Parietal Mass: Two Case Reports of Rare Cesarean Scar Endometriosis

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Two cases of scar endometriosis appeared in two young ladies after cesarean sections, discovered by a parietal mass near the cesarean scars.

“We report two cases of scar endometriosis that appeared in two young ladies after cesarean sections, discovered by a parietal mass near the cesarean scars.”

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Ultrasonography in Case 1 showed a subcutaneous right paramedian mass measuring 7 x 3 cm attached to the rectus abdominis muscle that was well-defined, hypoechoic, and heterogeneous with arteriovenous vascularization on color Doppler.

“Ultrasonography showed a subcutaneous right paramedian mass measuring 7 x 3 cm attached to the rectus abdominis muscle that was well-defined, hypoechoic, and heterogeneous with an arteriovenous vascularization on a color Doppler study.”

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Case 2 was a 31-year-old female patient who had undergone two cesarean sections and the mass appeared two years after her last cesarean section.

“A 31-year-old female patient, married and the mother of two children, presented with complaints of a painful hypogastric mass next to a cesarean section scar.”

• Also stated in: § Case presentation · plain

  “Her past medical and surgical histories were negative, except that she had undergone two cesarean sections and the mass had appeared two years after her last cesarean section.”

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Case 1 was a 44-year-old female patient with a cesarean section performed three years prior to presentation.

“Case 1 was a 44-year-old female patient, married, and the mother of one child who had, as a surgical antecedent, a cesarean section performed three years prior to presentation.”

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Anatomopathology in Case 2 confirmed the presence of benign fibrous tissue with multiple endometrial glands and stroma, confirming the diagnosis of endometriosis.

“Anatomopathology confirmed the presence of benign fibrous tissue with multiple endometrial glands and stroma, confirming the diagnosis of endometriosis.”

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Pelvic MRI with intravenous contrast in Case 2 revealed a subcutaneous fat mass of the left lateral pelvic wall, roughly rounded with spiculated contours, measuring 28 x 23 mm, and showing heterogeneous enhancement.

“A pelvic magnetic resonance imaging (MRI) scan with intravenous contrast revealed evidence of a subcutaneous fat mass of the left lateral pelvic wall, roughly rounded with spiculated contours, measuring 28 x 23 mm, and showing heterogeneous enhancement(Figure 2).”

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In Case 2, surgical exploration revealed a mass at the left lower rectus wall, and en bloc excision of the mass was performed.

“Under general anesthesia, surgical exploration revealed a mass at the left lower rectus wall, and en bloc excision of the mass was performed (Figure 3).”

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Case 2 presented with complaints of a painful hypogastric mass next to a cesarean section scar.

“A 31-year-old female patient, married and the mother of two children, presented with complaints of a painful hypogastric mass next to a cesarean section scar.”

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Physical examination of Case 1 found a parietal mass at the right iliac fossa measuring 4 cm that was mobile with no inflammatory signs.

“The physical examination found a parietal mass at the right iliac fossa measuring 4 cm that was mobile with no inflammatory signs.”

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Case 1 had a three-month history of cyclic hypogastric pain and pain in the right iliac fossa without irradiation and without favoring or sedative factors.

“She described a three-month history of the appearance of cyclic hypogastric pain and pain in the right iliac fossa without irradiation and without favoring or sedative factors.”

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Endometriosis is the main reason for infertility and chronic pain in women of reproductive age.

“It is the main reason for infertility and chronic pain in women of reproductive age.”

• cites [1] Abdominal wall endometrioma; a 10-year experience and brief review of the literature J Surg Res Bektas H Bilsel Y Sarı YS 0 81 164 2010 20855082Not checked yet

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Scar endometriosis is an uncommon type of extra-pelvic endometriosis.

“Scar endometriosis is an uncommon type of extra-pelvic endometriosis.”

• cites [1] Abdominal wall endometrioma; a 10-year experience and brief review of the literature J Surg Res Bektas H Bilsel Y Sarı YS 0 81 164 2010 20855082Not checked yet

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In any woman of childbearing age complaining of a cyclic, painful nodule in a scar from a previous obstetric or gynecologic procedure, scar endometriosis should be suspected after excluding other differential diagnoses.

“However, it should be suspected in any woman of childbearing age complaining of a cyclic, painful nodule in a scar from a previous obstetric or gynecologic procedure, after excluding other differential diagnoses.”

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Surgical treatment is the treatment of choice for cesarean scar endometriosis, offering the best chance for definitive diagnosis and treatment.

“The treatment of choice is surgical resection.”

• cites [15] Cesarean scar endometriosis: presentation of 198 cases and literature review BMC Womens Health Zhang P Sun Y Zhang C Yang Y Zhang L Wang N Xu H 14 19 2019 30658623 PMC6339338Not checked yet

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Abdominal wall endometriosis incorporated into the musculature of the abdominal wall requires en bloc resection of the underlying myofascial elements and the excision site must be sterilized by neomycin solution or 0.9% sodium chloride solution.

“In addition to this, the abdominal wall endometriosis incorporated into the musculature of the abdominal wall requires en bloc resection of the underlying myofascial elements and the excision site must be sterilized by neomycin solution or 0.9% sodium chloride solution [17-18].”

• cites [17] Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases Am J Surg Horton JD Dezee KJ Ahnfeldt EP Wagner M 207 212 196 2008 18513698Not checked yet

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• cites [18] Clinical characteristic analysis of 32 patients with abdominal incision endometriosis J Obstet Gynaecol Zhu Z Al-Beiti MAM Tang L Liu X Lu X 742 745 28 2008 19065373Not checked yet

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Local recurrence is very variable and can occur, especially after an inadequate surgical excision.

“Local recurrence is very variable and can occur, especially after an inadequate surgical excision.”

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The prevalence of extra pelvic endometriosis is between 9% and 15% in the literature.

“The prevalence of extra pelvic endometriosis is between 9% and 15% in the literature [1].”

• cites [1] Abdominal wall endometrioma; a 10-year experience and brief review of the literature J Surg Res Bektas H Bilsel Y Sarı YS 0 81 164 2010 20855082Not checked yet

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There are case reports of spontaneous occurrences of abdominal wall endometriosis discovered in up to 20% of gynecological laparotomies.

“However, there are also case reports of spontaneous occurrences discovered in up to 20% of gynecological laparotomies [6].”

• cites [6] Spontaneous endometriosis of the abdominal wall Dig Surg Ideyi SC Schein M Niazi M Gerst PH 246 248 20 2003 12759505Not checked yet

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Non-invasive imaging modalities, like ultrasonography, CT scan, and MRI, are helpful to determine the location and extension of the masses, but they are unsatisfactory for confirming a diagnosis.

“Non-invasive imaging modalities, like ultrasonography, CT scan, and MRI, are helpful to determine the location and extension of the masses, but they are unsatisfactory for confirming a diagnosis.”

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The most common treatment options for scar endometriosis include medical therapy and surgery.

“The most common treatment options for scar endometriosis include medical therapy and surgery [15].”

• cites [15] Cesarean scar endometriosis: presentation of 198 cases and literature review BMC Womens Health Zhang P Sun Y Zhang C Yang Y Zhang L Wang N Xu H 14 19 2019 30658623 PMC6339338Not checked yet

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Medical therapy has a low success rate and is associated with adverse effects.

“Medical therapy has a low success rate and is associated with adverse effects.”

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Abdominal wall endometriosis is defined as any endometrial tissue found in the superficial peritoneum due to gynecologic surgeries, especially hysterectomy (2%) and cesarean section (< 0.4%) which are the most common provoking factors.

“It is defined as any endometrial tissue found in the superficial peritoneum due to gynecologic surgeries, especially hysterectomy (2%) and cesarean section (< 0.4%) which are the most common provoking factors [5].”

• cites [5] Cytodiagnosis of scar endometriosis: a case series J Case Rep Images Pathol Santosh T Patro MK 29 32 2 2016 http://www.ijcripathology.com/archive/2016-archive/100011Z11TS2016-santosh/100011Z11TS2016-santosh.pdfNot checked yet

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The risk of parietal endometriosis in scars was 2.7% after obstetric interventions, 1.5% after gynecologic surgery, and 0.5% after laparoscopic procedures.

“Paşalega et al. found that the risk of parietal endometriosis in scars was found to be 2.7% after obstetric interventions, 1.5% after gynecologic surgery, and 0.5% after laparoscopic procedures [8].”

• cites [8] Parietal abdominal endometriosis following Cesarean section Rom J Morphol Embryol Paşalega M Mirea C Vîlcea ID 503 508 52 2011 http://www.rjme.ro/RJME/resources/files/521111503508.pdf 21424102Not checked yet

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Endometriosis is a common gynecologic condition that affects up to 22% women of all age groups: 8-15% in the reproductive age group (most frequently, multipara between 25 and 35 years) and 6% in the premenopausal age group.

“It is a common gynecologic condition that affects up to 22% women of all age groups: 8-15% in the reproductive age group (most frequently, multipara between 25 and 35 years) and 6% in the premenopausal age group [9].”

• cites [9] A retrospective review of abdominal wall endometriosis in Shanghai, China Int J Gynaecol Obstet Ding Y Zhu J 41 44 121 2013 23352735Not checked yet

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Abdominal wall mass differential diagnoses include desmoid tumor, fibrosis, suture granuloma, fat necrosis, nodular fasciitis, incisional and ventral hernias, hematomas, abscesses, and primary or metastatic malignancies.

“Abdominal wall mass differential diagnoses include desmoid tumor, fibrosis, suture granuloma, fat necrosis, nodular fasciitis, incisional and ventral hernias, hematomas, abscesses, and primary or metastatic malignancies [12].”

• cites [12] 5-year data analysis of patients following abdominal wall endometrioma surgery BMC Womens Health Khamechian T Alizargar J Mazoochi T 151 14 2014 25476548 PMC4263010Not checked yet

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Bektas et al. found a recurrence rate of 9.1%.

“Bektas et al. found a recurrence rate of 9.1% [1].”

• cites [1] Abdominal wall endometrioma; a 10-year experience and brief review of the literature J Surg Res Bektas H Bilsel Y Sarı YS 0 81 164 2010 20855082Not checked yet

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The coelomic metaplasia theory by Meyer suggests that metaplasia of the coelomic epithelium was the origin of endometriosis.

“The coelomic metaplasia theory by Meyer suggests that metaplasia of the coelomic epithelium was the origin of endometriosis [4].”

• cites [4] Ueber den stand der Frage der Adenomyositis und Adenomyome in algemeinen und insbesondere iiber Adenomyositis serosoepithelialis und Adenomyometritis sarcomatosa (Article in German) Zentralbl Gynaekol Meyer R 745 750 36 1919Not checked yet

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The overall frequency of malignant transformation from endometriosis is estimated to be up to 1%.

“Some of those functional endometrial cells continue their growth and become malignant, although the overall frequency of malignant transformation from endometriosis is estimated to be up to 1% [11].”

• cites [11] Clear cell carcinoma arising from scar endometriosis: a case report and literature review Ci Ji Yi Xue Za Zhi Wei CJ Huang SH 55 58 29 2017 28757766 PMC5509184Not checked yet

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The interval between the onset of symptoms to past surgery varies from a few months to 10 years.

“In general, the history of gynecological or obstetrical surgery may lead us to think about this diagnosis; the interval between the onset of symptoms to past surgery varies from a few months to 10 years [5].”

• cites [5] Cytodiagnosis of scar endometriosis: a case series J Case Rep Images Pathol Santosh T Patro MK 29 32 2 2016 http://www.ijcripathology.com/archive/2016-archive/100011Z11TS2016-santosh/100011Z11TS2016-santosh.pdfNot checked yet

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The most common site of extrapelvic endometriosis is the Pfannenstiel scar which represents 44% of all the 34 cases reported in the 2004 study by Douglas and Rotimi.

“The most common site of extrapelvic endometriosis is the Pfannenstiel scar which represents 44% of all the 34 cases reported in the 2004 study by Douglas and Rotimi [7].”

• cites [7] Extragenital endometriosis--a clinicopathological review of a Glasgow hospital experience with case illustrations J Obstet Gynaecol Douglas C Rotimi O 804 808 24 2004 15763794Not checked yet

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Endometriosis at a scar site can be found after cesarean sections, hysterectomies, amniocenteses, laparoscopic trocar tracts, or perineal episiotomies.

“Endometriosis at a scar site can be found after cesarean sections, hysterectomies, amniocenteses, laparoscopic trocar tracts, or perineal episiotomies”

• cites [3] Caesarean scar endometriosis J Nepal Health Res Counc Sedhain N Dangal G Karki A 292 294 15 2018 29353906Not checked yet

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In a review of 445 cases, Horton et al. noted a recurrence rate of 4.3% in the range of follow-up evaluations that lasted from one to 18 years.

“In a review of 445 cases, Horton et al. noted a recurrence rate of 4.3% in the range of follow-up evaluations that lasted from one to 18 years [17].”

• cites [17] Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases Am J Surg Horton JD Dezee KJ Ahnfeldt EP Wagner M 207 212 196 2008 18513698Not checked yet

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An increase in the concentration of hepatocyte growth factor and a decrease in the concentration of interferon gamma-inducible protein-10 in the peritoneal fluid of women with endometriosis may stimulate angiogenesis and the development of endometriosis.

“An increase in the concentration of hepatocyte growth factor and a decrease in the concentration of interferon gamma-inducible protein-10 in the peritoneal fluid of women with endometriosis may stimulate angiogenesis and the development of endometriosis [10].”

• cites [10] Current concepts of the pathogenesis of endometriosis Reprod Med Biol Osuga Y 1 7 9 2009 29699325 PMC5906831Not checked yet

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The excision should include clear margins of at least 1 cm away from the solid tissue.

“The excision should include clear margins of at least 1 cm away from the solid tissue [16].”

• cites [16] The clinical characteristics and surgical approach of scar endometriosis: a case series of 14 women Bosn J Basic Med Sci Tatli F Gozeneli O Uyanikoglu H 275 278 18 2018 29285999 PMC6087557Not checked yet

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The manifestations of endometriosis are various in the form of dysmenorrhea, chronic pelvic pain, dyspareunia, and a mass in the abdominal incision during menses.

“The manifestations of endometriosis are various in the form of dysmenorrhea, chronic pelvic pain, dyspareunia, and a mass in the abdominal incision during menses [13].”

• cites [13] Practice Bulletin No. 114: management of endometriosis Obstet Gynecol Committee on Practice Bulletins-Gynecology Falcone T Lue JR 223 236 116 2010 20567196Not checked yet

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The different imaging modalities are nonspecific but useful in determining the extent of disease and assist in the planning of the operative resection.

“The different imaging modalities are nonspecific but useful in determining the extent of disease and assist in the planning of the operative resection [14].”

• cites [14] Abdominal wall endometrioma: ultrasonographic features and correlation with clinical findings Balkan Med J Solak A Genç B Yalaz S Sahin N Sezer TÖ Solak I 155 160 30 2013 25207093 PMC4115979Not checked yet

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The most frequent localization of endometriosis in surgical scars is in the abdominal skin and subcutaneous tissue.

“the most frequent localization of endometriosis in surgical scars is in the abdominal skin and subcutaneous tissue [3].”

• cites [3] Caesarean scar endometriosis J Nepal Health Res Counc Sedhain N Dangal G Karki A 292 294 15 2018 29353906Not checked yet

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The metastatic theory suggests that distant lesions are established by the hematogenous or lymphogenous spread of viable endometrial cells which logically explains the rare endometriotic lesions distant from the uterus.

“The metastatic theory suggests that distant lesions are established by the hematogenous or lymphogenous spread of viable endometrial cells which logically explains the rare endometriotic lesions distant from the uterus [10].”

• cites [10] Current concepts of the pathogenesis of endometriosis Reprod Med Biol Osuga Y 1 7 9 2009 29699325 PMC5906831Not checked yet

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The most common type of malignant transformation from endometriosis is clear-cell carcinoma with overall survival in five years estimated to be 80%.

“The most common type is clear-cell carcinoma with overall survival in five years estimated to be 80% [12].”

• cites [12] 5-year data analysis of patients following abdominal wall endometrioma surgery BMC Womens Health Khamechian T Alizargar J Mazoochi T 151 14 2014 25476548 PMC4263010Not checked yet

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May combine two claims.

Surgical treatment consists of the total excision of the mass and is still the gold standard treatment with a very low rate of recurrence if done properly.

“Surgical treatment consists of the total excision of the mass and is still the gold standard treatment with a very low rate of recurrence if done properly.”