Endometriosis of the umbilicus

ENDOMETRIOSIS

OF THE UMBILICUS*

BENJAMIN J. WEISBAND, M.D. AND CHARLES New York, New York

T

MODICA, M.D.

between the peritonea1 cavity and the umbiIicus and there were no signs of endometriosis eIsewhere. Therefore, the ceIomic metapIasia thoery seems to be the most IogicaI expIanation for the subject on hand. This theory, by Ivanoff and Meyer, is based on the fact that the entire epitheIiaI apparatus of the femaIe genita1 tract is derived from the primitive peritoneum which forms the epitheIia1 Iining of the ceIomic cavity. The mtiIIerian duct is deveIoped from the invagination of this ceIomic epitheIium and remnants of this remains at the umbiIicus and undergo endometria1 differentiation. Bingham and TempIetons state that while endometriosis is not maIignant, these growths have been known to recur and metastasize. VisibIe endometrium has been found in the peIvic Iymph nodes on numerous occasions and, according to Berman, cases of endometriosis of the arm and thigh have been reported.

HIS paper is written for the purpose of adding two cases of endometriosis of the umbiIicus to this reIativeIy rare entity and aIso to review some of the literature on this subject. Novak’ states that about forty cases of endometriosis of the umbiIicus have been reported. However, according to Berman,2 Stranger found a tota of sixty-eight cases reported in the entire worId unti1 the end of ‘935. Since 1935, we found that in American Iiterature Jenkins and Brown3 reported onIy three cases of endometriosis of the umbiIicus out of a tota of I 17 cases of endometriosis eIsewhere in the body. FaIIon, Brosman and Moran4 reported 200 cases of endometriosis in a recent articIe but faiIed to mention any cases invoIving the umbilicus. Green” in 1899 was among the first to describe a case whose history and physica findings were very suggestive of endometriosis of the umbiIicus and CuIIen6 in 1920 reported two cases. Samson’ in his very thorough and interesting articIe discusses endometriosis or adenoma of the peritonea1 cavity but makes no mention of endometriosis eIsewhere in the body. Histogenesis There are a number of theories concerning the histogenesis of endometriosis of the umbiIicus.. We are in agreement with Meyer, Novak and others that the Sampson theory of regurgitation of endometria1 particIes through a tube does not expIain endometriosis of the umbiIicus because, as previousIy mentioned, Sampson did not take into consideration endometriosis outside of the peritonea1 cavity. We found in our cases, as did Berman2 and others, that no communication existed

CASE

REPORTS

CASE I. K. M., (No. I 13538), a thirty year old coIored female, was admitted to the Surgical Service of Harlem Hospital on January 29, 1939, with a history of umbilical “tumor” of It was painful and bled one year’s duration. intermittentIy for a month prior to admission. There was no periodicity to the pain. The past history revealed that the patient had had a hysterectomy for fibroid uterus followed by amenorrhea three years prior to admission. The physical examination revealed a bvell developed and well nourished colored female in no acute distess. Her head and neck showed no gross abnormality. The lungs were clear and the heart was essentially negative. The abdomen was scaphoid and there was a well heared lower mid-abdomenal scar present. There were no paIpabIe masses. The umbilicus

* From the Surgical Service of HarIem Hospital, New York City, Dr. Louis T. Wright, Surgical Director. 827

828

American

Journal

of’ Surgery

Weisband,

Modica-Endometriosis

FIG. I. Showing skin, appendages within the superficia1 portion ofcutis and nests ofendometrial glands in the deeper portions.

showed a bluish discoloration with tumor formation in the center, tender and cystic in character. The admitting diagnosis was (I) umbilical tumor and (2) possible hemangioma. At operation on January 20, 1939, an umbilectomy was performed. A discoloration was found to extend to the peritoneum; however, no intraperitoneal involvement was present. The postoperative course was uneventful except for several episodes of stuporous and semi-stuporous states due to hysteria. The patient was discharged on the eighteenth postoperative day in exceIIent condition. The pathologic report is as follows: Gross: The specimen consisted of skin and subcutaneous tissue in the center of which the umbilicus was found. The skin measured I I by 4 cm. The umbilicus had a raised, Iight purplish mass in its center. On cut section, the mass was seen to consist of fibrous tissue. Microscopically, sections of the tumor reveIaed endometriosis of the umbilicus. CASE II. G. R., (No. 239484), a thirty-four year old coIored fernare, was admitted to the Surgical Service of HarIem HospitaI on November 9, 1945, complaining of painful swelling of the umbilicus of two years’ duration. The pain was most severe during her menstrual periods and became progressively worse. The periods were regular, every twenty-eight days and Iast-

IkCbhl

6l.H.

,+-

FIG. 2. Presents a higher magnification of Figure I, showing endometrial glands in secretory phnsc surrounded by endomctrial stroma.

ing for four days, with no dysmenorrhea or menorrhagic. There was no history of external bIeeding. The patient had one chiId and no miscarriages. The physical examination revealed a well developed and we11 nourished colored femaIe in no acute distress. The head and neck showed no gross abnormaIities. The lungs were clear and the heart was essentiaIIy normal. The abdomen was obese and non-tender. The umbilicus was enlarged, tender, with a smaI1 area of uIceration in the center. There was no gross evidence of bleeding. The peIvic examination was essentially negative. The admittingdiagnosis was (I) endometriosis of the umbilicus and (2) omphalitis. Five days after admission, the pain in the umbilicus became severe and the umbilicus showed a small clot in the center. On November 27, 1945, fourteen days after admission, an umbilectomy and incidenta appendectomy were performed. The essential findings at the operation were as foIIows: The umbilicus showed uIceration with bIood clot in the center and purpIish discoIoration extending to the periteonea1 surface. However, the peritonea1 cavity revealed no endometrial impIants. The uterus was two to three times the norma size and boggy (premenstual).

Var. I.XXIV, No. 6

Weisband,

Modica-Endometriosis

The postoperative course was uneventful and the patient was discharged, symptom-free, on the thirteenth postoperative day. The pathologic findings were as follows: Gross: The specimen consisted of a mass of tissue 6 by 3 by z cm. in the center of which was an ulceration with a purplish discoloration. The microspic section revealed endometiosis of the umbilicus.

Comment. These two patients were admitted to the surgicaI wards of this hospita1 instead of to the gyneccIogic wards without the correct diagnosis being made. It seems worth while, therefore, to call the attention of the surgeons, who do not do gynecoIogic work, to this simpIe but unusua1 condition. In one instance It was mistaken for a tumor; in the second instance it was mistaken for omphalitis. Endometriosis of the umbilicus has never been reported in patients under the age of puberty and past the menopause. It is most prevaIent in the third and fourth decades of life. Diagnosis of endometriosis of the umbiIicus can usuaIIy be made without diffIcuIty based on a history of painfu1 swelIing of the umbiIicus most severe during, before, and/or after the menstrua1 period. FrequentIy, vicarious menstruation from the umbiIicus is elicited. The most prevaIent physica findings are a swoIIen, tender mass in the umbilicus with discoIoration (purpIish or bIuish) and occasionally the presence of bIood or a cIot in the center. Treatment consists of excision of the umbiIicus. However, for cosmetic affect, and for no other reason, steriIization is

American Journal 01 Surgery

829

indicated. We believe that this procedure wouId then cause a recession of the signs and symptoms as it does in endometriosis of the PeritoneaI cavith-

SUMMARY

I. Endometriosis of the umbilicus is a relatively rare entity, sixty-eight cases being reported untiI the end of 1935. 2. Review of some of the Iiterature is presented. 3. Histogenesis of endometriosis of the umbiIicus is discussed. 4. Two cases are presented with a description of surgica1 and pathologic findings. 5. It is important for surgeons to keep this condition in mind. 6. The characteristic history and physical findings are given. 7. Treatment-is suggested. REFERENCES NOVAK, E. Gynecological and Obstetricat PathoIogy. 1940. W. B. Saunders. B. Endometriosis of the umbilicus. Am. J. Obst. w Gynec. JENKINS, E. and BROWN, I\:. H. Endometriosis. J. A. M. A., June 5, 1943. FALLON, J., BROSMAN, .J. T. and MORAX, Whm. G. Endometriosis. Net0 England J. Med., 239: 669674, 1946. GREEN, C. G. A case of umbilical papilloma. Tr. Pd. Sot. London, I : 24, 1899. CULLEN, T. S. The distribution of adenomyomas containing uterine mucosa. Arch. Sure., I : ZJ~283, 1920. SAMPSON,J. A. Perforating hemorrhagic (chocolate) cyst of the ovary. Arch. Surg., 3: 245-324, 1921. BI%\I(;HAM, E. B. and TEMPLETON, W. K. UmbiIicaI endomrtrioma. Calijornia @Y West. Med., 41 : 33o,

I* Philadelphia, 2. BURMAN, W. 3’ *.

” 6. 7. ‘.

1034.