Left Psoas Research Articles

A CASE OF LIPOSARCOMA OF THE ABDOMINAL WALL IN WHICH A DEFECT OF THE ABDOMINAL WALL WAS RECONSTRUCTED USING AUTOLOGOUS FASCIA LATA

A 58-year-old man was seen at the hospital because of a left lower abdominal mass. Abdominal CT revealed a giant tumor in the left lower abdomen, which had infiltrated into the left rectus muscle of the abdomen, being adjacent to the left iliopsoas muscle and greater psoas muscle posteriorly, and displacing the left exterior iliac artery and vein posteriorly. Because a malignant fibrous histiocytoma or liposarcoma was suspected from percutaneous needle biopsy, extended resection with a sufficient surgical margin from the tumor and reconstruction of the abdominal wall using autologous fascia lata to make up for a defect of the abdominal wall were conducted. The histopathological diagnosis was made as polymorphic liposarcoma, and the CYVADIC therapy was carried out to prevent any postoperative remote metastases. Liposarcoma arising in the abdominal wall is extremely rare, and there are no such case reports in Japan. Reconstruction of the abdominal wall using autologous fascia lata, which carriers a low risk of infection, is useful for malignant soft tissue tumors in the abdomen that require both abdominal wall reconstruction together with extensive local resection and postoperative chemotherapy.

Trunk muscle parameters determined from MRI for lean to obese males

Transverse magnetic resonance images at the L 4–L 5 level of 26 males ranging in body mass index from 19.7 to 39.5 were digitized using a computer video monitor with mouse-mediated digitization software. The digitized musculature included the right and left psoas, rectus, abdominis, quadratus lumborum, oblique, and paraspinal muscle groups. From the digitized profiles, cross-sectional areas, and anteroposterior and mediolateral moments from the vertebral centroid were subsequently calculated. Multiple regression formulae were derived to predict the muscle parameters from the most strongly related anthropometrics. Cross-sectional area and moment arms for lean and obese groups were also compared. Significant regression formulae were derived for the cross-sectional area of the rectus abdominis and obliques, for mediolateral moment arms of the paraspinals, psoas, and obliques, and for anteroposterior moments of all four muscles. Comparison of muscle parameters for lean and obese subjects revealed minimal differences, though normalization of muscle cross-sectional areas by trunk area produced values which were statistically smaller for all muscles of the obese relative to lean subjects.

Postmortem diffusion of drugs from gastric residue: an experimental study.

Postmortem drug diffusion from gastric residue was assessed in a human cadaver model. Fifty milligrams of amitriptyline (Ami) and 5 g of paracetamol (Par) suspended in 350 ml of 10% methanol, 0.1 N HCl, and 50 ml urograffin with 5 g lithium carbonate (alkaline model) or without lithium (acidic model) was instilled into the stomach through an esophageal tube via a neck dissection. Multiple samples were obtained after 48 h at room temperature (range in mean hourly room temperature: 15.6-20.7 degrees C, n = 9). The pH of the gastric contents (alkaline model range = 8.3-8.9, n = 5; acidic model range = 3.4-3.8, n = 5) had no significant effect. Drug diffusion was most marked in the left lung base, with drug concentrations (micrograms/g) of 0.1-13.9 for Ami, 65-524 for Par, and 13-161 for lithium. Similarly affected were the left lobe of the liver (Ami, 0.1-54.9; Par, 7-218; lithium, 7-39), the spleen (Ami, 0.6-24.3; Par, 104-663; lithium, 27-106), and pericardial fluid (Ami, 0-4.5; Par, 48-641; lithium, 12-56). Diffusion into gallbladder bile, cardiac blood, aortic blood, and blood of the inferior vena cava was less severe. The left kidney and left lung were more severely affected than the right kidney and lung, and similarly the left and right psoas muscles. Least affected was the right anterior lobe of the liver and the lung apexes. This phenomenon may significantly influence drug concentrations in liver and in blood samples obtained from the torso, and consequently liver/blood drug ratios. To circumvent the problem of postmortem drug diffusion from the stomach, it is recommended that blood be sampled from a peripheral vessel, skeletal muscle from a limb, liver from deep within the right lobe, and lung from the apex rather than the base.

Case report: Ossifying metastases from carcinoma of the large bowel demonstrated by bone scintigraphy

A 65-year-old man was admitted with abdominal pain. He had a history of resection of a carcinoma of the sigrnoid colon two years previously, after which he had two laparotomies for episodes of intestinal obstruction, secondary to peritoneal and omental metastases. On this admission an abdominal film showed no evidence of intestinal obstruction but several amorphous clusters of calcific density were noted in the lower abdomen (Fig. 1) which had not been present on previous abdominal films. The patient was also complaining of back pain and a bone scan was performed to exclude bone metastases. This showed no abnormal skeletal uptake but very high uptake of tracer in the dense soft tissue opacities (Fig. 2). A limited CT scan was undertaken to establish the site of these lesions, demonstrating most to be in the anterior abdominal wall and left psoas (Fig. 3). The anterior abdominal wall lesions were palpable, lying within taparotomy scars, and one of these was biopsied two days later. Histologically, the fragments consisted of connective tissue which was quite densely infiltrated by metastatic adenocarcinoma. The tttmour was forming occasional glands and there was also abundant metaplastic bone formation. The bony trabeculae appeared orderly, and there was also a little osteoid. Clusters of tumour cells and also extracellular mucin were both associated with bone formation. It was concluded that this showed metastastic adenocarcinoma with metaplastic bone formation. Figure 4 shows a representative sample of the specimen. Review of the report on the microscopy of the primary tumour, excised two years previously, revealed that this too had shown adenocarcinoma 'with a few areas of mucin secretion, and in much of the tumour there is striking metaplasfic ossification'.

The geometry of the psoas muscle as determined by magnetic resonance imaging

Magnetic resonance images from fifteen physically active and asymptomatic male volunteers were collected to present morphometric parameters on the psoas and its moment arms, which are important in the study of spinal mechanics and models for the investigation of low back pain. The mean age of the subjects was 21.5 +/- 1.8 years. Data were obtained from nine vertebral and/or intervertebral levels (L2, L2/L3, L3, L3/L4, L4, L4/L5, L5, L5/S1, S1). In general, the psoas increased in size as it descended the trunk, moving anteriorly and slightly laterally in relation to the vertebral column. Maximum cross-sectional areas for the psoas (M = 16.3cm2) were observed at the L4/L5 level. Right-left symmetry was apparent in the aforementioned dimension, but not with respect to the mediolateral (X) diameter of the muscle. The length of the X moment arm was significantly (p < .05) greater for the right versus the left psoas from L3 to S1, with the length increasing as the psoas descended the trunk. However, this trend was not noted for the anteroposterior (Y) moment arm where observed values remained relatively small throughout the course of the muscle. These results will contribute to the study of low back pain onset and the design of appropriate rehabilitation interventions by providing accurate morphometric parameters for biomechanical models to predict of the loading conditions of the spine in vivo.

TWO CASES OF ABDOMINAL TUBERCULOUS LYMPHADENITIS WITH UNUSUAL CLINICAL FEATURES

Case 1: A 44-year-old man was admitted to the hospital because of fever, jaundice and abdominal pain. Abdominal ultrasonography showed swelled peripancreatic lymph nodes and dilatation of the biliary tract. Lymph node metastasis of pancreatic cancer or malignant lymphoma was suspected and a laparotomy was performed. Bulky peripancreatic mass formed by hardened lymph nodes was detected and the intraoperative histopathology of the mass revealed tuberculous lymphadenitis. Case 2: A 20-year-old female was admitted to the hospital because of swelled lymph nodes on the left side of the neck. CT scan showed swelled peripancreatic lymph nodes and huge left psoas abscess. PPD was strongly positive. Biopsy of the left cervical lymph node and aspiration cytology of the left psoas abscess confirmed the presence of tuberculosis. Tuberculosis markedly decreased due to the progress of antituberculous chemotherapy. Recently this disease, however, has been gradually increasing again. These two cases remind us of the importance to entertain the presence of tuberculosis as a possible differential diagnosis, when a patient having a swelling of peripancreatic lymph node is encountered.

Treatment of metastatic chemodectoma.

Six patients were treated for metastatic chemodectoma at Memorial Sloan-Kettering Cancer Center from 1971 through 1988. Four patients' primary tumors arose in the cervical region, and two arose in the retroperitoneum. Four patients received a total of eight different chemotherapeutic regimens, including cisplatin, doxorubicin, cyclophosphamide, and dacarbazine. Metastatic sites treated included bone, liver, lung, and retroperitoneum. No patient had a response to chemotherapy. Four patients received a total of nine courses of radiation therapy for palliation of bone metastases. Pain relief was complete in eight patients and partial in one. One patient was irradiated for a mass in the left psoas muscle, with stabilization of disease for 6 months after treatment. One patient was irradiated for epidural compression at T6, with resolution of neurologic symptoms and 50% clearing of the spinal block on follow-up myelogram. Recurrence or progression of disease in a previously irradiated site occurred in one patient 2 years after treatment. One patient was lost to follow-up 3 months after radiation therapy for epidural compression. The other five patients died of widespread metastatic disease 6 months to 9 years after initial treatment for their metastatic disease.

Echinococcosis of the psoas muscle: Clinical case

A rare case of hydatid cyst of the left psoas muscle with a short account of the nosological, physiopathological and therapeutical aspects due to muscular echinococcosis is reported. The Authors particularly emphasize the diagnostic difficulties due to discrepancies between radiological imaging and serological data and specially recommend prudence in surgical management.

高浸透圧性非ケトン性糖尿病昏睡を来した腎う癌による腸腰筋膿ようの一例

A 85-year-old man was admitted to our hospital because of semicomatous status. Laboratory data on admission showed elevation of blood sugar (823 mg/dl) and serum osmotic pressure (345 mOsm/l), but ketonuria was not detected. Non-ketotic hyperosmolar diabetic coma was diagnosed. The insulin infusion and physiological saline improved the blood sugar level and consciousness within a day. The abdominal ultrasound examination revealed an abscess in the left kidney and right psoas muscle. The same findings were seen by abdominal computed tomography but the possibility of malignant neoplasm of the left kidney could not be ruled out because of a swelling of the left adrenal gland. Pain associated with psoas abscess and low grade fever were observed. Because of his poor general condition, drainage of the abscess was not performed and conservative therapy using antibiotics was administered. Without any improvement of the abscess, he died due to general deterioration four months later. Autopsy findings showed carcinoma of the left renal pelvis and metastasis to the right psoas muscle, left adrenal gland, liver, bilateral lungs and lymph modes. Psoas abscess is a relatively uncommon disease, especially in elderly patients. The etiology of the disease is divided into primary and secondary causes. Most secondary psoas abscess cases are caused by intestinal diseases, and Crohn's disease has been related to the highest incidence. A few cases of psoas abscess caused by colorectal carcinoma have been reported. Ultrasound and computed tomography are useful in diagnosing this disease and drainage of an abscess is necessary for therapy and proving the cause. Cancer metastasis should considered in differential diagnoses, when psoas abscess is seen in elderly patients.

The psoas sign in normal subjects without bowel preparation: The influence of scoliosis on visualisation

The lumbar spine films of 1494 subjects who were examined for low back pain or prior to job placement were studied to assess psoas muscle visualisation. The study group were almost all aged 18-39 years. None of the subjects had prior bowel preparation for a contrast examination. In the subjects without scoliosis only 36% had well seen psoas shadows on both sides. Taking the psoas shadows separately, 72% of left psoas shadows were well seen, while only 40% were seen on the right side. In the scoliotic group, the psoas shadow was seen bilaterally in 30% of subjects while in another 50% the muscle was seen only on the convex side of the curve. In no case was it seen only on the concave side. The direction of the curve to left or right did not influence visualisation. Thus in 80% of subjects with scoliosis of 5 degrees or more, the psoas was seen on the convex side, while in only 30% was it seen on the concave side.

Case report: Metastatic adenocarcinoma masquerading as a psoas abscess

A 71-year-old man presented with signs of a left psoas lesion 4 years after a sigmoid colectomy for adenocarcinoma. Radiological appearances were thought to be typical of an abscess, but an attempted aspiration was unsuccessful. A biopsy was taken and histology showed metastatic adenocarcinoma.

Coincidence of Primary Malignant Melanoma of Skin and Eye

Although primary malignant melanomas of the skin or eye alone are not too rare, their coincidence is most uncommon. The case of a 41-year-old Caucasian male is reported who developed superficially spreading melanoma on the skin of his trunk 9 years after the enucleation of his right eye because of a fusiform melanoma of the choroidal membrane. Staging revealed a further malignancy: hemangiopericytoma inside and adjacent to the left psoas muscle. Both theoretical and practical conclusions to be drawn from the case are discussed.

The plain abdominal radiograph in acute pancreatitis

The radiographs of 100 patients with acute pancreatitis were reviewed and compared with 100 controls by two radiologists and a surgeon. Our aim was to assess the frequency and usefulness of the signs described in the literature. Calcification of the pancreas was seen in one case only. Abnormalities of the biliary tree (visible gallbaldder, biliary gas and gallstones) were seen in 10%. The left psoas shadow was more frequently absent in the pancreatitis series. Paucity of gastrointestinal gas although observed in 12 cases was ascribed to vomiting. A more important sign was the gaseous outline of an adynamic duodenal loop which was seen in half of the patients examined in the left lateral decubitus position. Dilated jejunum was seen in 31 cases, associated with sentinel loops in 10 and multiple fluid levels in 25 patients. Dilatation of thet ransverse colon was the most constant colonic sign (18%), but the colon 'cut-off' sign was not seen. It was concluded that the most prominent signs in order of importance are a gaseous distension of the duodenal loop, gas in the duodenal cap, a dilated transverse colon and the sentinel loop. The gasless abdomen is a striking but rare sign and in our series was always associated with severe pancreatitis.

Evaluation of retroperitoneal hemorrhage by computed tomography before and after translumbar aortography.

Twenty patients were prospectively studied by computed tomography (CT) before and after undergoing translumbar aortography (TLA). Changes indicative of retroperitoneal bleeding were depicted by CT in all 20 patients despite the predominantly small size of the hematomas. CT scans obtained within two hours after TLA demonstrated: (a) thickening of the diaphragmatic crura, (b) enlargement of the left psoas muscle, and (c) obscuration of the aortic outline by soft-tissue density. Follow-up scans at 24 hours (10 patients) and one week (3 patients) revealed marked decrease in abnormalities, suggesting rapid resorption of the hematoma.

The psoas sign, hepatic angle, normal patients, and everyday practice.

While extensive previous references in the literature leave little doubt that disease in the posterior pararenal space can obliterate the psoas margin either in its entirety or in part, little work has been done to evaluate the frequency of when the psoas cannot be visualized in normal individuals. The data presented here indicate that as the right psoas can be expected to be absent in normal patients from 16 to 43% of the time, therefore one cannot ;lean' heavily on it as a clinical tool. On the other hand, absence of the left psoas margin on a single film in the proper clinical setting may be sufficient to draw one's attention to the retroperitoneal space, more particularly the posterior pararenal space, as a possible site of abnormality. However, ancillary radiographic signs such as mass displacement, gas, calcium, or abnormal depositions of fat, should be carefully sought. Preservation of either or both psoas margins certainly does not exclude by any means significant extraperitoneal disease, as can be seen even in our small anecdotal series. The hepatic angle is absent with such frequency in normal patients that it too can only be of questionable value as a primary radiographic sign. In our normal group of patients the splenic angle was absent more frequently than it was present.

Lipids of human myocardium.

AbstractThe major lipid classes, including some phospholipids, and their fatty acid profiles have been measured in portions of left ventricular muscle and psoas muscle obtained at autopsy. Atrial appendages and ventricular muscle removed during cardiac surgery were examined also. The proportions of the individual phospholipids were the same in all the muscles, having an excess of phosphatidyl ethanolamine and phosphatidyl serine compared with the serum. Their fatty acid profiles resembled those obtained from other locations. The triglyceride content of the myocardium was relatively constant (except in the atrial appendage) but did rise slightly with increasing obesity. The free fatty acid concentration in the myocardium was relatively high and had a variable fatty acid profile.

Value of angiography in the diagnosis of retractile mesenteritis.

FIG. i. (A) Intravenous pyelogram shows large rounded mass (arrows) with upward displacement of left kidney and hydronephrosis. Note obliteration of the left psoas muscle margin. Irregular calcification (arrowhead) at surgery was found to be present in old scar. (B) Small bowel series roentgenogram shows large mesentenic mass displacing central bowel loops (arrow) characteristic of mesenteric cyst or neoplasm. JUNE, 1972

RELATION BETWEEN BONE MASS AND MUSCLE WEIGHT

The ash weight of the third lumbar vertebral body and the weight of the left psoas muscle from forty-six routine necropsies were significantly correlated (p<0·001) when bodyweight, age, and height were taken into account. It is proposed that the weight of a muscle reflects the forces that it exerts on bones to which it is attached and that muscle weight is an important determinant of bone mass.

An exercise in radiologic-pathologic correlation.

Improved technical methodology has increased the radiologist's diagnostic capability immeasurably in recent years. Nowhere is this more true than in the study of renal disease. Nephrotomography and aortography have permitted more subtle in vivo anatomic analysis, and, more recently, selective opacification of renal arteries has allowed visualization of even the very small renal vessels. The case this month illustrates a disease in which the renal angiographic findings are diagnostic, and the pathologic findings manifested in the radiographs should alert the radiologist to a potential complication that was present in this patient. Radiographic Findings A plain film of the abdomen of this 45-year-old man was obtained because of pain in the left flank. The margins of the left kidney and psoas were indistinct, but the findings were otherwise unremarkable. An excretory urogram (Fig. 1) demonstrates a normal right kidney and, again, the poor definition of the left renal and psoas margins. Contrast material is seen in the left ureter, but the remainder of the left upper collecting system is not visualized. The differential diagnostic possibilities considered at this time were renal neoplasm, perirenal abscess, and perirenal hematoma. Because of the possibility of a renal neoplasm and the patient's history of severe hypertension, aortography was performed. The findings led to bilateral selective renal arteriography, which showed that the main renal arteries were unremarkable. On the selective arteriograms (Figs. 2 and 3) collections of contrast material seen in the renal parenchyma were considered to be aneurysms. One on the right (Fig. 3) was considerably larger than the others. It should be noted that these abnormal dilatations of the renal arterial tree are rather uniform in size, about 1 to 5 mm, and are associated with the medium-size and small vessels exclusively. On the nephrogram phase of the right selective renal arteriogram (Fig. 4), persistent opacification of the aneurysms is noted, as well as scalloping of the renal contour, suggesting loss of renal cortex. Clinical History This 45-year-old Negro had intermittent pain in the left upper quadrant of the abdomen for the four weeks prior to admission to the hospital. During this time he was seen as an outpatient, and findings from the physical examination were within normal limits, with the exception of a low-grade fever (38° C.) and a blood pressure of 230/160. A chest roentgenogram showed minimal left ventricular enlargement but was otherwise within normal limits. Urinalysis demonstrated proteinuria, microscopic hematuria, and a few granular casts. The hematocrit was 45 per cent and white blood cells numbered 16,800. On the day of admission to the hospital he was brought to the emergency room in a confused state. At this time his blood pressure was 130/80, temperature 38° C, and the left upper quadrant was tender, although a mass could not be detected.

Left-Upper-Quadrant Mass Following Trauma

Dr. Milton A. Weiner: A 15-year-old girl came to the hospital complaining of persistent left-upper-quadrant pain of four days' duration, following a fall while skating. Physical examination showed a listless, pale girl who was mildly uncomfortable but in no acute distress. There was a tender left-upper-quadrant mass extending 5 cm below the left costal margin. Her hematocrit reading was 29%. Discussion Dr. Laurence L. Robbins: Dr. Weber, will you discuss this case? Dr. Alfred L. Weber: There is evidence of an increased density in the left-upper-quadrant, with slight inferior displacement of the splenic flexure and obliteration of the left psoas shadow (Fig 1). There is no displacement of the colon from the lateral abdominal wall, and there are no fractures in the lower-rib cage. There appears to be indentation upon the inferior margin of the fluid-filled stomach, which is slightly displaced medially. The spleen cannot be outlined. I think, with