Symptomatic Pelvic Mass Research Articles

Endomyometriosis of the Rectum With Disseminated Peritoneal Leiomyomatosis 8 Years After Laparoscopic Myomectomy: A Case Report

Endomyometriosis is a rare finding and it can be challenging to diagnose and to treat. It can arise in the uterus, in the ovary, in the broad ligament, in the peritoneal surface and in other pelvic structures. Usually patients with endomyometriosis are asymptomatic, but symptoms could occur due to large dimensions or site of the mass. We present a case of a 49-year-old woman with a symptomatic pelvic mass in the rectal wall, with no history of endometriosis, who underwent laparoscopic myomectomy 8 years earlier.

Retroperitoneal lipo-leiomyomata in a woman with history of breast cancer and antiestrogen therapy.

e22542 Background: Retroperitoneal lipo-leiomyomata are extremely rare. The usual-type retroperitoneal leiomyoma is itself a rare tumor that is mistaken preoperatively for malignant retroperitoneal tumors or thought of as an exophytic subserosal leiomyoma of the uterus. Lipo-leiomyoma is a variant of leiomyoma with an incidence in uterus ranging between 0.03% - 0.2%, but its presentation as a retroperitoneal mass has not been documented in literature yet. We present a unique case of retroperitoneal lipo-leiomyoma that presented as a diagnostic challenge due to its unique location and unusual histologic appearance. Methods: A 68-year-old female patient with a history of breast cancer diagnosed 4 years ago, currently on antiestrogen therapy (Fulvestrant) and Herceptin, presented to our university hospital with symptomatic left pelvic mass. An abdominal CT showed a heterogeneous low-density pelvic mass with foci of internal calcification and fat with surrounding intermixed intermediate and high density fluid in the expected location of the uterus. Results: A debulking surgery including radical hysterectomy was planned. Intraoperatively, a normal sized uterus was found, the myometrium of which contained multiple variable-sized intramural leiomyomata. In addition, a huge left retroperitoneal mass was found that had no connection to the uterus. Histopathological examination revealed abenign lipoleiomyomatous tumor, composed of an encapsulated proliferation of benign adipocytes and myoid cells intimately admixed. Immunohistochemistry confirmed myoid differentiation, with negative reactions for HMB45 and CKIT, and . MDM2 gene amplification by fluorescence in situ hybridization (FISH) was negative. Conclusions: Some unusually located extra-uterine leiomyomata have been reported; retroperitoneal leiomyoma being among them. Such a tumor with the added feature of lipomatous differentiation presents a differential diagnosis that includes leiomyosarcoma, liposarcoma, angiomyolipoma, and gastrointestinal stromal tumor. The association of an uncommonly located leiomyoma with subsequent lipomatous change withantiestrogen therapy is an unexplored issue that merits further investigation.

Palliative pelvic radiotherapy for symptomatic incurable prostate cancer – A prospective multicenter study

Background and purposeRadiotherapy is used to palliate pelvic symptoms of castration resistant prostate cancer (CRPC). However, magnitude and time course of effects and toxicities are poorly documented. Study aims were to evaluate changes in patient-reported target symptoms (TS), health-related quality of life (HRQOL) and toxicity following palliative pelvic radiotherapy (PPRT) of CRPC. Material and methods47 patients with CRPC and a symptomatic pelvic mass prescribed PPRT with 30–39Gy were prospectively included. Primary endpoint was patient-reported improvement or complete resolution of the TS twelve weeks after PPRT. HRQOL changes were explored. Toxicity was physician-evaluated. ResultsLower urinary tract symptoms (LUTS) (45%), hematuria (26%) and pain (19%) were the most common TS. In the 40 evaluable patients, overall TS response twelve weeks after PPRT was 70%. TS responses were 8/18 for LUTS, 11/12 for hematuria, and 7/9 for pain. Global HRQOL improved transiently. The most common toxicity was grade 1 or 2 diarrhea (50%). There was no grade 4 toxicity. ConclusionsIn the majority of patients with CRPC and a symptomatic pelvic tumor, PPRT with 30–39Gy contributes to relief of hematuria, pain and other pelvic symptoms, with acceptable toxicity. Future studies should investigate whether PPRT regimens can be simplified.

Coexistence of Malignant Struma Ovarii and Cervical Papillary Thyroid Carcinoma

Struma ovarii is an uncommon monodermal teratoma in which thyroid tissue is the predominant element. Malignant transformation of struma ovarii is an even rarer occurrence. We describe a 42-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a symptomatic left pelvic mass. Histology revealed malignant struma ovarii with classical papillary thyroid carcinoma expression. Ultrasonography of the cervical neck showed thyroid micronodules and a dominant 1-cm nodule in the left thyroid lobe. As the ovarian tumor was large, the patient underwent a total thyroidectomy with the intention of administering ¹³¹I therapy in an adjuvant setting. Histology of the cervical thyroid gland revealed bilateral multifocal papillary thyroid carcinoma with extrathyroidal extension and perithyroidal lymph node metastasis. Morphological (microscopy), immunohistochemical (Hector Battifora mesothelial cell 1, cytokeratin-19, galectin-3), and molecular (BRAF V600E, RAS, RET-PTC) characteristics and clonality analysis of the cervical thyroid and ovarian tumors were explored to distinguish them as separate malignancies. The thyroid-type tumors from the cervical gland and ovary were discordant in terms of tissue histology and level of cytokeratin-19 expression. The clinical features and tumor profile results supported the independent existence of these two embryologically related, although topographically distinct, malignancies. Our findings provided support for synchronous, albeit distinct, primary tumors in the ovary and cervical thyroid. "Field cancerization" and early genomic instability may explain multifocality in all thyroid-type tissue. In this regard, patients with malignant struma ovarii should undergo imaging of their thyroid gland for coexisting disease and thyroidectomy recommended for suspected malignancy or in preparation for radioiodine therapy.

Undescended Testis: The Risk Always Lives

The testes develop in the abdomen and descend during the third trimester into the scrotum. The testicle can be arrested anywhere during its descent or it can migrate into an abnormal position. Undescended testis, otherwise known as cryptorchidism, is a well-described disorder with a spectrum of complications ranging from torsion to necrosis, infertility, and atrophy. The risk of developing testicular cancer in an undescended testicle has been well-documented, as high as 32 times the general population if the testicle is not brought down before the age of 12. In clinical practice, surgical exploration for the testicle and definitive fixation in the scrotum is warranted at age two to three if it fails to descend to the normal position, with clinical success rate of 90%. However, the problem with an undescended testicle arises when surgical exploration is negative, and the usefulness of other approaches, including imaging tests, in this setting is not clearly established. We report a case of a 45 year-old man with history of undescended left testicle diagnosed at birth, and repeated negative surgical explorations presenting with symptomatic pelvic mass, and eventually diagnosed with testicular tumor. This case highlights the potential difficulty in establishing this diagnosis despite the generally favorable outcomes with orchiopexy. Given its high prevalence, testicular neoplasm must be included in the differential diagnosis of patients with a history of an undescended testicle who present with an acute abdomen. Surgical resection without pelvic lymph node dissection is the standard of care for an abdominal testicle found at exploration.

Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer

BackgroundTo evaluate the palliative role of radiotherapy (RT) and define the effectiveness of chemotherapy combined with palliative RT (CCRT) in patients with a symptomatic pelvic mass of metastatic colorectal cancer.MethodsFrom August 1995 to December 2007, 80 patients with a symptomatic pelvic mass of metastatic colorectal cancer were treated with palliative RT at Samsung Medical Center. Initial presenting symptoms were pain (68 cases), bleeding (18 cases), and obstruction (nine cases). The pelvic mass originated from rectal cancer in 58 patients (73%) and from colon cancer in 22 patients (27%). Initially 72 patients (90%) were treated with surgery, including 64 complete local excisions; 77% in colon cancer and 81% in rectal cancer. The total RT dose ranged 8-60 Gy (median: 36 Gy) with 1.8-8 Gy per fraction. When the α/β for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the median RT dose was 46.8 Gy10 (14.4-78). Twenty one patients (26%) were treated with CCRT. Symptom palliation was assessed one month after the completion of RT.ResultsSymptom palliation was achieved in 80% of the cases. During the median follow-up period of five months (1-44 months), 45% of the cases experienced reappearance of symptoms; the median symptom control duration was five months. Median survival after RT was six months. On univariate analysis, the only significant prognostic factor for symptom control duration was BED ≥40 Gy10 (p < 0.05), and CCRT was a marginally significant factor (p = 0.0644). On multivariate analysis, BED and CCRT were significant prognostic factors for symptom control duration (p < 0.05).ConclusionsRT was an effective palliation method in patients with a symptomatic pelvic mass of metastatic colorectal cancer. For improvement of symptom control rate and duration, a BED ≥ 40 Gy10 is recommended when possible. Considering the low morbidity and improved symptom palliation, CCRT might be considered in patients with good performance status.

Rare Case of Ovarian Cystic Lymphangioma

Lymphangiomas are rare, generally benign tumors of the lymphatic system comprised of multiple cystic spaces lined with endothelium. Lymphangiomas may arise in any part of the body. Lymphangioma of the ovary is rare; we have identified only 13 reports in a 50-year literature survey (PubMed 1959–2009). Typically, lymphangiomas are slow-growing tumors that remain asymptomatic for a long time. They are most often found incidentally in abdominal or pelvic imaging studies or at surgery or autopsy. Wide excision of the lesion with microscopically clear margins is the best approach when feasible. A postmenopausal woman had a symptomatic pelvic mass. Imaging studies demonstrated a complex left ovarian cyst. Complete removal of a cystic lymphangioma was successfully performed at laparoscopy. Cystic lymphangiomas should be included in the differential diagnosis of an ovarian cystic mass, and laparoscopic excision may be the method of treatment.

Prise en charge cœlioscopique des masses latéro-utérines pendant la grossesse

To determine the feasibility, safety and limiting factors of laparoscopic management of pelvic mass in pregnancy.and methods. During a 10-year period, 21 laparoscopic procedures were performed in patients with pelvic masses in pregnancy after exclusion of appendicitis and ectopic pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 8 cases, the second trimester in 12 cases and the third trimester in one case. All the procedures were performed with general anesthesia and the laparoscopic cystectomies were performed with the intraperitoneal technique.The indications were: persistent or sonographically abnormal ovarian cyst (12 cases), torsion of ovarian cyst (5 cases), and symptomatic pelvic mass (4 cases: 2 painful cysts and 2 infarction of fibroma). One borderline tumor were discovered. The laparoscopic procedure could not be performed in two cases due to difficulty of access to the lesion. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 4.5 days. The outcome of the pregnancy was normal in all cases.Laparoscopic management of pelvic masses in pregnancy by an experienced team, is a safe and effective procedure.

Isolated fallopian tube torsion: a rare diagnosis in a perimenopausal patient with adnexal mass and raised Ca 19-9

Isolated torsion of the fallopian tube in perimenopausal women is very rare. A patient who presented with an adnexal mass with possible ovarian torsion and with a raised Ca 19-9 titer is reported. A 48-year-old perimenopausal woman had acute lower right abdominal pain accompanied by nausea and vomiting. Ultrasonographic studies revealed a multiloculated cystic mass in the right adnexum, and Ca 19-9 was raised. The symptoms worsened, and emergency laparoscopy and salpingoophorectomy were performed. Histology revealed isolated fallopian tube torsion with a benign ovarian cyst. Torsion of the fallopian tube, although rare, should always be considered as part of the differential diagnosis of any symptomatic pelvic mass, even in a perimenopausal woman. Characteristic ultrasonographic and CT findings have been reported, an early diagnosis can be made, and an endoscopic, less radical procedure will be the treatment of choice resulting in shorter hospitalization, increased patient satisfaction, and more cost benefits.

Laparoscopic management of adnexal masses in pregnancy: a case series

Objective: To determine the feasibility, safety, limiting factors, and advantages of laparoscopic management of adnexal masses in pregnancy. Study design: During a 12-year period, 48 laparoscopic procedures were performed in 47 patients with adnexal masses in pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 17 cases, the second trimester in 27 cases and the third trimester in four cases. All the procedures were performed with general anesthesia and curarization. The laparoscopic cystectomies were performed either with the intra-peritoneal or the trans-peritoneal technique. Results: The indications were: persistant or sonographically abnormal ovarian cyst (36 cases), torsion or rupture of ovarian cyst (8 cases), and symptomatic pelvic mass (3 cases). Two borderline tumors were discovered. The laproscopic procedure could not be performed in two cases due to dense adhesions and difficulty of hemostasis. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 3.8 days. The outcome of the pregnancy was normal in all cases except one fetal loss 4 days after the laparoscopy. Conclusion: Laparoscopic management of adnexal masses in pregnancy by an experienced team, is a safe and effective procedure that allows, compared to the traditional surgery, a shorter hospital stay, a reduced rate of post-operative complications and a decreased maternal and fetal morbidity.

The Antiestrogen Tamoxifen in the Treatment of Recurrent Benign Cystic Mesothelioma

Benign cystic mesothelioma is a tumor characteristically found in women during the reproductive years. These tumors are infrequently found after castration or menopause, suggesting some degree of hormonal sensitivity. Such aspects of the tumor suggest a potential role for antiestrogens as medical management and an alternative to radical surgery. We treated a 19-year-old woman with a symptomatic pelvic mass secondary to a recurrent benign cystic mesothelioma 2 years after radical surgery with the antiestrogen tamoxifen. An initial reduction in volume and arrest of growth was followed by stabilization in size and disappearance of symptoms. Therapy was continued for 18 months with no change in the volume of the cystic structure. The patient continued to be asymptomatic. Periodic surveillance with quantitative digital radiography for bone density showed no change in bone mineral density. Serum testing for liver function studies was normal throughout treatment. This case suggests that antiestrogens may have a role in the medical management of these rare estrogen-dependent neoplasms. The initial reduction in size and arrest in growth further suggest extreme sensitivity of this tumor to manipulation of the hormonal milieu. Therapy with the antiestrogen tamoxifen in this setting may provide an option for long-term medical management in cases of symptomatic recurrent cystic mesotheliomas.

Patient satisfaction with laparoscopic-assisted removal of large myomas

The main indications for laparoscopic myomectomy in 10 women (mean age 39.8 yrs) were symptomatic pelvic mass (9), menorrhagia (6), dyspareunia (5), dysmenorrhea (2), and infertility (2). All patients had one or more fibroids larger than 5 cm removed, and in seven the myomata were larger than 10 cm. The mean fibroid mass was 394.7 g (range 130-675 g), and extensive morcellation was required in all women. The mean length of surgery was 153 minutes and hospital stay 3 to 4 days. Overall recovery was excellent in seven and good in three patients. The mean return to normal activity and work was 5.3 weeks (mode 3.0 wks, median 4.5 wks). All women reported improvement in their symptoms as follows: symptomatic mass (9), gone in six and smaller in three; menorrhagia (6), lighter in five and unchanged in one; dyspareunia (5), gone in four and less in 1; dysmenorrhea (2) gone and less in one each. Of the three women trying to conceive since the procedure, two were successful. The mean scar length was 4.9 cm (range 1-6 cm), reported by five women as expected, by four as shorter, and one as longer than expected, but all the patients were satisfied with the scars.

Stress and hopelessness in the promotion of cervical intraepithelial neoplasia to invasive squamous cell carcinoma of the cervix

Stress and hopelessness have been associated with the development of invasive cervical cancer by previous research. Subjects in this study were recruited from a colposcopy clinic awaiting work-up of an abnormal pap smear and from those admitted to an in-patient gynecology ward for còne biopsy of the cervix or hysterectomy to treat a symptomatic pelvic mass thought to be uterine leiomyomas. After data collection, pathology reports and colposcopic findings were used to determine group assignment independent of subjects' knowledge of their diagnosis. A modest stress-promotion correlation was derived, which was greatly enhanced by significant interactions with low levels of cooperative coping style and for high levels of premorbid pessimism, future despair, somatic anxiety, and life threat reactivity. These stress-moderator interactions are discussed in terms of immune system deficit with concomitant enhancement of promotion of CIN to invasive squamous cell cervical cancer.

Ultrasonic Diagnosis of the Bladder as a Symptomatic Pelvic Mass

Diagnostic ultrasound for pelvic masses is now a well established modality. Its ability to distinguish between fluid-filled and solid lesions is important in the diagnostic study of pelvic masses. Two cases are presented of bladder distension causing clinical symptoms suggesting pathology outside the urinary tract, which when finally evaluated by ultrasound proved bladder distension as the etiology of the symptoms.