{"paper_id":"f0fa5d6d-d452-4a21-9582-4bce8a8a88e5","body_text":"Endometriosis is defined as a growth of ectopic endometrial tissue outside the uterine cavity that responds to hormonal stimulation. It occurs most commonly in pelvic sites such as the ovaries, posterior cul-de-sac, ligaments of the uterus, pelvic peritoneum and rectovaginal septum and is found in 8%–15% of all menstruating women. Extrapelvic endometriosis is less common but can affect many sites, including the lungs, appendix, nose, umblicus, peritoneum and even the intestinal wall.1 The most common extrapelvic form of endometriosis is cutaneous endometriosis, mainly in scars following obstetric or gynecologic surgery.2 Surgical scar endometriosis following cesarean section has an incidence of 0.03%–0.4%.3 Because it is often mistaken for a suture granuloma, incisional hernia, lipoma, abscess, cyst or a strange body, diagnosis of this disease is not easy. However, a mass in a cesarean section scar with symptoms of cyclic pain related to menses is nearly pathognomonic. We report the cases of 3 women, aged 32, 22 and 30 years, respectively, who presented with a painful abdominal wall mass.\nCase report\nThe 3 patients presented between September 2006 and May 2007. Each patient had had a cesarean section; otherwise, their medical histories were not significant. The 32-year-old woman had undergone surgery 5 years, the 22-year-old 3 months and the 30-year-old 12 months before presentation. Each patient described a sharp, rarely radiating pain at the site of the mass, occurring most often a few days before their menses. None had a history of endometriosis. On physical examination, each patient had a firm mass and restricted mobility along the right superolateral aspect of the cesarean section scar. The masses measured about 3 × 2 cm in the 32-year-old woman, 1 × 1 cm in the 22-year-old and 2 × 2 cm in the 30-year-old. Other findings from physical examination were normal in all patients. Each patient underwent surgical excision. All 3 masses extended from subcuticular tissue but not through the fascial layer, and they were easily excised. The histopathology report for each specimen confirmed a diagnosis of endometriosis (Fig. 1 and Fig. 2). Each patient recovered uneventfully.\nDiscussion\nIncisional endometriosis is an underappreciated phenomenon in general surgery. The literature indicates that cesarean section scar endometriosis is very rare; however, it may occur more commonly than believed.\nIn most patients, surgical scar endometriosis involves a painful mass that becomes swollen and more tender before menses. In the literature, the mean size of masses has been 3.1 (range 1.5–4.8) cm. Patients may present from months to years (mean 21 mo) after their last obstetric/gynecologic surgery.4 In our patients’ cases, presentation occured 5 years, 3 months and 12 months after surgery, respectively.\nIt is hypothesized that failure to close the parietal and visceral peritoneum with sutures at the time of cesarean section may markedly increase the postoperative occurrence of an endometrioma in the incision scar. Furthermore, endometrial tissue can be transplanted and survive at ectopic locations.5\nTherapy with oral contraceptives, progestins, medroxy-progesterone acetate and gonadotropin-releasing hormone agonists has been tried with minimal success.2 In some patients, the effects can be relatively long-lasting, but complete, permanent regression of endometriosis is rare with medical therapy. For cutaneous endometriosis, total surgical excision is considered to be the gold standard for both diagnosis and treatment. Resection must be complete with clear margins to prevent recurrence.\nConclusion\nCesarean section incisional endometriosis is very rare and difficult to diagnose. In addition, it is an underappreciated phenomenon in general surgery, so it may be more common than reflected in the literature. Familiarity with its signs and symptoms will increase awareness of this disease. Endometriosis should be included in the differential diagnosis of abdominal scar lesions following gynecological operations. A mass involving cesarean section scars with symptoms intensifying before each menses is almost pathognomonic. Medical treatment may decrease symptoms for some time; however, to provide both diagnostic and therapeutic intervention, surgical management is the best choice.\nReferences\n- 1.Mascaretti G, Di Berardino C, Mastrocola N, et al. Endometriosis: rare localizations in two cases. Clin Exp Obstet Gynecol. 2007;34:123–5. [PubMed] [Google Scholar]\n- 2.Taff L, Jones S. 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