Bifocal endometriomas involving a Pfannenstiel incision. Clinical case

Abstract

Endometrioma of the anterior abdominal wall (EAAW) is a rather rare variant of extragenital endometriosis, which in most cases occurs after obstetrical and gynecological procedures. EAAW presented predominantly as a single tumour‑like mass, and multiple ectopias were observed in only 1.9—5.6% of cases, exclusively after Pfannenstiel laparotomy.

Here we present a clinical case of a 37‑year‑old patient who complained of the large tumour‑like nodules along the postoperative anterior abdominal wall scar, accompanied by severe cyclic, catamenial pain. Additionally, the patient noted an increase in tumour size during menstruation. Thirty‑three months ago, she underwent an elected cesarean section for obstetric indications. Based on ultrasonography and computed tomography scans, the presence of two EAAW in the corners of the postoperative scar was established: 46 × 32 × 31 mm and 14 × 18 × 13 mm, respectively. Both lesions were excised out without damaging their integrity. The fascial defect was replaced by synthetic polypropylene mesh. The diagnosis of EAAW was finally confirmed based on pathological (presence of endometrial glands and cytogenic stroma) and immunohistochemical (positive membrane expression of CD10 in cytogenic stroma, intense cytoplasmic expression of CK7 in endometrial glands, marked nuclear expression of progesterone (PR) and estrogen (ER‑α) receptors in endometrial glands and cytogenic stroma, proliferative activity index Ki‑67 — 2%) studies. At a follow‑up after 19 months, the patient was asymptomatic; according to physical examination and ultrasound scan, there was no evidence of recurrence.

Abdominal wall endometriosis is a rare condition. Clinicians should be aware of this pathology, especially in women presenting with a painful mass near the scar of a previous obstetrical and gynecological surgery. Surgery is the best treatment modality for endometrioma, whereas its optimal volume is considered to be R0 resection with preservation of endometriomas’ integrity. The final diagnosis of EAAW requires pathological and immunohistochemical confirmation.