::: Pakistan Armed Forces Medical Journal :::

Issue Year : 2011, Issue Number : 3, Issue Month : September Written By : Sadiqa Batool, Kashif Raza Kazmi* Capt Sameed Hussain* Belongs To : Combined Military Hospital Sialkot, *Combined Military Hospital Tarbela

SCAR ENDOMETRIOSIS - CASE REPORTS OF TWO PATIENTS

Article INTRODUCTION Endometriosis is defined as the presence of endometrial like tissue, that is glands and stroma, outside the uterine cavity. Most common affected sites are pelvic organ and peritoneum, although other parts of the body can be involved. The prevalence is estimated to be 8-10% in women in the reproductive years1. Scar endometriosis is defined as the presence of endometrial like tissue in surgical scars. It is reported in previous cesarean section scars and in scars after abdominal hysterectomy2. Exact etiology is not known, different theories were proposed, but no one could explain its occurrence in different sites. It was assumed that endometriosis is a heterogeneous, not single disease, resulting from different disease processes each with its own etiology3. CASE REPORT-1 A 30 Years old female presented at CMH Sialkot with complaints of pain and swelling on the right margin of cesarean section scar for last 2 yrs after her last surgery. There was no significant past medical history. On examination there was nothing significant on general physical and systemic examination. Local examination of lower segment cesarean section scar revealed approximately 3x3cm mass at the right margin of scar. Her history was very suggestive, she complained of regular cyclical pain in the scar, clinical suspicion was made of scar endometriosis. She was put on Danazol for 3 months but the symptoms persisted. Plan was made to excise the scar and the post operative period was uneventful. She was advised to return with biopsy report. Histopathology of the excised mass confirmed the diagnosis of scar endometriosis, patient was advised to have follow up after 3-6 months for recurrence. CASE REPORT – 2 A 35 years old lady, P4 + A0, reported to CMH Sialkot. She had her last born child by lower segment cesarean section 5 years back. Since then she developed complaint of pain and swelling at the site of scar. She had been visiting various general practitioners and gynaecologist for this problem for which she was advised to take analgesics and various medical treatments but had no relief. On general physical examination she was obese but there was nothing significant on systemic examination. Deep palpation of the scar revealed 4x3cm mass on the left margin of cesarean section scar. Plan was made for excision of the mass and it was sent for histopathology. Post-operative period was uneventful. Histopathology revealed that it was a case of scar endometriosis. DISCUSSION Endometriosis is one of the most common benign gynaecological conditions. Endometrio-sis is defined as a disease characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium. It contains functional endometrial glands and stroma in ectopic locations outside the uterine cavity. The ectopic endometrial tissue responds generally to hormones and drugs in similar manner to ectopic endometrium undergoing cyclical changes. Cyclical bleeding from the endometrial deposit appears to contribute to the induction of a local inflammatory reaction and fibrous adhesions. Regarding its etiology and presence of endometrioses at various sites, exact pathogenesis is still controversial4. Extra pelvic endometriosis has been reported virtually in every organ system and tissue but less frequently than pelvic endometriosis. Over all the incidence of extra pelvic disease represents less than 12% reported cases of endometriosis. Endometrioma is a well circumscribed mass of endometrial tissue5. Abdominal wall endometriosis clinically presents as a painful swelling resembling haemotoma, abscess, stitch granuloma or tumors. Scar Endometriosis most commonly occurs after lower segment cesarean section or hysterectomy. Incidence of scar endometriosis following hysterectomy is 1.08-2% whereas after cesarean section the incidence is 0.03-0.4%6. Preoperative diagnosis is difficult to make and sometimes the diagnosis is made after excision only. Various diagnostic methods have been described in literature, ultrasonography gives a varied picture of hypoechoic mass with scattered internal echoes7,8. FNAC (fine needle aspiration cytology) has also been reported to be helpful for the preoperative diagnosis of endometriosis9. Various diagnostic modalities like computerized tomography scan and magnetic resonance imaging have been used in various studies10. Treatment of choice is excision of the mass. Medical treatment as used for pelvic endometriosis like oral contraceptive pills and danazol is not effective. Although GnRh analogues are used effectively for treatment of pelvic endometriosis but there was no change in size of lesion11. If abdominal wall wound is thoroughly cleared & irrigated vigorously with high jel-solution before closure scar endometriosis is preventable12. There is high index of clinical suspicion when a woman presents with past history of cyclical painful swelling and previous gynecological or obstetrical surgery. Treatment is excision of the mass. Follow up is required for recurrence of the condition. Reference 1.Eskenazi B & WarnerML Epidemiology of endometriosis. Obstet Gynecol Clin North Am: 1997: 24,235-58. 2.Bhowmick RN, Paul P, Dutta S, Roy B. Endometriosis of laparotomy scar. J Obstet Gynaecol India 1986; 36:130-2. 3.Koninckx PRIs mild a condition occurring intermittently in all women? Human Reprod: 1994: 9,2205 – 5. 4.Koninckx PR,Barlow D & Kenedy.S Implantation Versus Infiltration : the Sampson versus the Endometriotic disease theory.Gynecol Obstet Invest, 1999: 47,3-9. 5.Dwivedi AJ, Agarwal SN, Silva YJ. Abdominal wall endometriomas. Dig Dis Sci 2002;47:456-61. 6.Chatterjee SK. Scar endometriosis: A Clinicopathological study of 17 cases. Obstet Gynecol 1980; 56: 81-4. 7.Moore J, Copley S, Morris J, Lindsell D, Golding S & Kennedy S A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis.Ultrasound obstet Gynecol 2002: 20, 630 – 4. 8.Francica G, Giardiello C, Angelone G, Cristaino 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 2000; 22:1041-7. 9.Simsir A, Thorner K, Waisman J, Cangiarella J. Endometriosis in abdominal scars: a report of three cases diagnosed by fine needle aspiration biopsy. Am Surg 2001;67:984-6 10.Balleyguier C, Chapron C, Chopin N, Helenon O, Menu Y. Abdominal wall and surgical scar endometriosis. results of magnetic resonance imaging. Gynecol Obstet Invest 2003; 55: 220-4. 11.Shaw RW Evaluation of treatment with gonadotrophin release of harmone analogues.In : Shaw RW (ed) Endometriosis.Current understanding & Management. Blackwell science, Oxford, PP 1995: 206-34. 12.Wasfie T, Gomez E, Seon S, Zado B. Abdominal wall endometrioma after cesarean section: a preventable complication. Int Surg 2002;87:175-7

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