{"paper_id":"de4f3432-94ff-41d0-8260-66992d23a482","body_text":"Volume 5- Issue 4: 2018 \n5450\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2018.06.001397\nWan Ahmad Hazim Wan Ghazali. Biomed J Sci & Tech Res\nCase Report\nCutaneous/Subcutaneous Implantation of Endometriotic \nTissue Following Surgery: A Case Report\nEmily Christine D’Silva, Noor KhairiyahBinti Mustafa and Wan Ahmad Hazim Wan Ghazali*\nDepartment of Obstetrics and Gynecology, Putrajaya Hospital, Malaysia\nReceived: \n  July 02, 2018; Published: \n  July 12, 2018\n*Corresponding author: Wan Ahmad Hazim Wan Ghazali, Putrajaya Hospital, Pusat Pentadbiran Kerajaan Persekutuan, Presint 7, \n62250 Putrajaya, Malaysia\nAbstract\nBackground: Scar endometriosis is a rare disease and poses a great challenge in diagnosis and thus its management. \nCase: We present in this report a 32years old lady with underlying severe endometriosis who presented with persistent discharge and pain \nover her midline surgical scar site after two previous laparotomies. She was treated for wound breakdown which failed to resolve despite multiple \ncourses of antibiotics and wound dressing. Surgical excision of the scar was done and sent for histopathology which confirms scar site endometriosis. \nResult: Scar endometriosis should be suspected in women presenting with recurrent pain or discharge at an abdominal incision site. \nConclusion: Surgical excision should be the primary treatment with hormonal suppression as adjunct therapy.\nKeywords: Scar Endometriosis; Cutaneous Endometriosis; Surgical Scar Endometriosis\nBiomedical Journal of \nScientific & Technical Research (BJSTR)\nOpen Access\nIntroduction\nThe presence of endometrial-like tissue outside the uterus, also \nknown as endometriosis, induces a chronic, inflammatory that may \naffect 6-10% of total number of women[1,2].About 25% women \nwith endometriosis are asymptomatic, while the majority may \nexperience painful symptoms and or infertility. Nearly half of those \naffected women have chronic pelvic pain, while 70% present with \ndysmenorrheal [3].\nDiagnosis of endometriosis is based on the women’s history, \nsigns and symptoms. It is supported by physical examination and \nimaging techniques. However, histopathological evidence of either \nfrom a direct biopsy of a lesion or from the tissue collected during \nsurgery is required to confirm the diagnosis. The aetiology of \nendometriosis is not entirely clear. Structures that are close to the \nuterus within the pelvic cavity are commonly affected. However, in \nrare cases endometriotic tissue may also be implanted to other parts \nof the body including surgical scar sites following an abdominal \ngynaecological surgery.Endometriosis outside the pelvis occurs in \nabout 12% of women with endometriosis[4].\nScar endometriosis, also known as cutaneous/subcutaneous \nendometriosis is a rare disease, and poses a great challenge in \ndiagnosis. It occurs at surgical scar from abdominal or pelvic \nprocedures including hysterectomy, Caesarean sections, episiotomy, \nand laparoscopy[5,6]. The prevalence has been estimated to be only  \n0.03% to 0.15% of all cases of endometriosis. The most accepted \ntheory for the etiology of scar endometriosis is the iatrogenic  \n \ntransplantation of endometrial implants to the wound edge \nduring an abdominal or pelvic surgery[7,8].The symptoms of scar \nendometriosis are nonspecific, classically involving abdominal wall \npain or discomfort over the lesion which becomes more prominent \nespecially at the time of menstruation. It may also be associated with \nswelling and slight bleeding or discharge from the lesion. Just like \nany other endometriosis, the diagnosis of scar endometriosis can \nonly be confirmed by histopathological examination of the excised \ndiseased tissue. The following is a case report of a patient with a \nlower midline scar following two gynaecological laparotomies, \npresented with scar endometriosis. The pathogenesis, differential \ndiagnosis and treatment of this condition are discussed.\nCase Report\nA 32 years old Malay lady, nulliparous, married for 6 years \nwas referred by a fertility specialist from another tertiary centre \nfor laparoscopic bilateral salphingectomy and excision of stitch \ngranuloma over previous incision site.She first presented 5 years \nago in 2011 with infertility and underwent diagnostic laparoscopy, \nwhich was converted to laparotomy due to severe dense adhesions \nintra-operatively. A left endometrioma with bilateral hydrosalphinx \nwere noted. Both ovaries and tubes were adhered to the uterus. \nEvisceration of left endometrioma was done and confirmed by \nhistopathology. She was diagnosed with severe endometriosis \nand was treated with gonadotropins releasing hormones (GnRH) \nanalogues for 6 months post-operatively. She was well for the next \n\n\nBiomedical Journal of Scientific & Technical Research \nVolume 6- Issue 4: 2018 \nCite this article: Wan Ahmad Hazim Wan Ghazali. Cutaneous/Subcutaneous Implantation of Endometriotic Tissue Following Surgery: A Case \nReport. Biomed J Sci&Tech Res 6(4)- 2018. BJSTR. MS.ID.001397. DOI: 10.26717/ BJSTR.2018.06.001397.\n 5451\n3 years until 2014 when she presented to a private medical centre \nwith complaints of prolonged fever for two weeks associated with \nlower abdominal pain. Imaging studies noted massive bilateral \nhydrosalphinx. An urgent exploratory laparotomy was done after \ncommencing broad-spectrum antibiotics. Large amount of pus was \ndrained. \nHowever bilateral salpingectomy was deferred due to friable \ntissue, which tends to bleed on touch. Unfortunately she underwent \nre-laparotomy during the same admission due to re-accumulation \nof pus in the pelvic cavity.2 weeks after the surgery, she started \nexperiencing discharge and intermittent discomfort from the \nsurgical wound. She was treated for surgical wound breakdown \nwith multiple courses of antibiotics and normal saline dressing.\nNevertheless, symptoms did not improve and she notices the \ndischarge was more periodic and prominent especially during \nmenstruation. There was brownish discharge from the lesion. She \nwas then treated with short trial of hormonal suppression with \noral Dienogest. This improved her symptoms but recurred with \ncessation of treatment. A collection was detected by the ultrasound \nscan underneath the dark brown lesion over the scar site and \na preliminary diagnosis of stitch granuloma was made with a \ndifferential diagnosis of possible scar endometriosis. She was then \nreferred to our centre for further management.\nFigure 1: The CT film findings of the patient display two \ncalcification places.\nA reassessment was done at our centre. She was noted to have \na raised, non-mobile, dark brown pigmented lesion measuring \napproximately 3x1cm at the lower part of her old laparotomy scar \n(Figure 1). She had delicate point of tenderness to palpation over \nthe raised dark brown lesion. The trans-abdominal ultrasound \nshowed a normal size anteverted uterus with left hydrosalphinx. \nA pocket of fluid collection was also noted beneath the pigmented \nlesion. She was posted for diagnostic laparoscopy, adhesiolysis, \nbilateral salphingectomy and excision of possible stitch granuloma \nunder general anaesthesia.Intra-operatively, there were multiple \nadhesions between the uterus, fallopian tubes and the bowel. \nAdhesiolysis and bilateral salphingectomy were done and both \nFallopian tubes sent for histopathological examination. The old \nlower midline scar and the lesion were explored. The lesion \ncontained a cavity that breaches and extends to the rectus sheath. \nHemoserous, non foul smelling fluid was drained from the cavity. \nThe scar was completely excised with the granuloma portion and \nsent for histopathological evaluation (Figure 2).The incision wound \nwas closed by subcuticular method using monosyn3/0.\nFigure 2: Intra-op: Old Lower midline scar with granuloma \nremoved.\nFigure 3: 9 months post-surgery.\nHer post-operative recovery was unremarkable. She was \ndischarged on day 3 post surgery. A single dose of GnRH analogue \nwas administered prior to discharge. We continued to review her \nat our out-patient clinic. At 9 months post-surgery, the wound \nwas clean and well healed (Figure 3). Her pain has subsided and \nshe no longer experience discharge from the surgical scar wound. \nShe started to regain her normal menstruation and is currently \nundergoing IVF treatment at a fertility centre.The histopathological \nreports showed mild chronic salphingitis of the right Fallopian \ntube, whilst the left Fallopian tube was consistent with chronic \nsalphingitis with foci of endometriosis.The sample from the excised \nscar showed foreign body granuloma with endometriosis. This \nis also known as cutaneous endometriosis. Microscopically, the \nsection showed skin with the underlying dermis and subcutaneous \ntissue. A cystic cavity was noted in the dermis lined by flattened \nepithelium surrounded by haemosiderin laden macrophages \nand dense lymphoplasmacytic cells (Figure4). There were suture \nmaterials surrounded by multinucleated giant cells of foreign body \ntypes present (Figure 5). Few islands of endometrial glands and \nstroma were noted within the stroma.\n\nBiomedical Journal of Scientific & Technical Research \nVolume 6- Issue 4: 2018 \nCite this article: Wan Ahmad Hazim Wan Ghazali. Cutaneous/Subcutaneous Implantation of Endometriotic Tissue Following Surgery: A \nCase Report. Biomed J Sci&Tech Res 6(4)- 2018. BJSTR. MS.ID.001397. DOI: 10.26717/ BJSTR.2018.06.001397.\n 5452\nFigure 4: A: Magnified x 4: A few endometrial glands and stroma in the underlying fibrocollagenous tissue stroma. B: Magnified \nx 20: A few endometrial glands surrounded by endometrial stroma.\nFigure 5: A: Magnified x 10: A few multinucleated giant cells of foreign body types, B: Magnified x 20: Suture material \nsurrounded by multinucleated giant cells of foreign body type.\nDiscussion \nThe diagnosis of scar endometriosis may be difficult and \nchallenging. Clinically the characteristics of scar endometriosis \ninclude lumps or nodule over the scar site that usually associates \nwith pain and gradual increasing in size, bleeding or discharge from \nthe lesion and skin discolouration. Only 20% of the patients presents \nwith cyclical manifestation of symptoms with menstruation. Most \npatients would usually complain of tenderness over a raised, \nhideous hyperthrophic scar which can be easily misdiagnosed as \ninfected wound or keloid.In order to provide a rapid and accurate \npre-operative diagnosis, fine needle aspiration (FNAC) can be \nemployed to determine the nature of the lesion. It can be done over \nthe lesion which classically appears as a firm nodule. This will help \nin differentiating it from other possible lesions such as metastatic \ndisease, desmoid tumor, lipoma, sarcoma, cysts, nodular and \nproliferative fasciitis, fat necrosis, hematoma or abscesss[9,10].\nImaging studies are only useful in determining the extent of \nthe disease and planning of operative resection. This is especially \nuseful in recurrent and large lesions. However, these modalities are \nnon-specific and there are insufficient data available to suggest the \nbest imaging tool over the other.Both surgical excision and medical \ntreatment are part of the management of scar endometriosis. \nHormonal suppression with oral contraceptives, progestogen and \nGnRH analogues have shown to alleviate symptoms. However, \nhormonal suppression provides temporally relive and recurrence \nis common after therapy cessation[11]. Therefore, it is strongly \nrecommended that complete surgical excision of the lesion remains \nas the gold-standard of treatment.\nConclusion\nScar endometriosis is an uncommon and is often a subtle \ndiagnosis. A Proper detailed history and thorough physical \nexamination should always be performed. Thus, any women \npresenting with recurrent pain or discharge at an abdominal \nincision site, especially following gynaecological pelvic surgery \nwith underlying endometriosis should be suspected to have scar \nendometriosis as part of the differential diagnosis. These women \nare ideally referred to a tertiary centre for further assessment \nand management to reduce morbidity and improve quality of life. \nSurgical excision should be the primary treatment with hormonal \nsuppression as adjunct therapy.\nReferences\n1. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T , Dunselman G, et \nal. (2005) ESHRE Guideline for The Diagnosis and Treatment of \nEndometriosis. Hum Reprod 20: 2698-2704.\n2. Bulletti C, Coccia ME, Battistoni S, Borini A (2010) Endometriosis and \nInfertility. J Assist Reprod Genet 27(8): 441-447.\n3. Culley L, Law C, Hudson N, Denny E, Mitchell H, et al. (2013) The social \nand psychological impact of endometriosis on women’s lives: A critical \nnarrative review. Human Reproduction Update 19(6): 625-639.\n\nBiomedical Journal of Scientific & Technical Research \nVolume 6- Issue 4: 2018 \nCite this article: Wan Ahmad Hazim Wan Ghazali. Cutaneous/Subcutaneous Implantation of Endometriotic Tissue Following Surgery: A Case \nReport. Biomed J Sci&Tech Res 6(4)- 2018. BJSTR. MS.ID.001397. DOI: 10.26717/ BJSTR.2018.06.001397.\n 5453\n4. (2010) American College of Obstetricians and Gynecologists 2010, \nManagement of endometriosis (Practice Bulletin No. 114): News release. \nObstetrics & Gynecology 116(1): 223-236.\n5. Steck WD (1965) Cutaneous Endometriosis. JAMA 191: 167.\n6. Albrecht LE, Tron V, Rivers JK (1995) Cutaneous endometriosis. \nInternational Journal of Dermatology 34(4): 261-262.\n7. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, et al. (2003) \nAbdominal wall endometriosis near cesarean delivery scars. J Ultrasound \nMed 22: 1041-1047.\n8. Kaloo P , Reid G, Wong F (2002) Caesarean section scar endometriosis: \nTwo cases of recurrent disease and a literature review. Aust NZ. J Obstet \nGynaecol 42: 218-220.\n9. Pathan SK, Kapila K, Haji BE, Mallik MK, Al-Ansary TA, et al. (2005) \nCytomorphological spectrum in scar endometriosis: A study of eight \ncases. Cytopathology 16: 94-99.\n10. Catalina-Fernández I, López-Presa D, Sáenz-Santamaria J (2007) \nFine needle aspiration cytology in cutaneous and subcutaneous \nendometriosis. Acta Cyto l51: 380-384.\n11. Schoelefield HJ, Sajjad Y, Morgan PR (2002) Cutaneous endometriosis \nand its association with caesarean section and gynaecological \nprocedures. J Obstet Gynaeco l22: 553-554.\nSubmission Link: https://biomedres.us/submit-manuscript.php\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nhttps://biomedres.us/\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2018.06.001397\nAhmad Hazim Wan Ghazali. Biomed J Sci & Tech Res","source_license":"CC0","license_restricted":false}