FNAC diagnosis of Scar endometriosis: A Report of 3 cases with review of literature

Abstract

Endometriosis is defined as the presence of endometrial-like glands and stroma outside the uterine endometrial lining. Endometrial tissue can be rarely identified on abdominal wall following numerous surgical or procedure scars, including cesarean section and hysterectomy. Cytological diagnosis of scar endometriosis is difficult, as it can be easily misinterpreted as benign spindle cells tumor. We report three cases where patients presented with a chief complaint of nodule in parietal abdominal wall adjacent to previous cesarean section scars and associated with history of cyclical pain. Provisional clinical diagnosis of desmoid tumor was made in one patient while the other two were diagnosed as endometriosis and they were referred for Fine needle aspiration cytology which revealed endometrial-like epithelial cells, stromal cells and hemosiderin-laden macrophages. Based on the cytological findings, diagnosis of Endometriosis arising in scar tissue was made which was confirmed on histopathology and wide local excision was done.

Fine-needle aspiration cytology of a cesarean scar endometriosis

“…The presence of a lump at the scar site, pain, a fluctuation in the size of the lump, bleeding, and the cyclical nature of the symptoms in parallel with menstruation are the main clinical presentations of scar endometriosis [ 3 4 5 6 7 8 9 10 ]. The cyclical nature of symptoms is pathognomonic; however, it may not be seen with all cases [ 3 4 5 6 7 8 9 10 ]. Imaging techniques are nonspecific in terms of diagnosis; however, ultrasonography of abdominal wall endometriosis may show cystic, multicystic, mixed or solid lesions or, even a hypoechoic lesion, below the skin layer [ 10 11 ].…”

“…The cyclical nature of symptoms is pathognomonic; however, it may not be seen with all cases [ 3 4 5 6 7 8 9 10 ]. Imaging techniques are nonspecific in terms of diagnosis; however, ultrasonography of abdominal wall endometriosis may show cystic, multicystic, mixed or solid lesions or, even a hypoechoic lesion, below the skin layer [ 10 11 ]. The presence of endometrial glands, stromal cells, and hemosiderin-laden macrophages has been used as cytological clues when diagnosing endometriosis [ 3 10 ].…”

“…Imaging techniques are nonspecific in terms of diagnosis; however, ultrasonography of abdominal wall endometriosis may show cystic, multicystic, mixed or solid lesions or, even a hypoechoic lesion, below the skin layer [ 10 11 ]. The presence of endometrial glands, stromal cells, and hemosiderin-laden macrophages has been used as cytological clues when diagnosing endometriosis [ 3 10 ]. The cytological findings depend on the hormonal phase of the patient's menstrual cycle.…”

“…These cells have scant cytoplasm, round to ovoid nuclei with unremarkable chromatin. In secretory phase, the cells gradually increase in size developing cytoplasmic vacuolations together with predecidual changes and an epithelioid appearance of stromal cells, which can cause diagnostic difficulties [ 3 10 ]. In the present case, the patient was on the 24 th day of her menstrual cycle.…”

A rare case of perineal endometriosis with anal sphincter involvement

“…Differential diagnosis of this entity includes suture granulomas, abscesses, hematomas, chelodid, lipomas, sebaceous cysts, desmoids or malignant tumour. 5 Fine needle aspiration (FNA) provides a rapid, inexpensive and accurate diagnosis and rules out other differentials; but is stated as controversial by some authors as it might result in new endometriotic implants. 6,7 Imaging modalities such as ultrasound and MRI are indicated in case of large lesions, anal involvement and surgical planning.…”