Int J Clin Exp Pathol 2017;10(7):7534-7541 www.ijcep.com /ISSN:1936-2625/IJCEP0053216

Original Article Serous adenocarcinoma arising from endometriosis in cesarean section abdominal wall scar: a case report and literature review

Wenting Ji1,2*, Jiayue Wu1,2*, Jiejun Cheng3, Wen Di1,2

Departments of 1Obstetrics and Gynecology, 3Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; 2Shanghai Key Laboratory of Gynecologic Oncology, China. *Equal contribu- tors. Received March 18, 2017; Accepted June 5, 2017; Epub July 1, 2017; Published July 15, 2017

Abstract: Background: Abdominal wall endometriosis has been well-described and can occur after caesarean sec- tion. However, malignant transformation of abdominal wall endometriosis is rare, less than 40 cases have been reported so far and its pathogenesis is still poorly understood. Case report: Here, we report a 48-year-old woman, gravida 1, para 1, with a history of uneventful caesarean delivery presented with increasing pain and a rapid grow- ing mass in her cesarean section scar. Serum tumor markers, especially CA125 and CA199 increased remarkably. Physical examination and pelvic magnetic resonance imaging showed a mass sized 15 cm in maximum diameter and the enlarged pelvic lymph nodes. Neoadjuvant chemotherapy and surgery were performed, followed by che- motherapy. The surgery contained radical resection, excision of bilateral accessory, hysterectomy, omentectomy, lymph node excision and abdominal dermoplasty. Histopathological examination showed a serous adenocarcinoma of endometrial origin with lymph node metastasis. Recurrence was noted 3 months after surgery and the patient was followed up until now. 33 literatures on similar cases were reviewed. Conclusion: Extensive lymph nodes metas- tasis might predict a poor prognosis in case of malignant transformation of abdominal wall endometriosis. Radical resection followed by chemotherapy is the most common treatment. Once recurrence occurs, treatments including chemotherapy and radiotherapy are usually ineffective.

Keywords: Serous adenocarcinoma, endometriosis, malignant transformation, cesarean section, lymph node metastasis

Introduction endometriosis in the cesarean section abdomi- nal wall scar and relevant literatures were Endometriosis is a common gynecological dis- reviewed about this rare disease. ease and affects 8.5% of women in childbear- ing age. The most common site of endometrio- Case presentation sis is tissues and organs in the pelvic cavity such as bilateral ovaries, uterosacral ligament, A 48-year-old patient received cesarean sec- fallopian tubes and pelvic wall. However, endo- tion 15 years ago (2001), but a mass was found metriosis can also occur in other organs and in the cesarean section scar accompanied by tissues such as bladder, rectum and abdominal cyclic pain in 2002. Subsequently, the mass wall. In the abdominal wall, it can occur after was excised and pathological examination hysterectomies, particularly after cesarean showed an abdominal scar endometriosis. The section [1]. As the prevalence of cesarean sec- margin was free and no further treatment was tions increases, the incidence of abdominal prescribed after surgery. However, a similar endometriosis is increasing in recent years, but mass was found in the scar again in 2007. the malignant transformation of abdominal wall Macroscopically, the mass was 2 cm in maxi- endometriosis is still rare. Here, we report a mum diameter. Within nearly a year, she felt the case of serous adenocarcinoma arising from mass grew quickly, and the cyclic pain even Serous adenocarcinoma arising from endometriosis

Figure 1. Pelvic MRI before neoadjuvant chemotherapy in Feb.2016. (A-D) Transverse T2-weighted spectral attenu- ated inversion recovery (A), diffusion weighted imaging; b=1000 (B), fat-suppressed T1-weighted (C) and gadolini- um-enhanced fat-suppressed T1-weighted (D). MR images show an anterior abdominal wall mass (white arrow) and several metastatic lymph nodes (black arrow). The mass is 11.5 cm×7.0 cm×7.9 cm. Mixed signals are found in both T1W and T2W (white arrows in A, C), and hyperintense signal in DWI (white arrow in B). Visible marginal separation enhancement is observed (white arrow in D), which is better shown on T1-weighted image. affected her sleep significantly in menstrual this disease. Experts recommended the neoad- cycle. The recent physical examination in Feb juvant chemotherapy to reduce the mass size 2016 revealed a mass sized 15 cm in maximal for further surgical intervention. Three courses diameter on the middle of the cesarean section of chemotherapy were performed in 4th March, scar. The pelvic magnetic resonance imaging 24th March and 14th April, respectively, with (MRI) showed a mass along the abdominal scar albumin paclitaxel (400 mg on Day 1) and car- and the inguinal lymph nodes were enlarged boplatin (600 mg on Day 2). After chemothera- (Figure 1). Pelvic CT and ultrasonography also py, CA125 and CA199 decreased to 20.77 U/ml revealed a lesion measuring 15 cm×12 cm in and 34.75 U/ml, respectively. MRI showed the the abdominal wall. She received fine needle mass reduced to 7 cm in diameter (Figure 3). aspiration biopsy and subsequent pathological examination of the mass and enlarged left The patient received surgery on 17th May. inguinal lymph nodes revealed serous adeno- During laparoscopy, a mass was found to carcinoma (Figure 2). Laboratory examination invade the full thickness abdominal wall to the revealed significant increase in the serum peritoneum. Intra-operative pathological exam- tumor markers, especially CA125 (715.6 U/ml) ination was done and malignancy was con- and CA199 (486.3 U/ml). Multi-disciplinary firmed. Therefore, she underwent radical resec- team (MDT) consultation was hold in March tion including: resection of the mass, excision 2016 and experts from the departments of of bilateral accessory, hysterectomy, omentec- oncology, radiotherapy, pathology, imaging, tomy, lymph node excision and abdominal der- nuclear, surgery, orthopedics and plastic sur- moplasty (the mass was so large that the skin gery discussed the diagnosis and treatment for was difficult to heal after when it was removed).

7535 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

Immunohistochemistry sh- owed the cancer was ER(-), PR(-), Vim(-), CK7(+), CA125 (+), p16(+), p53(+), NapsinA (-), WT1(+), Ki67(70%+) (Fi- gure 2). Post-operative path- ological examination revea- led an abdominal wall adeno- carcinoma without evident evidence of malignancy in the ovaries, fallopian tubes and uterus. Thus, the conclu- sion was malignant transfor- mation from the abdominal wall endometriosis. There were 11/18 positive pelvic lymph nodes, 1/9 positive para-aortic lymph nodes and 2/5 positive bilateral ingui- nal lymph nodes. Therefore, adenocarcinoma mass of the abdominal wall perhaps arising from endometriosis after cesarean section was diagnosed.

On 30th May, the MDT con- sultation was hold again and chemotherapy was still rec- ommended after surgery. Therefore, three courses of chemotherapy were done on 8th June, 28th June and 22nd July, respectively, with albu- min paclitaxel (400 mg on Day 1) and carboplatin (550 mg on Day 2). During the chemotherapy, the serum Figure 2. A. Pathological findings of serous adenocarcinoma within the lymph CA125 and CA199 were nodes (green arrow) (hematoxylin and eosin stain, magnification ×200). B. High Ki67 & p53 expression shown in the immunohistochemistry (green normal. arrow) (magnification ×200) (left: lymph node; right: Ki67 positive cells). C. Positive p16 expression shown in the immunohistochemistry (magnification Unfortunately, in the sixth ×200). D. Positive WT1 expression shown in the immunohistochemistry (mag- course of chemotherapy, a nification ×200). E. Positive CK7 expression shown in the immunohistochem- nodular lesion was found in istry (magnification ×200). F. Negative PR expression shown in the immuno- her abdominal again (Figure histochemistry (magnification ×200). G. Positive CA125 expression shown in 4). On 22nd August, she was the immunohistochemistry (magnification ×200). H. Positive p53 expression shown in the immunohistochemistry (magnification ×200). hospitalized for resection of the recurrent mass. Patho- logical examination of the Macroscopical observation also showed the recurrent tumor revealed adenocarcinoma. inguinal lymph nodes, pelvic lymph nodes and Considering platinum resistance, gemcitabine para-aortic lymph nodes were all enlarged. was used for chemotherapy. However, clinically significant myelosuppression occurred after After surgery, pathological examination showed the first course of gemcitabine treatment. Fin- adenocarcinoma and tumor interstitial fibrosis. ally, liposomal doxorubicin, ifosfamide and bev-

7536 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

Figure 3. Pelvic MRI after neoadjuvant chemotherapy in Apr. 2016. (A-D) Transverse T2-weighted spectral attenuat- ed inversion recovery (A), diffusion weighted imaging; b=1000 (B), fat-suppressed T1-weighted (C) and gadolinium- enhanced fat-suppressed T1-weighted (D). MR images show an anterior abdominal wall mass as lesion after che- motherapy (white arrow). The mass is 6.8 cm×2.3 cm×2.9 cm. Hyperintense signal is found in both T1W and T2W (white arrows in A, C), and hyperintense signal in DWI (white arrow in B). Visible marginal separation enhancement is observed (white arrow in D), which is better shown on T1-weighted image. The mass size significantly reduces as compared to that before treatment (Feb. 2016). acizumab were used for another 3 courses of tumors [4]. Scott added a fourth criterion to chemotherapy up to now (Nov. 2016). In addi- these criteria: transition between benign endo- tion, Traditional Chinese herbal medication was metriosis and carcinoma [5]. However, only a also used during the treatment and she was fol- few cases of malignant abdominal wall endo- lowed up by clinical examination, detection of metriosis meet all four criteria. serum tumor markers (CA125 and CA199), and radiological examinations once monthly. Abdominal wall endometriosis presents as a mass in the abdominal wall, and the patient Discussion usually has a history of surgery, most of which is cesarean section. In 33 cases found in the Surgical scar endometriosis is rare with its inci- literatures, 30 (91%) had a history of cesarean. dence of roughly 0.03-1% [2] and the risk of Most of carcinomas derived from endometrio- transformation of endometriosis to a malignant sis are endometrioid and clear cell adenocarci- disease ranges from 0.3 to 1.0% [3]. The malig- noma, accounting for 91% of all the subtypes in nant transformation of abdominal wall endo- 33 cases found in the literature. In our case, a metriosis is more rare, and less than 40 cases serous adenocarcinoma arose from an endo- have been reported in the literatures (Table 1). metriotic cesarean scar and was about 15 Sampson proposed following 3 criteria for the cm×12 cm accompanied by lymph node metas- diagnosis of a malignant transformation of tasis, but primary ovarian mass was not found. endometriosis: presence of both neoplastic Thus, it was a unique case. In this case, immu- and benign endometrial tissues in the tumor, nohistochemistry showed the tumor was posi- endometrial histology, and no other additional tive for CK7, CA125, p16, p53 and WT1(+), but

7537 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

Figure 4. Plevic MRI of relapse in Aug. 2016. (A-D) Transverse T2-weighted spectral attenuated inversion recov- ery (A), diffusion weighted imaging; b=1000 (B), fat-suppressed T1-weighted (C) and gadolinium-enhanced fat- suppressed T1-weighted (D). MR images show two abnormal signals in lateral rectus abdominis (white arrow and black arrow). The masses are 1.7 cm×1.4 cm and 1.7 cm×1.0 cm, respectively. Hypointense signal is found in T1W (white and black arrows in C), and hyperintense in T2W (white and black arrows in A) as well as in DWI (white and black arrows in B). Visible marginal separation enhancement is observed (white arrow in D), which is better shown on T1-weighted image. negative for ER, PR, Vim, and NapsinA(-). cutaneous cyst, and hematoma. CA125 has Additionally, 70% of cells were positive for Ki67 been reported as normal to mildly elevated [6] in this case, which is accordance with the diag- and has high sensitivity and specificity at 87 nostic criteria for serous adenocarcinoma. The and 92%, respectively. In our case, the serum diagnosis of malignant transformation of CA125 and CA199 increased, and thus both abdominal wall endometriosis should be based were used in the follow up. on following examinations: 1. reviewing of med- ical history: patients usually have a surgical his- In 33 cases found in the literatures, surgical tory, most of which is cesarean section. 2. treatment was performed for malignant trans- imaging examination (such as ultrasonography, formation of abdominal wall endometriosis, of CT and MRI) is needed. 3. cytological examina- which local resection was employed in all tion: fine-needle aspiration of the mass may be cases, and total abdominal hysterectomy or considered. 4. Detection of serum tumor mark- salpingo-oophorectomy in 18 cases (54.5%). ers such as CA125. However, in all the cases reviewed, malignant transformation was not found in either the In the differential diagnosis of abdominal wall uterus or the adnexa. Thus, the significance of mass, following diseases should be consid- hysterectomy and oophorectomy remains ered: abscess, hernia, lymphoma, lipoma, sub- unknown.

7538 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

Table 1. Literatures of the malignant transformation of abdominal wall endometriosis Age Previous Delay Surgical Treat- Follow up Year References Nationality Histology LN CT RT Outcome (years) Surgery (years) ment (Month) 1986 Schnieber, D. and D. Germany 40 CS 15 CCC - LR+TAH+BSO - + 18 DOD Wagner-Kolb [12] 1990 Hlitti et al [17] USA 46 CS 14 CCC - LR+TAH+BSO - - 30 NED 1996 Markopoulos et al [18] Greece 40 CS 25 EC - LR - - 24 NED 1997 Gücer et al [9] Austria 45 CS 8 EC - LR Carboplatin and cyclophosphamide - 20 DOD 1998 Miller et al [19] Canada 38 CS 9 CCC - LR+TAH+BSO Cisplatin - 60 NED 1999 Park et al [20] Korea 54 CS 26 CCC - LR - - NA NA 2003 Li et al [21] China 38 CS 15 CCC - LR+TAH+BSO+OMT Epirubicin, cyclophosphamide and - 14 NED cisplatin 2003 Matter et al [3] Switzerland 60 CS 41 EC - LR - - 18 NED 2003 Ishida et al [1] Japan 56 CS 24 CCC - LR + + 48 DOD 2006 Sergent et al [13] France 45 CS 28 CCC - LR+BSO Taxol and carboplatin - 6 DOD 2006 Leng et al [10] China 41 CS 16 Carcinosarcoma - LR Cisplatin and ifosfamide - 15 DOD 2006 Alberto et al [22] Irland 38 CS 11 CCC - LR Taxol and carboplatin. + NA NA 2007 Harry et al [23] UK 55 Open tubal sterilization 30 CCC - LR - + 18 NED 2008 Bats et al [14] France 38 CS 13 CCC + LR+TAH+BSO+OMT Taxol and carboplatin. - 8 REC 2009 William et al [2] Canada 53 CS 17 CCC + LR+TAH+BSO+OMT Taxol and carboplatin. - 11 DOD 2009 Matsuo et al [15] USA 37 LC 10 CCC + LR+TAH+BSO+OMT Taxol and carboplatin. - 18 REC 2010 Omranipour and Naja [24] Iran 59 Laparotomy for uterine 20 SC - LR+TAH+BSO Platinum-based + 12 NED perforation 2010 Bourdel et al [7] France 43 CS 20 CCC + LR+TAH+BSO Taxol and carboplatin. + 22 DOD 2010 Drukala et al [8] Poland 43 CS 17 EC + LR+TAH+BSO 9 PAC (cyclophosphamide, cisplatin, + 132 DOD doxorubicin) +1 VFP (cisplatin, etoposide, 5-fluorouracil) 2011 Da Ines et al [25] France 48 CS 16 EC+SC + LR+LH+BSO Taxol and carboplatin. - 15 NED 2011 Yan et al [26] China 41 CS NA CCC - LR + - 24 NED 2012 Mert et al [27] USA 42 CS NA CCC - LR+TAH+BSO+OMT Taxol and carboplatin. - 26 NED 2012 Mert et al [27] USA 51 CS NA CCC - LR+BSO+OMT - + 49 NED 2012 Shalin et al [28] USA 47 CS NA CCC + LR Cisplatin-based + 7 NED 2012 Li et al [29] China 49 CS 25 CCC - LR Taxol and carboplatin. - 8 NED 2013 Fargas et al [30] Spain 49 CS 15 SC + LR+LH+BSO Taxol and carboplatin. - 48 NED 2013 Vinchant et al [31] France 43 CS 10 EC + LR Caelyx and carboplatin - N/A NA 2013 Taburiaux et al [32] Switzerland 56 CS 29 EC - LR Taxol and carboplatin. - 17 NED 2013 Stevens et al [33] USA 51 CS NA EC - LR + + 6 NED 2014 Liu et al [11] China 39 CS 10 CCC + LR+TAH+BSO+OMT Taxol and carboplatin. - 12 DOD 2014 Ljichi et al [6] Japan 60 CS 35 CCC - LR - - 8 REC 2015 Ruzi et al [16] USA 41 CS 20 CCC - LR+TAH+BSO+OMT Taxol and carboplatin. + 6 REC 2015 Ruzi et al [16] USA 57 CS 30 CCC + LR+TAH+BSO Taxol and carboplatin. + NA NA 2016 This case China 48 CS 15 SC + LR+TAH+BSO+OMT Taxol and carboplatin; Gemcitabine; - Follow-up Follow-up Liposomal doxorubicin, ifosfamide and bevacizumab Notes: LN: lumph node invasion, CT: chemotherapy, RT: radiotherapy, BSO: bilateral salpingo-oophorectomy, TAH: total abdominal hysterectomy, OMT: omentectomy, LR: local resection, CCC: clear cell adenocarcinoma, SC: serous adenocarci- noma, EC: endometrioid adenocarcinoma, CS: cesarean section, LC: laparoscopic cystectomy, DOD: died of disease, NED: no evidence of disease, REC: recurrence, NA: not available.

7539 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

In our case, the mass was too large to remove, Address correspondence to: Dr. Wen Di, Depart- and thus neoadjuvant chemotherapy was ment of Obstetrics and Gynecology, Ren Ji Hospital, performed before surgery. Three courses of School of Medicine, Shanghai Jiao Tong University, neoadjuvant chemotherapy were done and Shanghai 200127, China. Tel: 86-21-68383801; blood biochemical examinations showed both E-mail: [email protected] CA125 and CA199 decreased substantially. MRI showed the mass reduced to 7 cm in diam- References eter. The patient received surgical intervention [1] Ishida GM, Motoyama T, Watanabe T and Emu- thereafter, including resection of the mass, ra I. Clear cell carcinoma arising in a cesarean excision of bilateral accessory, hysterectomy, section scar. Report of a case with fine needle omentectomy, lymph node excision and abdom- aspiration cytology. Acta Cytol 2003; 47: 1095- inal dermoplasty. Since the lymph nodes were 1098. positive, chemotherapy continued after surgery [2] Williams C, Petignat P, Belisle A and Drouin P. with paclitaxel and carboplatin. However, this Primary abdominal wall clear cell carcinoma: patient experienced a relapse in the cesarean case report and review of literature. Anticancer section scar after three courses of chemother- Res 2009; 29: 1591-1593. [3] Matter M, Schneider N and McKee T. Cystade- apy. In the available cases, 9 patients (27.3%) nocarcinoma of the abdominal wall following died of this disease [1, 2, 7-13] and 4 patients caesarean section: case report and review of (12.1%) had relapse [6, 14-16]. Once recur- the literature. Gynecol Oncol 2003; 91: 438- rence occurred, there is no effective treatment 443. including chemotherapy and radiotherapy [11]. [4] Sampson JA. Endometrial carcinoma of the As the prevalence of cesarean section is ovary arising in endometrial tissue in that or- increasing, the incidence of malignant transfor- gan *. American Journal of Obstetrics & Gyne- mation of abdominal wall endometriosis is cology 1925; 9: 111-114. expected to increase. More studies are war- [5] Scott RB. Malignant changes in endometriosis. ranted to investigate the optimal treatments for Obstet Gynecol 1953; 2: 283-289. malignant transformation of abdominal wall [6] Ijichi S, Mori T, Suganuma I, Yamamoto T, Mat- sushima H, Ito F, Akiyama M, Kusuki I and Kit- endometriosis. awaki J. Clear cell carcinoma arising from ce- sarean section scar endometriosis: case Conclusion report and review of the literature. Case Rep Obstet Gynecol 2014; 2014: 642483. We report a 48-year-old woman who was diag- [7] Bourdel N, Durand M, Gimbergues P, Dauplat J nosed with serous adenocarcinoma arising and Canis M. Exclusive nodal recurrence after from endometriosis in cesarean section ab- treatment of degenerated parietal endometrio- dominal wall scar. She received neoadjuvant sis. Fertil Steril 2010; 93: 2074, e2071-2076. chemotherapy, followed by surgical interven- [8] Drukala Z, Ciborowska-Zielinska B, Kubrak J tion and post-operative chemotherapy, but and Rogowska D. Outcome of a multimodal recurrence occurs during radiotherapy and che- therapy of a recurrent adenocarcinoma arising motherapy. By reviewing literature, extensive from caesarean section scar endometriosis-a lymph nodes metastasis usually predicts a case report. Rep Pract Oncol Radiother 2010; poor prognosis. Once recurrence occurs, there 15: 75-77. [9] Gucer F, Reich O, Kometter R and Pieber D. En- is no effective treatment including chemothera- dometroid carcinoma arising with a scar endo- py and radiotherapy. More studies are needed metriosis. Eur J Gynaecol Oncol 1997; 18: 42- to investigate the optimal treatment for this 43. disease. [10] Leng J, Lang J, Guo L, Li H and Liu Z. Carcino- sarcoma arising from atypical endometriosis in Acknowledgements a cesarean section scar. Int J Gynecol Cancer 2006; 16: 432-435. The study was supported by Shanghai Munici- [11] Liu H, Leng J, Lang J and Cui Q. Clear cell carci- pal Health and Family Planning Commission noma arising from abdominal wall endometrio- Funding (15GWZK0701). sis: a unique case with bladder and lymph node metastasis. World J Surg Oncol 2014; Disclosure of conflict of interest 12: 51. [12] Schnieber D and Wagner-Kolb D. [Malignant None. transformation of extragenital endometriosis].

7540 Int J Clin Exp Pathol 2017;10(7):7534-7541 Serous adenocarcinoma arising from endometriosis

Geburtshilfe Frauenheilkd 1986; 46: 658- [24] Omranipour R and Najafi M. Papillary serous 659. carcinoma arising in abdominal wall endome- [13] Sergent F, Baron M, Le Cornec JB, Scotte M, triosis treated with neoadjuvant chemotherapy Mace P and Marpeau L. [Malignant transfor- and surgery. Fertil Steril 2010; 93: 1347. mation of abdominal wall endometriosis: a e1317-1348. new case report]. J Gynecol Obstet Biol Reprod [25] Da Ines D, Bourdel N, Charpy C, Montoriol PF, (Paris) 2006; 35: 186-190. Petitcolin V, Canis M and Garcier JM. Mixed en- [14] Bats AS, Zafrani Y, Pautier P, Duvillard P and dometrioid and serous carcinoma developing Morice P. Malignant transformation of abdomi- in abdominal wall endometriosis following ce- nal wall endometriosis to clear cell carcinoma: sarean section. Acta Radiol 2011; 52: 587- case report and review of the literature. Fertil 590. Steril 2008; 90: 1197, e1113-1196. [26] Yan Y, Li L, Guo J, Zheng Y and Liu Q. Malignant [15] Matsuo K, Alonsozana EL, Eno ML, Rosen- transformation of an endometriotic lesion de- shein NB and Im DD. Primary peritoneal clear rived from an abdominal wall scar. Int J Gynae- cell adenocarcinoma arising in previous ab- col Obstet 2011; 115: 202-203. dominal scar for endometriosis surgery. Arch [27] Mert I, Semaan A, Kim S, Ali-Fehmi R and Mor- Gynecol Obstet 2009; 280: 637-641. ris RT. Clear cell carcinoma arising in the ab- [16] Ruiz MP, Wallace DL and Connell MT. Transfor- dominal wall: two case reports and literature mation of abdominal wall endometriosis to review. Am J Obstet Gynecol 2012; 207: e7-9. clear cell carcinoma. Case Rep Obstet Gynecol [28] Shalin SC, Haws AL, Carter DG and Zarrin- 2015; 2015: 123740. Khameh N. Clear cell adenocarcinoma arising [17] Hitti IF, Glasberg SS and Lubicz S. Clear cell from endometriosis in abdominal wall cesare- carcinoma arising in extraovarian endometrio- an section scar: a case report and review of sis: report of three cases and review of the lit- the literature. J Cutan Pathol 2012; 39: 1035- erature. Gynecol Oncol 1990; 39: 314-320. 1041. [18] Markopoulos C, Gogas H, Eleftheriou G and [29] Li X, Yang J, Cao D, Lang J, Chen J and Shen K. Floros D. Endometrioid carcinoma arising in a Clear-cell carcinoma of the abdominal wall af- scar of caesarean section. Case report. Eur J ter cesarean delivery. Obstet Gynecol 2012; Gynaecol Oncol 1996; 17: 520-521. 120: 445-448. [19] Miller DM, Schouls JJ and Ehlen TG. Clear cell [30] Fargas Fabregas F, Cusido Guimferrer M, carcinoma arising in extragonadal endometrio- Tresserra Casas F, Baulies Caballero S and sis in a caesarean section scar during preg- Fabregas Xaurado R. Malignant transforma- nancy. Gynecol Oncol 1998; 70: 127-130. tion of abdominal wall endometriosis with [20] Park SW, Hong SM, Wu HG and Ha SW. Clear lymph node metastasis: case report and re- cell carcinoma arising in a Cesarean section view of literature. Gynecol Oncol Case Rep scar endometriosis: a case report. J Korean 2014; 8: 10-13. Med Sci 1999; 14: 217-219. [31] Vinchant M, Poncelet C, Ziol M, Vons C and Bri- [21] Li JY, Chen YJ, Wu YC, Hung JH, Yuan CC, Shu cou A. Malignant transformation of abdominal LP and Wang PH. Two- and three-dimensional wall endometriosis: case report and literature Doppler ultrasound analysis of abdominal wall review. Tumori 2013; 99: e49-54. clear cell carcinoma. Ultrasound Obstet Gyne- [32] Taburiaux L, Pluchino N, Petignat P and Wenger col 2003; 22: 98-100. JM. Endometriosis-associated abdominal wall [22] Alberto VO, Lynch M, Labbei FN and Jeffers M. cancer: a poor prognosis? Int J Gynecol Cancer Primary abdominal wall clear cell carcinoma 2015; 25: 1633-1638. arising in a caesarean section scar endome- [33] Stevens EE, Pradhan TS, Chak Y and Lee YC. triosis. Ir J Med Sci 2006; 175: 69-71. Malignant transformation of endometriosis in [23] Harry VN, Shanbhag S, Lyall M, Narayansingh a cesarean section abdominal wall scar: a GV and Parkin DE. Isolated clear cell adenocar- case report. J Reprod Med 2013; 58: 264- cinoma in scar endometriosis mimicking an 266. incisional hernia. Obstet Gynecol 2007; 110: 469-471.

7541 Int J Clin Exp Pathol 2017;10(7):7534-7541