**3. Occurrence and diagnostics**

86 Endometriosis - Basic Concepts and Current Research Trends

Vascular dissemination theory (27), in turn, with endometrial cells spread into blood or lymphatic circulation may explain distal locations of endometriosis. Very interesting was one of cases described by Agarwal and Fong (1). This Chinese woman suffering from sterility and a lump in right inguinal region had twice laparoscopy and ablation of endometriotic intraperitoneal lesions without managing of the lump. Third laparoscopy revealed endometriotic deposits along the right round ligament contiguous with this lump which was afer excision diagnosed as an endometrioma. It may be speculated, that in some conditions endometriotic cells can infiltrate per continuitatem like a malignant

The etiopathogenetic mechanism of endometriosis localized in surgical scars would be related to iatrogenic transplantation of endometrium during delivery or surgery, mostly

All the mentioned above theories could only elucidate mainly the way on which endometrial cells or fragments could be transported to their improper localizations. But still

Endometriosis is defined as a steroid-dependent condition with a particular genetic background (37). It is well known, that estrogens promote the development of endometriotic

There is substantial evidence that not only hormonal but first of all immunologic factors play a role in the pathogenesis of endometriosis (3, 54, 56). Immune alterations include increased number and activation of macrophages, decreased T cells reactivity and NK cells cytotoxicity, increased circulating antibodies and changes in the cytokine system. These alterations are responsive for implantation and survival of the ectopic endometrial cells and concomitant inflammatory reaction and pain. Increased oxidative stress appears to be a common contributory factor in the pathogenesis of endometriosis (3). Wicherek et al. (56) in discussion consider that endometral cells are implanted in ectopic places usually during the maintenance of higher immunotolerance, including pregnancy. The ectopic endometrium preserves the ability to undergo reversible decidualization. Once implanted develops further when estrogens level raise with a concomitant lack of

The next factor, playing a potent role are endometrial stromal cells themselves. When stimulated by estrogens the endometriotic cells may proliferate until they become symptomatic. Moreover, endometriotic lesions can thanks to aromatase activity produce

It is known, that in patients suffering from endometriosis higher activity of integrins and cadherin E on surface of endometrial and mesothelial cells is expressed (24). This may explain the better ability of adhesion of these cells in another places than uterine cavity. The invasion of them is enhanced by metalloproteinases. It was shown, that in patients with endometriotic lesions even eutopic endometrium expresses higher activity of matrix metalloproteinase -2 (MMP-2) whereas lower of tissue matrix metalloproteinase inhibitor – 2 (TIMP-2) (14). The ability of endometrial cells to regulate the cytotoxic immune activity by expression of factors such as RCAS 1 or metallothionein enables their survival in ectopic

remains unclear why in these places the endometrial cells survive and proliferate.

lesions and anti-estrogen or gestagen therapy can diminish the symptoms.

tumour.

gynecological.

adequate progesterone level.

estrogens locally themselves (9).

The disease is uncommon but not so rare. The extraperitoneal localizacion of the lesion is mainly the abdominal wall scar, but should be also in episotomy scar, bowel, bladder, lung, kidneys, brain, umbilicus, groin (29) and even in male urinary tract (51). Leite et al. (38) mentioning except those liver, extremities and pericardium, confirm the opinion that extrapelvic endometrioma occurs mainly as a complication of cesarean section, hysterectomy and episiotomy. Akagi et al. (2) reported an asymptomatic case of endometriosis of the appendix. Endometriosis in the inguinal channel usually occurs on the right side (90%) and in 32% may be associated with an hernia (15, 20). This feature seems to be due to the clockwise circulation of the peritoneal fluid and to the presence of sigmoid colon that shields the left inguinal ring (20). Vulvar involvement of endometriosis is extremely rare. Buda et al. (8) described a case of endometriosis in a scar after excicion of the Bartholin gland.

According to Chaterjee (11) endometriosis of the abdominal wall occurs in 0,03 – 1,08% of women with previous history of obstetric or gynecologic procedures. Leite et al. (38) reviewing bibliography estimates the incidence of abdominal wall endometrioma on 0,03 – 3,5%. Nominato et al. (41) in their large series report the incidence of scar endometrioma in 0,2% women submitted former to cesarean section but only in 0,06% when episiotomy was made. Singh et al. (52) reported three cases, considering that the true incidence of this disease (0,8%) is underestimated because a lot of cases remains undetected. Agarwal and Fong (1) reporting 10 cases (among them six in Pfannenstiel scar) estimate the frequency of cutaneous localization of disease 1,1%. Unusually high percent (5,2%) of cutaneous localization of endometriosis was reported from Glasgow (18).

Concerning the coincidence of peritoneal and abdominal wall endometriosis das Chagas Medeiros et al. (10) basing on literature data estimates the frequency of abdominal wall endometriosis on about 0,5 – 1% in women with pelvic endometriosis. According to another data in 13% both of the forms of disease are present (29), more often by spontaneous abdominal wall endometriosis without any previous surgery (1).

The diagnosis of endometriosis in the postoperative scars is usually established basing on characteristic clinical symptoms as the presence of slowly developing immobile lump, which seems to be attached to the anterior fascia, in the scar or near of them, often swelling during menstruation and painful, especially in this period in most of cases. Sometimes occurs periodical bleeding from the superficial lesions and lower abdominal pain (1, 4, 29). The boundary of the mass is not clear usually. Incision of it looks grey or slightly yellowish (59). Leite et al. (38) in turn, describe it as whitish fibrous tumor with thick chocolate-like colored liquid areas.

Endometrial Tumors in Postoperative Scars - Pathogenesis, Diagnostics and Treatment 89

cytology. Some authors (12) consider, that needle biopsy may be dangerous, because of

The diagnostic pitfalls are more common among general surgeons, who are very often first contact physicians (5, 13, 34), especially when no palpable masses are present. Sometimes are misleading the age of the patient (4) or enormously long time between the cesarean section and occurrence of the first symptoms. The disease most often occurs in adult young women in their twenties till forties but Attia et al. (4) also reported a case of

Abdominal wall endometriosis is often misdiagnosed as a hernia, hematoma, lyphadenopathy, lymphoma, lipoma, abscess, subcutaneous cyst, suture granuloma, neuroma, soft tissue sarcoma, desmoid tumours and metastatic cancer, particularly as many endometrial tumours of the abdominal wall are not related to prior surgical procedures (29). Even cellulites is mentioned as a possible misdiagnostic condition (1). Gajjar et al. (22) and Khoo (33) described a case of cesarean scar endometriosis presenting as an acute abdomen. Umbilical endometriosis can pose a next diagnostic dilemma (1, 48) simulating malignant melanoma or the "sister Mary Joseph nodule" – a manifestation of intraabdominal malignancy. Endometriosis should mimick hernia recurrence in tne inguinal region, especially if it is painless (19). On the other hand not only endometrial tissue can implant into postoperative scars. Neumann et al. (40) reported a rare case of implantation of adenosquamous cervical carcinoma in an episiotomy scar mentioning 13 another cases

The occurrence of the endometriosis in an postoperative scar is usually the result of a previous caesarean section or abdominal hysterectomy but any other surgery might be a cause of this disease. Harry et al. (28) presented a case of the scar endometriosis converting in a clear cell adenocarcinoma more than 30 years after an open tubal sterilization. Zhu et al. (59) basing on another reports, are of opinion, that tubal mucosa after simply tubal ligation brought into the incision is able to transform to the endometrial tissue. Kaunitz and Di Saint'Agnese reported about endometriosis as a complication of amniocentesis (30). One of the cases presented by Agarwal and Fong (1) had an endometriotic lesion after appendectomy. Kurotsuchi et al. (36) described a case of abdominal scar endometriosis as a complication of laparotomy performed because of uterine perforation during dilatation and curettage. Aydin (4) mentioned about rising incidence of endometriomas in port sites after

A surgical resection with complete and wide negative margins is the treatment of choice of endometriotic lesions in the abdominal wall, taking into account the risk of recurrence and the potential for their malignant transformation (1, 8, 12, 13, 28, 29, 43, 59). If the endometriosis is incorporated into the musculature, en bloc resection of all the myofascial elements is recommended and often mesh repair of the abdominal wall is necessary (1, 29, 43, 59). Figures 1 – 6 illustrate the procedure in such a case of 15 cm endometrioma in Bytom

dissemination of endometrial or even neoplasmatic cells.

15 years old girl.

reported to date.

laparoscopy.

clinical centre.

**4. Surgical treatment** 


Horton et al. (29) summarized their review of 445 cases from 29 reports till 2006 as follows (table 1):

٭ largest single dimension

NC = not calculated

Table 1. Summary of review data of cases of abdominal wall endometriosis

No other diagnostic tools are necessary if the anamnesis and physical examination are classical. In another cases, especially if the lesion is large, further investigation should be very useful (29).

The preoperative diagnosis should be confirmed by ultrasound scan of the lesion (21, 52, 59). Francica et al. (21) described extensionally ultrasonographic picture of small (0,7 – 2,6 cm) and large (3 – 6 cm) lesions. The most typical ultrasound pattern was that of a solid nonhomogenous hypoechoic nodule with infiltrating margins, echogenic rim and increased vascularity in the musculocutaneous planes of the abdominal wall near the cesarean section incision. In large lesion there was significantly higher grey-scale, higher incidence of cystic areas and fistulous tracts, loss of round or oval shape, multiple vascular pedicles and central vascularity comparing to small lesions.

Very useful should be a computerized tomography or magnetic resonace imaging. The data from these diagnostic procedures may be helpful even during planning a reconstructional operation of the abdominal wall (29, 39), though Francica et al. (21) consider that they often are nonspecific.

Sometimes, if the lesion is very superficial, epiluminescence microscopy should be used (23) to exclude melanoma.

Fine-needle aspiration cytology (10, 26) in suspicious cases is very good and cheap diagnostic tool if an incisional hernia is ruled out, of course. Epithelial endometrial-like cells, stromal cells or hemosiderin-laden macrophages are essential to confirm endometriosis on cytology. Some authors (12) consider, that needle biopsy may be dangerous, because of dissemination of endometrial or even neoplasmatic cells.

The diagnostic pitfalls are more common among general surgeons, who are very often first contact physicians (5, 13, 34), especially when no palpable masses are present. Sometimes are misleading the age of the patient (4) or enormously long time between the cesarean section and occurrence of the first symptoms. The disease most often occurs in adult young women in their twenties till forties but Attia et al. (4) also reported a case of 15 years old girl.

Abdominal wall endometriosis is often misdiagnosed as a hernia, hematoma, lyphadenopathy, lymphoma, lipoma, abscess, subcutaneous cyst, suture granuloma, neuroma, soft tissue sarcoma, desmoid tumours and metastatic cancer, particularly as many endometrial tumours of the abdominal wall are not related to prior surgical procedures (29). Even cellulites is mentioned as a possible misdiagnostic condition (1). Gajjar et al. (22) and Khoo (33) described a case of cesarean scar endometriosis presenting as an acute abdomen. Umbilical endometriosis can pose a next diagnostic dilemma (1, 48) simulating malignant melanoma or the "sister Mary Joseph nodule" – a manifestation of intraabdominal malignancy. Endometriosis should mimick hernia recurrence in tne inguinal region, especially if it is painless (19). On the other hand not only endometrial tissue can implant into postoperative scars. Neumann et al. (40) reported a rare case of implantation of adenosquamous cervical carcinoma in an episiotomy scar mentioning 13 another cases reported to date.

The occurrence of the endometriosis in an postoperative scar is usually the result of a previous caesarean section or abdominal hysterectomy but any other surgery might be a cause of this disease. Harry et al. (28) presented a case of the scar endometriosis converting in a clear cell adenocarcinoma more than 30 years after an open tubal sterilization. Zhu et al. (59) basing on another reports, are of opinion, that tubal mucosa after simply tubal ligation brought into the incision is able to transform to the endometrial tissue. Kaunitz and Di Saint'Agnese reported about endometriosis as a complication of amniocentesis (30). One of the cases presented by Agarwal and Fong (1) had an endometriotic lesion after appendectomy. Kurotsuchi et al. (36) described a case of abdominal scar endometriosis as a complication of laparotomy performed because of uterine perforation during dilatation and curettage. Aydin (4) mentioned about rising incidence of endometriomas in port sites after laparoscopy.
