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Cutaneous Abdominal Nodule After Cesarean Delivery



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Am Fam Physician. 2009 Dec 15;80(12):1483-1484.

A 24-year-old woman presented with a tender mass in the midline of her lower abdomen that had been slowly enlarging for one year. The lesion became more painful and bled during menses. She had had two cesarean deliveries, but no other notable medical or surgical history. Review of systems and medication history was unremarkable.

Physical examination revealed a midline vertical scar with a 5.5-cm, dark brown, firm, fixed nodule (see accompanying figure). On palpation, the nodule appeared to be firmly adhered to deeper structures.

Question

Based on the patient's history and physical examination, which of the following is the most likely diagnosis?

A. Cutaneous endometrioma.

B. Cutaneous sarcoidosis.

C. Direct hernia.

D. Keloid.

E. Suture granuloma.

Discussion

The answer is A: cutaneous endometrioma. Endometriosis is defined as endometrial tissue located outside of the uterine cavity. When this tissue takes the form of a tumor, it is known as an endometrioma.1,2 Computed tomography of the patient's abdomen and pelvis showed a 2.5-cm mass within the subcutaneous fat, without involvement of the peritoneal cavity or bowel.

A cutaneous endometrioma typically appears as an intermittently painful, tender, enlarging, deep red to violaceous, multilobulated, cystic mass. The pain usually occurs during menses.3,4 The lesions are located in surgical scars after procedures such as hysterectomy,5 cesarean delivery,58 amniocentesis, episiotomy, and tubal ligation.24,9

A biopsy of the lesion confirms the diagnosis. The histology consists of poorly circumscribed, nodular collections of endometrial glands in various phases of development surrounded by stroma and inflammation in the dermal and subcutaneous layers.3,4,6 Occasionally, these tumors also involve the fascia.

With the increasing number of hysterectomies and cesarean deliveries, the incidence of endometriomas is likely to increase.9 Endometriomas may present as early as three months after surgery and as late as 10 years after surgery, with the median time being two to three years postsurgery.35 Wide local excision is the preferred treatment.5 Medical therapies such as oral contraceptives, stanozolol (no longer available in the United States), or gonadotropin-releasing hormone analogues may lead to temporary benefits, but are associated with a high recurrence rate.7,10

Cutaneous sarcoidosis may be part of a systemic granulomatous disease that usually affects middle-aged black women. The condition has a range of cutaneous presentations, including patches, plaques, and nodules. However, the lesions typically are not painful and do not bleed. The most common presentation is a reddish-brown nodule in a previous scar.

Direct hernias often do not cause overlying cutaneous change. Typically, they are diagnosed by palpation because they are more prominent with increased abdominal pressure and may be reduced with external pressure. Patients should be referred for elective surgical repair.

Keloids are common, benign neoplasms consisting of increased fibroblasts and collagen that may occur after a trauma or surgical procedure. They typically present in the months following a trauma or procedure, as the wound heals. Although keloids may be painful, the pain usually is not associated with menses, and the lesions do not bleed.

A suture granuloma essentially is a foreign body reaction to suture remaining in the tissue after surgery. It is generally a tender, erythematous nodule that occurs several days to weeks after surgery. A suture granuloma is treated with intralesional steroids or excision.

Summary Table

Condition Characteristics

Cutaneous endometrioma

Intermittent pain, typically during menses; tender, enlarging, deep red to violaceous, multilobulated, cystic mass

Cutaneous sarcoidosis

A range of cutaneous presentations, including patches, plaques, and nodules; most commonly appears as a reddish-brown nodule in a previous scar

Direct hernia

Usually no overlying cutaneous change; typically has greater prominence with increased abdominal pressure and is diagnosed by palpation

Keloid

Usually appears in the months following a trauma or surgery, as the site heals; occasionally tender or painful

Suture granuloma

Tender, erythematous nodule occurring several days to weeks after surgery

Summary Table

View Table

Summary Table

Condition Characteristics

Cutaneous endometrioma

Intermittent pain, typically during menses; tender, enlarging, deep red to violaceous, multilobulated, cystic mass

Cutaneous sarcoidosis

A range of cutaneous presentations, including patches, plaques, and nodules; most commonly appears as a reddish-brown nodule in a previous scar

Direct hernia

Usually no overlying cutaneous change; typically has greater prominence with increased abdominal pressure and is diagnosed by palpation

Keloid

Usually appears in the months following a trauma or surgery, as the site heals; occasionally tender or painful

Suture granuloma

Tender, erythematous nodule occurring several days to weeks after surgery

Author disclosure: Nothing to disclose.

Address correspondence to Lana H. Hawayek, MD, at lanahawayek@gmail.com. Reprints are not available from the authors.

REFERENCES

1. Sholefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its association with caesarean section and gynaecological procedures. J Obstet Gynaecol. 2002;22(5):553–554.

2. Bumpers HL, Butler KL, Best IM. Endometrioma of the abdominal wall. Am J Obstet Gynecol. 2002;187(6):1709–1710.

3. Steck WD, Helwig EB. Cutaneous endometriosis. JAMA. 1965;191:167–170.

4. Steck WD, Helwig EB. Cutaneous endometriosis. Clin Obstet Gynecol. 1966;9(2):373–383.

5. Chatterjee SK. Scar endometriosis: a clinicopathologic study of 17 cases. Obstet Gynecol. 1980;56(1):81–84.

6. Tidman MJ, MacDonald DM. Cutaneous endometriosis: a histopathologic study. J Am Acad Dermatol. 1988;18(2 pt 1):373–377.

7. Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. J Obstet Gynaecol Res. 2005;31(5):471–475.

8. Gaunt A, Heard G, McKain ES, Stephenson BM. Caesarean scar endometrioma. Lancet. 2004;364(9431):368.

9. Scar endometrioma: a cause for concern in the light of the rising caesarean section rate. J Obstet Gynaecol. 2003;23(1):86.

10. Wolf GC, Singh KB. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44(2):89–95.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


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