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Original Research |
1 Department of Radiology, MCH Westeinde Hospital, The Hague, Lijnbaan 32, PO
Box 432, NL-2501 CK, The Netherlands.
2 Department of Radiology, Rijnland Hospital, Leiderdorp, NL-2350 CC, The
Netherlands.
Received October 18, 2004;
accepted after revision February 1, 2005.
Address correspondence to J. B. C. M. Puylaert
(dr.jbcmpuylaert{at}wxs.nl).
Abstract
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MATERIALS AND METHODS. A computerized search of our institution's database over a 5-year period was performed, yielding 12 surgically proven cases of abdominal wall endometriosis that were retrospectively studied. All patients had undergone sonography including power Doppler examination. Additional CT was performed in one patient and MRI in four. Pathologic material was preoperatively obtained by sonographically guided puncture in six patients. The clinical data were analyzed, and the imaging studies were reviewed by two radiologists working in consensus.
RESULTS. All patients had a history of at least one prior cesarean section. All presented with focal pain near the surgical scar, which was cyclic in three patients. Nine patients presented with a palpable mass near the scar. Sonography detected 11 lesions within the abdominal wall, with a mean diameter of 25 mm. All lesions were hypoechoic, vascular, and solid, with some cystic changes in one. The calculated frequency of abdominal wall endometriosis is approximately 0.8% of all women who had a cesarean delivery.
CONCLUSION. Abdominal wall endometriosis frequently presents with noncyclic symptoms. Imaging findings of a solid mass near a cesarean section scar strongly suggest its diagnosis.
Keywords: abdominal wall • cesarean delivery • endometriosis • soft-tissue neoplasms • women's imaging
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Endometriosis of the abdominal wall may be difficult to diagnose; it is often mistaken—both clinically and with diagnostic imaging—for other abnormal conditions such as a suture granuloma, an incisional hernia, or primary or metastatic cancer [2-5]. This may be partly due to the fact that abdominal wall endometriosis is a comparatively unknown entity that has scarcely received attention in the radiologic literature.
The goal of our study was to describe the clinical presentation and sonographic features of abdominal wall endometriosis and also to present its CT and MR appearance.
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Sonographic examination was performed in all patients using 3.5- and 5.0-MHz convex-array and 7.5-MHz linear-array transducers (Sonoline Elegra, Siemens Medical Solutions). Power Doppler sonography was used to assess the vascularity of all lesions. In addition to sonography, a CT examination that included IV contrast material was performed in one patient on an MDCT scanner (Somatom Volume Zoom, Siemens) with 4.0 x 2.5 mm collimation at a table feed of 12 mm/rotation. Four other patients also underwent MRI on a 1.5-T scanner (Magnetom Symphony, Siemens); those examinations included spin-echo T1-, fast spin-echo fat-saturated T2-, and fast spin-echo fat-saturated gadolinium-enhanced T1-weighted sequences and were performed with the patient in the prone position.
Pathologic material was preoperatively obtained by sonographically guided fine-needle aspiration (FNA) in six patients, and an additional sonographically guided histologic biopsy using an 18-gauge needle was performed in two of these patients, eventually confirming the diagnosis in all six cases. All patients underwent an operation, with surgical removal of the affected part of the abdominal wall. In all cases the diagnosis was pathologically made by the presence of endometrial stroma and glands within the soft tissue and muscle of the abdominal wall, along with inflammatory cells and surrounding fibrosis [6] (Fig. 1).
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Sonography showed the endometrioma in 11 patients, whereas the lesion could not be found in one case, yielding a sensitivity of 92%. On sonography, five lesions were confined to the rectus sheath, three were located in the subcutaneous fat, and three infiltrated both of these layers. The size of the lesions ranged from 15 to 55 mm with a mean of 25 mm. All masses were hypoechoic and heterogeneous with scattered internal echoes (Figs. 2A, 2B, 3A, 3B, 3C, and 3D). Ten masses were completely solid on sonography, whereas one lesion also contained some cystic changes. None of the lesions showed hyperechoic regions or calcifications. Internal vascularity was noted in all cases (Figs. 2A, 2B, 3A, 3B, 3C, and 3D).
At CT examination, performed to evaluate the extent of the mass in the abdominal wall, the lesion appeared solid, ill-defined, and isodense compared with muscle and showed slight enhancement (Figs. 3A, 3B, 3C, and 3D). MRI depicted the lesions as isointense to muscle on the T1-weighted sequence, as high signal intensity on fat-saturated T2-weighted images, and with marked enhancement (Figs. 4A, 4B, and 4C).
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Two patients were initially treated with hormone therapy, receiving progestogens orally, without sufficient results. Finally all patients underwent surgery with complete excision of the masses. At surgery, the size of the endometriomas was similar to the sonographic measurements, and the sonographically missed lesion had a diameter (20 mm) within the range of the other masses. One patient had a recurrence of abdominal wall endometriosis 30 months after resection.
In the 5-year study period, approximately 1,500 cesarean sections were performed in our hospital. Given our study group of 12 women, the calculated frequency of abdominal wall endometriosis is approximately 0.8% of all women who had a cesarean delivery.
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Extrapelvic endometriosis has been described in nearly all body cavities and organs, but its most frequent location is in the abdominal wall [7]. Although an incidental case of spontaneous endometriosis in a scarless abdominal wall has been reported [7], it is usually associated with operations in which the uterus is opened [1-6]. In all our patients the endometriomas developed in association with a cesarean section scar and in the absence of any history of pelvic endometriosis, thereby supporting the etiologic concept of iatrogenic transport. We found abdominal wall endometriosis to be present in approximately 0.8% of all women who had cesarean deliveries at our institution, which appears more frequent than is generally assumed but lies within the range of rates described in the published literature (0.03-1%) [4, 8]. The true incidence rate is probably higher than 0.8%, as some cases of abdominal wall endometriosis may have remained undetected because our study did not include routine follow-up in all women after a cesarean section.
In general, the characteristic clinical symptom of endometriosis is cyclic pain associated with menses [8, 9]. All our patients with abdominal wall endometriosis presented with focal abdominal pain; however, this pain was constantly present and not associated with the menstrual cycle in the majority of cases (75%). The noncyclic nature of pain in endometriosis of the abdominal wall has occasionally been reported by others [2, 5] but has generally been regarded as atypical, which may explain why it is clinically often misdiagnosed, as was the case in our patients.
Most patients also presented with a palpable mass at the site of maximum tenderness in the region of the surgical scar. Sonography showed these masses to be solid, hypoechoic lesions in the abdominal wall and to contain internal vascularity on power Doppler examination. Only one of the endometriomas also contained cystic areas. In view of the wide morphologic spectrum of endometriosis—varying from purely cystic chocolate cyst to solid deposits or fibrosis [9]—the almost invariably pure solid aspect of abdominal wall endometriosis in our study is remarkable. The imaging appearance might be expected to be more heterogeneous, with frequent cystic changes due to intralesional bleeding associated with menstruation. The solid aspect of the abdominal wall endometriomas in our study, however, concurs with some other imaging reports [10, 11]. Sonographic examination missed the abdominal wall endometrioma in one of our patients, possibly because the examiner did not focus on the near field.
These sonographic findings are nonspecific, and a wide spectrum of disorders presenting as a mass in the abdominal wall should be considered in the imaging differential diagnosis. This should include neoplasms, such as a sarcoma, desmoid tumor, lymphoma, or metastasis, and nonneoplastic causes, such as a suture granuloma, ventral hernia, hematoma, or abscess [9, 10]. Sonography may be able to exclude the latter three in view of the solid appearance and vascular nature of abdominal wall endometriomas.
The CT and MR characteristics of abdominal wall endometriosis are nonspecific also, both showing a solid enhancing mass in the abdominal wall [12, 13]. The major role of CT and MRI may be to depict the extent of the disease preoperatively.
In half of our patients, the final diagnosis was preoperatively made by sonographically guided puncture. Sonographically guided FNA is a rapid and accurate diagnostic procedure in women with abdominal wall masses associated with endometriosis, enabling malignancy to be excluded and a definitive treatment to be defined [6]. If the FNA results are inconclusive, as may occur because endometriomas are often fibrous in nature [4], an additional histologic biopsy may be considered.
Therapeutic options for abdominal wall endometriosis are pharmacologic therapy with hormonal agents, such as progestogens, or surgical excision. The success rate of medical therapy has been reported to be low, offering only temporary alleviation of symptoms often followed by recurrence after cessation of the drug [2]. Wide surgical excision therefore is the treatment of choice [1-3].
Our study is limited by its retrospective nature, concerning only patients with a final diagnosis of abdominal wall endometriosis. No defined standardized protocol was used to scan our patients, which might have led to lack of uniformity. However, all patients were imaged on sonography in both the transverse and longitudinal views, and power Doppler examination was performed in all cases. We therefore believe that this limitation is minor and would not change the overall impression of our analysis.
In conclusion, abdominal wall endometriosis after a cesarean section is more frequent than generally assumed. Clinically it is often misdiagnosed because endometriosis may occur years after the cesarean section, the pain is often noncyclic in nature, and there is not always a palpable mass. The sonographic finding of a solid mass in the abdominal wall is not pathognomonic for endometriosis, but if located close to a cesarean section scar it should be of prime consideration in the differential diagnosis.
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