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Cutaneous umbilical endometriosis

  • Author(s): Lee, Arnold
  • Tran, Hien T
  • Walters, Ruth F
  • Yee, Herman
  • Rosenman, Karla
  • Sanchez, Miguel R
  • et al.
Main Content

Cutaneous umbilical endometriosis
Arnold Lee MD PhD, Hien T Tran MD PhD, Ruth F Walters MD, Herman Yee MD PhD, Karla Rosenman MD, Miguel R Sanchez MD
Dermatology Online Journal 14 (10): 23

Department of Dermatology, New York University

Abstract

A 35 year-old woman presented with a four-month history of a tender umbilical nodule that bleeds during her menstrual period. Physical examination showed a hyperpigmented umbilical nodule. A biopsy specimen showed fibrotic dermis with increased numbers of blood vessels and scattered glandular structures with areas of hemosiderin deposition consistent with a diagnosis of endometriosis. Cutaneous umbilical endometriosis is rare, with an estimated incidence of 0.5 to 1.0 percent. Although anti-gonadotropin medications, such as danazol, have been used for symptomatic control, but surgical excision is the treatment of choice owing to the possibility of malignant degeneration of cutaneous endometriosis.



Figure 1Figure 2

History

A 35-year-old woman presented to the Dermatology Clinic at Bellevue Hospital Center with a four-month history of a tender umbilical mass that bleeds during her menstrual period. A punch biopsy was performed. Her past medical history includes perianal warts and vulvar lichen simplex chronicus for which she applies hydrocortisone 2.5 percent cream and econazole cream twice daily to her vulva.


Physical Examination

A hyperpigmented umbilical nodule was present.


Lab

None.


Histopathology

Within the reticular dermis, there are glands lined by bland cuboidal cells that are surrounded by a stroma of spindle cells in which there are focal hemosiderin deposits.


Comment

Endometriosis is the presence of functional endometrial tissue outside the uterine cavity. It typically occurs in women during their reproductive years. Extrapelvic endometriosis in women with endometriosis has been estimated to occur in up 12 percent [1]. Although ectopic endometrial tissue has been documented in almost every organ of the body, the intestine, skin, inguinal region, and lungs are the most frequently observed sites [2, 3]. In particular, cutaneous endometriosis occurs most commonly in surgical scars after abdominal or pelvic operations [3]. These operations include hysterectomy, tubal ligation, Caesarean section, episiotomy, and laparoscopy. In contrast, umbilical endometriosis is uncommon, with an estimated incidence of 0.5 to 1 percent [1, 4].

The classic presentation for cutaneous endometriosis is a parous woman, who complains of a tender nodule with associated swelling and slight bleeding during the menses [1]. The use of non-invasive imaging modalities, such as sonography and computed tomography scans, to help distinguish cutaneous endometriosis from a suture granuloma, lipoma, abscess, cyst, or incisional hernia has met with limited success [6]. Immunohistochemical staining with CD10 can be used to confirm the presence of endometrial stroma, with an estimated sensitivity of 88 percent [5]. A single case report using dermoscopy has described the presence of red atolls that were homogenously distributed in the cutaneous endometrial lesions. Correlations between dermatoscopic and histopathologic features have shown that these red atolls are related to the presence of multiple irregular glands that contain red blood cells, which are embedded in a cellular stroma. The homogeneous red hue is associated with the presence of myxoid, vascular stroma, which contains extravasated erythrocytes [4].

Multiple theories have been proposed to explain the development of endometriosis. Endometrioma in scars are likely due to direct inoculation and implantation of endometrial cells [2]. This theory is consistent with experiments that demonstrate that transplantation of normal menstrual effluent to the abdominal wall results in subcutaneous endometriosis [7]. For cases of spontaneous cutaneous endometriosis, the endometrial cells may reach the sites via lymphatic or vascular dissemination [1, 3]. It has been hypothesized that these ectopically implanted endometrial cells do not proliferate to form endometrioma. Instead, they lodge in certain tissues with a high degree of pleuripotentiality and induce cell replication [3].

Surgical excision of cutaneous endometriosis is the treatment of choice. Malignant degeneration of extragonadal endometriosis occurs in 21.3 percent. However, malignant conditions, such as endometrial carcinoma that arise from cutaneous endometriosis in surgical scars, are rare at 0.3 to 1 percent [5, 8]. Anti-gonadotropin medications, such as danazol, have been used to provide relief of symptoms such as pain [1, 2]. However, this type of medication has undesirable androgenic side-effects, such as amenorrhea, hirsutism, weigh gain, and acne, which may influence compliance [2, 9].

References

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