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1 Presidio Ospedaliero "S. Maria della Pietà" Camilliani Casoria 80026, Italy
I read with interest the article by Dr. Hensen and colleagues [1] on abdominal wall endometriosis near a Pfannenstiel incision. The authors should be commended on calling radiologists' and clinicians' attention to an often neglected disease that is more prevalent than previously reported, especially if one considers the increasing cesarean section rate. However, several points about the article deserve comments.
First, the authors report atypical pain (i.e., not related to the menses) in 75% of their patients: This is an intriguing issue because in my experience [2], the opposite is true. In addition, 65% of those patients complained of cyclic swelling of the nodules, whereas in a minority of cases skin bruising over the palpable nodule during the menses was reported. This discrepancy could be ascribed either to individual pain threshold or to the retrospective nature of the study by Hensen et al. [1], which prevented a detailed pain history from being obtained.
Sonographic features of endometriomas are not fully reported and discussed. One of the most important findings is the irregularity of margins, appearing in the majority of patients, that are frankly spiculated and infiltrating adjacent tissues [2]. Hensen et al. [1] did not mention this sonographic feature, which reproduces the gross pathologic aspect of abdominal wall endometriomas and explains why surgeons are forced to perform a wide excision that includes muscle planes that are often repaired by mesh prostheses. Another sonographic feature overlapping the pathologic reality is the echogenic ring [2, 3] that is sometimes fully encircling the nodule; it is an expression of the peripheral inflammatory reaction triggered by cyclic hemorrhages.
The authors' statement that "the almost invariably pure solid aspect of abdominal wall endometriosis in our study is remarkable" is not entirely warranted. In my initial experience [2], all endometriomas in 12 patients showed a solid aspect, and small liquid areas inside the nodules could be recognized in only three patients with masses larger than 3 cm. At the time of this writing, I have seen 10 more patients with 12 endometriomas, and the solid aspect is still the rule—anechoic lacunae being hardly ever found and almost exclusively in larger nodules.
Similarly, I disagree with the systematic use of fine-needle biopsy for the diagnosis of abdominal wall endometrioma and with the authors' statement that CT and MRI examinations can be used for disease staging [1]. As the authors admit, fine-needle biopsy may yield inconclusive data [4], and both CT and MRI provide aspecific findings [5, 6]. In addition, the extent of disease in musculocutaneous planes of the abdominal wall may be assessed using electronic wideband high-frequency ultrasound probes as accurately as using CT or MRI.
At our institution, a common practice in assessing a palpable nodule near Pfannenstiel incisions (with or without pain) is to rely solely on clinical evaluation and sonography. Over the past 7 years, this approach has turned out to be cost-effective: After the first three misdiagnosed cases (suture granulomas and sarcoma), a correct diagnosis of endometrioma was reached in the remaining 19 patients, and six more lesions near cesarean section scars were correctly identified as nonendometrioma nodules (one abscess, two cases of chronic inflammation, one desmoid tumor, one metastasis, one incisional hernia). In no case were CT, MRI, and fine-needle biopsy used for the diagnostic workup, and surgery was not delayed.
The clinical scenario (palpable mass near cesarean section scar and pain, especially if cyclic with the menses) along with a careful sonographic examination of the entire abdominal wall of the lower quadrants, taking into account all the suggestive sonographic features—solid inhomogeneous nodule with infiltrating margins, peripheral hyperechoic ring, and visible vascularization—may be sufficient for a confident preoperative diagnosis of abdominal wall endometrioma without prolonging diagnostic workup with an undue increase in medical costs.
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