La tunisie Medicale - 2010 ; Vol 88 ( n°011 ) : 841 - 843
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Summary

Background: Endometriosis is characterized by the presence of an ectopic endometrial tissue. It affects between 1% and 5% of women in reproductive age. Its main clinical symptoms are dysmenorrhoea and infertility. Among women having had abdominal surgery for any gynecological reason, the prevalence of endometriosis is between 15% and 50%.
Case report : We report the case of a 15 year-old patient who underwent surgery twice : once for appendicitis two years before and once for acute salpingitis and tubo-ovarian abscesses one year before. Laparotomy was performed by Pfannenstiel incision. The post operative course was uneventful. The patient reported the
gradual emergence of two bluish nodes on the abdominal scar. These nodules became painful and turgid during the menstrual period. She also reported the issue of blood from the abdominal scar during menstruation. The abdominal examination, performed during the
menstrual period, showed a scar of good quality and two regular shiny and bluish cutaneous nodules measuring 1 cm in size. These elements were firm and painless. An endometriosis node on the scar of laparotomy was suspected. Surgery was performed in order to remove both nodules. At surgery the depth of nodules reached the top of the abdominal fascia of the major rights. The content of these nodules was chocolate brown. The histo-pathological examination confirmed that these nodules contained ectopic endometrial tissue.
Conclusion : The etiopathogeny of endometriosis is still a subject of debate. This case illustrates the possibility of occurrence of endometriosis on abdominal scars after laparotomy: an unusual location.

Key - Words
Article

Endometriosis is characterized by the presence of an ectopic endometrial tissue. It affects between 1% and 5% of women in reproductive age. Cutaneous endometriosis is characterized by the presence of extrauterine endometrial tissue in or under the skin. It appears most often on surgical scars of pelvic interventions and in the physiologic scar of the umbilicus.

CASE REPORT

A 15 year-old patient who underwent surgery twice: once for appendicitis two years before and once for acute salpingitis and tubo-ovarian abscesses one year before presented in our departement. Laparotomy was performed by Pfannenstiel incision. The post operative course was uneventful. The patient reported the gradual emergence of two bluish nodes on the abdominal scar (Fig 1).
These nodules became painful and turgid during the menstrual period. She also reported the issue of blood from the abdominal scar during menstruation. The abdominal examination, performed during the menstrual period, showed a scar of good quality and two regular shiny and bluish cutaneous nodules measuring 1 cm in size. These elements were firm and painless.
An endometriosis node on the scar of laparotomy was suspected. Surgery was performed in order to remove both nodules (Fig 2). At surgery the depth of nodules reached the top of the abdominal fascia of the major rights. The content of these nodules was chocolate brown. The histo-pathological examination confirmed that these nodules contain ectopic endometrial tissue (Fig3). A pelvic MRI was realized to this patient. The MRI did not suggest the existence of associated pelvis endometriosis.

Figure 1:
Two bluish cutaneous nodules



Figure 2: Surgical appearance scar-related endometriosis



Figure 3: Histopathogical exam: glandular structures lined by endometrial epithelial cells and surrounded by a cellular stroma with extravasated erythrocytes



DISCUSSION

Although endometriosis is usually related anatomically to the uterus and its attachments, extrapelvic endometriosis may occur in 12% of women with endometriosis [1]. It occurs most often at the following extra pelvic sites: intestine, skin, including umbilicus and abdominal scars, inguinal region; and the lung [1]. Cutaneous endometriosis occurs most commonly as a secondary process in scars after an abdominal or pelvic intervention such as hysterectomy, caesarean sections,
episiotomy and laparoscopy or may arise on non cicatricle abdomen in the umbilical and inguinal regions [1, 2, 3].
Abeshouse [3] noted that in 39 of 56 cases of genitourinary endometriosis, previous pelvic surgery had been performed, suggesting that the dissemination of endometrial tissue may be the cause of endometriosis in some women. The average time that elapsed between surgery and the clinical emergence of endometriosis on the scar was approximately 30 months. [3] Our patient underwent surgery twice: once for appendicitis two years before and once for acute salpingitis and tubo-ovarian abscesses one year before.
When associated with a scar, the lesion most likely arises as a result of iatrogenic mechanical implantation and imitative metaplasia induced by endometrial cells in susceptible tissue [1]. The dissemination of endometrial cells is related to the previous operation. However, 75% of the patients with cutaneous endometriosis who underwent abdominal surgery had no evidence of coexisting abdominal endometriosis [4]. Thus, a negative history for abdominal endometriosis does not
eliminate cutaneous endometriosis from the differential diagnosis. As a matter of fact, in our case, the patient did not have abdominal endometriosis.
A bluish, painful, cutaneous nodule with a history of bloody or brown discharge and increased symptoms during menstrual flow is considered pathognomonic for cutaneous endometriosis [5]. This classic clinical presentation is the exception rather than the rule. Bleeding is observed in only 15% of the lesions and cyclic symptoms associated with menstruation in 52%. [4] Both surgical and medical treatments have been used in the management of cutaneous endometriosis. Excisional biopsy with clinically guided margins offers a recurrence rate of 11%, most recurrences being evident within one year [4,5]. Medical management for cutaneous endometriosis was attempted by Chatterjee [4] with daily oral norethisterone resulting in no clinical improvement. Studies comparing the concentration of
hormone receptors in ectopic and intrauterine endometrium note a lower concentration of these receptors in ectopic endometriosis, which may partially explain the poor response rates to medical therapy [4]. Also, Mostoufizadeh [6] noted that excess endogenous or exogenous estrogens may play a role in the development of a malignancy such as clear cell carcinoma and stressed on caution in the decision to use estrogens. Given the ineffective results and potential risks of medical
management, combined with the frequent need for an excisional biopsy to aid in the diagnosis, surgical intervention is the treatment of choice for cutaneous endometriosis [7].

CONCLUSION

The pathogenesis of endometriosis is still a subject of debate.
This case illustrates the possibility of occurrence of endometriosis on abdominal scars after laparotomy: an unusual location. Although malignant transformation of cutaneous endometriosis is extremely rare, we can prevent this rare event by good technique and proper care during abdominal or pelvic surgery. Finally, the treatment of cutaneous endometriosis is based on surgery.

Reference
  1. Ying AJ, Copeland LJ, Hameed A, Myxoid Change in non decidualized cutaneous endometriosis resembling malignancy. Gynecol Oncol 1998; 68: 301–3.
  2. Teh WT, Vollenhoven B, Harris PI. Umbilical endometriosis, a pathology that a gynecologist may encounter when inserting the Veres needle. Fertil Steril 2006;86:1764 -2.
  3. Choi SW, Lee HN, Kang SJ, Kim HO. A case of cutaneous endometriosis developed in postmenopausal woman receiving hormonal replacement. J Am Acad Dermatol 1999; 41:327-9.
  4. Chatterjee SK. Scar endometriosis: a clinicopathologic study of 17 cases. Obstet Gynecol. 1980;56:81-4.
  5. Fernandez Acenero MJ, Cordova S. Cutaneous endometriosis : review of 15 cases diagnosed at a single institution. Arch Gynecol Obstet 2010 [Epub ahead of print] PMID: 20422419.
  6. Mostoufizadeh M, Scully RE. Malignant tumors arising in endometriosis. Clin Obstet Gynecol. 1980;23:951-63.
  7. Sergent F, Baron M, Le Cornec JB, Scotté M, Mace P, Marpeau L. Malignant transformation of abdominal wall endometriosis: a new case report. J Gynecol Obstet Biol Reprod 2006; 35:186 – 190.
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