Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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Dr. Mamta Gupta
Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2012 | Month : June | Volume : 6 | Issue : 5 | Page : 881 - 883

Villar’s Nodule: A Rare Case Report

Kuladeepa Ananda Vaidya, Prashanth Adiga, Lakshman.I.K

1. Assistant Professor In Pathology, SIMS & RC. 2. Assistant Professor In General Surgery, SIMS & RC. 3. Assistant Professor In General Surgery, SIMS & RC.

Correspondence Address :
Dr. Kuladeepa Ananda Vaidya
Department of Pathology, SIMS&RC, Srinivas Nagar, Mukka,
Surathkal, Karnataka - 575021 (India).
E-mail: vaidyakuldeep@gmail.com

Abstract

Villar’s Nodule or primary umbilical endometriosis is a rare condition, with an estimated incidence of 0.5 to 1% among all the patients with endometrial ectopia. Endometriosis remains a diagnostic and therapeutic enigma even today, largely due to its variable presentations. We are hereby reporting a case of primary umbilical endometriosis due to its rarity and unusual presentation.

Keywords

Umbilical, Endometriosis

INTRODUCTION
Umbilical endometriosis, also known as Villar’s Nodule, was first described by Villar in 1886. It is extremely rare, the incidence being only 0.5-1% among all the women with extra gonadal or external endometriosis (1). This condition should not be mistaken for scar endometriosis which occurs in a sub-umbilical incision scar (2). Various theories with regards to its pathogenesis have been suggested, none of which can unequivocally account for the endometriosis in all the various locations in which it has been reported. The umbilicus is one of the less common sites for the localization of the ectopic endometrium. According to the literature, a total of only 109 cases of umbilical endometriosis has been reported (3). The presentation of endometriosis to the general surgeons is rare and atypical and it presents diagnostic difficulties (4),(5).

Case Report

A 30-year old woman presented with a dark brown, painless umbilical nodule of 1 year’s duration and a history of cyclical bleeding from the umbilicus during menstruation [Table/Fig-1]. Surgical excision of the lesion and reconstruction were performed and the post-operative course was uneventful. Grossly, the umbilicus showed nodularity on its surface and the cut section of the resected umbilicus showed multiple, tiny cystic structures which were filled with a brownish material (Table/Fig 2). Microscopically, the islands of the endometrial glands and the stroma were appreciated below the stratified squamous epithelium (Table/Fig 3) & (Table/Fig 4). A pathological diagnosis of umbilical endometriosis was given.

Discussion

Endometriosis, which is defined as the presence of endometrial tissue (glands and stroma) outside the uterine cavity, affects 5 to 10% of the fertile women. The most pronounced symptoms are dyspareunia, pelvic pain, and infertility (6). The other symptoms may include diarrhoea or constipation (in particular, in connection with menstruation), abdominal bloating (in connection with menstruation), heavy or irregular bleeding and fatigue (7). The clinical presentations of umbilical endometriosis are an umbilical pigmented nodule and umbilical weeping, especially cyclical bleeding and cyclical pain (8). Most of the endometrial deposits are found in the pelvis, which include the ovaries, the peritoneum, the uterosacral ligaments, the pouch of Douglas, and the rectovaginal septum, but they may also rarely occur in extra pelvic locations. These include most of the body cavities, as well as organs which include the lung, gallbladder, bowel, kidney, central nervous system, extremities, perineum, and the abdominal wall. Extra pelvic endometriosis may occur in up to 12 percent of the women with endometriosis. More commonly, cutaneous endometriosis occurs in the surgical scars from abdominal or pelvic procedures, which include hysterectomies, caesarean sections, episiotomies and laparoscopy (9),(10),(11).

Umbilical endometrioma is a rare condition, with an estimated incidence of 0.5 to 1% among all patients with endometrial ectopia. The development of umbilical endometriomas can occur following laparoscopic surgical procedures which involve the umbilicus (12),(13). Several aetiological theories have been proposed for its pathogenesis, with coelomic metaplasia being the most favoured one and also, the umbilicus may act as a physiological scar with a predilection for the endometrial tissue, in the development of spontaneous umbilical endometriosis (14),(15). Umbilical endometriosis can pose a diagnostic dilemma as it can simulate a malignant melanoma or the “sister Mary Joseph nodule”— a manifestation of an intra-abdominal malignancy. Any other condition that presents with a subcutaneous mass or discolouration of the umbilical skin, such as a benign nevus, a lipoma, an abscess, a cyst, or a hernia, as well as a metastatic deposit from a systemic malignancy, should be considered in the differential diagnosis [16,17]. Primary umbilical endometriosis is defined as the presence of ectopic endometrial glands within the umbilicus without a prior history of pelvic endometriosis (17).

Some rare cases had undergone malignant transformation and they had given rise to endometrial carcinomas. The possibility of a coexisting genital-pelvic endometriosis should be investigated. Hormonal therapy may be a consideration when there is a coexistent pelvic endometriosis (21).

The treatment of umbilical endometriosis consists of medical and surgical approaches. In treating pelvic pain, both drug and surgical treatments are effective (18). Pre-operative hormone therapy may be used in patients with large mass of umbilical endometriosis, to reduce the size (19). Umbilical defects which result from the resection of umbilical endometriosis can mostly be repaired directly by using a local advancement flap, a pedicled flap or a modified unfolded cylinder flap (20).

Some rare cases had undergone malignant transformation and they had given rise to endometrial carcinomas. The possibility of a coexisting genital-pelvic endometriosis should be investigated. Hormonal therapy may be a consideration when there is a coexistent pelvic endometriosis (21).

Conclusion

Primary umbilical endometriosis is a rare condition with an overall incidence of around 0.5% to 1% among all the endometriosis cases, but sometimes, it poses a diagnostic dilemma. Hence, a histopathological examination is required for the confirmation of the diagnosis. Primary umbilical endometriosis usually presents as a brown coloured umbilical nodule. The other common symptoms are, pain and bleeding. Although a preoperative hormone therapy may help in reducing the size of the umbilical lesion, surgical resection remains the treatment of choice, with an extremely low recurrence rate.

References

1.
Michovitz M, Baratz M, Stavorovsky M. Endometriosis of the umbilicus. Dermatologica 1983; 167: 326-30.
2.
Panicker SCR, Pillai N, Nagarsekar U. Villar’s Nodule: A rare presentation of external endometriosis. MJAFI 2010; 66 : 70-71.
3.
Blumenthal N.J.A. Umbilical endometriosis; a case report, SA Medical Journal 1981; 198-9.
4.
Firilas A, Soi A, Max M. Abdominal incision endometriomas. Am Surg 1994; 60: 259-61.
5.
Koger KE, Shatney CH, Hodge K, McClenathan JH. Surgical scar endometrioma. Surg Gynaecol Obstet 1993; 177:243-46.
6.
Chatzikokkinou P, Thorfinn J, Angelidis IK, Papa G, Trevisan G. Acta Dermatoven APA; 2009; Vol 18 (3).
7.
D’Hooghe TM, Hill JA. Endometriosis. In: Berek JS, Adashi EY, Hillard PA, editors. Novak’s Gynaecology. 13th ed. Lippincott Williams and Wilkins. 2002; 887-914.
8.
Frischknecht F, Raio L, Fleischmann A, Dreher E, Luscher KP, Mueller MD. Umbilical endometriosis. Surg Endosc 2004; 18: 347.
9.
Steck WD, Helwig EB. Cutaneous endometriosis. JAMA 1965; 191: 167-70.
10.
Albrecht LE, Tron V, Rivers JK. Cutaneous endometriosis. Int J Dermatol 1995; 34(4): 261-62.
11.
Geranpaye L, Fadaei-Araghi M, Irani S, Shakiba B. Spontaneous endometriosis of the abdominal wall. Acta Medica Iranica 2009; 47(2): 154-56.
12.
Goldberg JM, Bedaiwy MA. Recurrent umbilical endometriosis after the laparoscopic treatment of minimal pelvic endometriosis: a case report; J Reprod Med. 2007;52:551-52.
13.
Michowitz M, Baratz M, Stavorovsky M. Endometriosis of the umbilicus. Dermatologica. 1983;167:326–30.
14.
Agarwal A, Fong YF. Cutaneous endometriosis. Singapore Med J. 2008;49(9):704-09.
15.
Yu CY, Perez-Reyes M, Brown JJ, Borrello JA. MR appearance of umbilical endometriosis. J Comput Assist Tomogr. 1994;18:269-71.
16.
Skidmore RA, Woosley JT, Katz VL. Decidualized umbilical endometriosis. Int J Gynaecol Obstet 1996; 52: 269-73.
17.
Yu Hsueh Y, Shieh S, Hsueh Y-Y, Shieh S-J. Primary umbilical endometriosis. J.P.S.A.R.O.C. 2009; 18(1) :66-69.
18.
Olive DL, Pritts EA. Treatment of endometriosis. N Engl J Med 2001; 345:266-75.
19.
Purvis RS, Tyring SK. Cutaneous and subcutaneous endometriosis. Surgical and hormonal therapy. The Journal of Dermatologic Surgery and Oncology 1994;20:693-95.
20.
Franco D, Medeiros J, Farias C, Franco T. Umbilical reconstruction for patients with a midline scar. Aesthetic Plast Surg 2006;30:595-98.
21.
Shrestha NS, Pande S, Joshi M, Padhye SM. Primary umbilical endometriosis. A case report. NJOG 2011 May-June; 6 (1): 51-52.

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ID: JCDR/2012/4330:2233
Date of Submission: Mar 23, 2012
Date of Peer Review: Apr 14, 2012
Date of Acceptance: Apr 18, 2012
Date of Publishing: Jun 22, 2012

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