Advanced imaging of abdominal wall endometriosis: a case report highlighting panoramic ultrasound

Endometriosis is an estrogen-dependent condition affecting 10–15% of women of reproductive age. While it typically involves pelvic structures, extrapelvic locations are also possible [1]. One of the most common extrapelvic sites is the abdominal wall, particularly in cesarean section scars. Abdominal wall endometriosis (AWE) occurs in 0.03% to 0.4% of women following cesarean delivery [2, 3]. AWE usually presents as a single, small, painful nodule associated with the menstrual cycle [3]. Due to its non-specific symptoms, AWE is frequently misdiagnosed, leading to an average treatment delay of 38.6 months from symptom onset [4]. Initial imaging typically involves transabdominal ultrasound using a linear probe. However, in cases of more extensive disease, magnetic resonance imaging (MRI) offers superior visualization of the lesion's extent. Another valuable technique is panoramic ultrasound, which merges multiple images into a single wide-view image, providing a more comprehensive assessment of the abdominal wall structures. CASE REPORT A 31-year-old woman (G2P2) was referred to a tertiary hospital for evaluation of cyclic abdominal pain and large palpable masses in the anterior abdominal wall. Her symptoms significantly impacted on her ability to perform daily activities. Her surgical history included two cesarean sections via Pfannenstiel incision (2014 and 2017), as well as a uterine septum resection. The patient first noticed pain and small nodules near her cesarean scar in 2019. In 2020, she was evaluated by an oncologist and underwent imaging and a biopsy. MRI revealed five soft tissue masses, the largest measuring 30 × 45 × 50 mm. Histopathological examination ruled out malignancy and confirmed abdominal wall endometriosis. Due to personal reasons, the patient delayed further treatment. In 2023, she was admitted to our clinic to initiate therapy. During her hospitalization, further imaging was performed. Panoramic ultrasound revealed a large, mixed-echogenicity mass in the abdominal wall (Fig. 1A). MRI showed a single, large endometriotic lesion measuring 32 × 65 × 78 mm, infiltrating the rectus abdominis muscle and involving subcutaneous tissue and skin (Fig. 1B and C). Hyperintense signals on both T1- and T2-weighted fat-saturated sequences indicated the presence of blood products, while an irregular hypointense rim surrounded the mass. After surgical consultation, the patient was referred for operative treatment. She underwent complete excision of the AWE and abdominal wall reconstruction using a 10 × 15 cm synthetic mesh via a vertical incision. Postoperatively, she did not receive hormonal therapy. At the one-year follow-up, there was no evidence of recurrence, and the patient reported complete satisfaction with the outcome.

Abdominal wall endometriosis should be considered in the differential diagnosis of anterior abdominal wall masses in women, particularly those with a history of cesarean section. Malignancy should be ruled out especially in large or highly vascularized AWE, as a 1% such lesions may be malignant [5]. While MRI remains the gold standard for assessing extensive AWE due to its superior tissue characterization, panoramic ultrasound offers a cost-effective and time-efficient alternative, particularly valuable in visualizing large lesions. Accurate preoperative imaging plays a crucial role in determining the need for synthetic mesh reconstruction and planning surgical approach. Management of large AWE often requires a multidisciplinary team to ensure optimal patient outcomes. Article information and declarations Ethics statement The study was conducted in accordance with the Declaration of Helsinki. Ethics approval was not sought for the present study. The patient data was anonymized. Author contributions FFK — clinical data collection, research, concept, analysis of the results, article draft, corresponding author; FG — research, analysis of the results, article draft; AF — analysis of the results, article draft; TSz — concept, data collection; KSz — review of the manuscript. Acknowledgments The scientific work was written in cooperation with the student scientific club “SKN Ginekologii Onkologicznej i Endometriozy”. Funding All authors declare no funding. Conflict of interest All authors declare no conflict of interest.