Surgical Scar and Rectus Abdominus Muscle Endometriosis: A Report of Two Cases

ndometriosis is the presence of functional endometrial glands and stromaoutsidetheuterinecavity.1,2 Extrapelvicendometriosisrefers toendometriosisfoundatbodysitesotherthanthepelvis.1,2 Endometriosisoftheabdominalwallisasubtypeofextrapelvicendo9 metriosis.Commonpresentationincludespalpablemass,cyclicpainduring the menstruation, bleeding and discharge. Differential diagnosis includes abscess,lipoma,hematoma,sebaceouscyst,suturegranuloma,inguinalher9 nia,incisionalhernia,desmoidtumor,sarcoma,lymphomaandprimaryor metastaticcancer.1 TurkiyeKlinikleriJMedSci2011;31(6) 1599 SurgicalScarand RectusAbdominusMuscleEndometriosis: AReportofTwoCases A BS TRA C T En do met ri o sis is the pre sen ce of func ti o nal en do met ri al glands and stro ma out si de the ute ri ne ca vity. The ab do mi nal wall is an un com mon si te of ex tra pel vic en do met ri o sis, whe re it usu9 ally de ve lops in an old sur gi cal scar. Com mon pre sen ta ti on inc lu des a pal pab le mass, cyclic pa in du 9 ring mens tru a ti on, ble e ding and disc har ge. Dif fe ren ti al di ag no sis inc lu des abs cess, li po ma, he ma to ma, se ba ce o us cyst, su tu re gra nu lo ma, in gu i nal her ni a, in ci si o nal her ni a, des mo id tu mor, sar9 co ma, lympho ma and pri mary or me tas ta tic can cer. En do met ri o sis in vol ving the rec tus ab do mi nis musc le is al so a ra re con di ti on. We pre sent two ca ses of ex tra pel vic en do met ri o sis; one is a sur gi 9 cal skin scar (Pfan nens ti el Ca e sa re an sec ti on ci cat rix) en do met ri o sis and the ot her is a rec tus ab do 9 mi nus en do met ri o sis. Key Words: En do met ri o sis; rec tus ab do mi nis; ci cat rix ÖZET En do met ri o zis ute rus boş lu ğu dı şın da fonk si yo nel en do met ri al bez le rin ve stro ma nın var lı 9 ğı dır. Ka rın du va rı pel vis dı şı en do met ri o zi sin na dir gö rül dü ğü bir yer dir ve bu ra da ge nel lik le es ki bir cer ra hi skar üze rin de ge li şir. Sık baş vu ru şek li pal pab le kit le, adet sı ra sın da sik lik ağ rı, ka na ma ve akın tı dır. Ayı rı cı ta nı ap se, li pom, he ma tom, se ba se kist, di kiş gra nü lo mu, ka sık fı tı ğı, in siz yo 9 nel her ni, des mo id tü mör, sar kom, len fo ma ve pri mer ve ya me tas ta tik kan se ri içe rir. Rek tus ab do 9 mi nis ka sı nı tu tan en do met ri o zis ay rı ca na dir bir du rum dur. Biz pel vis dı şı en do met ri o zis li iki ol gu sun mak ta yız; bi ri cer ra hi cilt ska rı (Pfan nens ti el se zer yan ke si ska rı) en do met ri o zi si ve di ğe ri de bir rek tus ab do mi nis en do met ri o zi si. A nah tar Ke li me ler:En do met ri oz; rek tus ab do mi nis; skat ris Turkiye Klinikleri J Med Sci 2011;31(6):15999601 Fazlı DEMİRTÜRK, MD,a Ahmet Cantuğ ÇALIŞKAN, MD,a Hakan AYTAN, MD,a R. Doğan KÖSEOĞLU, MDb Departments of aObstetrics and Gynecology, bPathology, Gaziosmanpaşa University Faculty of Medicine, Tokat Ge liş Ta ri hi/Re ce i ved: 23.11.2009 Ka bul Ta ri hi/Ac cep ted:06.03.2010 Ya zış ma Ad re si/Cor res pon den ce: Fazlı DEMİRTÜRK, MD Gaziosmanpaşa University Faculty of Medicine, Department of Obstetrics and Gynecology, Tokat, TÜRKİYE/TURKEY [email protected] doi:10.5336/medsci.2009f16228 Cop yright © 2011 by Tür ki ye Kli nik le ri OLGU SUNUMU The ab do mi nal wall is an un com mon si te of ex tra pel vic en do met ri o sis, which usu ally de ve lops in an old sur gi cal scar. En do met ri o sis in vol ving the rec tus ab do mi nis musc le is al so a ra re con di ti on.1 We pre sent two ca ses of ex tra pel vic en do met 9 ri o sis; one is a sur gi cal skin scar [Pfan nens ti el Ca e 9 sa re an sec ti on (C/S) scar] en do met ri o sis whi le the ot her is a rec tus ab do mi nus en do met ri o sis. Both pa ti ents ga ve the ir ver bal in for med con sent re gar 9 ding pub li ca ti on. CA SE RE PORTS CA SE 1 The pa ti ent was 31 ye ars old. She had two births with C/S. Her last C/S was seven ye ars ago. She comp la i ned of cyclic swel ling and pa in just be low her C/S scar for the previous four months. Du ring physi cal exa mi na ti on, the re was a so lid and pa in ful mass of 5 x 5 cm un der her C/S scar and a blu e9 purp le skin co lor over the mass. Magnetic reso9 nance imaging sho wed a mass of ap pro xi ma tely 5 x 5 cm in the sub cu ta ne o us tis su e(Fi gu re 1A). Du r9 ing sur gery,a 5 x 5 cm firm tis su e was ex cised. The his topat ho logicre sult con fir med en do met ri o sis(Fi 9 gu re 1B, C). She was disc har ged from the hos pi tal the day af ter sur gery. We ad mi nis te red two do ses of 11.5 mg le up ro li de ace ta te thre e months apart. CA SE 2 The pa ti ent was 26 ye ars old. She had a me di cal his tory of a C/S in ye ar2001 and two la pa ro to mi es for en do met ri o ma.She comp la ined of de ep, con ti 9 nu o us low ab do mi nal pa in for six months. Her ul9 tra so und exa mi na ti on sho wed no evidence of en do met ri o ma in ova ri es, and the ute rus was nor9 mal. On physi cal exa mi na ti on, she had pa in in the lower part of rec tus ab do mi nis musc le. The re was no mass in the pa in ful re gi on, but the are as which we re pa in ful and ten der we re stif fer than the nor9 mal musc le tis su e. Du ring sur gery; the lower part of rec tus musc les we re hard and had a black co lor (Fi gu re 2A). The ex ci si on of the ab nor mal tis su e was dif fi cult and was car ri ed out with scal pel rat her than scis sors. Histopathologic re sult was en do met 9 ri o sis of rec tus musc les(Fi gu re 2B, C).She was dis9 c har ged from hos pi tal the day af ter the sur gery. We ad mi nis te red two do ses of 11.5 mg le up ro li de ace ta te of for thre e months apart. DIS CUS SI ON En do met ri o sis, a di sor der aff lic ting as many as 59 10% of wo men of child be a ring age, is de fi ned as the pre sen ce of func ti o nal en do met ri al glands and stro ma out si de the ute ri ne ca vity. 1 The most wi 9 dely ac cep ted the ory is that en do met ri o sis re sults from ret rog ra de mens tru a ti on.2 Ex tra pel vic en do 9 met ri o sis can in vol ve al most every or gan in the hu 9 man body with a me an age of pre sen ta ti on of 34 ye ars. 2 For cu ta ne o us en do met ri o sis, the imp lan ta 9 ti on of in tra9ab do mi nal en do met ri al cells most li 9 kely oc curs thro ugh lympha tic or vas cu lar spre ad, or by dis lo ca ting en do met ri al tis su e du ring sur gery, such as la pa ros co pic pro ce du res. 2 The se ro u tesex9 Turkiye Klinikleri J Med Sci 2011;31(6)1600 Demirtürk ve ark. Kadın Hastalıkları ve Doğum A B C FIGURE 1: A: Magnetic resonance imaging of subcutaneous endometriosis mass. B: Endometrial gland in scar tissue showing light hemorrage (HE, X20). C: Damaged endometrial gland in scar tissue showing heavy hemorrage (HE, X20). p la in the oc cur ren ce of en do met ri o sis at dis tant lo9 ca ti ons.2 Rec tus ab do mi nis en do met ri o ma is ra re, whe re in the en do met ri al fo cus is so lely con fi ned therec tus ab do mi nis musc le and spar sely re por ted in li te ra tu re 2 with only 11 new ca ses sin ce it was first des cri bed in 1993 by Co ley.3Ex tra pel vic en9 do met ri o sis has an in ci den ce of 8.9%, as re por ted in li te ra tu re.1 It may in vol ve pe ri to ne um, the uri nary blad9 der and the ure ter, the lungs, the gall blad der, the bre asts, theex tre mi ti es, the co lon and the rec tum. En do met ri o sis of the ab do mi nal wall has an in ci 9 den ce of 4% and is ma inly lo ca li zed at sur gi cal scars, at the um bi li cus and ra rely at the in gu i nal ca 9 nal or the rec tus ab do mi nis musc le. 1The tre at ment for en do met ri o tic fo ci in the rec tus ab do mi nis mus9 c le is usu ally sur gi cal,1,4but can al so be ob ser va ti o 9 nalde pen ding on the se ve rity of symptoms. Le up 9 ro li de ace ta te is com monly used in in tra pe ri to ne al and ex tra pe ri to ne al en do met ri o sis ca ses for re li e 9 ving symptoms. In both ca ses, we used le up ro li de ace ta te af ter the ope ra ti ons. CONC LU SI ON En do met ri o sis sho uld be considered in the dif fe 9 ren ti al di ag no sis in the work9up of a mass in the ab9 do mi nal wall of sub cu ta ne o us tis su e in yo ung wo men du ring child be a ring age, es pe ci ally if the re is a his tory of ab do mi nal or pel vic sur gery. Alt ho ugh cyclic pa in is cha rac te ris tic for en do met ri o sis; even if the pa in is not cyclic but con ti ni o us the sur ge on sho uld still con si der pos si bi lity of en do met ri o sis. Turkiye Klinikleri J Med Sci 2011;31(6) 1601 Gynecology and Obstetrics Demirtürk et al A B C FIGURE 2: A: Rectus muscle piece with endometriosis. B: Multiple endometriosis foci in rectus muscles (Arrows) (HE, X5). C: Close up view of an endometrial focus. Endometrial gland formation in cellular endometrial stroma (HE, X15). 1. Gourgiotis S, Veloudis G, Pallas N, Lagos P, Salemis NS, Villias C. Abdominal wall enf dometriosis: report of two cases. Rom J Morf phol Embryol 2008;49(4):553f5. 2. Witz CA. Current concepts in the pathogenef sis of endometriosis. Clin Obstet Gynecol 1999;42(3):566f85. 3. Coley BD, Casola G. Incisional endometrioma involving the rectus abdominis muscle and subcutaneous tissues: CT appearance. AJR Am J Roentgenol 1993;160(3):549f50. 4. Cevrioğlu S, Yılmaz S, Yılmazer M, Tokyol Ç. [Endometriosis in cesarean scar: a case presf entation and literature review]. Turkiye Klinikleri J Gynecol Obst 2004;14(1):44f7. REFERENCES