Atypical Endometrial Hyperplasia Arising in a Cesarean Section Scar: A Mechanism of Malignant Transformation

Case Reports in Oncology
15 May, 2019 ,

This report presents anatomopathological evidence of an early-stage malignant transformation in endometriotic tissue from a post-Cesarean scar and briefly reviews possible underlying mechanisms. A 40-year-old woman with a body mass index of 42.7 was referred to the gynecological department with recurrent pain and presence of a palpable mass in her Cesarean section scar. She had undergone this procedure 7 years earlier and began experiencing discomfort and pain at the incision site 6 months postoperatively.  Anatomopathological examination revealed endometriotic tissue intertwined with atypical endometrial hyperplasia and fibrosis. 

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This case report is in line with CARE guidelines. A morbidly obese 40-year-old woman, para 1, was referred to the gynecological department with persistent pain in the abdominal wall scar after a Cesarean section. She underwent this procedure 7 years earlier and began experiencing discomfort and pain at the operated site 6 months postoperatively. Over the past 3 years, she felt both a 4 × 4 cm mass at the right edge of the Cesarean section scar and pain in the hypogastric area for which she received various analgesics, with no improvement. The pain always intensified with menstruation. Additionally, she suffered from chronic arterial hypertension managed with an angiotensin receptor blocker (losartan 50 mg p.o. daily). Her body mass index was 42.7 (body mass 115 kg; height 164 cm). The patient’s mother died of colorectal cancer 2 years earlier.

Two nodules of endometriotic foci were surgically removed with wide margins. The first one, located at the right border of the abdominal scar, was 4 cm in diameter and penetrated the fascia and abdominal muscles. The second was an endometriotic tumor, 5 cm in diameter, located in the scar’s midline. It infiltrated the fascia and abdominal muscles. Following removal and wound suturing, drainage was assured with a flexible subcutaneous catheter. The postoperative period was uneventful. The pathology report revealed endometriotic foci coexisting with atypical endometrial hyperplasia and fibrosis. A detailed anatomopathological verification revealed clear margins. Immunohistochemical examination displayed positive staining for cytokeratins CKMNF 116 and CKAE1/AE3, and for CD10 and CD68, whereas vimentin was moderately positive (+/–).

The patient was discharged on postoperative day 3. At a current follow-up of 2 years, she is asymptomatic, assessed both clinically and with ultrasound examination.