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doi:10.1111/jog.12502

J. Obstet. Gynaecol. Res. Vol. 41, No. 1: 149–152, January 2015

Ultrasound-guided excision of rectus abdominis muscle endometriosis Maria Elisabetta Coccia1, Francesca Rizzello1, Sara Nannini1, Mauro Cozzolino1, Tommaso Capezzuoli1 and Francesca Castiglione2 Departments of 1Clinical and Experimental Biomedical Sciences and 2Human Pathology and Oncology, School of Medicine, University of Florence, Florence, Italy

Abstract We report a rare case of rectus abdominis muscle endometriosis excised under ultrasound guidance. A 36-year-old woman came to our observation presenting an abdominal nodule located in the right side of the umbilical area. Ultrasound of the abdominal wall showed two hypoechogenic nodules in the context of the right rectus abdominis muscle and a fine-needle aspiration, performed under ultrasound guidance, confirmed the diagnosis of endometriosis. The patient underwent surgical excision of the lesions. Intraoperative localization was performed through ultrasonography. In our case, the diagnosis was essentially based on ultrasound scan. Computed tomography and magnetic resonance imaging were not performed. A high-resolution ultrasound is a simple, inexpensive and safe method and is sufficient for indicating surgery. Furthermore, the use of intraoperative ultrasound allowed adequate margins of excision. Key words: endometriosis surgery, endometriosis, fine-needle aspiration, rectus abdominis, ultrasonography.

Introduction

Case Report

Endometriosis is an estrogen-dependent benign inflammatory disease characterized by the presence of ectopic endometrial implants.1 Typically, endometriotic implants occur in the pelvis but have also been described in the upper abdomen, peripheral and axial skeleton, lungs, diaphragm, and central nervous system.2 Abdominal wall endometriosis (AWE) is a rare localization and it is often related to a previous surgical scar. Cesarean section is the surgical procedure most frequently associated with AWE with an incidence of about 0.03– 1%.3,4 We report an unusual case of rectus abdominis muscle endometriosis excised under ultrasound guidance.

A 36-year-old woman came to our observation presenting an abdominal nodule located in the right side of the umbilical area. She complained of pain at the site of the nodule persisting for 10 months and worsening during the menstrual cycle. Her medical history included a cesarean section performed 4 years earlier. There was no history of endometriosis. She referred to her heavy intake of non-steroidal anti-inflammatory drugs during the days of severe pain. Neither bleeding nor gastrointestinal symptoms were associated. At physical examination, an ovoid, smooth, solid mass of about 3 cm in diameter could be palpated in

Received: December 14 2013. Accepted: May 14 2014. Reprint request to: Dr Francesca Rizzello, Largo Brambilla, 3, 50134 Firenze, Italy. Email: [email protected]

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Figure 1 Ultrasound appearance of the lesions of the right rectus abdominis muscle. The nodules appear poorly defined and not homogeneously hypoechoic to surrounding muscular tissue.

the right side of the umbilical area. Tenderness was elicited through palpation. Ultrasound of the abdominal wall using an RAB4-8D multi-frequency transducer (Voluson E8 Ge Healthcare) showed two hypoechogenic nodules in the context of the right rectus abdominis muscle, extending from the subcutaneous layer until the fascia muscularis. The larger nodule was more superficial and measured 27 × 10 mm. A second smaller nodule of 18 × 9 mm was localized closest to the muscularis fascia. In both nodules, the margins were poorly delimited and the pattern was characterized by inhomogeneously dispersed echogenic contents (Fig. 1). Power-Doppler examination revealed a poor and inhomogeneous peripheral vascularization (score 2). The transvaginal ultrasound showed normal anteverted uterus and follicular ovaries. No findings suggestive of endometriosis were observed. The serum level of cancer antigen (CA)-125 was within the normal range (13.7 UI/mL). A fine-needle aspiration (FNA), under ultrasound guidance, of the larger lesion was performed with a 14-gauge needle. Histological examination revealed endometrial glands surrounded by stroma, typical of endometriosis (Fig. 2). The patient underwent surgical excision of the lesions. Intraoperative localization was performed through ultrasonography (Voluson-e, GE Healthcare, GE 4C-RS ultrasound probe). The transducer was covered with a sterile plastic sleeve. Ultrasound gel

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Figure 2 Histological photomicrograph of fine-needle aspiration: Histological appearance of the lesion, endometrial glands and stroma in the context of muscular fibers and hemosiderin-laden macrophages.

Figure 3 Intraoperative ultrasound finding: appearance of endometriotic nodule during intraoperative scan.

was placed inside the sleeve over the head of the probe and sterile gel was also placed on the abdomen 1 cm above the region where the nodules were palpated. The probe was then moved and angled in order to visualize the lesions on the ultrasound screen by a second operator (Fig. 3). The surgeon made a 2.5-cm cutaneous incision at the site of the more superficial nodule and, under ultrasound guidance, performed a wide excision of both the lesions leaving 5–10 mm of free tissue as surgical margins. During the surgical procedure, the probe position was adjusted by the second operator to obtain real-time ultrasound imaging. At various stages

© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

Endometriosis of rectus abdominis

Figure 4 Macroscopic appearance of the two nodules.

during the excision, the ultrasound imaging was used to check that the lesion in question was encompassed within the lines of excision (Figs 3,4). The closure of the abdominal wound was achieved through the suture of the anterior fascia of the rectus, the subcutaneous tissue and skin. The patient’s postoperative course was good and she was discharged home 6 h after surgery (Day Surgery Unit). The histological examination confirmed the diagnosis of endometriosis, showing the presence of endometrial glands and stroma in the context of muscular fibers and hemosiderin-laden macrophages. At the 6-month follow-up, the patient had no further pain, her serum CA-125 value was normal (10.4 UI/mL) and ultrasound examination did not show any signs, which raised suspicions of endometriosis.

Discussion We present a rare case of rectus abdominis muscle endometriosis. In our case, although the patient had previously undergone cesarean section, the endometriotic nodules were localized in the right side of the umbilical area, quite far from the transverse abdominal incision of the previous cesarean section (3 cm above the symphysis pubis). Although in cases of previous cesarean section the hypothesis of direct implantation is the most likely, the metastatic spread theory cannot be excluded in our case. According to this theory, menstrual tissue travels from the endometrial cavity through lymphatic channels and veins to distant sites. It has been previously observed that women with endometriosis have altered immunity,5 preventing them from clearing the endometrial cells/fragments

outside the uterine cavity. This would help explain why some women develop endometriosis, whereas others do not. Actually, in our case, the histological sample showed that endometrial glands and stroma in the context of muscular fibers were surrounded by hemosiderin-laden macrophages and histiocytes. Nevertheless the immune reaction was ineffective in eliminating cells with the potential of establishing ectopic endometrial implants. The theory of altered immune response does not explain the absence of pelvic disease. Thus a ‘local’ factor intrinsic to the muscle might act, resulting in the implant of ectopic foci. In our case, ultrasonography was essential for both diagnosis and treatment of endometriosis. The patient was seen by a gynecologist who is an expert in endometriosis care. Endometriosis was suspected on the basis of symptoms and ultrasonographic appearance. Transabdominal ultrasound images showed two hypoechoic nodules with inner hyperechoic punctuate echoes as previously described.6 The differential diagnosis of AWE includes both benign and malignant diseases: hernia, hematoma, lymphoma, lipoma, abscess, lymphadenopathy, subcutaneous cysts, neuroma, soft tissue sarcoma, desmoids tumor and metastasis.7 Malignant transformation of endometriosis in a cesarean section abdominal wall scar has also been described.8 In our case, to exclude a possible malignancy, an FNA was performed. The pathologist rejected the diagnosis of malignant pathology and endometriosis was histologically confirmed. A high-resolution ultrasound is a simple, inexpensive and safe technique and, in expert hands, comparable to magnetic resonance imaging. Thus, in our case, diagnosis was essentially based on ultrasound scan.9 Furthermore, Power-Doppler examination revealed a poor and inhomogeneous peripheral vascularization, according to the endometriosis findings described by other authors.6 These findings contradict previous studies on AWE in the region of a previous cesarean section, which reported a high proportion of strongly vascularized lesions.10 Ultrasound is the most practical means of providing imaging guidance for interventional procedures, such as FNA. Surgeons are increasingly realizing the benefits of using ultrasound during surgical procedures. Ultrasound has gained a fundamental role in the diagnosis of endometriosis, including unusual localizations of the disease.11 Although abdominal lesion excision is considered the treatment of choice,

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during surgery, the margins of the lesion are not always clear, making intervention very difficult sometimes. We used the ultrasonically guided approach in order to define with higher precision the nodule’s margins. In this context, the use of ultrasound may assist adequate lesion removal, saving healthy tissue. To our knowledge, this is the first published case of histologically confirmed rectus abdominis muscle endometriosis treated by ultrasound-guided excision.

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Disclosure

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None of the authors has anything to disclose. 9.

References 1. Giudice LC, Kao LC. Endometriosis. Lancet 2004; 364: 1789– 1799. 2. Coccia ME, Rizzello F. Ultrasonographic staging: A new staging system for deep endometriosis. Ann N Y Acad Sci 2011; 1221: 61–69. 3. Hensen JH, Van Breda Vriesman AC, Puylaert JB. Abdominal wall endometriosis: Clinical presentation and imaging

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10.

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features with emphasis on sonography. AJR Am J Roentgenol 2006; 186: 616–620. Horton JD, DeZee KJ, Ahnfeldt EP, Wagner M. Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg 2008; 196: 207–212. Marci R, Lo Monte G, Soave I, Bianchi A, Patella A, Wenger JM. Rectus abdominis muscle endometriotic mass in a woman affected by multiple sclerosis. J Obstet Gynaecol Res 2013; 39: 462–465. Savelli L, Manuzzi L, Di Donato N et al. Endometriosis of the abdominal wall: Ultrasonographic and Doppler characteristics. Ultrasound Obstet Gynecol 2012; 39: 336–340. Giannella L, La Marca A, Ternelli G, Menozzi G. Rectus abdominis muscle endometriosis: Case report and review of the literature. J Obstet Gynaecol Res 2010; 36: 902–906. Stevens EE, Pradhan TS, Chak Y, Lee Y. Malignant transformation of endometriosis in a cesarean section abdominal wall scar: a case report. J Reprod Med 2013; 58: 264–266. Calò PG, Ambu R, Medas F, Longheu A, Pisano G, Nicolosi A. Rectus abdominis muscle endometriosis. Report of two cases and review of the literature. Ann Ital Chir 2012; pii: S0003469X12018891. Francica G, Scarano F, Scotti L, Angelone G, Giardiello C. Endometriomas in the region of scar from cesarean section: Sonographic appearance and clinical presentation vary with the size of the lesion. J Clin Ultrasound 2009; 37: 215–220. Guerriero S, Spiga S, Ajossa S et al. Role of imaging in the management of endometriosis. Minerva Ginecol 2013; 65: 143– 166.

© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

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Ultrasound-guided excision of rectus abdominis muscle endometriosis.

We report a rare case of rectus abdominis muscle endometriosis excised under ultrasound guidance. A 36-year-old woman came to our observation presenti...
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