NOT SIMPLY A FIBROID UTERUS: A RARE DIAGNOSTIC DISCOVERY

Resident(s): Bhumin Patel, MD PYG-3

Attending(s): Henry Dalsania, MD, Phillip Zeni, MD, and Jim Machin, MD

Program/Dept(s): Diagnostic & Interventional Radiology

Laparotomy Pelvic

angiogram Repeat

Laparotomy

Repeat Pelvic

Angiogram Pathology

Surgical removal

CHIEF COMPLAINT AND TIMELINE OF EVENTS

31 y/o AAF with complaints of menometrorrhagia and was initially admitted for total abdominal hysterectomy. Initial abdominal laparotomy demonstrated a highly vascular, unresectable pelvic mass

Initial pelvic angio to assess vascularity and Gelfoam of Right iliac supply, non-diagnostic

Repeat laparotomy for biopsy was unsuccessful due to hemorrhage

Repeat pelvic angio for complete vascular embolization

RELEVANT HISTORY

Past Medical History G2P2 female

Past Surgical History Bilateral tubal ligation

Family & Social History Nonsmoker, 1-2 alcoholic drinks per day, single sexual partner

Review of Systems Fatigue

Pelvic pain

Abdominal distention

INITIAL IR INTERVENTION QUESTION

What is the abnormality demonstrated on the CT A/P coronal images ?

A) Multifibroid Uterus

B) Pelvic AVM

C) Enlarged Uterus

D) Hypervascular Pelvic Mass

E) Uncertain

CORRECT!

What is the abnormality demonstrated on the CT A/P coronal images ?

A) Multifibroid Uterus

B) Pelvic AVM

C) Enlarged Uterus

D) Hypervascular pelvic Mass

E) Uncertain

At this point in the diagnostic workup, all possibilities are correct. No tissue diagnosis could be made. Although, an enlarged hypervascular uterus is demonstrated, which is most commonly secondary to leiomyoma.

Return to Case

Sorry, That’s not the best answer.

What is the abnormality demonstrated on the CT A/P coronal images ?

A) Multifibroid Uterus

B) Pelvic AVM

C) Enlarged Uterus

D) Hypervascular pelvic Mass

E) Uncertain

At this point in the diagnostic workup, all possibilities are correct. No tissue diagnosis could be made. Although, an enlarged hypervascular uterus is demonstrated, which is most commonly secondary to leiomyoma.

Return to Case

DIAGNOSTIC DILEMMA

Biopsy could not be completed despite multiple laparotomy attempts secondary to hemorrhage

Multiple imaging modalities were performed to possibly indicate diagnosis Including CT with & without IV contrast, CTA of the pelvis,

MRI/MRA

CT w/ contrast demonstrated a large hypervascular mass concerning fro a high-grade sarcoma, possibly angiosarcoma versus vascular malformation. Of note, hemoperitoneum was also present.

DIAGNOSTIC WORKUP QUESTION

T2 coronal images are presented and the large pelvic mass is obvious. What do the serpiginous T2 hypointense areas demonstrate?

A) Fat

B) Hemorrhage

C) Packed Tumor cells

D) Flow voids

CORRECT!

T2 coronal images are presented and the large pelvic mass is obvious. What do the serpiginous T2 hypointense areas demonstrate?

A) Fat

B) Hemorrhage

C) Packed Tumor cells

D) Flow voids

These hypointense regions are due to flow voids interspersed within the hypervascular pelvic mass.

Return to Case

Sorry, that’s incorrect.

T2 coronal images are presented and the large pelvic mass is obvious. What do the serpiginous T2 hypointense areas demonstrate?

A) Fat

B) Hemorrhage

C) Packed Tumor cells

D) Flow voids

These hypointense regions are due to flow voids interspersed within the hypervascular pelvic mass.

Return to Case

REVIEW OF INTERVENTIONAL DIAGNOSTIC WORKUP

Roberts catheter was used to isolate each illiac artery

Right iliac artery is preferentially demonstrated on these images

Multiple small branches are visualized originating from multiple internal illiac a. branches

DIAGNOSTIC WORKUP QUESTION

Initial pelvic angiogram was performed and gelfoam was used for Right Iliac branch vessel embolization. Why was gelfoam chosen over other embolization techniques?

A) Large Mass

B) Acute Hemorrhage

C) Large Vessel Extravasation

D) Multivascular Supply

CORRECT!

Initial pelvic angiogram was performed and gelfoam was used for Right Iliac branch vessel embolization. Why was gelfoam chosen over other embolization techniques?

A) Large Mass

B) Acute Hemorrhage

C) Large Vessel Extravasation

D) Multivascular Supply

While in emergency situations embolization with coils is preferred if a single vessel injury is identified, multiple arterial malformations/injuries are better managed with gelfoam

Return to Case

Sorry, That’s not the best answer

Initial pelvic angiogram was performed and gelfoam was used for Right Iliac branch vessel embolization. Why was gelfoam chosen over other embolization techniques?

A) Large Mass

B) Acute Hemorrhage

C) Large Vessel Extravasation

D) Multivascular Supply

While in emergency situations embolization with coils is preferred if a single vessel injury is identified, multiple arterial malformations/injuries are better managed with gelfoam

Return to Case

DIAGNOSIS

Finally after EtOH embolization of all branching vessels and hemostasis was obtained a needle biopsy yielded results: spindle cell tumor consistent with solitary fibrous tumor Rare diagnosis

Few case reports of pelvic solitary fibrous tumors; our case is one of the few reported uterine manifestation2,3

Patient underwent en bloc resection of uterus, rectum, cervix, fallopian tubes, ovaries, and bladder

SUMMARY & TEACHING POINTS

In summary, our case demonstrates a rare diagnosis, which could have been easily masked for a common finding

A multimodality approach helped to guide our diagnosis and eventual surgical cure for this patient

Angiography contraindications 5

Anaphlaxis to contrast media, uncorrectable coagulopathy, severe renal insufficiency

Pregnancy, active pelvic infection, prior pelvic radiation, connective tissue disease

Gelfoam is a good embolization technique with a multivascular case such as this

Solitary fibrous tumor of the uterus is a rare finding Most have a benign course4 but can cause extensive mass effect and require large

anatomical resection, as in our case

REFERENCES

1. Chen, HY, et al. Aterial Embolization for controlling Life-Threatening Traumatic Pelvic Hemorrhage. Mid Taiwan J. Med. 2009; 14: 16-26.

2. Katsuno, H, et al. Trans-sacral resection of a solitary fibrous tumor in the pelvis: report of a case. Surg. Today. 2011; 41 (11): 1548-51.

3. Kawamura, S, et al. Advanced malingnant solitary fibrous tumor in pelvis responding to radiation therapy. Pathology International. 2007; 57 (11): 213-18.

4. Hasegawa, T, et al. Extrathoracic solitary fibrous tumors: Their histological variability and potentially aggressive behavior. Human Pathology. 1999; 30 (12): 1464-73

5. Spies JB, Spector A, Roth AR et-al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol. 2002;100 (5 Pt 1): 873-80