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IMAGING FOR RESIDENTS – QUIZ |
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| Ahead of print
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| Cesarean section scar nodule, ovarian cyst, and dysmenorrhea |
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Manuel Goncalves.Henriques1, Pedro Brandão2, Amélia Almeida3, Paula Ramôa4
1 Department of Obstetrics and Gynecology, Hospital Professor Fernando da Fonseca, Amadora, Lisbon, Portugal
2 Department of Reproductive Medicine, Instituto Valenciano de Infertilidad, Valencia, Spain; Faculty of Medicine, University of Porto, Porto, Portugal
3 Department of Obstetrics and Gynecology, Centro Hospitalar Médio Ave, Famalicão, Portugal
4 Department of Obstetrics and Gynecology, Hospital Lusíadas Porto, Porto, Portugal
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| Date of Submission | 04-May-2020 |
| Date of Decision | 17-Jun-2020 |
| Date of Acceptance | 07-Aug-2020 |
| Date of Web Publication | 02-Oct-2020 |
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| Section 1 – Quiz | |  |
Case description
A 38-year-old female was admitted in the gynecology outpatient's clinic due to secondary infertility. She was Gesta I Para I, with one previous uneventful pregnancy and a cesarean section 7 years before. She had hypothyroidism and was medicated with levothyroxine 150 μg. As soon as she left the combined pill in order to conceive, she started complaining of severe dysmenorrhea (pain score: 8/10). At physical examination, a hard and painful nodule was palpable at midline, under the cesarean section scar. She had a nonmobile uterus. A painful hard mass was palpable at rectal digital examination, 3 cm away from the anus.
Abdominal wall soft tissue ultrasound revealed a nodule of heterogeneous echogenicity with 41 mm × 34 mm × 17 mm located medially at the level of the rectus abdominis muscle, under the cesarean section scar [Figure 1], [Figure 2], [Figure 3]. Abdominal magnetic resonance imaging confirmed the presence of a nodule with 4.9 cm × 3.8 cm × 2.0 cm on the rectus abdominis muscle and its fascia [Figure 4] and [Figure 5]. Pelvic transvaginal ultrasound revealed normal uterus and right adnexa and a cyst at the left ovary with 30 mm × 26 mm, with no septa or solid components and with ground glass echogenicity. | Figure 1: Abdominal soft tissue ultrasound in the axial plane revealing abdominal wall nodule
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 | Figure 2: Abdominal soft tissue ultrasound in the sagittal plane revealing abdominal wall nodule
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 | Figure 3: Abdominal soft tissue ultrasound in the axial plane with color Doppler revealing vascularized abdominal wall nodule
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 | Figure 4: Abdominal magnetic resonance imaging in the axial plane revealing abdominal wall nodule
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 | Figure 5: Abdominal magnetic resonance imaging in sagital plane revealing abdominal wall nodule
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The patient was submitted to laparotomy. During surgery, a hard median nodule with 5 cm of length was found located in the rectus abdominis muscle and its fascia [Figure 6] and [Figure 7]. Pelvic anatomy was completely distorted with several adhesions between the uterus, the adnexa, colon, and pelvic wall. The left adnexa was involved in adhesions, the left tube was enlarged, and there was a 3 cm cyst in the left ovary. The abdominal wall cyst was removed, and ovarian cystectomy, left salpingectomy, and contralateral tubal patency test were performed. The ovarian cyst had a dark brown thick liquid inside. Despite the adhesions, the right adnexa was normal and the right tube was patent. | Figure 6: Hard median nodule involving both rectus abdominis muscles and fascia (in vivo picture)
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 | Figure 7: Hard median nodule with 5 cm length removed from the rectus abdominis muscles and fascia (ex vivo picture)
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| What is the Diagnosis? | | |
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Correspondence Address:
Pedro Brandão,
Department of Reproductive Medicine, Instituto Valenciano de Infertilidad, Plaza de la Policia Local 3, 46015 Valencia
 Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] |
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