 |
|
An Ulcerated Umbilical Nodule
Heidi Muñoz, MD;
Leon Waxtein, MD;
M. Elisa Vega, MD;
Roberto Cortes, MD;
M. Teresa Hojyo, MD;
Luciano Dominguez-Soto, MD
Arch Fam Med. 2000;9:501-502.
REPORT OF A CASE
A 46-year-old woman presented with a 4-month history of a slowly growing, 6-mm-diameter, ulcerated, violaceous nodule on the umbilicus (Figure 1). She complained of local tenderness and occasional bleeding that increased during her menstruation. She had no history of previous illnesses or abdominal surgery.
The lesion was excised, and the histopathologic features are shown in Figure 2.
What is your diagnosis?
From the General Hospital "Dr Manuel Gea González," Mexico City, Mexico.
Diagnosis and Discussion: Primary Cutaneous Endometriosis
HISTOPATHOLOGIC FINDINGS AND CLINICAL COURSE
Histopathologic examination of the lesion revealed irregular glandular structures within a highly cellular and vascular stroma. The glandular structures were lined by a single layer of epithelium showing decapitation secretion into the lumen.
The patient underwent a gynecologic and endocrinologic evaluation. Two months after the umbilical nodule was surgically excised, she underwent an abdominal hysterectomy because of uterine myomatosis. No evidence of intra-abdominal endometriosis was found. The patient has been followed up for 1 year and has been completely asymptomatic.
DISCUSSION
Endometriosis, which is defined as the presence of extrauterine endometrial tissue, is a relatively common condition, affecting as many as 10% of females of childbearing age.1 Patients usually present with chronic abdominal or pelvic pain, which may be related to the menstrual cycle.2 Cutaneous endometriosis is commonly related to abdominal surgical scars due to pelvic surgery (cesarean section mainly), apparently being implanted or seeded during the surgical procedure.3 Primary cutaneous endometriosis is rare, with a prevalence of 0.5% to 1.0%,3 with no history of abdominal surgery, but should be suspected in any female with a tumoral nodule near the umbilicus who presents with cyclic pain or bleeding related to the menstrual cycle.4
The histopathologic features of endometriosis can be reminiscent of the main phases of the menstrual cycle. The proliferative phase has a uniform stromal cell population and pronounced epithelial mitotic activity; the secretory phase has decapitation secretion within the glandular cells and 2 stromal cell types: a large cell and a small clear cell that are morphologically similar to the uterine "predecidual cell" and the "endometrial granulocyte," respectively. Disintegration of the epithelium and dissociation from the stroma resemble menstruation. Most of the time, there is a poor correlation between the histologic appearance of the endometrioma and the menstrual stage, depending on many factors, such as adequacy of local blood supply and the presence of estrogen and progesterone receptors.5
The clinical differential diagnosis, which includes other acquired benign tumors of the umbilicus, such as pyogenic granuloma, umbilical polyp, melanocytic nevus, seborrheic keratosis, epithelial inclusion cyst, desmoid tumor, hemangioma, granular cell tumor, keloid, and foreign body granuloma, can be extensive. Malignant lesions, such as melanoma, and metastasis from the gastrointestinal tract (eg, Sister Joseph nodule) should also be included.6
Complete surgical excision remains the treatment of choice. A gynecologic examination and a hormonal evaluation are recommended for patients with cutaneous endometriosis.7
AUTHOR INFORMATION
Selected from Arch Dermatol. 1993;135:1113-1118. Off-Center Fold.
REFERENCES
|
1. Albrech L, Tron V, Rivers J. Cutaneous endometriosis. Int J Dermatol. 1995;34:261-262.
PUBMED
2. Wolf C, Singh K. Cesarean scar endometriosis: a review. Obstet Gynecol Surv. 1989;44:89-95.
PUBMED
3. Purvis R, Tyring S. Cutaneous and subcutaneous endometrisois: surgical and hormonal therapy. J Dermatol Surg Oncol. 1994;20:693-695.
PUBMED
4. Bergqvist A. Extragenital endometriosis: a review. Eur J Surg. 1992;158:7-12.
ISI
| PUBMED
5. Tidman M, MacDonald D. Cutaneous endometriosis: a histopathologic study. J Am Acad Dermatol. 1988;18:373-377.
PUBMED
6. Firilas A, Soi A, Max M. Abdominal incision endometriomas. Am Surg. 1994;60:259-261.
PUBMED
7. Tanos V, Anteby S. Cesarean scar endometriosis. Int J Gynecol Obstet. 1994;47:163-166.
PUBMED
|
