{"paper_id":"db8ecf75-3e94-45d4-8d2a-f5c5517e09a7","body_text":"R E S E A R C H A R T I C L E Open Access\n5-Year data analysis of patients following\nabdominal wall endometrioma surgery\nTahere Khamechian 1, Javad Alizargar 2 and Tahere Mazoochi 3*\nAbstract\nBackground: Endometriosis is a disorder in which an ectopic endometrial tissue grows outside the uterine cavity.\nThe ectopic endometrium embedded in the subcutaneous fatty layer and the muscles of abdominal wall is called\nas abdominal wall endometriosis (AWE). AWE is a rare condition; however, it is usually known to develop along\nwith previous surgical scars. Caesarean section and hysterectomy are considered to be commonly associated with\nthe development of AWE.\nMethods: We evaluated the data of the patients who underwent AWE surgery between March 2009 and March\n2014.\nResults: The mean age of the patients was 32.5 years. We found a previous history of caesarean section in all of\nthe patients. The most frequent symptoms of the patients were abdominal mass sensation and abdominal pain.\nInvasion of endometriosis to fat layer, fascia, muscular layer, and peritoneum was recorded. Three masses were\nlocated within the scar regions.\nConclusions: We can conclude that there is a high prevalence of caesarean sections among the women with AWE.\nKeywords: Endometrioma, Abdominal wall endometriosis, Scar endometriosis\nBackground\nEndometriosis was first described by an Austrian path-\nologist, Karl Freiherr von Rokitansky in 1860 who re-\nferred to the disease as adenomyoma [1]. Endometriosis\nis a rare condition in which ectopic endometrial tissue\ngrows outside the uterine cavity and responds to hormo-\nnal stimuli [2]. Although its prevalence in adult women\nis not completely known, it is said to occur in 5% –10%\n[3]. Although it is more common in pelvic regions such\nas the ovaries, posterior cul-de-sac, ligaments of the\nuterus, pelvic peritoneum, and rectovaginal septum [4],\nit can also be extrapelvic. The extrapelvic occurrence of\nendometriosis is rare and it occurs more commonly in\nabdominal wall followed by umbilicus, vulva, appendix,\nileum, hernia sac, and colon [5]. It is known to develop\nspontaneously [6] and is usually found near or at the site\nof scars of surgeries like hysterectomies, caesarean sec-\ntions, laparoscopies, tubal ligations, and episiotomies [4,7].\nThese sites propose the “iatrogenic direct implantation\ntheory”, which emphasizes on the implantation of the es-\ncaped endometrial cells caused by the surgery into the\nsurgical wound [8].\nThe ectopic endometrium is embedded in subcutane-\nous fatty layer and muscles of abdominal wall in abdom-\ninal wall endometriosis (AWE) [9]. AWE is considered\nvery rare with the overall prevalence of around 0.01 –1%\nafter caesarean section [10]. In addition, AWE is often\nmistaken with some surgical conditions like abscess, lip-\noma or incisional hernia [11]. Although manifestations\nof endometriosis may range from dysmenorrhea to even\nbowel perforation [12], the most prevalent clinical fea-\nture of endometriosis includes a painful mass with a cyc-\nlic pain that exacerbates with menstruation [4].\nThe present study presents the features of AWE in a\nfive-year experience of surgeons from Shahid Beheshti\nHospital. It describes the patients ’ characteristics and\nmanifestations of the disease.\nMethods\nAfter obtaining written informed consent, the data of\nthe patients who underwent surgery for AWE between\n* Correspondence: jaz_1365@yahoo.com\n3Gametogenesis Research Center, Kashan University of Medical Sciences,\nKashan, I.R Iran\nFull list of author information is available at the end of the article\n© 2014 Khamechian et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the\nCreative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,\ndistribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public\nDomain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this\narticle, unless otherwise stated.\nKhamechian et al. BMC Women's Health 2014, 14:151\nhttp://www.biomedcentral.com/1472-6874/14/151\n\nMarch 2009 and March 2014; including age, parity, re-\nlated past medical history, chief complaint, the exact site\nof AWE, and any information gained after the surgery\nwere entered in the study. This study has complete\napproval by the institutional review board of Kashan\nUniversity of Medical Sciences.\nResults\nHistological confirmation of endometrioma is based on\ndetecting at least two of the three following features:\nendometrial stroma, endometrial like glands and hemo-\nsiderin pigment [10]. After histopathological confirm-\nation (Figure 1), the data of 30 patients who underwent\nAWE surgery were entered in our study. All the patients\nhad at least two features of endometrioma. Table 1 sum-\nmarizes the characteristics of the patients with abdom-\ninal wall endometriosis. The age of the patients ranged\nfrom 23 to 67 years. The mean age of the patients was\n32.5 ± 8.24 years. Their number of parities ranged from\none to four. We found a previous history of caesarean\nsection in all of the patients. Eleven patients (36.6%) had\na single caesarean section. Fourteen patients (46.7%) had\ntwo caesarean sections and five (16.7%) had three caesar-\nean sections. Eight patients (26.7%) had surgeries other\nthan caesarean section. These surgeries include one myo-\nmectomy, three hysterectomies, one tubalectomy, and\nthree appendectomies. All patients had a notable mass\nas a presenting symptom. Other than the mass, 24 patients\n(80%) experienced pain, among whom 14 patients (46.7%)\nexperienced cyclic pain. Two patients (6.7%) had dyspar-\neunia, three (10%) had dysmenorrhea, and one (3.3%) had\nbleeding as presenting symptoms. Four patients did not\nhave any symptoms and AWE was discovered during the\ncaesarean sections. The mean duration of symptoms was\n12.7 ± 10.44 months, ranging from three to forty-five\nmonths. The mean time between the previous surgery\nand diagnosis of AWE was 30.5 ± 12.65 months. In 28\npatients (93.3%), the ultrasonography was used to diag-\nnose AWE, computed tomography (CT) scan and mag-\nnetic resonance imaging (MRI) were used in five (16.6%)\nFigure 1 Histopathological characteristics of endometriosis in different tissue types. A : Endometrial strauma and glands in fatty connective\ntissue (X10). B: Endometrial strauma and glands in fatty connective tissue (X40). C: Endometrial strauma and glands in fibro-connective tissue\n(X10). D: Endometrial strauma and glands in muscular tissue (X10). E: Endometrial strauma and glands in muscular tissue adjacent to fatty layer (X10).\nKhamechian et al. BMC Women's Health 2014, 14:151 Page 2 of 5\nhttp://www.biomedcentral.com/1472-6874/14/151\n\nand two (6.6%) patients, respectively. Twenty-seven pa-\ntients (90%) had a single mass, whereas, three (10%) had\ntwo masses at the time of diagnosis. In nineteen patients\n(63.3%), the initial diagnosis was AWE, whereas abdom-\ninal wall tumour was diagnosed in four patients (13.3%),\nincisional hernia in three (10%) cases, suture granuloma in\ntwo cases (6.7%), and inguinal hernia and desmoid tumour\neach in one case (3.3%). The location of the masses was in\nor under the scar of the previous surgery in 21 patients\n(70%) (in three cases the mass was located in the scar),\nhypochondrium away from the scar and umbilicus each in\nfour cases (13.3%), and groin region in one case (3.3%).\nThe mean diameter of the masses was 2.59 ± 1.21 cm, ran-\nging between 1 cm and 6 cm. Nine cases (30%) had a mass\nin the fat tissue, fourteen (46.7%) in muscle tissue, eleven\n(36.7%) in the fascia of the abdomen muscles, ten (33.3%)\nin the omentum, and one (3.3%) in the dermis. Hematoma\nand necrosis were observed in one (3.3%) and two patients\n(6.7%), respectively. No case of malignancy was reported\namong our study patients. All the patients underwent\nfollow-up tests and one patient was diagnosed with a re-\ncurred mass after six months, which was removed with\nclear margins.\nDiscussion\nCaesarean section and hysterectomy are considered to\nbe commonly associated with AWE, and the surgical\nscar of the caesarean section is the most common site\nfor extra pelvic endometriosis known as caesarean scar\nendometriosis with the incidence of 0.07% –0.47% [4]. In\nthe current study, all the patients with AWE had a prior\nhistory of caesarean section and some patients had an-\nother gynaecological surgery such as hysterectomy be-\nsides caesarean section. In our study, the majority of\npatients had one or two caesarean sections.\nThere are two theories that are more accepted for the\ncause of AWE: transport theory and metaplasia theory.\nThe transport theory explains that direct inoculation or\ntransport of the endometrial tissue into the surgical scars\nor adjacent tissues during the surgery is responsible for\nAWE. In metaplasia theory, primitive pleuropotential\nmesenchymal cells that have gone under differentiation\nmetaplasia are said to cause AWE. Alternative theories\nlike lymphatic or haematogenic dissemination and cell\nimmunity change theory are among the other proposed\ntheories [8,10]. The fact that all the patients of our study\nhad undergone a cesarean section, and some had other\ngynecological surgeries may be in favor of transport the-\nory. This theory might explain that endometrial tissues\ncan be iatrogenically transported into the abdominal wall\nor into the scars of the surgery. Although the presence of\nendometrial tissues in the abdominal wall can be ex-\nplained with this theory, some other features of endomet-\nriosis, like why the endometrial tissues can survive and\nproliferate in the new sites cannot be explained with the\ntransport theory.\nMass sensation, pain, dysmenorrhea and bleeding are\namong the symptoms of endometriosis. Although the\ncycle symptoms may be pathognomonic of endometri-\nosis, the symptoms can be non-cyclic, too. Endometri-\nosis can be categorized as a steroid-dependant disease\n[13]. It is known that oestrogens can trigger the develop-\nment of endometriotic lesions. Endometrial cells can be\nstimulated with oestrogen and proliferate until they be-\ncome symptomatic. The oestrogen can be further pro-\nduced in the endometrial lesions by aromatase activity\nTable 1 Characteristics of the patients with abdominal\nwall endometriosis\nn % Range Mean +/- SD\nAge 23-67 32.5 ± 8.24\nParity 0-4 2\nOne CS 11 36.6\nTwo CS 14 46.7\nThree CS 5 16.7\nSurgeries other than CS\nMyomectomy 1 3.3\nHysterectomy 3 10\nTubalectomy 1 3.3\nAppendectomy 3 10\nPresenting symptom\nMass 30 100\nPain (noncyclic) 10 33.3\nPain (cyclic) 14 46.7\nDyspareunia 2 6.7\nDysmenorrhea 3 10\nBleeding 1 3.3\nDuration of symptoms (months) 3-45 12.77 ± 10.44\nAsymptomatic period (months) 2-53 30.5 ± 12.65\nDiagnosing tool\nUltrasonography 28 93.3\nCT 5 16.6\nMRI 2 6.6\nSingle mass 27 90\nTwo masses 3 10\nAccurate diagnosis 19 63.3\nWrong diagnosis 11 36.7\nLocation of the mass\nUnder the scar 18 60\nIn the scar 3 10\nFar from the scar 9 30\nDiameter of the mass (cm) 1-6 2.59 ± 1.21\nCS: Caesarean Section.\nKhamechian et al. BMC Women's Health 2014, 14:151 Page 3 of 5\nhttp://www.biomedcentral.com/1472-6874/14/151\n\n[14]. All the patients in our study had symptoms of ab-\ndominal mass sensation. Additionally, 46.7% of them ex-\nperienced cyclic pain and 33.3% experienced noncyclic\npain. Dysmenorrhea and bleeding were the presenting\nsymptoms in 10% and 3.3% of the patients, respectively.\nUltrasonography is mentioned as the most frequently\nused technique for diagnosing AWE and we used this\ndiagnostic tool in 93.3% of the patients. CT scan and\nMRI were the least used methods.\nNot all of the endometriosis patients had cyclic symp-\ntoms. The diagnosis of this disease might be challenging\nand several differential diagnoses might exist for a mass\nin the abdominal wall, including desmoid tumour, fibrosis,\nsuture granuloma, fat necrosis, nodular fasciitis and pri-\nmary or metastatic malignancies lesions [15]. Although\nthe history of previous gynaecological surgeries might be\nhelpful and leading us to AWE, the definite diagnosis of\nendometriosis might be possible only after the surgery and\nremoval of the mass and pathological evaluations. Using\nof fine needle aspiration cytology (FNAC) can be helpful\nbefore the surgery and can be used for determining all\nthree criterion of endometriosis [15], but it was not per-\nformed in our study.\nThe presence of AWE in the surgery scar is quite infre-\nquent. The series of one, five, and six scar endometriosis\nhad been reported earlier [11,16,17]. We only found ten\npercent of the masses of the patients (3 masses) were\nlocated within the scars of the previous caesarean\nsections.\nAlthough the risk of malignancy transformation of\nendometriosis is not known and less than 1% of endo-\nmetriosis patients are reported to develop associated\nneoplasms, the most common type is clear-cell carcin-\noma. This neoplasm has 5-year survival of 80% [8]. Al-\nthough there are some reports of clear-cell carcinoma\nassociated with AWE [18], there was none in our study.\nConclusion\nIn conclusion, it is worth saying that although abdom-\ninal wall endometriosis is a rare disorder, it can occur\nafter gynaecological surgeries and caesarean sections es-\npecially near or within the scars. As caesarean section\nrates are becoming more frequent, and there is a high\nprevalence of caesarean section among women with AWE,\nwe may encounter higher rates of this uncommon entity in\nthe future.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthors’ contributions\nJA analyzed and interpreted the patient data regarding the pathological\ndisease and the preparation of paraffin sections. TK performed the\nhistological examination, participated in the design of the study and\nperformed the statistical analysis, and was a contributor in writing the\nmanuscript. TM conceived of the study, and participated in its design and\ncoordination and helped to draft the manuscript. All authors read and\napproved the final manuscript.\nAuthors’ information\nAfter medical school, Javad has conducted research in a wide range of\nmedical fields. He began to participate in the Student Research Committee\nof Kashan University Of Medical Sciences (SRC of KAUMS) beginning the first\nyear of medical school. He participated as a lecturer in SRC and different\ncongresses and seminars and was chosen to be the Distinct Researcher of\nKAUMS. He has a range of publications in the departments of Pathology,\nPhysiology, Social Sciences, Health, Infectious Disease, Pediatrics, and Surgery\nand Emergency Medicine of KAUMS. He contributed to data collecting, data\nanalysis, writing, and editing research results. He also likes to design studies\nand write proposals in various areas of medicine. Working as a general\nphysician in different clinics and emergency rooms helped him evaluate a\nvariety of alternative medications and gave him the opportunity to observe\nrare cases.\nAcknowledgements\nWe gratefully acknowledge the contribution of all the staff of obstetrics and\ngynaecology department of Shahid-Beheshti hospital in gathering the data.\nAuthor details\n1Anatomical Sciences Research Center, Kashan University of Medical\nSciences, Kashan, I.R Iran. 2Student Research Committee, Kashan University of\nMedical Sciences, Kashan, I.R. Iran. 3Gametogenesis Research Center, Kashan\nUniversity of Medical Sciences, Kashan, I.R Iran.\nReceived: 19 June 2014 Accepted: 17 November 2014\nReferences\n1. Benagiano G, Brosens I: The history of endometriosis: identifying the\ndisease. Hum Reprod 1991, 6(7):963–968 [PMCID: PMC3394553].\n2. Williams HE, Barsky S, Storino W: Umbilical endometrioma (silent type).\nArch Dermatol 1976, 112(10):1435–1436 [PMID 962339].\n3. 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Akdemir A, Akman L, Tore Yavuzsen H, Zekioglu O: Clinical features of the\npatients with endometriosis on the cesarean scar. Kaohsiung J Med Sci\n2014, 30(10):541–543.\n18. Yan Y, Li I, Guo J, Zheng Y, Liu Q: Malignant transformation of an\nendometriotic lesion derived from an abdominal wall scar. Int J Gynecol\nObstet 2011, 115(2):202–203.\ndoi:10.1186/s12905-014-0151-4\nCite this article as: Khamechian et al. : 5-Year data analysis of patients\nfollowing abdominal wall endometrioma surgery. BMC Women's Health\n2014 14:151.\nSubmit your next manuscript to BioMed Central\nand take full advantage of: \n• Convenient online submission\n• Thorough peer review\n• No space constraints or color figure charges\n• Immediate publication on acceptance\n• Inclusion in PubMed, CAS, Scopus and Google Scholar\n• Research which is freely available for redistribution\nSubmit your manuscript at \nwww.biomedcentral.com/submit\nKhamechian et al. 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