Can a C-section (cesarean section) scar endometrioma spread?

Can C-Section Scar Endometrioma Spread?

Yes, C-section scar endometrioma can spread both locally and to distant pelvic sites, though this occurs in a minority of cases, making complete surgical excision with adequate margins the critical intervention to prevent recurrence and progression.

Understanding the Spread Potential

C-section scar endometrioma develops through implantation of endometrial tissue along the surgical tract during cesarean delivery, affecting 1-2% of patients who undergo the procedure 1. While the condition primarily manifests as a localized abdominal wall mass, the disease demonstrates capacity for both local and distant spread:

Local Recurrence Pattern

• Local recurrence occurs when surgical margins are inadequate, with documented cases showing recurrence after incomplete excision 1
• The endometriotic tissue can infiltrate along tissue planes including skin, subcutaneous tissue, abdominal wall muscles, and even intraperitoneally 2
• Excision with histologically proven free surgical margins of at least 1 cm is mandatory to prevent local recurrence 1

Pelvic/Intraperitoneal Spread

• Scar endometriosis may be associated with synchronous pelvic endometriosis, indicating potential for intraperitoneal disease spread 1
• One documented case series showed pelvic recurrence requiring surgical treatment during follow-up (mean 34.6 months) 1
• Explorative abdominal laparoscopy may be indicated to exclude intraperitoneal spread in symptomatic patients, particularly those with pelvic pain beyond the scar site 1

Clinical Recognition and Diagnosis

The typical presentation includes:

• Painful, tender abdominal wall mass located on the previous Pfannenstiel incision (most commonly at the right end in 62% of cases) 3
• Cyclical pain intensifying prior to menstruation is characteristic, though present in only a subset of patients 4, 5
• Average onset occurs 32.9 months post-cesarean section, with symptoms persisting an average of 25.3 months before diagnosis 3
• Average lesion size is 30 mm at presentation 3

Diagnostic Imaging

• MRI with T1 fat-saturated sequences is the most sensitive imaging method, with hyperintense (hemorrhagic) foci strongly supporting the diagnosis 2
• CT may show a non-specific contrast-enhancing hypodense nodule with spiculated edges 2
• Ultrasound findings are non-specific but useful for ruling out differentials and guiding biopsy 2
• Histopathology provides definitive diagnosis 2

Treatment Algorithm to Prevent Spread

Primary Treatment

Surgical excision remains the treatment of choice and the only definitive intervention 1, 4, 5:

1. Wide local excision with minimum 1 cm histologically confirmed free margins 1
2. Complete removal of all visible endometriotic tissue along the surgical tract 2
3. Histopathological confirmation in all cases 1, 3

Assessment for Spread

In symptomatic patients (particularly those with pelvic pain beyond the scar), perform diagnostic laparoscopy to:

• Exclude intraperitoneal endometriosis 1
• Identify synchronous pelvic disease requiring treatment 1
• Guide comprehensive surgical planning 1

Follow-Up Surveillance

• Monitor for local recurrence with clinical examination 1
• Average follow-up of 31.3 months shows no recurrence when complete excision with adequate margins is achieved 3
• Remain vigilant for pelvic symptoms suggesting distant spread 1

Critical Pitfalls to Avoid

• Inadequate surgical margins are the primary cause of local recurrence - always obtain at least 1 cm of histologically confirmed free margins 1
• Failing to consider synchronous pelvic endometriosis in patients with symptoms beyond the scar site 1
• Misdiagnosing as incisional hernia - scar endometrioma is commonly referred to general surgery with this incorrect diagnosis 4
• Delaying diagnosis - average symptom duration before diagnosis is 25.3 months, representing significant quality of life impairment 3

The condition may be more common than reflected in literature given the rising prevalence of cesarean sections 2. While spread is not the typical course, the documented cases of both local and pelvic recurrence underscore the importance of complete initial excision and appropriate surveillance 1.