Diagnostic evaluations and management of surgical scar endometriosis: a case series of 13 cases over 9 years

Jamuna Kanakaraya, S. Kanakaraya, Chandrahasa, Avni Bhardwaj
In: International Journal of Reproduction, Contraception, Obstetrics and Gynecology · 2024 · vol. 13(4) , pp. 1025–1032 · doi:10.18203/2320-1770.ijrcog20240807 · W4393315351
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This case series reviewed 13 patients with scar endometriosis, finding MRI suggestive of diagnosis, histopathology definitive, and surgical excision the treatment of choice.

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This paper reports diagnostic evaluations and management of surgical scar endometriosis in 13 women identified over 9 years, focusing on incisional site endometrioma presenting as cyclical pain and a mass in the 2nd to 3rd decade after prior surgery. Ultrasonography was hypoechoic but inconclusive in most cases, whereas MRI was suggestive of diagnosis in almost all cases, and definitive confirmation relied on histopathological examination. All patients underwent surgical excision (with wide excision described as 1 cm around the mass), and three received hormonal therapy beforehand, with the caveat that medical treatment provided only temporary symptomatic pain relief while hormone effects lasted. This paper is centrally about endometriosis — specifically surgical scar (incisional site) endometriosis and how it is diagnosed and treated.

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Abstract

Endometriosis is defined as localization of ectopic functional endometrial gland and stroma. Scar endometriosis is a rare benign gynecological disease affecting women in the reproductive age group. It’s incidence in post-caesarean and post-hysterotomy scar tissue is approximately 0.03-0.4% and 1.08-2% respectively. This case series reviews literature of medical data of 13 patients who presented over 9 years with incisional site endometrioma, diagnostic approaches and treatment is discussed. The patients presented in 2nd to 3rd decade of life with complaints of cyclical pain and mass at previous surgery scar. Ultrasonography (USG) detected hypoechoic mass/granuloma and inconclusive in most cases. Magnetic resonance imaging (MRI) though was suggestive of diagnosis in almost all cases. Definitive diagnosis was histopathological examination. Treatment was achieved with surgical excision in all patients, and 3 are preceded by hormonal treatment. Medical treatment can only yield symptomatic relief in pain till the hormone effect lasts. Treatment of choice is wide excision that is excision of 1 cm tissue around the mass. Endometriosis in operative site scar tissue may present as a discrete mass which may be painful and can be confused clinically with a variety of surgical conditions. It is extremely important to recognize the condition so as to avoid potential clinical pitfalls in the diagnosis of this treatable entity.
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Diagnostic evaluations and management of surgical scar endometriosis: a case series of 13 cases over 9 years DOI: https://doi.org/10.18203/2320-1770.ijrcog20240807Keywords: Surgical site cyclical pain, Incisional site endometrioma, Wide excisionAbstract Endometriosis is defined as localization of ectopic functional endometrial gland and stroma. Scar endometriosis is a rare benign gynecological disease affecting women in the reproductive age group. It’s incidence in post-caesarean and post-hysterotomy scar tissue is approximately 0.03-0.4% and 1.08-2% respectively. This case series reviews literature of medical data of 13 patients who presented over 9 years with incisional site endometrioma, diagnostic approaches and treatment is discussed. The patients presented in 2nd to 3rd decade of life with complaints of cyclical pain and mass at previous surgery scar. Ultrasonography (USG) detected hypoechoic mass/granuloma and inconclusive in most cases. Magnetic resonance imaging (MRI) though was suggestive of diagnosis in almost all cases. Definitive diagnosis was histopathological examination. Treatment was achieved with surgical excision in all patients, and 3 are preceded by hormonal treatment. Medical treatment can only yield symptomatic relief in pain till the hormone effect lasts. Treatment of choice is wide excision that is excision of 1 cm tissue around the mass. Endometriosis in operative site scar tissue may present as a discrete mass which may be painful and can be confused clinically with a variety of surgical conditions. It is extremely important to recognize the condition so as to avoid potential clinical pitfalls in the diagnosis of this treatable entity. Metrics References Çöl C, Yilmaz EE. Cesarean scar endometrioma: Case series. World J Clin Cases. 2014;2(5):133-6. Gupta P, Gupta S. Scar Endometriosis: Case Report with Literature Review. Acta Med Iran. 2015;53(12):793-5. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R, Tramontano G. Abdominal wall endometriomas near cesarean delivery scars: sonographic and color doppler findings in a series of 12 patients. J Ultrasound Med. 2003;22(10):1041-7. Balleyguier C, Chapron C, Chopin N. Abdominal wall and surgical scar endometriosis. Results of magnetic resonance imaging. Gynecol Obstet Invest. 2003;55(4):220-4. Wolf GC, Singh KB. Cesarean scar endometriosis: A review. Obstet Gynecol Surv. 1989;44(2):89-95. Ashfaq R, Molberg KH, Vuitch F. Cutaneous endometriosis as a diagnostic pitfall of fine needle aspiration biopsy. A report of three cases. Acta Cytol. 1994;38(4):577-81. Rivlin ME, Das SK, Patel RB, Meeks GR. Leuprolide acetate in the management of cesarean scar endometriosis. Obstet Gynecol. 1995;85(5):838-9. Sumathy S, Mangalakanthi J, Purushothaman K, Sharma D, Remadevi C, Sreedhar S. Symptomatology and Surgical Perspective of Scar Endometriosis: A Case Series of 16 Women. J Obstet Gynaecol India. 2017;67(3):218-23.

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