- Email: [email protected]
Leiomyoma of the Seminal Vesicle
0022-534 7/94/1514-1027$03.00/0 Vol. 151, 1027-1029, April 1994
THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
LEIOMYOMA OF THE SEMINAL VESICLE ANDREW T. GENTILE, H. STEPHENS MOSELEY,* STEPHEN F. QUINN, DAISY FRANZINI AND THOMAS M. PITRE From Legacy Cancer Services and the Departments of Surgery/Urology, Radiology and Pathology, Good Samaritan Hospital, Portland, Oregon
ABSTRACT
Leiomyoma of the seminal vesicle is exceedingly rare, with only a few cases reported in the literature. To our knowledge we present the first case of primary leiomyoma of the seminal vesicle to be evaluated by magnetic resonance imaging using a rectal coil. KEY WORDS:
leiomyoma, seminal vesicles, magnetic resonance imaging
The accessory nature and anatomic location of the seminal vesicle have caused its role in serious pathological change to remain ill-defined. The technological advances in magnetic resonance imaging (MRI) using endorectal surface coil systems and endorectal ultrasound has better defined the prostate gland and periprostatic structures, allowing easier evaluation of subtle tissue abnormalities and early noninvasive diagnosis of pathological change. Surface coil endorectal MRI provides images of prostate and periprostatic structures far superior to body coil MRI and has proved to be 90% accurate in identifying seminal vesicle involvement by metastatic prostate cancer. 1 Leiomyomatous tumors are generally benign, ubiquitous growths found infrequently in the genitourinary system. Primary leiomyoma of the seminal vesicle is exceedingly rare with few cases reported. Pathological change of the seminal vesicles will become more easily interpretable with refinements in MRI, such as the use of fast-spin echo and multi-coil array images. We report a case of primary leiomyoma of the seminal vesicle, which demonstrates current MRI capabilities and resulted in complete surgical removal for cure. CASE REPORT
A 66-year-old man was found to have an asymptomatic rectal mass on routine examination. The mass was extrinsic to the colon, behind the bladder and lateral and superior to the Accepted for publication September 24, 1993. * Requests for reprints: Comprehensive Cancer Program, Good Samaritan Hospital and Medical Center, 1015 N. W. 22nd Ave., Portland, Oregon 97210.
FIG. 1. CT of pelvis shows soft tissue mass (M) deforming left posterolateral aspect of bladder (arrows). Fat plane separates mass from rectum (curved arrow). Site of origin cannot be determined. B, bladder. R, rectum.
prostate. Computerized tomography (CT) of the pelvis showed a soft tissue mass left paracentral and posterior to the bladder, and intimately associated with the seminal vesicles (fig. 1). The site of origin of the mass could not be defined on CT because margins blended with the bladder, prostate and seminal vesi-
Fm. 2. A, axial MRI (TR/TE 3000/85) shows low signal intensity mass (arrows) arising from seminal vesicles. Signal intensity of left seminal vesicle (curved arrow) is increased because of obstruction by mass. B, sagittal MRI (TR/TE 3000/85) reveals mass (arrows) situated superior to prostate, posterior to bladder and anterior to rectum. C, coronal MRI demonstrates relationships of mass (arrows) to seminal vesicles, which are splayed and displaced. P, prostate. B, bladder. R, rectum. SV, seminal vesicles. 1027
1028
LEIOMYOMA OF SEMINAL VESICLE DISCUSSION
FIG. 3. Operative findings of partially dissected 6.5 X 4 x 3.5 cm. mass. Long suture is on left vas deferens. B, bladder. M, mass. R, rectum. VD, vas deferens.
des. MRI of the pelvis was performed, using phased array pelvic coils above coupled with an endorectal surface coil. MRI showed a low signal intensity mass arising from the left seminal vesicle and separate from the prostate and bladder (fig. 2). MRI diagnosis was seminal vesicle fibroma. The patient underwent transrectal Tru-Cut* core needle biopsies of the pelvic mass on October 29, 1992, which revealed a benign, bland collagenous fibrous tumor involving the seminal vesicle. He was hospitalized on November 23. Preoperative cystoscopy and bilateral ureteral stenting revealed medial displacement of the left ureteral orifice. Laparotomy through a lower midline incision confirmed a firm 5 X 5 cm. mass adjacent to and involving the left seminal vesicle. The mass was well circumscribed, freely movable and easily dissected from the posterior trigone of the bladder with a small remnant of the left seminal vesicle and a portion of the left vas deferens (fig. 3). Convalescence was uneventful and the patient was discharged home in 5 days. Gross pathological findings indicated a benign, well circumscribed rubbery mass. Microscopically, the lesion was hyalinized and fibrotic. Cellular bundles of bland spindle cells were noted (fig. 4). No mitotic activity was apparent. Pathological findings were consistent with hyalinized leiomyoma of the seminal vesicle. * Travenol Laboratories, Deerfield, Illinois.
Genitourinary leiomyomas are uncommon but may arise from any structure containing smooth muscle. 2 Genitourinary leiomyomas usually originate in the kidney capsule. 3 Leiomyomatous tumors of the seminal vesicles are exceedingly rare. In 1944 Plaut and Standard reported a case of a complex leiomyoma of the seminal vesicle,4 confirmed the rarity of this condition and discussed 4 other cases, the earliest of which was described by Emmerich in 1910. 5 As with uterine myomas, leiomyomatous tumors of the seminal vesicle are thought to arise from vestigeal remnants of the mid portion of the mullerian duct. Remnants of the proximal mullerian duct, the hydatid of Morgagni, are commonly found, as is the remnant of the distal portion of the mullerian duct, the utriculus. A report similar to ours was published by Buck and Shaw in 1972. 6 Various other benign tumors of the seminal vesicles have been noted, including cysts,7 fibroadenoma, neuroma and angioendothelioma,8 mesenchymoma9 and fibromuscular hyperplasia of the seminal vesicle. 10 Malignant neoplasms of the seminal vesicles, including leiomyosarcoma, are also rare. 11 A total of 40 cases of primary carcinoma of the seminal vesicle has been reported in the United States and 12 in Japan. 12 These lesions may present with metastasis, pelvic pain or mass affect secondary to encroachment on other retrovesical structures. Most reports note that lesions appear as an asymptomatic mass found on digital rectal examination. Historically, detecting disease of the seminal vesicle has been difficult but recent advances in ultrasound, CT and MRI have made the organ visually accessible. 13 Evaluation of the seminal vesicles by en do rectal prostatic sonography has become routine. We believe MRI with phased array pelvic and endorectal coils to be the best diagnostic imaging modality available. Surgical excision without the need for wide margins is the procedure of choice. Ureteral stenting aids in safe dissection of the tumor from the bladder or trigone. Surgical management in this and other cases in the literature has been associated with no local recurrences.
REFERENCES
1. Chelsky, M. J., Schnall, M. D., Seidman, E. J. and Pollack, H. M.:
Use of endorectal surface coil magnetic resonance imaging for local staging of prostatic cancer. J. Urol., 150: 391, 1993. 2. Belis, J. A., Post, G. J., Rochman, S. C. and Milam, D. F.: Genitourinary leiomyomas. Urology, 13: 424, 1979. 3. Zuckerman, I. C., Kershner, D., Laytner, B. D. and Hirschl, D.: Leiomyoma of the kidney. Ann. Surg., 126: 220, 1947. 4. Plaut, A. and Standard, S.: Cystomyoma of seminal vesicle. Ann.
FH_; .. 4. A, rr:iicroscopic view shows irregular whirls of bland spindle cells. Mitotic activity was rare. B immunoperoxidase stain reveals reactivity of spmdle cells for muscle specific actin, supporting diagnosis of smooth muscle tumor. Reduced fr~m X400.
LEIOMYOMA OF SEMINAL VESICLE
Surg., 119: 253, 1944. 5. Emmerich, E.: Zentrable F. Allg. Path. U. Anat., 21: 673, 1910. 6. Buck, A. C. and Shaw, R. E.: Primary tumours of the retro-vesical region with special reference to mesenchymal tumours of the seminal vesicles. Brit. J. Urol., 44: 47, 1972. 7. Reddy, Y. N. and Winter, C. C.: Cysts of the seminal vesicles: a case report and review of the literature. J. Urol., 108: 134, 1972. 8. Kan, D. V.: Benign tumors of seminal vesicles. Urologia, 28: 27, 1963. 9. Islam, M.: Benign mesenchymoma of seminal vesicles. Urology, 13: 203, 1979.
1029
10. Hatcher, P. A., Tucker, J. A. and Carson, C. C.: Fibromuscular hyperplasia of the seminal vesicle. J. Urol., 141: 957, 1988. 11. Schned, A. R., Ledbetter, J. S. and Selikowitz, S. M.: Primary leiomyosarcoma of the seminal vesicle. Cancer, 57: 2202, 1986. 12. Kawahara, M., Matsuhashi, M., Tajima, M., Sawamura, Y., Matsushima, M., Shirai, M. and Ando, K.: Primary carcinoma of the seminal vesicle. Diagnosis assisted by sonography. Urology, 32: 269, 1988. 13. Bahn, D. K., Brown, R. K. J., Shei, K. Y. and White, D. B.: Sonographic findings of leiomyoma in the seminal vesicle. J. Clin. Ultrasound, 18: 517, 1990.
THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
LEIOMYOMA OF THE SEMINAL VESICLE ANDREW T. GENTILE, H. STEPHENS MOSELEY,* STEPHEN F. QUINN, DAISY FRANZINI AND THOMAS M. PITRE From Legacy Cancer Services and the Departments of Surgery/Urology, Radiology and Pathology, Good Samaritan Hospital, Portland, Oregon
ABSTRACT
Leiomyoma of the seminal vesicle is exceedingly rare, with only a few cases reported in the literature. To our knowledge we present the first case of primary leiomyoma of the seminal vesicle to be evaluated by magnetic resonance imaging using a rectal coil. KEY WORDS:
leiomyoma, seminal vesicles, magnetic resonance imaging
The accessory nature and anatomic location of the seminal vesicle have caused its role in serious pathological change to remain ill-defined. The technological advances in magnetic resonance imaging (MRI) using endorectal surface coil systems and endorectal ultrasound has better defined the prostate gland and periprostatic structures, allowing easier evaluation of subtle tissue abnormalities and early noninvasive diagnosis of pathological change. Surface coil endorectal MRI provides images of prostate and periprostatic structures far superior to body coil MRI and has proved to be 90% accurate in identifying seminal vesicle involvement by metastatic prostate cancer. 1 Leiomyomatous tumors are generally benign, ubiquitous growths found infrequently in the genitourinary system. Primary leiomyoma of the seminal vesicle is exceedingly rare with few cases reported. Pathological change of the seminal vesicles will become more easily interpretable with refinements in MRI, such as the use of fast-spin echo and multi-coil array images. We report a case of primary leiomyoma of the seminal vesicle, which demonstrates current MRI capabilities and resulted in complete surgical removal for cure. CASE REPORT
A 66-year-old man was found to have an asymptomatic rectal mass on routine examination. The mass was extrinsic to the colon, behind the bladder and lateral and superior to the Accepted for publication September 24, 1993. * Requests for reprints: Comprehensive Cancer Program, Good Samaritan Hospital and Medical Center, 1015 N. W. 22nd Ave., Portland, Oregon 97210.
FIG. 1. CT of pelvis shows soft tissue mass (M) deforming left posterolateral aspect of bladder (arrows). Fat plane separates mass from rectum (curved arrow). Site of origin cannot be determined. B, bladder. R, rectum.
prostate. Computerized tomography (CT) of the pelvis showed a soft tissue mass left paracentral and posterior to the bladder, and intimately associated with the seminal vesicles (fig. 1). The site of origin of the mass could not be defined on CT because margins blended with the bladder, prostate and seminal vesi-
Fm. 2. A, axial MRI (TR/TE 3000/85) shows low signal intensity mass (arrows) arising from seminal vesicles. Signal intensity of left seminal vesicle (curved arrow) is increased because of obstruction by mass. B, sagittal MRI (TR/TE 3000/85) reveals mass (arrows) situated superior to prostate, posterior to bladder and anterior to rectum. C, coronal MRI demonstrates relationships of mass (arrows) to seminal vesicles, which are splayed and displaced. P, prostate. B, bladder. R, rectum. SV, seminal vesicles. 1027
1028
LEIOMYOMA OF SEMINAL VESICLE DISCUSSION
FIG. 3. Operative findings of partially dissected 6.5 X 4 x 3.5 cm. mass. Long suture is on left vas deferens. B, bladder. M, mass. R, rectum. VD, vas deferens.
des. MRI of the pelvis was performed, using phased array pelvic coils above coupled with an endorectal surface coil. MRI showed a low signal intensity mass arising from the left seminal vesicle and separate from the prostate and bladder (fig. 2). MRI diagnosis was seminal vesicle fibroma. The patient underwent transrectal Tru-Cut* core needle biopsies of the pelvic mass on October 29, 1992, which revealed a benign, bland collagenous fibrous tumor involving the seminal vesicle. He was hospitalized on November 23. Preoperative cystoscopy and bilateral ureteral stenting revealed medial displacement of the left ureteral orifice. Laparotomy through a lower midline incision confirmed a firm 5 X 5 cm. mass adjacent to and involving the left seminal vesicle. The mass was well circumscribed, freely movable and easily dissected from the posterior trigone of the bladder with a small remnant of the left seminal vesicle and a portion of the left vas deferens (fig. 3). Convalescence was uneventful and the patient was discharged home in 5 days. Gross pathological findings indicated a benign, well circumscribed rubbery mass. Microscopically, the lesion was hyalinized and fibrotic. Cellular bundles of bland spindle cells were noted (fig. 4). No mitotic activity was apparent. Pathological findings were consistent with hyalinized leiomyoma of the seminal vesicle. * Travenol Laboratories, Deerfield, Illinois.
Genitourinary leiomyomas are uncommon but may arise from any structure containing smooth muscle. 2 Genitourinary leiomyomas usually originate in the kidney capsule. 3 Leiomyomatous tumors of the seminal vesicles are exceedingly rare. In 1944 Plaut and Standard reported a case of a complex leiomyoma of the seminal vesicle,4 confirmed the rarity of this condition and discussed 4 other cases, the earliest of which was described by Emmerich in 1910. 5 As with uterine myomas, leiomyomatous tumors of the seminal vesicle are thought to arise from vestigeal remnants of the mid portion of the mullerian duct. Remnants of the proximal mullerian duct, the hydatid of Morgagni, are commonly found, as is the remnant of the distal portion of the mullerian duct, the utriculus. A report similar to ours was published by Buck and Shaw in 1972. 6 Various other benign tumors of the seminal vesicles have been noted, including cysts,7 fibroadenoma, neuroma and angioendothelioma,8 mesenchymoma9 and fibromuscular hyperplasia of the seminal vesicle. 10 Malignant neoplasms of the seminal vesicles, including leiomyosarcoma, are also rare. 11 A total of 40 cases of primary carcinoma of the seminal vesicle has been reported in the United States and 12 in Japan. 12 These lesions may present with metastasis, pelvic pain or mass affect secondary to encroachment on other retrovesical structures. Most reports note that lesions appear as an asymptomatic mass found on digital rectal examination. Historically, detecting disease of the seminal vesicle has been difficult but recent advances in ultrasound, CT and MRI have made the organ visually accessible. 13 Evaluation of the seminal vesicles by en do rectal prostatic sonography has become routine. We believe MRI with phased array pelvic and endorectal coils to be the best diagnostic imaging modality available. Surgical excision without the need for wide margins is the procedure of choice. Ureteral stenting aids in safe dissection of the tumor from the bladder or trigone. Surgical management in this and other cases in the literature has been associated with no local recurrences.
REFERENCES
1. Chelsky, M. J., Schnall, M. D., Seidman, E. J. and Pollack, H. M.:
Use of endorectal surface coil magnetic resonance imaging for local staging of prostatic cancer. J. Urol., 150: 391, 1993. 2. Belis, J. A., Post, G. J., Rochman, S. C. and Milam, D. F.: Genitourinary leiomyomas. Urology, 13: 424, 1979. 3. Zuckerman, I. C., Kershner, D., Laytner, B. D. and Hirschl, D.: Leiomyoma of the kidney. Ann. Surg., 126: 220, 1947. 4. Plaut, A. and Standard, S.: Cystomyoma of seminal vesicle. Ann.
FH_; .. 4. A, rr:iicroscopic view shows irregular whirls of bland spindle cells. Mitotic activity was rare. B immunoperoxidase stain reveals reactivity of spmdle cells for muscle specific actin, supporting diagnosis of smooth muscle tumor. Reduced fr~m X400.
LEIOMYOMA OF SEMINAL VESICLE
Surg., 119: 253, 1944. 5. Emmerich, E.: Zentrable F. Allg. Path. U. Anat., 21: 673, 1910. 6. Buck, A. C. and Shaw, R. E.: Primary tumours of the retro-vesical region with special reference to mesenchymal tumours of the seminal vesicles. Brit. J. Urol., 44: 47, 1972. 7. Reddy, Y. N. and Winter, C. C.: Cysts of the seminal vesicles: a case report and review of the literature. J. Urol., 108: 134, 1972. 8. Kan, D. V.: Benign tumors of seminal vesicles. Urologia, 28: 27, 1963. 9. Islam, M.: Benign mesenchymoma of seminal vesicles. Urology, 13: 203, 1979.
1029
10. Hatcher, P. A., Tucker, J. A. and Carson, C. C.: Fibromuscular hyperplasia of the seminal vesicle. J. Urol., 141: 957, 1988. 11. Schned, A. R., Ledbetter, J. S. and Selikowitz, S. M.: Primary leiomyosarcoma of the seminal vesicle. Cancer, 57: 2202, 1986. 12. Kawahara, M., Matsuhashi, M., Tajima, M., Sawamura, Y., Matsushima, M., Shirai, M. and Ando, K.: Primary carcinoma of the seminal vesicle. Diagnosis assisted by sonography. Urology, 32: 269, 1988. 13. Bahn, D. K., Brown, R. K. J., Shei, K. Y. and White, D. B.: Sonographic findings of leiomyoma in the seminal vesicle. J. Clin. Ultrasound, 18: 517, 1990.