AABBSS TTRRAACCTT Ret ro pe ri to ne al le i om yo sar co ma is a ra re ne op lasm. Be ca u se the se le si ons are of ten asym pto ma tic du ring growth, the tu mor can be mas si ve at the ti me of di ag no sis. Abo ut two thirds of le i om yo sar co mas are fo und in the ret ro pe ri to ne al spa ce. Sur gi cal re sec ti on is the tre at ment of cho i ce, and the most im por tant fac tor in pre ven ting lo cal re cur ren ce and at ta i ning a go od out co me is to be ab le to re mo ve the tu mor comp le tely.; ho we ver, comp le te re mo val is so me ti mes dif fi -cult if the re is an in va si on of the sur ro un ding tis su es, af fec ting the in fe ri or ve na ca va or re nal ve ins.
In this ca se re port, ima ging fin dings of a his to pat ho lo gi cally pro ven ret ro pe ri to ne al le i om yo sar -co ma in a 38-ye ar-old wo man are pre sen ted. Al so, the be ne fits of dif fe rent ima ging mo da li ti es (Ul-tra so und, Dopp ler and MDCT) in the di ag no sis are dis cus sed.
KKeeyy WWoorrddss:: Ret ro pe ri to ne al ne op lasms, le i om yo sar co ma, com pu ted to mog raphy, in fe ri or ve na ca va, ute rus
ÖÖZZEETT Ret ro pe ri to ne al le yo mi yo sar kom na dir bir ne op lazm dır. Bu lez yon lar ge liş me le ri sı ra sın da sık lık la asemp to ma tik ol duk la rı için tü mör, ta nı anın da ol duk ça bü yük ola bi lir. Le yo mi yo sar kom la rın yak la şık üç te iki si ret ro pe ri to ne al boş luk ta bu lu nur. Cer ra hi re zek si yon bir te da vi se çe ne ği -dir ve lo kal re kür ren si ön le mek ve iyi so nuç lar el de et me de en önem li fak tör kit le nin ta ma men çı ka rıl ma sı nı ba şar mak tır. Bu nun la bir lik te, in fe ri yor va na ka va ve ya re nal ven le ri et ki le yen çev re do ku in vaz yo nu mev cut ise kit le nin ta ma men çı ka rıl ma sı ba zen güç ola bi lir. Biz bu ra da, 38 ya -şın da ki ba yan has ta da his to pa to lo jik ola rak ret ro pe ri to ne al le yo mi yo sar kom ol du ğu ka nıt lan mış ol gu nun gö rün tü le me bul gu la rı nı sun mak ta yız. Ay nı za man da, fark lı gö rün tü le me mo da li te le ri nin (ul tra so nog ra fi, Dopp ler ve çok ke sit li bil gi sa yar lı to mog ra fi) fay da la rı nı da tar tış tık.
AAnnaahh ttaarr KKee llii mmee lleerr:: Ret ro pe ri to ne al ne op lazm, le yo mi yo sar kom, bil gi sa yar lı to mog ra fi, in fe ri or ve na ka va, ute rus
TTuurr kkiisshh MMee ddii ccaall JJoo uurr nnaall 22000099;;33((11))::3399--4433 Nilgün IŞIKSALAN ÖZBÜLBÜL, MD,a
Muharrem TOLA, MD,a Tülay TEMUÇİN, MD,b Levent IŞIKAY, MDc Departments of aRadiology,
bPathology,
cUrology,
Türkiye Yüksek İhtisas Hospital, Ankara Ya zış ma Ad re si/Cor res pon den ce:
Nilgün IŞIKSALAN ÖZBÜLBÜL, MD Türkiye Yüksek İhtisas Hospital, Department of Radiology, Ankara, TÜRKİYE/TURKEY
nilgunisiksalan@yahoo.com
Cop yright © 2009 by Türk Tıp Dergisi
OLGU SUNUMU
a well-en cap su la ted tu mor that tends to grow by ex pan si on, rat her than in va ding the sur ro un ding or gans.5This re port des cri bes an unu su al ca se with ret ro pe ri to ne al LMS in va ding the IVC, ute rus and left ovary at the ti me of di ag no sis. We be li e ved that this is the first re port to be des cri bing the ima ging fin dings of vis se ral and ve no us in va si on in the sa -me pa ti ent.
CA SE RE PORT
38 ye arold wo man had the comp la int abo ut in ter -mit tent left flank pa in which had star ted a 2 month ago. Her past me di cal his tory was un re mar kab le.
The re was no his tory of va gi nal disc har ge, uri nary and bo wel comp la ints. Physi cal exa mi na ti on was wit hin nor mal li mits. Blo od che mistry was nor mal ex cept for an ESR of 67 mm/hr. Uri ne analy sis sho -wed mic ros co pic he ma tu ri a. Ab do mi nal ul tra so und re ve a led the he te ro ge no us ec ho tex tu re of the so lid mass of in de ter mi na te ori gin in the lo wer qu ad rant of ab do men (Fi gu re 1A). Be ca u se of the mass exten ding to the left ad ne xi al loj, trans va gi nal ul tra -so und was per for med. In this exa mi na ti on, the fin dings of the in va si on of the ute rus and left ad-ne xi al re gi on such as he te ro ge no us myo met ri um and non-vi su a li zed left ovary se pe ra ted from the
A B
C
FI GU RE 1: So lid non nec ro tic ret ro pe ri to ne al le i om yo sar co ma in a 38-ye ar-oldD wo man with left flank pa in. So nog ram of the left lo wer qu ad rant shows a lar -ge ec ho -ge nic mass ad ja cent to lo wer po le of the left kid ney (A), myo met ri um is he te ro ge no us and has an in cre a sed vas cu la rity (B). Al so, no te the nu me -ro us pel vic col la te ralls (ar -rows). Con trast-en han ced CT scan ob ta i ned du ring ar te ri al pha se (C) shows in ten se he te ro ge no us en han ce ment of a mass on sa git tal re for mat ted ima ges. The en han cing tu mor throm bus par ti ally occ lu ding and ex pan ding the IVC and the left ili ac ve in (ar row). Axi al con trasten -han ced CT in the por tal-ve no us pha se (D) de mons tra tes en -han cing tu mor and tu mor throm bus in the IVC (black ar row).
M: Mass, LK: Left Kid ney, RK: Right Kid ney, Utr: Ute rus, IVC: In fe ri or ve na ca va.
mass we re de tec ted. The mass was hyper vas cu lar on Dopp ler ul tra so und. In ad di ti on, the re we re many col la te rals in the left ad ne xa and low re sis -tan ce ar te ri al flows in the myo met ri um (Fi gu re 1B). Sub se qu ently, thinsli ce mul tipha se (unen han ced, early ar te ri al, la te ar te ri al and por tal ve no -us pha se) com pu ted to mog raphy (CT) was per for med to re ve al the ori gin and the ex tent of the mass and the as sess ment of the he pa tic pa rench -yma. 16-sec ti on mul ti-de tec tor CT (MDCT) scan de mons tra ted in ten se in ho mo ge no us con trast en-han ce ment of the mass on the ar te ri al pha se and per sis ted for la te ar te ri al and por tal pha se. The mass star ted just be low the left kid ney in the ret ro pe ri to ne um and ex ten ding to the left ad nex. In ad di ti -on, myo met ri um sho wed he te ro ge no us en han ce ment. The left ovary was not se pe ra tely iden ti fi ed from the mass. Pe ri tu mo ral and pel vic nu me ro us col la te ral ve ins we re no ted. The in fra re nal IVC and left ili ac ve in ex pan ded and con ta i -ned throm bus which sho wed he te ro ge no us en han ce ment du ring ar te ri al pha se sug ges ting a tumo ral throm bus (Fi gu re 1C, D). The bi la te rally re -nal ve ins we re pa tent. No li ver me tas ta ses and ab do mi nal len fa de no pathy was de tec ted. At la pa ro tomy, a ret ro pe ri to ne al mass was par ti ally re sec -ted in con ti nu ity with the left ovary be ca u se the left ovary was in va ded by the tu mor. No vas cu lar re cons truc ti on was do ne. The tu mor was me a su red 20 cm in gre a test di a me ter. The cut sur fa ce pre sen -ted a yel low firm tis su e with are as of he morr ha ge.
The his to lo gi cal di ag no sis was LMS but the pre ci se si te of ori gin of the sar co ma re ma i ned un de ter -mi ned (Fi gu re 2A, B). The pos to pe ra ti ve co ur se was une vent ful. No che mot he raphy was gi ven. Ni ne months la ter the pa ti ent comp la i ned of poly me norr he a and me no met rorr ha gi a. Ga do li ni umen -han ced pel vic mag ne tic re so na ce ima ging (MRI) re ve a led mul tip le re si du mass (7 x 3 cm) in the pel -vic re gi on and ma lign throm bus in the IVC. At op-e ra ti on, utop-e rus, thop-e right ovary and par ti al omen tum was re mo ved. The rec to sig mo id co lon was re mo ved with the tu mor and bo wel con tu i nity was res to red. At pre sent, 2 ye ars af ter the first op-e ra ti on, thop-e pa ti op-ent is ali vop-e with no symptoms.
DIS CUS SI ON
Ret ro pe ri to ne al tu mors are un com mon, and typi cally re ma in aysm pto ma tic un til the tu mor be co -mes evi dent as a lar ge mass.3-5The most com mon ma lig nant tu mors in this si te are the lympho mas,
A
B
FI GU RE 2: A) Cut sec ti on of a ret ro pe ri to ne al le i om yo sar co ma shows wellde fi ned non nec ro tic mass. B) His to lo gic sec ti on con ta ins in ter sec ting fas cic -les with eo si nop hi lic cytop lasm and elon ga ted nuc le i with blunt ends (H&E).
The se cells are im mu no re ac ti ve for SMA (in set).
fol lo wed by the li po sar co mas and ot her soft tis su e tumors is very dif fi cult sin ce the symptoms are ex tre -mely va ri ab le and nons pe ci fic. The ul tra so und and CT fin dings of a ret ro pe ri to ne al LMS are not spe-ci fic and dif fe ren ti al di ag no sis with ot her mas ses can not be ma de by ra di o logy alo ne.6Ul tra so nog -raphy shows the con sis tency of the mass, so lid or cystic, and the pre sen ce of cal ci fi ca ti on.2,6CT can show the ex tent of the pri mary tu mor mass, iden-tify me tas ta ses, and lo ca li ze le si ons for bi opsy.9A ves-sel wall as well as ot her or gans.10MDCT enab les fast and thin ac qu i si ti on of the ab do mi nal ana tomy. This al lows mul ti-pha se and mul ti-pla nar stu di es that can be ob ta i ned du ring de fi ned cir cu la tory pha ses. bland and tu mor throm bus.10In our pa ti ent, MDCT with mul tip la nar re for mat ting con fir med the ex tent of the hyper vas cu lar mass and in va si on of the ad ja cent or gans such as ute rus and left ovary in the mul -ti-pha se study. Al so, tu mor throm bus was re ve a led
We thank Ms. Berna ASLAN for English editing of the manuscript.
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KAYNAKLAR
üperiyor mezenterik arter sendromu (SMAS) (Wilkie sendromu, ar-teriyomezenterik duodenal kompresyon sendromu veya kronik du-edonal ileus) oldukça ender rastlanan bir klinik tablodur. Duedonum üçüncü kıtasının, aort ile süperiyor mezenterik arter (SMA) arasındaki açıda sıkışmasıyla ortaya çıkan bir tablodur. Normalde, duedonumun ret-roperitoneal hareketsiz parçası yaklaşık L3 vertebra seviyesinde SMA ile aort arasından geçmektedir. Retroperitoneal yağ dokusu ve lenfatik do-ku, aorttan SMA’i uzaklaştırmaktadır. Aort ile SMA arasındaki açı ve