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| CASE REPORT |
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| Year : 2021 | Volume
: 4
| Issue : 3 | Page : 79-81 |
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Solitary mass of the male pelvis
Raunaq Chhabra1, Seena George2, Marzi Mehta3, Paresh Jain3
1 Department of General Surgery, H.B.T Medical College and R.N Cooper Medical College, Mumbai, Maharashtra, India
2 Department of Pathology, Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
3 Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
| Date of Submission | 12-Aug-2020 |
| Date of Decision | 06-Sep-2020 |
| Date of Acceptance | 28-Dec-2020 |
| Date of Web Publication | 24-May-2022 |
Correspondence Address:
Paresh Jain
Room No. 318, 3rd Floor, Tower Block, Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJCS.IJCS_28_20
Solitary fibrous tumor (STF) initially described as a tumor of the pleura has now been recognized at multiple anatomical sites. Pelvic STFs consist about 6% of all STFs. We present the case of a man with a long standing pelvic STF. He had symptoms of increased frequency of loose stools with passage of mucus since 2 years. A laparotomy and excision of the mass was done, but the patient developed complications and was re-explored on postoperative day 4 which showed a small rent in the anterior rectal wall mucosa. A colostomy was done after which the patient had a steady recovery. These lesions can be tricky to deal with due to their vascular nature and size. With no defined management protocol, the treatment must be tailor made and be more cautious especially when the pathology is long standing, causing pressure symptoms.
Keywords: Fibrous mesothelioma, pelvic tumour, solitary fibrous tumour
How to cite this article:
Chhabra R, George S, Mehta M, Jain P. Solitary mass of the male pelvis. Indian J Colo-Rectal Surg 2021;4:79-81 |
| Introduction | |  |
Solitary fibrous tumor (STF) initially described as a tumor of the pleura has now been recognized at multiple anatomical sites. Pelvic STF's consists about 6% of all STF's.[1] Overall, they account for 2.8 cases in 100,000 population.[2]
| Case Report | | |
A 42-year-old male presented to the hospital with a complaint of increased frequency of loose stools with passage of mucus since 2 years. He was treated empirically with antibiotics, probiotics and antimotility agents with no significant relief. There was no associated history of weight loss, bleeding per rectum, or loss of appetite. Abdominal examination revealed pelvic fullness with no other abnormal findings. Per-rectal examination revealed extrinsic anterior rectal wall compression with normal appearing mucosa. The patient had a 2-year-old computed tomography of the pelvis which showed 10 cm × 7.5 cm × 7.5 cm well defined multi-cystic solitary mass in the pouch of Douglas, with compression over the surrounding structures.
Colonoscopy revealed anterior bulge in the mid and lower rectum with normally appearing mucosa. To further quantify the nature of the lesion magnetic resonance imaging was done. It showed solitary, well-demarcated hyperperfused solid lesion with multiple nonenhancing cysts, epicenter in rectoprostatic pouch, measuring 10.0 cm × 7.9 cm × 7.9 cm. Multiphasic T1-weighted dynamic contrast-enhanced series revealed rapid early upstroke with progressive plateauing without overt delayed washout on the mean curve images. There were multiple tortuous vascular channels arborizing within the right inferolateral aspect of the mass, probably arising from or draining into the right internal iliac vessels. The lesion exerts significant mass effect on the pelvic soft tissues, smoothly indenting of the anterior wall of the rectum and posterior bladder wall [Figure 1]a, [Figure 1]b, [Figure 1]c. In view of static tumor size over 2 years and increased risk of procedural bleeding, tissue biopsy was not done. | Figure 1: (a and b) Sagittal and coronal sections of T2 images showing a well-circumscribed cystic mass compressing the rectum and urinary bladder; (c) T1 fat suppressed image showing heterogeneous enhancement
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Preoperative angio-embolization was not considered technically feasible as there were multiple collaterals. The patient was posted for laparotomy which showed mass measuring 9.5 cm × 8 cm × 6.5 cm occupying the entire narrow male pelvis, displacing the urinary bladder, vas deferens, and seminal vesicles anteriorly and rectum posteriorly. Large tortuous vessels were seen arborizing on its surface. Anteriorly, plane was created between the mass and bladder using energy device. Posteriorly, the mass was found to be adherent to the anterior wall of the rectum from which it was meticulously dissected. After dissecting the mass from all sides, the largest feeder from right internal iliac was ligated. The specimen was retrieved and sent for histopathology. At this point, anterior rectal wall did appear thinned out and mildly dusky, but there was no breach in continuity of the wall. Postoperative course was uneventful till postoperative day 4 when the patient developed fever, leukocytosis and feculent drain discharge.
The patient was re-explored which showed rent in the friable anterior rectal wall. Probably was due to pressure necrosis from the long-standing mass compounded by thermal injury while dissecting the posterior part of the mass. Thorough wash was given and a sigmoid loop diversion stoma was performed. The patient had a steady recovery and was discharged.
Histopathology showed alternate areas of hyper and hypo-cellularity. Hyper cellular areas showed compactly arranged ovoid tumor cells in pattern less pattern [Figure 2]a. Characteristic feature was the presence of thick keloidal collagen fibers separating tumor cells, at places appearing like rosettes. In addition, there are thick walled vessels showing perivascular hyalinization with mitotic activity 2/10 high-power field. Features suggestive of aggressive behavior were not seen. Inked peripheral margin was free. | Figure 2: (a) Compact ovoid tumor cells showing patternless patterns; (b and c) Immunohistochemistry staining with CD34 and CD99
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Immunohistochemistry (IHC) showed tumor cells strongly positive with CD99 and CD34 and diffuse positivity with moderate intensity with Bcl2 and Vimentin [Figure 2]b and [Figure 2]c. Rest of the IHCs were negative. MiB index was 8%–10%.
The diagnosis of Benign STF with locally aggressive potential in view of tumor size more than 5 cm and retroperitoneal location was made.
| Discussion | | |
STFs are rare benign neoplasms, also called fibrous mesotheliomas, arising from mesenchymal cells.[3]
STFs arising in the pleura as well as extra thoracic sites have similar clinical and histological features. Extra thoracic STFs are more likely to be symptomatic on presentation.[1] Like in our case where the patient presented with pressure symptoms such as increased frequency of stools and mucoid diarrhea.
Diagnosis is based on favorable radiology and biopsies. Here, biopsy was not feasible due to increased vascularity of the mass.
Paucity of literature makes its diagnosis and management customized to individual cases.
Size >5 cm and retroperitoneal location have a higher risk of malignancy, as in our case.[4] Surgical resection with negative margins is the mainstay of treatment.[1]
Trans-catheter arterial embolization (TAE) is a preoperative treatment modality which can be used to shrink the size of these tumors. Pisco et al. reported that preoperative trans-catheterembolization (TAE) of the internal iliac arteries for a pelvic tumor was effective in 97 of 108 cases, however, 70 patients developed complications ranging from nausea, vomiting to tumor necrosis, acute tubular necrosis, and bladder wall necrosis.[5],[6] We proceeded directly for surgical excision as the mass had multiple feeders not amenable for TAE.
Surgery can be done trans-sacrally, however there is a high risk of postoperative complications such as anorectal dysfunction and poor wound healing.[7] Here, trans-abdominal approach was used to excise the mass with negative margins.
Occasionally, there have been reports of STFs being managed with external beam radiation and chemotherapy with doxorubicin and cisplatin.[1] Bevacizumab and temozolomide are used in locally advanced, malignant, and recurrent STFs.[8]
Most STFs are benign but do carry malignant potential.[1],[3] Positive surgical margins and presence of histologically malignant components, tumor size >10 cm indicate a worse disease-free survival.[1] Lifelong follow-up is recommended as late reoccurrences do occur.[3] Tumors larger than 8 cm and have malignant component require a closer follow-up.[3]
| Conclusion | | |
Extra thoracic STFs present with varied symptoms. Although rare they must be thought of as a differential for solitary benign lesions where the preoperative diagnosis is uncertain. These lesions can be tricky to deal with due to their vascular nature and size. With no defined management protocol, treatment must be tailor made and be more cautious especially when the pathology is long standing, causing pressure symptoms.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gold JS, Antonescu CR, Hajdu C, Ferrone CR, Hussain M, Lewis JJ, et al. Clinicopathologic correlates of solitary fibrous tumors. Cancer 2002;94:1057-68.  |
| 2. | Liu J, Cai C, Wang D, Chen H, Cheng L, Shao W, et al. Video-assisted thoracoscopic surgery (VATS) for patients with solitary fibrous tumors of the pleura. J Thorac Oncol 2010;5:240-3. |
| 3. | Gholami S, Cassidy MR, Kirane A, Kuk D, Zanchelli B, Antonescu CR, et al. Size and location are the most important risk factors for malignant behavior in resected solitary fibrous tumors. Ann Surg Oncol 2017;24:3865-71. |
| 4. | Gengler C, Guillou L. Solitary fibrous tumour and haemangiopericytoma: Evolution of a concept. Histopathology 2006;48:63-74. |
| 5. | Katsuno H, Maeda K, Hanai T, Sato H, Masumori K, Koide Y, et al. Trans-sacral resection of a solitary fibrous tumor in the pelvis: Report of a case. Surg Today 2011;41:1548-51. |
| 6. | Pisco JM, Martins JM, Correia MG. Internal iliac artery: Embolization to control hemorrhage from pelvic neoplasms. Radiology 1989;172:337-9. |
| 7. | Adamietz IA, Gleumes L. Extensive gluteal necrosis following bilateral embolization of the internal iliac artery (a case report). Geburtshilfe Frauenheilkd 1987;47:63-4. |
| 8. | deLemos ML, Kang I, Schaff K. Efficacy of bevacizumab and temozolomide therapy in locally advanced, recurrent, and metastatic malignant solitary fibrous tumour: A population-based analysis. J Oncol Pharm Pract 2019;25:1301-4. |
[Figure 1], [Figure 2]
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