Abdominal Wall Endometrioma: Ultrasonographic Features and Correlation with Clinical Findings

Yıl 2013, Cilt: 2013 Sayı: 2, 155 - 160, 01.02.2013

Aynur Solak Berhan Genç Seyhan Yalaz Neslin Şahin Taylan Özgür Sezer İlhami Solak

https://doi.org/10.5152/balkanmedj.2012.102

Öz

Background: The diagnosis of abdominal wall endometrioma (AWE) is often confused with other surgical conditions. Certain factors relating to knowledge of the clinical history of the disease make correct diagnosis and treatment difficult. Aims: To present the clinical findings and ultrasonographic (US) features of AWE with special emphasis on size-related features. Study Design: This study reviewed abdominal wall endometriomas during a 2-year period in the Radiology Department of Sifa University Hospital, Izmir. Methods: Eleven women (mean age 32.6 years) with 12 scar endometriomas (mean diameter 29.2 mm) were consecutively evaluated by US and Colour Doppler examination (CDUS) prior to surgery. Lesions were grouped into large (≥3 cm) and small nodules. Vascularisation was classified as location (central, peripheral and mixed) and severity (absent, moderately vascular and hypervascular). In each patient, the nature of pain (absent, cyclic: associated with menstruation and continuous), historical and clinical data were documented. Four patients underwent Magnetic Resonance Imaging and their findings were presented. Fisher's exact test, χ2 test for categorical data and the unpaired T-test for continuous variables were used for statistical analysis. Results: In all the women, US of the AWE showed the presence of a solid hypoechoic mass (less echogenic than the surrounding hyperechoic fat) within the abdominal wall. There was a significant correlation between AWE sizes with repeated caesareans and the mean time between the last operation and admission to hospital (p<0.05). Large endometriomas showed increased central vascularity (p<0.05). Cyclic pain was more frequent in small lesions, whereas continuous pain was more commonly found in patients with larger lesions (p<0.05). Conclusion: AWE is often misdiagnosed clinically because endometriosis may occur years after the caesarean section, the pain is often non-cyclic in nature, and there is not always a palpable tender mass. The sonographic and Doppler findings, along with proper correlation with clinical data, may substantially contribute to the correct diagnosis of endometrioma. Turkish Anahtar Kelimeler: Abdominal duvar endometriozisi, ultrasonografi, siklik ağrı Arka Plan: Abdominal duvar endometrioması (ADE) sıklıkla diğer cerrahi patolojilerle karışmaktadır. Hastalığın öyküsüyle ilgili faktörlerin bilinmesi doğru tanı ve tedaviyi sağlayacaktır Amaç: ADE'lerin boyutlarıyla ilişkili olarak klinik bulgularını ve radyolojik özelliklerini sunmaktır. Çalışma Tasarımı: Olguların retrospektif analizi. Yöntemler: Ortalama yaşı 32.6 olan 12 skar endometriomalı 11 kadın hasta operasyon öncesinde Ultrasonografi (US) ve Renkli Doppler Ultrasonografi (RDUS) ile değerlendirilmiştir. Kitleler büyük (>3cm) ve küçük lezyonlar olarak gruplandırılmıştır. Lezyon kanlanması lokalizasyonuna göre (merkezi, çevresel ve karışık) ve şiddetine göre (kanlanma yok, orta derecede kanlanma gösteren, zengin kanlanma gösteren) gruplandırılmıştır. Her hastada ağrının özellikleri (ağrı yok, adetle birlikte-siklik, devamlı) hastanın öyküsü ve klinik bulguları kaydedilmiştir. Manyetik Rezonans Görüntülemeye (MRG) giren 4 hastanın ise MRG bulguları sunulmuştur. İstatistiksel analizler için kategorik verilerin değerlendirilmesinde Fischer's exact test, X2 testi sürekli değişkenler için ise bağımsız t testi kullanılmıştır. Bulgular: Hastaların hepsinde lezyonlar abdominal subkutanöz yağ dokusu veya rektus kası içinde hipoekoik solid nodüller halinde izlendiler. ADE boyutlarıyle tekrarlayan sezeryan sayıları ve son geçirilen operasyon tarihiyle hastaneye başvuru zamanı arasında anlamlı korelasyon mevcuttu (P<0.05). Büyük ADE'lerde artmış santral kanlanma görülmekteydi (P<0.05). Siklik ağrı küçük çaptaki lezyonlarda (P<0.05), sürekli ağrı ise büyük lezyonlarda sıktı (P<0.05). Sonuç: Lezyonlardaki ağrının non-spesifik özelliği, kitlenin palpe edilemeyişi nedeniyle ADE'nin doğru tanısı sıklıkla gözden kaçmaktadır. US ve RDUS bulgularının klinik verilerle uygun bir şekilde korelasyonu kesin tanıya büyük ölçüde katkıda bulunacaktır.

Anahtar Kelimeler

Abdominal wall endometriosis, ultrasonography, cyclic pain

Abdominal Wall Endometrioma: Ultrasonographic Features and Correlation with Clinical Findings

Öz

Kaynakça

• Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. Abdominal wall endometriomas. The American Journal of Surgery 2003;185:596-8. [CrossRef]
• Anand M, Deshmukh SD. Massive abdominal wall endometriosis masquerading as desmoid tumour. J Cutan Aesthet Surg 2011;4:141-3. [CrossRef]
• Applebaum GD, Iwanczyk L, Balingit PB. Endometrioma of the abdominal wall masquerading as hernia. Am J Emerg Med 2004;22:621-2. [CrossRef]
• Bachir JS, Bachir NM. Scar endometrioma: awareness and prevention. WMJ 2002;101:46-9.
• Buck Louis GM, Hediger ML, Peterson CM, Croughan M, Sundaram R, Stanford J, et al. Incidence of endometriosis by study population and diagnostic method: the ENDO study. Fertil Steril 2011;96:360-5. [CrossRef]
• Garwood E, Kumar A, Moes Gregory, Published Online: Wednesday, August 8, 2007 Abdominal scar endometrioma mimicking incisional hernia. http://www.hcplive.com/publications/surgicalrounds. Accessed August 8, 2007
• Iafrate F, Ciolina M, Iannitti M, Baldassari P, Pichi A, Rengo M, et al. Gallbladder and muscular endometriosis: a case report. Abdom Imaging 2012;37:616-27. [CrossRef]
• Roncoroni L, Costi R, Violi V, Nunziata R. Endometriosis on laparotomy scar. A three-case report. Arch Gynecol Obstet 2001;265:165-7. [CrossRef]
• Ozel L, Sagiroglu J, Unal A, Unal E, Gunes P, Baskent E, et al. Abdominal wall endometriosis in the cesarean section surgical scar: a potential diagnostic pitfall. J Obstet Gynaecol Res 2012;38:526-30. [CrossRef]
• Woodward PJ, Sohaey R, Mezzetti TP. Endometriosis: RadiologicPathologic Correlation. Radiographics 2001;21:193-216.
• Pikoulis E, Karavokiros J, Veltsista K, Diamantis T, Griniatsos J, Basios N, et al. Abdominal scar endometriosis after caesarean section: report of five cases. West Indian Med J 2011;60:351-3.
• Savelli L, Manuzzi L, Donato ND, Salfi N, Trivella G, Ceccaroni M, et al. Endometriosis of the abdominal wall: ultrasonographic and Doppler characteristics. Ultrasound Obstet Gynecol 2012;39:336-40. [CrossRef]
• Francica G. Reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar. World J Radiol 2012;28:135-40. [CrossRef]
• Stein L, Elsayes KM, Wagner-Bartak N. Subcutaneous abdominal wall masses: radiological reasoning. AJR Am J Roentgenol 2012;198:146-51. [CrossRef]
• Picard A, Varlet MN, Guillibert F, Srour M, Clemenson A, Khaddage A, et al. Three-dimensional sonographic diagnosis of abdominal wall endometriosis: a useful tool? Fertil Steril 2011;95:289.e1-4.
• Fleischer AC, Milam MR, Crispens MA, Shappell HW. Sonographic depiction of intratumoral vascularity with 2- and 3-dimensional color Doppler techniques. J Ultrasound Med 2005;24:533-7.
• Hensen JH, Van Breda Vriesman AC, Puylaert JB. Abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. AJR 2006;186:616-20. [CrossRef]
• Onbas O, Kantarci M, Alper F, Kumtepe Y, Durur I, Ingec M, et al. Nodular endometriosis: dynamic MR imaging. Abdom Imaging 2007;32:451-6. [CrossRef]
• Busard MP, Mijatovic V, van Kuijk C, Hompes PG, van Waesberghe JH. Appearance of abdominal wall endometriosis on MR imaging. Eur Radiol 2010;20:1267-76 [CrossRef]
• Randriamarolahy A, Perrin H, Cucchi JM, Fuerxer F, Brunner P, Bruneton JN. Endometriosis following cesarean section: ultrasonography and magnetic resonance imaging. Clin Imaging 2010;34:113-5. [CrossRef]
• Bektaş H, Bilsel Y, Sari YS, Ersöz F, Koç O, Deniz M, et al. Abdominal wall endometrioma; a 10-year experience and brief review of the literature. J Surg Res 2010;164:77-81. [CrossRef]
• Kaunitz A, Di Sant’Agnese PA. Needle tract endometriosis: an unusual complication of amniocentesis. Obstet Gynecol 1979;54:753-5.
• Pathan ZA, Dinesh U, Rao R. Scar endometriosis. J Cytol 2010;27:106-8. [CrossRef]
• Kumakiri J, Kikuchi I, Kitade M, Kuroda K, Matsuoka S, Tokita S, et al. Incidence of complications during gynecologic laparoscopic surgery in patients after previous laparotomy. J Minim Invasive Gynecol 2010;17:480-6. [CrossRef]
• Sawazaki H, Goto H, Takao N, Taki Y, Takeuchi H. Clear cell adenocarcinoma arising from abdominal wall endometriosis mimicking urachal tumor. Urology 2012;79:84-5. [CrossRef]