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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 5  |  Page : 241-244

A rare case of postmenopausal inguinal endometriosis


1 Department of General Surgery, Dr. Mehta Hospital Global Campus, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Chennai, Tamil Nadu, India
3 Department of Pathology, ACS Medical Collge, Chennai, Tamil Nadu, India

Date of Submission16-May-2021
Date of Decision29-Sep-2021
Date of Acceptance01-Oct-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Dr. Jayabal Pandiaraja
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_45_21

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  Abstract 


Endometriosis is a condition in which endometrial cells are located outside the uterine cavity, mostly in the abdominal cavity and the peritoneum. It is commonly located in the ovaries, bowel, and pelvic cavity. Sometimes, it can be located in the extrapelvic region also. Inguinal endometriosis is a rare form of extrapelvic endometriosis. Most of the inguinal endometriosis present around 30–40 years of age with a prior history of gynecological or abdominal wall surgery. Our patient presented with inguinal endometriosis in the postmenopausal period without a history of prior surgery. Moreover, she did not present with classical symptoms of abdominal wall endometriosis. Inguinal endometriosis can be considered as one of the differential diagnoses in postmenopausal women even without classical symptoms of endometriosis.

Keywords: Differential diagnosis of inguinal mass, extrapelvic endometriosis, inguinal endometriosis, inguinal mass, postmenopausal women


How to cite this article:
Pandiaraja J, Shalini A, Vidhya S. A rare case of postmenopausal inguinal endometriosis. Curr Med Res Pract 2021;11:241-4

How to cite this URL:
Pandiaraja J, Shalini A, Vidhya S. A rare case of postmenopausal inguinal endometriosis. Curr Med Res Pract [serial online] 2021 [cited 2021 Dec 3];11:241-4. Available from: http://www.cmrpjournal.org/text.asp?2021/11/5/241/329703




  Introduction Top


Endometriosis is a condition in which endometrial cells are located outside the uterine cavity, mostly in the abdominal cavity and the peritoneum.[1] It is commonly located in the ovaries, bowel, and pelvic cavity. Sometimes, it can be located in the extrapelvic region also. Inguinal endometriosis is a rare condition and is due to the presence of functional endometrial tissue in an inguinal region. Inguinal endometriosis is usually located in the skin and subcutaneous tissue. Intramuscular endometriosis is a type of abdominal wall endometriosis and it is very rare as compared to other locations. Inguinal endometriosis is also a type of abdominal wall endometriosis. The right inguinal region is involved more often as compared to the left due to the barrier effect of the sigmoid colon on the left side. Endometriosis is more common following surgery. The duration of onset of disease following surgery usually varies from 1 to 6 years. In our case, endometriosis was located in the intramuscular plane that to in a postmenopausal woman without prior history of surgery.


  Case Report Top


A 65-year-old postmenopausal female was admitted with a complaint of swelling over the right inguinal region and pain of 6-month duration. There was no history of previous pelvic or abdominal surgery. The patient denied any history related to postmenopausal symptoms. She was not on any prolonged medications. On examination, she was well built and nourished. Her general examination was within normal limits. Abdominal examination showed no organomegaly. The right inguinal region examination showed swelling of 5 cm × 4 cm with lobulation. The mass was firm to hard in consistency. There was no warmth or tenderness. Mass was adherent to the anterior abdominal wall.

Routine blood investigations such as complete blood count, renal function test, and liver function were normal. Ultrasound examination revealed multiple cystic lesions present over the right inguinal region with foci of calcification. Computed tomography of the whole abdomen showed no significant abnormality except for multiple cystic lesions in the right inguinal region. The image-guided fine-needle aspiration of mass was done. Cytopathological examination revealed foci of endometrial cells with calcification.

Inguinal lymphadenopathy and hidradenitis should be considered as one of differential diagnoses of inguinal endometriosis. She was diagnosed with abdominal wall endometriosis and underwent wide local excision under spinal anesthesia. An intraoperative image showed multiple cysts with calcification and the mass was adherent to the underlying subcutaneous tissue and muscle [Figure 1]. Cut and open section of mass revealed multiple cystic lesions with calcification [Figure 2]. Postexcision defect was closed primarily. Postoperative histopathology showed an area of calcification and fibrocollagenous tissue entrapping the endometrial glands surrounded by the stromal cells [Figure 3]. Final histopathology confirmed the endometriotic cyst with calcification of the right inguinal region. Postexcision biopsy, the patient recovered well and the patient is on follow-up for more than 2 years without any recurrence.
Figure 1: Intraoperative picture shows inguinal endometriosis

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Figure 2: Cut open section shows multiple cystic lesions with calcifications

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Figure 3: Postoperative histopathology shows multiple endometrial cells surrounding stromal cells

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  Discussion Top


Outside the uterine cavity, endometriosis is commonly located in the ovaries, bowel, and pelvic cavity. Sometimes, it can be located in the extrapelvic location also. Inguinal endometriosis is a rare condition and is due to the presence of functional endometrial tissue in the inguinal region. It is usually located on the skin and subcutaneous level. Inguinal endometriosis is a type of abdominal wall endometriosis. The right inguinal region is involved more often as compared to the left due to the barrier effect of the sigmoid colon on the left side.[2] Endometriosis is common during the reproductive age group. It is very rare in postmenopausal women. Endometriosis is more common following surgery. The duration of onset of disease following surgery usually ranges from 1 to 6 years.

The imaging findings of endometriosis depend on the stage of the menstrual cycle, the proportion of stoma and glandular elements, amount of bleeding, degree of inflammation, and fibrotic response. On ultrasound, abdominal wall endometriosis appears as solid/cystic lesion, hypoechoic and with increased internal vascularity. On computed tomography, inguinal endometriosis appears as hyperattenuating mass as compared to the muscle with mild-to-moderate contrast enhancement. MRI is superior to CT in defining tissue delineation. On MRI, endometriotic cyst appears as hyperintense on T1-weighted images and hypointense on T2-weighted images, which is typical of the endometriotic cyst.[3] Image-guided fine-needle aspiration cytology (FNAC) is a useful investigation to confirm inguinal endometriosis. FNAC is a fast and accurate method for the diagnosis of endometriosis.[4]

The pathogenesis of endometrial cyst is multifactorial. There are numerous proposed theories for endometriosis which include retrograde menstruation, coelomic metaplasia, endometrial stem cell implementation, mullerian remnant abnormalities, dysfunctional immunes response, genetic predisposition, aberrant peritoneal environment, unopposed estrogen therapy, and tamoxifen therapy.[5] Inguinal endometriosis occurs due to the transfer of endometrial cells to the surgical wound. It occurs following cesarean section, hysterectomy, amniocentesis, therapeutic abortion, and laparoscopic pelvic procedures. The reported incidence of inguinal endometriosis in the absence of a previous surgery is very rare.[6]

There are various factors for the pathogenesis of postmenopausal endometriosis such as estrogen-independent progression of previously deposited endometrial tissue, increased production of local estrogen hormone and increased sensitivity of tissue for a small amount of secreted estrogen hormones.[7]

The inguinal region is an uncommon site for extrapelvic endometriosis. It is more common following an old surgical scar site. The reported incidence of scar endometriosis is around 0.1% (0.03%–0.1%). It is usually present with an abdominal mass, pain during menstruation, and a history of previous surgery.[8] It usually presents with cyclical pain particularly occurring for the first few days of menstruation. The patient with noncyclical pain with endometriosis is usually misdiagnosed.

On gross appearance, endometriosis appears as multiple cystic spaces filled with hemorrhagic fluids. Sometimes, macroscopic calcification is also seen. Under microscopy, islands of endometrial tissue embedded in abundant collagen within desmoplastic stoma are the diagnostic features. The differential diagnosis for abdominal wall endometriosis includes subcutaneous lesions such as lipoma, hernia, hematoma, abscess, granuloma, desmoids tumor, sarcoma, lymphoma, metastasis.[9]

The treatment for endometriosis includes medical management, minimally invasive technique, and surgical management. Medical management includes progesterone, oral contraceptive pills, danazol, gonadotrophin agonist. Minimally invasive treatment includes image-guided intralesional ethanol injection.[10] Surgical management includes wide local excision with flap cover or bride the defect with mesh. A systematic review on diagnosis and management of abdominal wall endometriosis in 2017 highlighted that it generally follows a primary surgery but can arise spontaneously. A careful history and physical examination are sufficient for diagnosis. Ultrasound or MRI can delineate the lesion wall with precision enabling the surgeon to perform a complete excision. Reoccurrence is unlikely following a complete excision.[11] Malignant transformation is one of the important and rare complications of endometriosis. The incidence of malignancy in endometriosis is 0.3%–1%. Clear cell carcinoma is most common followed by endometrioid carcinoma.[12]


  Conclusion Top


Inguinal endometriosis is a rare condition and is due to the presence of functional endometrial tissue in the inguinal region. Endometriosis can present in postmenopausal women without history of prior surgery and without classical symptoms of endometriosis. It should be considered as one of the differential diagnoses of inguinal region mass in postmenopausal women.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Farquhar C. Endometriosis. BMJ 2007;334:249-53.  Back to cited text no. 1
    
2.
Pandey D, Coondoo A, Shetty J, Mathew S. Jack in the box: Inguinal endometriosis. BMJ Case Rep 2015;2015:bcr2014207988.  Back to cited text no. 2
    
3.
Siegelman ES, Oliver ER. MR imaging of endometriosis: Ten imaging pearls. Radiographics 2012;32:1675-91.  Back to cited text no. 3
    
4.
Kim DH, Kim MJ, Kim ML, Park JT, Lee JH. Inguinal endometriosis in a patient without a previous history of gynecologic surgery. Obstet Gynecol Sci 2014;57:172-5.  Back to cited text no. 4
    
5.
Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: Pathogenesis and treatment. Nat Rev Endocrinol 2014;10:261-75.  Back to cited text no. 5
    
6.
Wong WS, Lim CE, Luo X. Inguinal endometriosis: An uncommon differential diagnosis as an inguinal tumour. ISRN Obstet Gynecol 2011;2011:272159.  Back to cited text no. 6
    
7.
Asencio FD, Ribeiro HA, Ayrosa Ribeiro P, Malzoni M, Adamyan L, Ussia A, et al. Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: A systematic review and seven case reports. Gynecol Surg 2019;16:3.  Back to cited text no. 7
    
8.
Papavramidis TS, Sapalidis K, Michalopoulos N, Karayanopoulou G, Raptou G, Tzioufa V, et al. Spontaneous abdominal wall endometriosis: A case report. Acta Chir Belg 2009;109:778-81.  Back to cited text no. 8
    
9.
Ozel L, Sagiroglu J, Unal A, Unal E, Gunes P, Baskent E, et al. Abdominal wall endometriosis in the cesarean section surgical scar: A potential diagnostic pitfall. J Obstet Gynaecol Res 2012;38:526-30.  Back to cited text no. 9
    
10.
Bozkurt M, Çil AS, Bozkurt DK. Intramuscular abdominal wall endometriosis treated by ultrasound-guided ethanol injection. Clin Med Res 2014;12:160-5.  Back to cited text no. 10
    
11.
Rindos NB, Mansuria S. Diagnosis and management of abdominal wall endometriosis: A systematic review and clinical recommendations. Obstet Gynecol Surv 2017;72:116-22.  Back to cited text no. 11
    
12.
Tsili AC, Argyropoulou MI, Koliopoulos G, Paraskevaidis E, Tsampoulas K. Malignant transformation of an endometriotic cyst: MDCT and MR findings. J Radiol Case Rep 2011;5:9-17.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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