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1 Westeinde Hospital The Hague, The Netherlands
We thank Dr. Francica for his valuable comments regarding our article [1]. We would like to give the following response.
The classic clinical symptom for endometriosis is cyclic pain associated with menstruation [2]. We have, however, well documented that in our study of 12 patients with endometriosis in the abdominal wall after cesarean section, only three patients complained of cyclic pain. This also explained why the referring clinician actually suggested the diagnosis of endometriosis in only two patients. Although our study was, strictly speaking, retrospective in nature, we prospectively made the correct diagnosis during the first sonography examination in 11 of the 12 cases. Because of the presumptive diagnosis of endometriosis at the time of sonography examination, we specifically asked these 11 patients about cyclic pain, which was denied by nine. The noncyclic nature of the pain in abdominal wall endometriosis has also been reported by others [3, 4] and is certainly not unique.
Could it be that in Dr. Francica's study mainly patients were included who had clinically suspected endometriosis, and that other patients with atypical and noncyclic pain were not referred for sonography? In our hospital, we have a low threshold for sonography examination: Any patient with abdominal pain or mass eventually undergoes sonography. A sonographic examination always includes a routine scan with a high-frequency transducer to detect abnormalities of the abdominal wall (and also abnormalities of the bowel).
Dr. Francica is correct when he mentions that irregular and spiculated margins are a frequent sonographic feature of abdominal wall endometriomas. Although indeed we did not refer specifically to this sign in the text, the feature is clearly illustrated in our figures, both on sonography and on CT and MRI. This feature underlines, as Dr. Francica correctly mentions, the invasive and tumorlike nature of endometriosis, which has implications for the surgical approach.
Endometriosis has a wide morphologic spectrum, varying from mainly cystic chocolate cysts to solid deposits or fibrosis [2]. Many radiologists who are unfamiliar with the purely solid aspect of abdominal wall endometriosis may be surprised by the lack of cystic components within the majority of nodules. As such, we emphasized this aspect in the text of our article.
The finding of a solid vascularized lesion in the abdominal wall has a wide differential diagnosis. The sonographic pattern of abdominal wall endometriosis in itself is not specific and can be mimicked by benign lesions, such as suture granuloma, and by neoplastic lesions, such as metastases, sarcoma, and desmoid tumor. Especially in patients who do not have cyclic pain, malignancy should be ruled out even if the lesion is in close proximity to a cesarean incision. Fine-needle aspiration is a fast, cheap, and relatively noninvasive way to establish a preoperative diagnosis and exclude malignancy. In case of an unexpected desmoid tumor or sarcoma, the operative approach can be adapted accordingly.
Finally, it is not always easy for the surgeon to localize the lesion during operation. In two of our cases, we were obliged to perform sonography in the operating room because the surgeon was not able to find the lesion during the operation. Therefore, we have adopted a policy of marking the exact location and extent of the lesion preoperatively with indelible ink on the overlying skin of the abdominal wall.
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