Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–3 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1011107
ORIGINAL ARTICLE
Efficacy of transabdominal sonoelastography in the diagnosis of caesarean section scar endometrioma: A pilot study M. Fawzy & T. Amer
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Department of Obstetrics and Gynecology, Radiology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
Transabdominal sonoelastography (TASE) is a new imaging technique that maps the elastic properties of soft tissue. We evaluated 34, consecutive women with suspected scar endometrioma using standard B-mode ultrasound and elastography. Twenty-three women (23/34) underwent surgical excision and had the diagnosis confirmed by histopathology. All endometriomas (23 patients) in B-mode imaging appeared as hypoechoic masses along the line of a previous caesarean section incision and the outer borders were difficult to define precisely. By TASE, the endometrioma presented a typical blue-green-red appearance and the outer borders were clearly defined. (red and green area corresponds with the central hypoechoic soft areas). Strain ratios varied from 0.02 to 0.75. Real-time TASE is a simple, useful technique in confirming a clinical diagnosis of endometrioma in a caesarean section scar. Compared with B-mode ultrasound, it provides additional, preoperative information about the extent of the lesion that may be helpful to the surgeon. Keywords: Endometrioma, endometriosis of the abdominal wall, scar, sonoelastography
Introduction Endometriosis is defined as the presence of ectopic, functioning endometrial tissue outside the uterine cavity. In most cases it is located within the pelvis, but it can even be found in the lung, bowel, ureter and abdominal wall (Horton et al. 2008).The expression abdominal wall endometriosis is used to indicate the presence of ectopic endometrium located far from the peritoneum, embedded in the subcutaneous fatty tissue and the abdominal wall muscle layers. Cesarean section scars are the most common site of anterior abdominal endometriosis, which has an estimated incidence of approximately 0.03–0.4% among all women (Blanco et al. 2003; Francica et al. 2009). The symptoms of abdominal wall endometriosis are nonspecific and include cyclic or continuous pain associated with a palpable mass (Chatterjee 1980; Patterson and Winburn 1999; Blanco et al. 2003). Abdominal wall endometriosis is often misdiagnosed as a hernia, suture granuloma, primary or metastatic tumor, haematoma or lipoma of the abdominal wall, thus resulting in unexpected findings at surgery (Horton et al. 2008).
Preoperative diagnosis of abdominal wall mass is important to counsel the patient and to decide appropriate surgery. Transabdominal sonography using a linear transducer has been found to be useful in detecting and locating abdominal wall endometriosis. Real-time transabdominal sonoelastography (TASE) has recently been developed. This technique uses slight external tissue compression to quantify the strain produced in the structures examined (Fleury 2009). Elastography is a strain imaging technique that has been well established in the research literature as a promising technology to identify tissue stiffness of an abnormal growth. Sonoelastography examination represents an extension of palpation, where the physician assesses the shape and rigidity of the target tissue. When external pressure is applied to a target region, this pressure causes tissue deformation (strain). Using specific software, tissue deformation is expressed as a colour variation on the ultrasound. Therefore, based on the assumption that the lesions evaluated show different elasticities with respect to the surrounding areas, this may be a useful implement. The stiffness of the tissue is displayed in colours ranging from red (components with the greatest strain, i.e. the softest components) to blue (components with no strain, i.e. the hardest components). (Marco et al. 2011). A transabdominal sonoelastography used in a pilot study to evaluate frequently misdiagnosed condition: cesarean section scar endometrioma, on assumption that tissues with anatomopathological differences show different elasticity values.
Materials and methods The study was carried out in the Mansoura university hospital between July 2012 and June 2014. In the outpatient clinic, we observed 34 patients with suspected caesarean scar endometrioma complaining of painful abdominal mass. Patients were referred to radiology department to be examined by one sonographer. All examinations were performed with an ultrasound scanner Hitachi Medical Corporation EUB 7500 equipped with a sonoelastographic module. To acquire an elastography image, the ultrasonographer takes a regular ultrasound image and then pushes on the tissue with the ultrasound transducer to take a compressed image. Normal tissue and benign tumors are typically soft or elastic and will compress easily whereas hard malignant tumors does not depress at all. Diagnosis of scar endometrioma
Correspondence: Muhammad Fawzy, Obstetrics and Gynecology Department, Mansoura University Hospital, El Gomhouria Street, Mansoura, Ad Daqahliyah, Egypt. E-mail: [email protected]
2
M. Fawzy & T. Amer
was made by traditional ultrasound assessment if a fixed solid less echogenic mass was seen along a caesarean scar. After the B-mode evaluation, the mode was switched to sonoelastography. Area of interest (AOI) was displayed as a coloured area. The colours range from red to blue according to relative softness or hardness of the tissue. The B-mode and elastographic images were stored. Surgery was performed in 23 patients diagnosed primarily as caesarean section scar endometrioma (CSE) and a pre-operative diagnosis was confirmed by histopathological examination. This study was given approval by the Ethics Committee of Mansoura University Hospital. Normal variables were expressed as mean (standard deviation [SD]), median (range) and percentage.
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Results A total of 23 of the originally recruited 34 women were enrolled in the study. The characteristics of the study population are shown in Table I. Twenty (87%) patients had a single mass, one (4.3%) patient had two masses and two (8.7%) patients had multiple adjacent endometriotic masses. The median diameter of the masses was 23 (range: 9–65) mm. The endometrioma had an oval shape in some patients and an irregular morphology in other patients (Table II). In all 23 women, the caesarean scar endometrioma had ill-defined, blurred outer borders. All were located along the scar of a caesarean section. The echotexture was inhomogeneous in fifteen of 23 (65.2%) cases owing to the presence of inner echogenic punctate echoes or bright strands, small hypoechoic lacunae in three women (13%); and in the remaining 5/23 (21.7%) cases, the caesarean scar endometrioma was homogeneously hypoechoic. The same repetitive image of the AOI was obtained by elastography in all patients of CSE, as shown in Figure 1a,b. Strain ratio (SR) is a value based on determining the average strain measured in a lesion and comparing it with the average strain of a surrounding adjacent tissue. The SR ranged from 0.02 to 7.25.The histopathological evaluations of 23 (100%) excised masses primarily diagnosed to be CSE by sonoelastography confirmed the presence of endometrial tissues embedded within fibroblasts and collagen fibres.
Discussion Abdominal wall endometriosis represents a diagnostic challenge. Its low prevalence, together with the scanty data available regarding its sonographic criteria, is possible the cause of misdiagnosis. Scar endometriosis may be diagnosed at ultrasonography (US), computerised tomography (CT) and magnetic resonance imaging (MRI) in patients who are symptomatic or asymptomatic. In some patients, imaging data combined with clinical history are Table I. Clinical characteristics of 23 patients who underwent surgery for caesarean scar mass. Clinical data Mean age (yr) No. of caesarean sections Time since last caesarean section (months) Onset of symptoms (months before diagnosis) Continuous pain Cyclic pain Asymptomatic Spontaneous cyclic bleeding Known pelvic endometriosis Tenderness Data are given as mean (SD) and n (%).
Value 25.7 ⫾ 6.8 2.1 ⫾ 1.6 27.6 ⫾ 11.3 17.8 ⫾ 9.5 3 (13%) 21 (91.3%) 2 (8.7%) 1 (4.3%) 2 (8.7%) 23 (100%)
strongly suggestive of the diagnosis, whereas in other patients imaging findings are less specific. The appearance of scar endometriosis at US, CT and MRI depends on the phase of the patient’s menstrual cycle, the chronicity of the process, the number of stromal and glandular elements, and the amount of bleeding and associated inflammation (Wolf 1996). Ultrasound is usually the first imaging evaluation performed to evaluate focal abdominal wall mass identified on clinical examination, and it may be performed in patients with focal abdominal wall pain that is localised to a surgical scar with no identifiable abnormality on physical examination. Ultrasound depicts the extent and nature of such focal lesions. Sonographic features of scar endometriomas vary and are non-specific in the literature; B-mode features displayed CSEs in different diameters, shapes and echotextures (Table II). After B-mode examination, the mode was switched to sonoelastography. Elastography technique requires just 1 min to show typical blue-green-red (BGR) appearance in AOI. The borders of the endometrioma area correspond to the borders of the blue area, and more softness (red and green area) corresponds with the central hypoechoic areas. In almost all the cases, the red area in particular coincides with the anechoic areas visualised in the B-mode. SR is a semi-quantitative measurement of strain differences between two user-defined areas in an elastogram. The ratio value increases as a function of the relative stiffness of the target lesion (Havre et al. 2011). Distribution of the SR in differentiating benign from malignant lesions has become a subject of considerable debate. Wang et al. (2013) reported that adding SR (cutoff point of 3.8) measurement to ultrasound elastography would provide a more objective way to differentiate benign from malignant lesions. In this study, the SR is variable between 0.02 and 7.25 which is consistent with the results of Chong et al. (2013) who reported that adding SR to colour mapping of elastography was not better than coloured mapping alone. The histopathological evaluations of excised masses primarily diagnosed to be CSE confirmed the presence of scarce endometrial glands and stroma embedded within fibroblasts and collagen fibres. Head-to-head comparison between sonoelastography imaging and pathological slides examination revealed that red and green area corresponds to endometriotic tissue. The surrounding area around stromal and glandular element corresponds to tissue that has become edematous and filled with granulocyte and histiocytes. In this study, histopathological examination confirmed diagnosis of endometrioma for all 23 patients (100%). High efficacy of TASE in CSE diagnosis may be attributed to the extremely strict selection of the patients, each of whom had clinical Table II. Sonographical features of caesarean scar endometrioma. Sonographical feature B-mode features Diameter (mm) Shape Oval Stellate Echotexture Inhomogenous Cystic lacunae Homogenous Pain at pressure with probe Elastosonography BGR appearance
Value 23 (9–65) 18/23 (78.3%) 5/23 (21.7%) 15/23 (65.2%) 3/23 (13%) 5/23 (21.7%) 23/23 (100%)
23 (100%)
Data are given as median (range) and n (%); BGR, blue-green-red appearance.
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Elastography for diagnosis of caesarean scar endometrioma 3
Figure 1. (a) Caesarean scar endometrioma in a 34-year-old female patient, B-mode US revealed fairly defined hypoechoic stellate parietal mass 26.5 ⫻ 17.4 mm. (b) Caesarean scar endometrioma in a 34-year-old female patient, real-time scan elastography revealed typical BGR appearance, the red colour at posterior aspect of the mass represents endometrium, the mass has highest SR: 7.25.
symptoms and signs of CSE. Our observations were consistent with those of Mezzi et al. (2011) who reported that sonoelastography offers a non-invasive and sensitive technique to define the endometriotic infiltration in the rectosigmoid wall. Currently sonoelastography is being used, with good results, in the evaluation of breast and thyroid lesions and in prostate cancer (Vanhoutte 2008; Rubaltelli 2009; Miyagawa 2009), while its use in gynaecology has been limited to the evaluation of the uterine cervix, fibroids and adenomyosis (Thomas et al. 2007; Ami et al. 2009; Marco 2011). It is important to point out that to our knowledge this article is the first of its kind in the currently available medical literature to deal with this argument. Despite its limitations of relatively small study population, this study demonstrates that TASE combined with clinical history is strongly suggestive of scar endometriosis. Our preliminary data need to be confirmed by large clinical trials. Transabdominal real-time sonoelastography represents a newly developed technology for the measurement of tissue elasticity, being integrated into current ultrasound systems. Our initial clinical results suggest that real-time sonoelastography is a promising new implement for the diagnosis of caesarean scar endometrioma. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Ami O, Lamazou F, Mabille M, Levaillant JM, Deffieux X, Frydman R et al. 2009. Real-time transvaginal elastosonography of uterine fibroids. Ultrasound in Obstetrics & Gynecology 34:486–488. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. 2003. Abdominal wall endometriomas. The American Journal of Surgery 185:596–598. Chatterjee SK. 1980. Scar endometriosis: A clinicopathologic study of 17 cases. Obstetrics & Gynecology 56:81–84.
Chong Y, Shin JH, Ko ES, Han BK. 2013. Ultrasonographic elastography of thyroid nodules: is adding strain ratio to colour mapping better? Clinical Radiology 68:1241–1246. Fleury EF, Roveda DJ, Fleury JC, do Carmo QM, Piato S. 2009. Elastography: theory into clinical practice. Breast Journal 15:564–566 Francica G, Scarano F, Scotti L, Angelone G, Giardiello C. 2009. Endometriomas in the region of a scar from Cesarean section: sonographic appearance and clinical presentation vary with the size of the lesion. Journal of Clinical Ultrasound 37:215–220. Havre RF, Waage JR, Gilja OH, Odegaard S, Nesje LB. 2011. Real-Time Elastography: Strain Ratio Measurements Are Influenced by the Position of the Reference Area. Ultraschall in der Medizin [Epub ahead of print]. Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. 2008. Abdominal wallendometriosis: a surgeon’s perspective and review of 445 cases. The American Journal of Surgery 196:207–212. Marco T, Luca B, Marco D, Francesco D. 2011. Elastosonography: a possible new tool for diagnosis of adenomyosis? European Radiology 21:1546–1552 Mezzi G, Ferrari S, Arcidiacono PG, Di Puppo F, Candiani M, Testoni PA. 2011 Endoscopic rectal ultrasound and elastosonography are useful in flow chart for the diagnosis of deep pelvicendometriosis with rectal involvement. Journal of Obstetrics and Gynaecology Research 37:586–590. Miyagawa T, Tsutsumi M, Matsumura T, Kawazoe N, Ishikawa S, Shimokama T et al. 2009. Real-time elastography for the diagnosis of prostate cancer: evaluation of elastographic moving images. Japanese Journal of Clinical Oncology 39:394–398. Patterson GK, Winburn GB. 1999. Abdominal wall endometriomas: report of eight cases. The American Journal of Surgery 65:36–39. Rubaltelli L, Corradin S, Dorigo A, Stabilito M, Tregnaghi A, Borsato S et al. 2009. Differential diagnosis of benign and malignant thyroid nodules at elastosonography. Ultraschall in der Medizin 30:175–179. Thomas A, Kümmel S, Gemeinhardt O, Fischer T. 2007. Real-time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix. Academic Radiology 14:193–200. Vanhoutte A, Fellah L, Galant C, d’Hoore W, Berlière M, Leconte I. 2008. Contribution of sonoelastography to the characterization of breast lesions. Journal Belge de Radiologie – Belgisch Tijdschrift voor Radiologi 91:187–194. Wang H, Brylka D, Sun LN, Lin YQ, Sui GQ, Gao J. 2013. Comparison of strain ratio with elastography score system in differentiating malignant from benign thyroid nodules. Clinical Imaging 37:50–55. Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. 1996. Endometriosis in abdominal scars: a diagnostic pitfall. The American Journal of Surgery 62:1042–1044.
ORIGINAL ARTICLE
Efficacy of transabdominal sonoelastography in the diagnosis of caesarean section scar endometrioma: A pilot study M. Fawzy & T. Amer
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Department of Obstetrics and Gynecology, Radiology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
Transabdominal sonoelastography (TASE) is a new imaging technique that maps the elastic properties of soft tissue. We evaluated 34, consecutive women with suspected scar endometrioma using standard B-mode ultrasound and elastography. Twenty-three women (23/34) underwent surgical excision and had the diagnosis confirmed by histopathology. All endometriomas (23 patients) in B-mode imaging appeared as hypoechoic masses along the line of a previous caesarean section incision and the outer borders were difficult to define precisely. By TASE, the endometrioma presented a typical blue-green-red appearance and the outer borders were clearly defined. (red and green area corresponds with the central hypoechoic soft areas). Strain ratios varied from 0.02 to 0.75. Real-time TASE is a simple, useful technique in confirming a clinical diagnosis of endometrioma in a caesarean section scar. Compared with B-mode ultrasound, it provides additional, preoperative information about the extent of the lesion that may be helpful to the surgeon. Keywords: Endometrioma, endometriosis of the abdominal wall, scar, sonoelastography
Introduction Endometriosis is defined as the presence of ectopic, functioning endometrial tissue outside the uterine cavity. In most cases it is located within the pelvis, but it can even be found in the lung, bowel, ureter and abdominal wall (Horton et al. 2008).The expression abdominal wall endometriosis is used to indicate the presence of ectopic endometrium located far from the peritoneum, embedded in the subcutaneous fatty tissue and the abdominal wall muscle layers. Cesarean section scars are the most common site of anterior abdominal endometriosis, which has an estimated incidence of approximately 0.03–0.4% among all women (Blanco et al. 2003; Francica et al. 2009). The symptoms of abdominal wall endometriosis are nonspecific and include cyclic or continuous pain associated with a palpable mass (Chatterjee 1980; Patterson and Winburn 1999; Blanco et al. 2003). Abdominal wall endometriosis is often misdiagnosed as a hernia, suture granuloma, primary or metastatic tumor, haematoma or lipoma of the abdominal wall, thus resulting in unexpected findings at surgery (Horton et al. 2008).
Preoperative diagnosis of abdominal wall mass is important to counsel the patient and to decide appropriate surgery. Transabdominal sonography using a linear transducer has been found to be useful in detecting and locating abdominal wall endometriosis. Real-time transabdominal sonoelastography (TASE) has recently been developed. This technique uses slight external tissue compression to quantify the strain produced in the structures examined (Fleury 2009). Elastography is a strain imaging technique that has been well established in the research literature as a promising technology to identify tissue stiffness of an abnormal growth. Sonoelastography examination represents an extension of palpation, where the physician assesses the shape and rigidity of the target tissue. When external pressure is applied to a target region, this pressure causes tissue deformation (strain). Using specific software, tissue deformation is expressed as a colour variation on the ultrasound. Therefore, based on the assumption that the lesions evaluated show different elasticities with respect to the surrounding areas, this may be a useful implement. The stiffness of the tissue is displayed in colours ranging from red (components with the greatest strain, i.e. the softest components) to blue (components with no strain, i.e. the hardest components). (Marco et al. 2011). A transabdominal sonoelastography used in a pilot study to evaluate frequently misdiagnosed condition: cesarean section scar endometrioma, on assumption that tissues with anatomopathological differences show different elasticity values.
Materials and methods The study was carried out in the Mansoura university hospital between July 2012 and June 2014. In the outpatient clinic, we observed 34 patients with suspected caesarean scar endometrioma complaining of painful abdominal mass. Patients were referred to radiology department to be examined by one sonographer. All examinations were performed with an ultrasound scanner Hitachi Medical Corporation EUB 7500 equipped with a sonoelastographic module. To acquire an elastography image, the ultrasonographer takes a regular ultrasound image and then pushes on the tissue with the ultrasound transducer to take a compressed image. Normal tissue and benign tumors are typically soft or elastic and will compress easily whereas hard malignant tumors does not depress at all. Diagnosis of scar endometrioma
Correspondence: Muhammad Fawzy, Obstetrics and Gynecology Department, Mansoura University Hospital, El Gomhouria Street, Mansoura, Ad Daqahliyah, Egypt. E-mail: [email protected]
2
M. Fawzy & T. Amer
was made by traditional ultrasound assessment if a fixed solid less echogenic mass was seen along a caesarean scar. After the B-mode evaluation, the mode was switched to sonoelastography. Area of interest (AOI) was displayed as a coloured area. The colours range from red to blue according to relative softness or hardness of the tissue. The B-mode and elastographic images were stored. Surgery was performed in 23 patients diagnosed primarily as caesarean section scar endometrioma (CSE) and a pre-operative diagnosis was confirmed by histopathological examination. This study was given approval by the Ethics Committee of Mansoura University Hospital. Normal variables were expressed as mean (standard deviation [SD]), median (range) and percentage.
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Results A total of 23 of the originally recruited 34 women were enrolled in the study. The characteristics of the study population are shown in Table I. Twenty (87%) patients had a single mass, one (4.3%) patient had two masses and two (8.7%) patients had multiple adjacent endometriotic masses. The median diameter of the masses was 23 (range: 9–65) mm. The endometrioma had an oval shape in some patients and an irregular morphology in other patients (Table II). In all 23 women, the caesarean scar endometrioma had ill-defined, blurred outer borders. All were located along the scar of a caesarean section. The echotexture was inhomogeneous in fifteen of 23 (65.2%) cases owing to the presence of inner echogenic punctate echoes or bright strands, small hypoechoic lacunae in three women (13%); and in the remaining 5/23 (21.7%) cases, the caesarean scar endometrioma was homogeneously hypoechoic. The same repetitive image of the AOI was obtained by elastography in all patients of CSE, as shown in Figure 1a,b. Strain ratio (SR) is a value based on determining the average strain measured in a lesion and comparing it with the average strain of a surrounding adjacent tissue. The SR ranged from 0.02 to 7.25.The histopathological evaluations of 23 (100%) excised masses primarily diagnosed to be CSE by sonoelastography confirmed the presence of endometrial tissues embedded within fibroblasts and collagen fibres.
Discussion Abdominal wall endometriosis represents a diagnostic challenge. Its low prevalence, together with the scanty data available regarding its sonographic criteria, is possible the cause of misdiagnosis. Scar endometriosis may be diagnosed at ultrasonography (US), computerised tomography (CT) and magnetic resonance imaging (MRI) in patients who are symptomatic or asymptomatic. In some patients, imaging data combined with clinical history are Table I. Clinical characteristics of 23 patients who underwent surgery for caesarean scar mass. Clinical data Mean age (yr) No. of caesarean sections Time since last caesarean section (months) Onset of symptoms (months before diagnosis) Continuous pain Cyclic pain Asymptomatic Spontaneous cyclic bleeding Known pelvic endometriosis Tenderness Data are given as mean (SD) and n (%).
Value 25.7 ⫾ 6.8 2.1 ⫾ 1.6 27.6 ⫾ 11.3 17.8 ⫾ 9.5 3 (13%) 21 (91.3%) 2 (8.7%) 1 (4.3%) 2 (8.7%) 23 (100%)
strongly suggestive of the diagnosis, whereas in other patients imaging findings are less specific. The appearance of scar endometriosis at US, CT and MRI depends on the phase of the patient’s menstrual cycle, the chronicity of the process, the number of stromal and glandular elements, and the amount of bleeding and associated inflammation (Wolf 1996). Ultrasound is usually the first imaging evaluation performed to evaluate focal abdominal wall mass identified on clinical examination, and it may be performed in patients with focal abdominal wall pain that is localised to a surgical scar with no identifiable abnormality on physical examination. Ultrasound depicts the extent and nature of such focal lesions. Sonographic features of scar endometriomas vary and are non-specific in the literature; B-mode features displayed CSEs in different diameters, shapes and echotextures (Table II). After B-mode examination, the mode was switched to sonoelastography. Elastography technique requires just 1 min to show typical blue-green-red (BGR) appearance in AOI. The borders of the endometrioma area correspond to the borders of the blue area, and more softness (red and green area) corresponds with the central hypoechoic areas. In almost all the cases, the red area in particular coincides with the anechoic areas visualised in the B-mode. SR is a semi-quantitative measurement of strain differences between two user-defined areas in an elastogram. The ratio value increases as a function of the relative stiffness of the target lesion (Havre et al. 2011). Distribution of the SR in differentiating benign from malignant lesions has become a subject of considerable debate. Wang et al. (2013) reported that adding SR (cutoff point of 3.8) measurement to ultrasound elastography would provide a more objective way to differentiate benign from malignant lesions. In this study, the SR is variable between 0.02 and 7.25 which is consistent with the results of Chong et al. (2013) who reported that adding SR to colour mapping of elastography was not better than coloured mapping alone. The histopathological evaluations of excised masses primarily diagnosed to be CSE confirmed the presence of scarce endometrial glands and stroma embedded within fibroblasts and collagen fibres. Head-to-head comparison between sonoelastography imaging and pathological slides examination revealed that red and green area corresponds to endometriotic tissue. The surrounding area around stromal and glandular element corresponds to tissue that has become edematous and filled with granulocyte and histiocytes. In this study, histopathological examination confirmed diagnosis of endometrioma for all 23 patients (100%). High efficacy of TASE in CSE diagnosis may be attributed to the extremely strict selection of the patients, each of whom had clinical Table II. Sonographical features of caesarean scar endometrioma. Sonographical feature B-mode features Diameter (mm) Shape Oval Stellate Echotexture Inhomogenous Cystic lacunae Homogenous Pain at pressure with probe Elastosonography BGR appearance
Value 23 (9–65) 18/23 (78.3%) 5/23 (21.7%) 15/23 (65.2%) 3/23 (13%) 5/23 (21.7%) 23/23 (100%)
23 (100%)
Data are given as median (range) and n (%); BGR, blue-green-red appearance.
J Obstet Gynaecol Downloaded from informahealthcare.com by RMIT University on 08/18/15 For personal use only.
Elastography for diagnosis of caesarean scar endometrioma 3
Figure 1. (a) Caesarean scar endometrioma in a 34-year-old female patient, B-mode US revealed fairly defined hypoechoic stellate parietal mass 26.5 ⫻ 17.4 mm. (b) Caesarean scar endometrioma in a 34-year-old female patient, real-time scan elastography revealed typical BGR appearance, the red colour at posterior aspect of the mass represents endometrium, the mass has highest SR: 7.25.
symptoms and signs of CSE. Our observations were consistent with those of Mezzi et al. (2011) who reported that sonoelastography offers a non-invasive and sensitive technique to define the endometriotic infiltration in the rectosigmoid wall. Currently sonoelastography is being used, with good results, in the evaluation of breast and thyroid lesions and in prostate cancer (Vanhoutte 2008; Rubaltelli 2009; Miyagawa 2009), while its use in gynaecology has been limited to the evaluation of the uterine cervix, fibroids and adenomyosis (Thomas et al. 2007; Ami et al. 2009; Marco 2011). It is important to point out that to our knowledge this article is the first of its kind in the currently available medical literature to deal with this argument. Despite its limitations of relatively small study population, this study demonstrates that TASE combined with clinical history is strongly suggestive of scar endometriosis. Our preliminary data need to be confirmed by large clinical trials. Transabdominal real-time sonoelastography represents a newly developed technology for the measurement of tissue elasticity, being integrated into current ultrasound systems. Our initial clinical results suggest that real-time sonoelastography is a promising new implement for the diagnosis of caesarean scar endometrioma. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Ami O, Lamazou F, Mabille M, Levaillant JM, Deffieux X, Frydman R et al. 2009. Real-time transvaginal elastosonography of uterine fibroids. Ultrasound in Obstetrics & Gynecology 34:486–488. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. 2003. Abdominal wall endometriomas. The American Journal of Surgery 185:596–598. Chatterjee SK. 1980. Scar endometriosis: A clinicopathologic study of 17 cases. Obstetrics & Gynecology 56:81–84.
Chong Y, Shin JH, Ko ES, Han BK. 2013. Ultrasonographic elastography of thyroid nodules: is adding strain ratio to colour mapping better? Clinical Radiology 68:1241–1246. Fleury EF, Roveda DJ, Fleury JC, do Carmo QM, Piato S. 2009. Elastography: theory into clinical practice. Breast Journal 15:564–566 Francica G, Scarano F, Scotti L, Angelone G, Giardiello C. 2009. Endometriomas in the region of a scar from Cesarean section: sonographic appearance and clinical presentation vary with the size of the lesion. Journal of Clinical Ultrasound 37:215–220. Havre RF, Waage JR, Gilja OH, Odegaard S, Nesje LB. 2011. Real-Time Elastography: Strain Ratio Measurements Are Influenced by the Position of the Reference Area. Ultraschall in der Medizin [Epub ahead of print]. Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. 2008. Abdominal wallendometriosis: a surgeon’s perspective and review of 445 cases. The American Journal of Surgery 196:207–212. Marco T, Luca B, Marco D, Francesco D. 2011. Elastosonography: a possible new tool for diagnosis of adenomyosis? European Radiology 21:1546–1552 Mezzi G, Ferrari S, Arcidiacono PG, Di Puppo F, Candiani M, Testoni PA. 2011 Endoscopic rectal ultrasound and elastosonography are useful in flow chart for the diagnosis of deep pelvicendometriosis with rectal involvement. Journal of Obstetrics and Gynaecology Research 37:586–590. Miyagawa T, Tsutsumi M, Matsumura T, Kawazoe N, Ishikawa S, Shimokama T et al. 2009. Real-time elastography for the diagnosis of prostate cancer: evaluation of elastographic moving images. Japanese Journal of Clinical Oncology 39:394–398. Patterson GK, Winburn GB. 1999. Abdominal wall endometriomas: report of eight cases. The American Journal of Surgery 65:36–39. Rubaltelli L, Corradin S, Dorigo A, Stabilito M, Tregnaghi A, Borsato S et al. 2009. Differential diagnosis of benign and malignant thyroid nodules at elastosonography. Ultraschall in der Medizin 30:175–179. Thomas A, Kümmel S, Gemeinhardt O, Fischer T. 2007. Real-time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix. Academic Radiology 14:193–200. Vanhoutte A, Fellah L, Galant C, d’Hoore W, Berlière M, Leconte I. 2008. Contribution of sonoelastography to the characterization of breast lesions. Journal Belge de Radiologie – Belgisch Tijdschrift voor Radiologi 91:187–194. Wang H, Brylka D, Sun LN, Lin YQ, Sui GQ, Gao J. 2013. Comparison of strain ratio with elastography score system in differentiating malignant from benign thyroid nodules. Clinical Imaging 37:50–55. Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. 1996. Endometriosis in abdominal scars: a diagnostic pitfall. The American Journal of Surgery 62:1042–1044.
