Multimodality imaging and clinicopathologic assessment of abdominal wall endometriosis: knocking down the enigma
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To review the clinical, multimodality imaging, and pathologic characteristics of abdominal wall endometriosis (AWE), the most common type of extra-pelvic endometriosis.
116 women with histopathologically confirmed extragenital endometriosis diagnosed between 2/2014 and 6/2017 were evaluated retrospectively. Of these, 26 (22.4%) were found to have AWE and 18/26 met inclusion criteria for imaging. Available imaging studies were re-reviewed by two expert radiologists. Data regarding clinical features, histopathologic findings, and management were collected through medical record review.
21 pathology-proven AWE deposits were identified by imaging in 18 women [mean age at diagnosis of 38.5 years (range 31–48)]. Prior C-section was present in 15/18 (83.3%) and pelvic endometriosis in 3/18 (16.7%) patients. Patients presented with abdominal pain in 14/18 (77.8%) cases, which was cyclical in 8/14; palpable mass in 12/18 (66.7%); fluid discharge in 2/18 (11.1%); and local skin discoloration in 2/18 (11.1%). Of the 21 lesions, 15 were evaluated with US, 10 with CT, and 5 with MRI. Mean lesion dimensions were 2.5 × 2.2 × 2.6 cm, and deposits were predominantly located at midline or left hemiabdomen [22/30 (73.3%)], were either stellate [15/30 (50%)] or round [15/30 (50%)] in shape, had ill-defined margins [21/30 (70%)], were heterogenous in appearance [27/30 (90%)], and involved both deep and superficial abdominal wall layers [17/30 (56.7%)]. On US, lesions were mainly isoechoic/hyperechoic [7/15 (46.7%)], and scarcely vascular [8/15 (53.3%)] with a peripheral vascular pattern [8/13 (61.5%)]. On CT, AWEs were hypervascular and homogeneous [8/10 (80%)], superiorly located to scar tissue, and on MRI lesions appeared hyperintense [4/5 (80%)] to muscle with T2 cystic and T1 hemorrhagic foci [4/5 (80%)]. In 23/27 (85.1%) original reports, there was at least one known mass prior to imaging; AWE was correctly diagnosed in only 7/23 (30.4%) cases. In those with no prior knowledge of a mass, the lesion was detected in 3/4 (75%), but AWE was only diagnosed in a single case. Median time between onset of symptoms and histopathology was 24.41 moths (IQR 15.18–47.33).
AWE is a challenging clinical entity frequently diagnosed with a significant delay and easily misinterpreted despite multimodality imaging. Familiarity with its radiologic features holds the potential for positively impacting diagnosis.
KeywordsEndometriosis Abdominal wall Magnetic resonance imaging Computed tomography Ultrasound
Compliance with ethical standards
This study required no funding sources, and the authors would like to disclose neither financial nor nonfinancial conflicts of interest for this work. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards; this being a retrospective observational study, informed consent was waived by our institutional review board (IRB). This article does not contain any studies with animals performed by any of the authors.
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