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Brooke Army Medical Center Fort Sam Houston, TX 78234
A 36-year-old woman presented with left lower quadrant pain that had waxed and waned for several years but had worsened over recent weeks. Physical examination revealed focal tenderness with a questionable underlying mass. Laboratory evaluation was unrevealing. CT showed a homogenous intensely enhancing lesion in the subcutaneous tissues (Fig. 3). Differential diagnoses included infected sebaceous cyst; other possibilities such as hematoma were less likely. Given her age, we discounted malignancies. The patient was prescribed a course of antibiotics and discharged.
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Four weeks later the patient returned. She reported less pain since beginning her medication. Then, over the past 2 weeks, the pain and mass returned. Repeated CT scans showed no appreciable difference in the lesion, so biopsy was recommended. The patient was referred to surgery and underwent excisional biopsy that revealed a mixture of glandular cells and stroma consistent with endometrial tissue. The patient was diagnosed with an endometrioma and her symptoms resolved after the operation.
This case shows a rare but recognized form of endometriosis: subcutaneous endometrioma. Just as pulmonary endometriosis is not usually suspected in women with hemoptysis, subcutaneous endometriosis is rarely considered when a woman presents with a painful mass in the abdominal wall [1]. Because patient and provider often fail to recognize a correlation between symptoms and menses, the diagnosis may initially be missed [1, 2]. Further questioning revealed that symptoms centering along the left margin of her incision had begun 10–12 months after a cesarean delivery 4 years earlier.
Endometriosis is not rare and affects 1–2% of women [1]. It occurs when endometrial tissue forms implants outside the uterine cavity and results in bleeding, pain, and scarring [3]. Typical locations include the ovaries and peritoneum. Less common sites involve the rectum, inguinal canal, vagina, and the superficial abdominal wall. Subcutaneous endometriosis is almost invariably associated with prior abdominal surgery [2], although endometriosis of the umbilicus has been reported in cases with no prior surgery [1]. The most common culprit is a cesarean section, with an estimated frequency of 0.2% after such procedures [4]. Other implicated surgeries include appendectomies and hysterectomies. In the case of incision-associated endometriosis, it is postulated that endometrial cells are transplanted during surgery, providing a means for endometrial cells to access areas previously isolated from the peritoneal cavity. Surgical excision is considered the preferred therapy, providing both diagnosis and treatment in a single procedure [4].
Review of the literature shows only one other reported instance of a subcutaneous endometrioma being detected on diagnostic CT [2]. Therefore, this rare entity should not be routinely included in the differential diagnosis for an abdominal wall mass in a woman. However, if the proper clinical history of menses-related symptoms and prior abdominal surgery can be elicited, then subcutaneous endometrioma should be considered as a possibility.
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