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Cited by 29Endometriosis Research and TreatmentBreast Lesions and CarcinomasTeratomas and Epidermoid Cysts

Abdominal wall endometriosis: differentiation from other masses using CT features

Open access
Yarmish, Gail, Sala, Evis, Goldman, Debra A., Lakhman, Yulia, Soslow, Robert A., Hricak, Hedvig, Gardner, Ginger J., Vargas, H. Alberto·2017·Abdominal Radiology
DOI 10.1007/s00261-016-0998-yPMC PMC5507191
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Abstract

PurposeTo assess the utility of morphologic and quantitative CT features in differentiating abdominal wall endometriosis (AWE) from other masses of the abdominal wall.MethodsRetrospective IRB-approved study of 105 consecutive women from two institutions who underwent CT and biopsy/resection of abdominal wall masses. CTs were independently reviewed by two radiologists blinded to final histopathologic diagnoses. Associations between CT features and pathology were tested using Fisher’s Exact Test. Sensitivity, specificity, positive, and negative predictive values were calculated. P values were adjusted for multiple variable testing.Results24.8% (26/105) of patients had histologically proven abdominal wall endometriosis. The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105), and leiomyosarcoma (8.6%; 9/105). CT features significantly associated with endometriosis for both readers were location below the umbilicus (P = 0.0188), homogeneous density (P = 0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e., “gorgon” sign) (P < 0.0001). The highest combined sensitivity (0.69, 95% CI: 0.48–0.86) and specificity (0.97, 95% CI: 0.91–1.00) for both readers occurred for patients having all three of these features present. Border type (P = 0.0199) was only significant for R2, peritoneal extension (P = 0.0188) was only significantly for R1, and the remainder of features were insignificant (P = 0.06–60). There was overlap in Hounsfield units on non-contrast CT (N = 26) between AWE (median: 45HU, range: 39–54) and other abdominal wall masses (median: 38.5HU, range: 15–58).ConclusionCT features are helpful in differentiating AWE from other abdominal wall soft tissue masses. Such differentiation may assist decisions regarding possible biopsy and treatment planning.

AI snapshot

Written from the paper’s full text.

TL;DR

In a retrospective two-institution cohort of 105 women with histologically evaluated abdominal wall masses, 24.8% had abdominal wall endometriosis (AWE). CT features—especially the “gorgon” sign, homogeneous density, and location below the umbilicus—helped differentiate AWE from other masses, with all three features yielding high specificity but moderate sensitivity.

Key findings

  • Histologically proven AWE was present in 26/105 patients (24.8%). Other common diagnoses included adenocarcinoma NOS (abstract: 21%; 22/105), desmoid (14.3%; 15/105), and leiomyosarcoma (8.6%; 9/105).
  • CT features significantly associated with endometriosis for both readers were location below the umbilicus (p=0.0188), homogeneous density (p=0.0188), and the “gorgon” sign—linear infiltration irradiating peripherally from a central soft tissue nodule (p<0.0001). Proportions for AWE vs other diagnoses: gorgon sign 73.1% vs 3.8% (R1) and 73.1% vs 2.5% (R2); homogeneous density 88.5% vs 58.2% (R1) and 88.5% vs 57% (R2); below umbilicus 96.2% vs 70.9% (R1) and 96.2% vs 69.6% (R2).
  • Having all three features gave the highest combined sensitivity 0.69 (95% CI: 0.48–0.86) and specificity 0.97 (95% CI: 0.91–1.00) for both readers. At least 1 feature had sensitivity 0.96 but specificity 0.08–0.10; at least 2 features had sensitivity 0.92 and specificity 0.62–0.63.
  • Non-contrast CT attenuation overlapped: AWE median 45 HU (range 39–54) vs other abdominal wall masses median 38.5 HU (range 15–58). Border type was significant only for R2 (p=0.0199), peritoneal extension only for R1 (p=0.0188), and other features were insignificant (p=0.06–60). No relationship was found between IV contrast and heterogeneity in predicting endometriosis (p=0.96–0.97).

Methods

  • Retrospective HIPAA-compliant, IRB-approved study with waiver of written informed consent. Pathology databases at two institutions were searched for “abdominal wall mass” and “pelvic wall mass” in women ages 18–55 from January 2000 through April 2014; final cohort was 105 patients with CT within 12 months prior to histopathologic evaluation. Median age was 41 years (range 21–55).
  • Two fellowship-trained radiologists blinded to final histopathologic diagnoses independently reviewed CT scans for qualitative features and measured mass density on non-contrast cases using an ROI encompassing at least 50% of the lesion. IV contrast was administered in 76/105 patients (72.4%).
  • Associations were tested with Fisher’s exact test and adjusted for multiple testing using the false discovery rate; inter-reader agreement used Cohen’s kappa. Diagnostic accuracy, sensitivity, specificity, PPV, and NPV were calculated with exact 95% CIs. A logistic regression assessed contrast–heterogeneity interaction; non-contrast HU comparisons used descriptive statistics and box plots.

Limitations

  • The paper states the study was retrospective with a small sample size (26 AWE cases among 105), included only biopsied masses, introducing verification bias, and lacked pre- and post-contrast images in most cases, so enhancement characteristics could not be assessed.
  • The paper also states that heterogeneity assessment did not initially separate patients with and without IV contrast, though a sensitivity analysis showed no relationship between contrast and heterogeneity in predicting endometriosis (p=0.96–0.97); it notes the non-contrast sample was limited and should be repeated with a larger sample.
  • Evident from the text: the non-contrast density comparison was descriptive only, with no formal hypothesis testing due to small sample size (AWE N=5; total non-contrast density analysis N=26 after exclusions). The text also contains an internal inconsistency: the abstract reports adenocarcinoma NOS as 22/105, while the Results section states 28 patients with adenocarcinoma (21%).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s00261-016-0998-y

Cites

15 of 15 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 8 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Desmoid was diagnosed in 14.3% (15/105) of the cohort.

    “The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105) and leiomyosarcoma (8.6%; 9/105).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The presence of the gorgon sign was significantly associated with abdominal wall endometriosis for both readers (p<0.0001).

    “CT features significantly associated with endometriosis for both readers were location below the umbilicus (p=0.0188), homogeneous density (p=0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e. “gorgon” sign) (p<0.0001).”
    • Also stated in: § Univariate Analysis · plain
      “A higher proportion of patients with AWE had gorgon sign compared with patients having other diagnoses (R1: 73.1% vs. 3.8% and R2: 73.1% vs. 2.5%).”
    Quote in the paperSubstantial claim
  • Findingown data

    Homogeneous density was significantly associated with abdominal wall endometriosis for both readers (p=0.0188).

    “CT features significantly associated with endometriosis for both readers were location below the umbilicus (p=0.0188), homogeneous density (p=0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e. “gorgon” sign) (p<0.0001).”
    • Also stated in: § Univariate Analysis · plain
      “Additionally, endometriosis patients had a higher proportion of homogeneous density masses (R1: 88.5% vs. 58.2% and R2: 88.5% vs. 57%), and masses located below the umbilicus compared with other patients (R1: 96.2% vs. 70.9% and R2: 96.2% vs. 69.6%).”
    Quote in the paperSubstantial claim
  • Findingown data

    Cases with the gorgon sign exhibited a histopathologic appearance similar to deep pelvic endometriosis, with a predominance of histiocytic infiltration and fibrosis due to chronic hemorrhage and few glands.

    “Upon histopathologic evaluation, cases with the gorgon sign exhibited an appearance similar to that of deep pelvic endometriosis, in which there is a predominance of histiocytic infiltration and fibrosis due to chronic hemorrhage, and few glands (Fig. 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Masses located below the umbilicus were significantly associated with abdominal wall endometriosis for both readers (p=0.0188).

    “CT features significantly associated with endometriosis for both readers were location below the umbilicus (p=0.0188), homogeneous density (p=0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e. “gorgon” sign) (p<0.0001).”
    • Also stated in: § Univariate Analysis · plain
      “Additionally, endometriosis patients had a higher proportion of homogeneous density masses (R1: 88.5% vs. 58.2% and R2: 88.5% vs. 57%), and masses located below the umbilicus compared with other patients (R1: 96.2% vs. 70.9% and R2: 96.2% vs. 69.6%).”
    Quote in the paperSubstantial claim
  • May combine two claims. 8
  • Classified as probably not a substantial claim. 7

  • May combine two claims.

    Findingown data

    Border type was significantly associated with abdominal wall endometriosis for reader 2 (p=0.0199) but not for reader 1 (p=0.06).

    “Border type (p=0.0199) was only significant for R2, peritoneal extension (p=0.0188) was only significantly for R1 and the remainder of features were insignificant (p=0.06-60).”
    • Also stated in: § Univariate Analysis · plain
      “Border type was significant for reader 2 (p=0.0199), but not for reader 1 (p=0.06), and peritoneal extension was significant for reader 1 (p=0.0188) but not for reader 2 (p=0.06).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For patients with at least 2 features present, sensitivity was 0.92 (95% CI: 0.75-0.99) and specificity was 0.62 (95% CI: 0.50-0.73 for R1) and 0.63 (95% CI: 0.52-0.74 for R2).

    “Patients with at least 2 features present also had a high sensitivity in assessing AWE (0.92, 95% CI: 0.75-0.99 for both), but moderate specificity (0.62, 95% CI: 0.50-0.73 for R1 and 0.63, 95% CI: 0.52-0.74 for R2).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Leiomyosarcoma was diagnosed in 8.6% (9/105) of the cohort.

    “The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105) and leiomyosarcoma (8.6%; 9/105).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Other CT features, including calcifications, mass location, coexisting intraperitoneal disease, and additional similar masses, were not significantly associated with abdominal wall endometriosis (p=0.06-60).

    “No other features, including calcifications, mass location, coexisting intraperitoneal disease or additional similar masses were found to be significant (p=0.06-60) (Table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For patients with at least 1 feature present, sensitivity was 0.96 (95% CI: 0.80-1.00) and specificity was 0.08 (95% CI: 0.03-0.16 for R1) and 0.10 (95% CI: 0.04-0.19 for R2).

    “Patients with at least 1 feature present had the highest sensitivity in diagnosing AWE (0.96, 95% CI: 0.80-1.00 for both), but the lowest specificity (0.08, 95% I: 0.03-0.16 for R1 and 0.10, 95% CI: 0.04-0.19 for R2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Peritoneal extension was significantly associated with abdominal wall endometriosis for reader 1 (p=0.0188) but not for reader 2 (p=0.06).

    “Border type (p=0.0199) was only significant for R2, peritoneal extension (p=0.0188) was only significantly for R1 and the remainder of features were insignificant (p=0.06-60).”
    • Also stated in: § Univariate Analysis · plain
      “Border type was significant for reader 2 (p=0.0199), but not for reader 1 (p=0.06), and peritoneal extension was significant for reader 1 (p=0.0188) but not for reader 2 (p=0.06).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    No relationship was found between the use of IV contrast and heterogeneity in predicting endometriosis (p=0.96-0.97).

    “No relationship was found between the use of IV contrast and heterogeneity in predicting endometriosis (p=0.96-0.97).”
    • Also stated in: § Discussion · plain
      “However, a sensitivity analysis revealed no relationship between contrast and heterogeneity in predicting endometriosis (p=0.96-0.97).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The existing literature on CT features of abdominal wall endometriosis is limited to case reports, with CT features often described as nonspecific with variable attenuation and enhancement characteristics.

    “While some have studied sonographic features of AWE (5,6,7,8,9,10), the existing literature on CT is limited to case reports, with CT features often described as nonspecific with variable attenuation and enhancement characteristics (4,5,7,8,11).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [4] Gidwaney R, Badler RL, Yam BL, et al. (2012) Endometriosis of abdominal and pelvic wall scars: multimodality imaging findings, pathologic correlation, and radiologic mimics. Radiographics 32(7):2031–2043 source

      Not checked in the free run.

    • cites [5] Hensen JH, Van Breda Vriesman AC, Puvlaert J (2006) Abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. AJR Am J Roentgenol 186:616–620 source

      Not checked in the free run.

    • cites [7] Busard MP, Mijatovic V, van Kuijk C, Hompes PG, van Waesberghe JH (2010) Appearance of abdominal wall endometriosis on MR imaging. Eur Radiol 20:1267–1276 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    P-values were adjusted for multiple testing using the false discovery rate approach.

    “P-values were adjusted for multiple testing using the false discovery rate approach and values less than 0.05 were considered statistically significant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The study was retrospective and had a small sample size (26 cases of endometriosis among 105 cases).

    “First, it was retrospective and had a small sample size (26 cases of endometriosis among the 105 cases evaluated).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Due to lack of pre- and post-contrast images in most cases, enhancement characteristics could not be assessed.

    “Third, due to lack of pre and post-contrast images in most cases, we were not able to assess enhancement characteristics.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Due to the small patient sample, formal hypothesis tests were not conducted for the non-contrast density comparison.

    “Due to the small patient sample, formal hypothesis tests were not conducted.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In the assessment of lesion heterogeneity, the study did not differentiate between patients who received intravenous contrast and those who did not.

    “In our assessment of lesion heterogeneity, we did not differentiate between those patients who were given intravenous contrast and those who were not.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Clinical manifestations of abdominal wall endometriosis are often nonspecific, and patients may complain only of vague abdominal pain, a tender mass, or be asymptomatic.

    “Although the diagnosis may at times be made based on clinical presentation, in many scenarios, clinical manifestations of AWE are nonspecific, and patients may complain only of vague abdominal pain, a tender mass, or they may be asymptomatic (3).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Matter M, Schneider N, McKee T (2003) Cystadenocarcinoma of the abdominal wall following caesarean section: case report and review of the literature. Gynecol Oncol 91(2):438–443 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Two fellowship-trained radiologists independently reviewed all CT scans blinded to the final histopathologic diagnoses.

    “Two fellowship-trained radiologists (HAV and GY with 4 and 5 years of experience, respectively) blinded to the final histopathologic diagnoses independently reviewed all CT scans.”
    Quote in the paperSubstantial claim
15 of 15

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • CS is responsible for 57-92% of AWE cases.

    “Studies reveal that CS is responsible for 57–92% of AWE cases [3,5,23,26,32,33,34,35,36,37].”

    From Surgical Reconstruction of Abdominal Wall Endometriosis Post-Cesarean Section: A Monocentric Experience of a Rare Pathology (2025) · cites this paper as [37]

    The Introduction (page not provided) says AWE is commonly associated with Cesarean-section scars, but also with scars from hysterectomy and other uterine surgery. It gives no 57–92% estimate or proportion specifically attributable to Cesarean section. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • MRI should be performed for endometriotic nodular lesions >3 cm to guide optimal surgical planning.

    “According to Foley et al., an MRI should be performed for endometriotic nodular lesions > 3 cm to guide optimal surgical planning [37].”

    From Surgical Reconstruction of Abdominal Wall Endometriosis Post-Cesarean Section: A Monocentric Experience of a Rare Pathology (2025) · cites this paper as [37]

    The Discussion (page unavailable) says that imaging features of abdominal wall endometriosis may inform management and affect the extent of surgical dissection. The Methods describe a CT study, however, and the passages found when searching for MRI and a 3 cm threshold do not recommend MRI for lesions over 3 cm. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Although endometriosis can present without pain, the most common symptoms in patients with endometriosis involve pain that increases with pressure in the abdominal or pelvic cavity, localizing to the position of endometrial deposits.

    “Although endometriosis can present without pain, the most common symptoms in patients with endometriosis involve pain that increases with pressure in the abdominal or pelvic cavity, localizing to the position of endometrial deposits.26”

    From Endometriosis in Patients Undergoing Plastic Surgical Procedures: A Case Report and Review of the Literature (2024) · cites this paper as [26]

    The Introduction (page unavailable) says abdominal wall endometriosis may cause chronic abdominal or pelvic pain, a tender mass, or no symptoms. It does not say that pain increases with pressure, localizes to endometrial deposits, or is the most common symptom among patients with endometriosis generally. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Percentage for 28 adenocarcinoma cases is incorrect

    Minor

    The Results report 28 patients with adenocarcinoma as 21% of the 105-patient cohort, but 28/105 is 26.7%. The 21% figure corresponds to the 22 adenocarcinoma NOS cases reported in the abstract.

    Reported 21 · recomputed 26.666667

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Authors
Yarmish, G., Sala, E., Goldman, D. A., Lakhman, Y., Soslow, R. A., Hricak, H., Gardner, G. J., & Vargas, H. A.
Affiliations
  • Staten Island University Hospital (US)
  • Memorial Sloan Kettering Cancer Center (US)
Corresponding author
Yarmish, Gail
ORCID
Venue
Abdominal Radiology
Publisher
Springer Science and Business Media LLC
Published
2016-12-21
Volume
42
Issue
5
Pages
1517-1523
ISSN
  • 2366-004X (ISSN-L)
  • 2366-0058
DOI
10.1007/s00261-016-0998-y
PMC
PMC5507191
OpenAlex
W2562500883
Semantic Scholar
185d7ea9a1ae538c142d30a0723ad39794590279
Cited by
29
References
15
Citations by year
2026: 3 · 2025: 7 · 2024: 4 · 2022: 4 · 2021: 1 · 2020: 4 · 2019: 2 · 2018: 4
FWCI
2.66
Type
journal article
Language
en
Open access
Licence
www.springer.com/tdm (tdm)
Locations
  • Abdominal Radiology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Cancer Institute (P30CA008748)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Medicine › Pathology and Forensic Medicine › Breast Lesions and Carcinomas
  • Health Sciences › Medicine › Surgery › Teratomas and Epidermoid Cysts
Keywords
abdominal wall endometriosis, abdominal wall mass, computed tomography findings, differential diagnosis, Hounsfield units, leiomyosarcoma, adenocarcinoma, biopsy decision
MeSH terms
Adolescent, Adult, Biopsy, Diagnosis, Differential, Endometriosis, Female, Humans, Middle Aged, Predictive Value of Tests, Retrospective Studies, Sensitivity and Specificity, Tomography, X-Ray Computed, Abdominal Wall

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