**4. Surgical treatment**

88 Endometriosis - Basic Concepts and Current Research Trends

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

 Data Result 95% CI Mean age (years) 31,4 29,1 – 33,8 Mean interval to symptoms (years) 3,6 2,5 – 4,8 Presenting with mass 96% 93 – 99,7% Presenting with pain 87% 80 – 93% Cyclic symptoms 57% 44 – 70% Concurrent pelvic endometriosis 13% 5,6 – 20% Mean size of mass (cm)٭ 2,7 2,1 – 3,2 Recurrence rate 4,3% 1,2 – 7,4% Associated with a cesarean section scar 57% NC Associated with a hysterectomy scar 11% NC Associated with other surgeries 13% NC Spontaneous abdominal wall endometriosis 20% NC

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

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

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

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

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

(table 1):

٭ largest single dimension NC = not calculated

very useful (29).

are nonspecific.

to exclude melanoma.

vascularity comparing to small lesions.

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 clinical centre.

Endometrial Tumors in Postoperative Scars - Pathogenesis, Diagnostics and Treatment 91

Fig. 3. The polypropylene mesh ready to use

Fig. 4. Abdominal wall thoroughly repaired by mesh

Fig. 1. Large endometrioma penetrating abdominal wall.

Fig. 2. Endometrioma is totally excised with wide margins including peritoneum

Fig. 3. The polypropylene mesh ready to use

Fig. 1. Large endometrioma penetrating abdominal wall.

Fig. 2. Endometrioma is totally excised with wide margins including peritoneum

Fig. 4. Abdominal wall thoroughly repaired by mesh

Endometrial Tumors in Postoperative Scars - Pathogenesis, Diagnostics and Treatment 93

A wide surgical resection is also the therapy of choice when the endometrioma is localized in perineal scars (8, 11, 41, 51). If necessary, even anal sphincter reconstruction ought to be performed (6). Dougherty and Hull (11) clearly demonstrated in their series of patients that narrow excision only gives a very high rate of recurrences whereas wide excision does not. Fedele et al. (20) advise in cases of inguinal endometriosis also the removal of the

All the excised specimen must be examined histopathologically because of mentioned above reasons (12, 38, 43). The frozen section is advisable (59). Histopatological examination reveals usually ectopic endometrial glands with surrounding cellular stroma, occasionally associated with extravasation of erythrocytes and some inflammatory infiltrates around the

Recently, the largest and exhausting study on histopatology of cutaneous endometriosis basing on 73 patients presented Kazakov et al. (31). The excised nodules looked out macroscopically as a gray-white scar-like tissue with or without an evidence of hemorrhage containing tiny cysts when viewed under a magnifying glass. Two cases were excluded from study because of fibrotic granulation tissue in the first and cutaneous endosalpingiosis in the second one with a complete lack of endometriotic tissue in both. The resting cases showed typical endometriotic glands with a characteristic stroma. The müllerian epithelium is apt to show a broad spectrum of metaplastic changes. The authors discovered in glandular component in most of cases tubal metaplasia (61%), less often reactive atypia (23%), oxyphilic metaplasia (15%), hobnail metaplasia (10%), atypical mitoses in glands (6%), mucinous metaplasia (4%), papillary syncytial metaplasia in two cases and hyperplasia in one. The stromal component revealed mostly myxoid changes (69%), less often smooth muscle metaplasia (31%) and in single cases decidual changes, stromal endometriosis, micronodular stromal endometriosis and elastosis. In ¾ of specimens were observed large granular CD56 positive lymphocytes. Quite frequently occurred lipoblast like cells (15%), intranuclear inclusions in adipocytes (10%), atypically appearing myocytes (10%) and spiral arteries (4%). Perineural invasion was present in one case. The authors also

advertised, that endometrioid or clear cell cancer can occur in the skin lesions.

Zhang et al. (58) evidenced that bothersome pain caused usually by endometriotic lesion is caused by sensory nerve fibres which are present mainly in deeply infiltrating

Medical management of the endometriosis by drugs as danazol, GnRH-analogues, progestagens or oral contraceptives, results usually in the temporary relief of pain (53). Opinions concerning combined therapy are different. According to Horton et al. (29) there are no data to support postoperative hormonal therapy. Sometimes might be useful preoperative treatment by GnRH-analogues for three months to diminish the tumour size

A large use of coagulation is advised to diminish bleeding and a risk of recurrences (35).

extraperitoneal portion of the round ligament to avoid recurrences.

**5. Histopathology** 

glands (5, 33, 38).

endometriosis.

**6. Pharmacological treatment** 

Fig. 5. The skin is sutured.

Fig. 6. The excised endometrioma of size 15 cm.

A large use of coagulation is advised to diminish bleeding and a risk of recurrences (35).

A wide surgical resection is also the therapy of choice when the endometrioma is localized in perineal scars (8, 11, 41, 51). If necessary, even anal sphincter reconstruction ought to be performed (6). Dougherty and Hull (11) clearly demonstrated in their series of patients that narrow excision only gives a very high rate of recurrences whereas wide excision does not.

Fedele et al. (20) advise in cases of inguinal endometriosis also the removal of the extraperitoneal portion of the round ligament to avoid recurrences.
