsis \nAn otherwise healthy 35-year-old woman presented to our dermatology clinic with a 3.5 year history of an enlarging and \nintermittently tender nodule in her cesarean scar. This growth developed as a small nodule on the leftward aspect of her \nPfannenstiel incision approximately 6 months following \ncaesarean section 4 years prior. The nodule had waxed and \nwaned in size over two years and had been rapidly enlarging \nover six to eight months. She had not experienced any cyclic \nsymptoms such as increased pain, swelling, or bleeding from \nthe nodule associated with her menses. She had an obstetric \nhistory significant for three vaginal deliveries and one \ncesarean section via a standard Pfannenstiel incision for pre-\neclampsia at 29 weeks gestation. No treatments had been \nundertaken prior to initial presentation. Examination of the \nleft suprapubic skin revealed a 5 x7 cm, dark brown, firm, \nsmooth, mobile tender nodule with a 0.5 cm, light blue, \ntranslucent papule located in the superomedial portion of the \nnodule (Figure 1). An 8 mm punch biopsy of the lesion was \nobtained and sent for histopathological evaluation. No \nregional adenopathy was appreciated.  \nHistopathological examination revealed scattered and \ngrouped, variably sized glands in the mid and deep reticular \ndermis lined by cuboidal and focally columnar epithelium \nsurrounded by a mucinous and edematous stroma with an \n\nadmixed focally dense lymphocytic infiltrate and fibrosis (Figures 2, 3). These findings were diagnostic for cutaneous \nendometriosis in this clinical setting.   \n  \n  \nFigure 2. Variably sized glands in the mid and deep reticular dermis.  Figure 3. Glands lined by cuboidal and focally columnar epithelium \nsurrounded by a mucinous and edematous stroma. \nThe patient was referred to the gynecological surgery department for further management and definitive treatment. She underwent \nmagnetic resonance imaging (MRI) for pre-surgical evaluation for abdominal wall and deep pelvic endometriosis, which revealed \na multilobulated 4.5 x 4.4 cm mass located within the soft tissues of the left lower quadrant just anterior to the rectus abdominis \nmuscle. Additional smaller endometriomas within the medial aspect of the rectus abdominis muscles and infiltrating the \nunderlying fat were appreciated. The patient subsequently underwent an exploratory laparotomy with resection of three \nendometriomas from the skin and subcutaneous tissue of the left lower abdominal wall and the right and left rectus sheath. Her \npost-operative course was unremarkable and she remains pain-free to date.  \nDiscussion \nEndometriosis is a common gynecological disorder and is defined by the presence of functional ectopic glandular and stromal \nendometrial tissue in both pelvic and extra-pelvic locations, including the pelvic peritoneum, ovaries, and rectovaginal septum, \nand, in rare cases, on the diaphragm, pleura, and pericardium. Endometriosis affects 6 to 10% of women of reproductive age [1]. \nCutaneous endometriosis is a rare form of this disease, with an estimated prevalence of approximately 1% in all patients with \nextrapelvic disease [2]. It is characterized by implants of endometrial tissue in the dermis, subcutis, or even skeletal muscle [2]. \nThis presents as often painful and even intermittently bleeding firm red to bluish papules and nodules that may flare during \nmenses. These symptoms may be associated with menorrhagia, dysmenorrhea, abdominal pain, infertility, dyspareunia, and \npainful defecation, all of which are common signs of pelvic endometriosis. There are two theories proposed for the etiology of \ncutaneous endometriosis: primary (spontaneous) endometriosis, which frequently affects the umbilicus and arises owing to \ncellular metaplasia, and secondary endometriosis, which is theorized to develop as a consequence of tubal regurgitation, lymphatic \nor hematogenous spread, or iatrogenic mechanical uterine tissue implantation sustained during surgical interventions (e.g., \ncaesarean sections, myomectomies, abdominopelvic laparotomies, or episiotomies) [3,4]. The latter entity typically presents as a \nnodule within the scar of a previous surgical site [3].  \nClinical diagnosis is made by careful history and physical exam. Often suspicion is not raised owing to the rarity of this entity and \nbiopsy is necessary. Histopathological exam is essential for diagnosis and consists of an admixture of variably sized glandular \nstructures, which are capable of cyclical variation, comprised of cuboidal to columnar cells with largely banal cytomorphology \n[2]. The stroma is described as having a spindled cell appearance with an associated vascular network. Rarely, malignant \ntransformation can occur [2]. Immunohistochemistry may have utility in aiding in the diagnosis of cutaneous endometriosis. CD10 \nis expressed in a wide range of cell types, including strong expressivity in the cytoplasm of endometrial stroma; this latter \ncharacteristic has particular applicability if the lesion has limited glandular structures relative to stroma in the biopsy specimen \n[2]. Estrogen and progesterone receptor immunostains reveal strong nuclear positivity in both glands and stroma as well and are \nuseful for diagnostic support.  \nSubsequent imaging procedures can support the diagnosis, and MRI is particularly useful for pre-surgical mapping and \nobservation of infiltrative disease in the abdominal wall and subcutaneous tissues [5]. The clinical differential diagnosis includes \n\nkeloid scar, hernia, abscess, granulomatous inflammation, hemangioma, cyst, malignancy, desmoid tumor, melanocytic nevus, \nmelanoma [4, 5, 6].  \nWide local surgical excision is the accepted treatment of choice in most cases of cutaneous endometriosis with relatively minimal \nrisk for recurrence [4, 7]. Additionally, there are variably successful reports of use of hormonal-based therapies such as androgen \nand estrogen analogues and GnRH agonists. These may have particular advantages when used in cases with coexistent pelvic \nendometriosis [4]. Moreover, hormonal therapies may be employed preoperatively to reduce the total burden of disease, thereby \ndecreasing the ultimate surgical defect.  \nIn summary, cutaneous endometriosis is an infrequent type of extrapelvic endometriosis and should be considered in the \ndifferential diagnosis in women presenting with papular or nodular lesions of the umbilical skin or embedded within or near pelvic \nsurgical scars sustained following gynecological or obstetrical prodecures. The diagnosis is made after a thorough history and \nphysical exam in conjunction with histopathological review of lesional skin. The treatment of choice is surgical excision.  \nReferences \n1. Giudice L. Clinical Practice: Endometriosis. N Engl J Med. 2010 June 24; 362(25): 2389–2398. [PMID: 20573927] \n2. Farooq U, Laureano A, Miteva M, et al. Cutaneous endometriosis: Diagnostic immunohistochemistry and clinicopathologic \ncorrelation. J Cutan Pathol. 2011; 38: 525-528. [PMID:21352260] \n3. Vozmediano J, Hita J, and Santos J. Cutaneous endometriosis. Int J Dermatol. 2010; 49(12):1410-1412. [PMID:21091675] \n4. Purvis R and Tyring S. Cutaneous and subcutaneous endometriosis. J Dermatol Surg Oncol. 1994; 20:693-695. \n[PMID:7930017] \n5. Uzunçakmak C, Güldaş A, Ozçam H, et al. Scar endometriosis: A case report of this uncommon entity and review of the \nliterature. Case Rep Obstet Gynecol. 2013:386783. [PMID:23762683] \n6. Stojanovic M, Brasanac D, and Stojicic M. Cutaneous inguinal scar endosalpingiosis and endometriosis: Case report with \nreview of literature. Am J Dermatopathol. 2013; 35(2): 254-260. [PMID:23249836] \n7. Din A, Verjee L, and Griffiths M. Cutaneous endometriosis: A plastic surgery perspective. J Plast Reconstr Aesthet Surg. \n2013; 66(1):129-130. [PMID:22784788]","source_license":"CC0","license_restricted":false}