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Primary retroperitoneal pseudomucinous cyst
Primary
Retroperitoneal
Pseudomucinous
HARJIWAN L. KALANI, M.D., Detroit, Michigan, ROBERT W. KAPP, OLIVER EITZEN, M.D., Lakewood, Ohio
From tbe Departments of General Surgery and Pathology, Lakewood City Hospital, Lakewood, Obio.
RIMARY retroperitoneal
tumors, defined as which arise independentIy in the retroperitonea1 space and have no apparent connection with any adult structure save by areoIar tissue, are of reIativeIy infrequent occurrence, aIthough not extremeIy rare. Because of their situation, size, shape and other characteristics, these tumors are sometimes treated by the genera1 or genitourinary surgeon and at other times by the gynecoIogist. They are often overIooked in the differentia1 diagnosis and hence may be recognized onIy at the time of
P those
FIG. I. Intravenous pyeIogram showing outIine of retroperitoneal cyst on left, sIight media1 dispIacement of left ureter and bIadder deformity due to fibromyomas of uterus.
Cyst
M.D., AND
operation. There are occasions when the surgica1 approach might have been improved if the true nature of the Iesion had been recognized beforehand. During the past year an unusua1 case of retroper?toneaI cyst, histoIogicaIIy of pseudomutinous type, was observed. A search of avaiIabIe hospitai records and a review of the literature did not revea1 a case histoIogicaIIy simiIar to the foIlowing. CASE REPORT A forty-seven year oId woman, admitted to Lakewood HospitaI on JuIy 2 I, 1957, had had excessive and irregular vagina1 bleeding for the past six months and was suffering from weakness and discomfort in the lower abdomen. For the past two years the patient had noted swelhng in the Iower abdomen, which had graduahy increased. She had occasiona cramps, which Iasted for two or three days, but there had been no pain or tenderness. Her appetite had remained good, but occasionahy she was constipated. There were no compIaints referabIe to the urinary tract. Her Iast menstrua1 period had occurred one week before admission. PhysicaI examination reveaIed that the heart and lungs were normaI. The blood pressure was 150/80 mm. Hg. PaIpation of the abdomen showed a mass in the Ieft abdomen and flank, and two peIvic masses. The peIvic masses were hard, rounded and smooth. The Ieft abdomina1 mass was soft and indefinite. On vaginal examination the peIvic masses were felt. The clinical impression was that of uterine hbromyomas and left retroperitonea1 mass. RoentgenoIogic studies, incIuding intravenous pyeIography, showed a Iarge peIvic mass consistent with a diagnosis of uterine tibromyomas and another Iarge mass situated in the Iumbar area on the left side. (Fig. I .) This was suggestive of peritonea1 cyst or ectopic spleen. The bIood count showed 10.5 gm. per cent erythrocytes and 6,350 hemoglobin, 3,8 I 0,000 Ieukocytes. Microscopic examination of the urine
Pseudomucinous
Cyst Cystic growths are not so common as s&l retroperitonea1 tumors. MeIicow [2] found ten cysts in 162 cases, and Pack and Tahah [j] found five (one a teratoma) in 120 cases. In his cIassic articIe on retroperitonea1 cysts, HancIfieid-Jones [4] in 1924 asserted that they were formed from urogenital remnants. He classified them as follows: (I) urogenital, including
showed 40 white and 15 red cells per high power held, with a few epitheIia1 ceIIs. Chemical constituents in the blood were normal. CervicaI biopsy showed chronic cervicitis, and uterine curettage showed secretory endometrium. At operation on JuIy 30, 1957, a Iarge uterus, containing multipIe fibromyomas and a Iarge peduncuIated fibromyoma, and a Iarge retroperitoneal cyst were removed. The cyst was found in the retroperitonea1 space, directIy posterior to the descending coIon and its mesentery. The superior poIe of the cyst was overIying the inferior pole of the Ieft kidney. The inferior poIe of the cyst extended to the Ieft iliac fossa. The cyst was removed by incising the peritoneum aIong the Ieft gutter, relIecting the left coIon and its mesentery from the anterior surface of the cyst. The cyst was then shelled out, tinding no attachment to any of the surrounding structures. The uterus weighed 714 gm. and measured 12 by 0.5 IQ- 7 cm. The attached peduncuIated fibromyoma measured 12 by IO by 7 cm. The cyst weighed 470 gm. and measured 14 by I I by 8 cm. Its surface was mostIy smooth, with a few fibrous tags attached. On section the cyst contained clear, slightly viscid fluid. The waI1 was of the membranous type; its Iining was generaIIy smooth but some trabecuIations were present. No secondary cysts wc’rc noted. HistoIogic examination showed that the cyst was lined by taI1 columnar epithelium, with paIe cytoplasm and small nucIei basaIIy Iocated in the cells, similar to that seen in a pseudomucinous cystadenoma of the ovary. There was no significant ceIIuIar proliferation nor actual gIand formation. NucIear pleomorphism and infiItration were absent. A mucin stain was negative. The remainder of the wall consisted of connective tissue. The patient’s postoperative course was uneventful and she was discharged from the hospita1 on August I o, 1957. Further examination one year later showed her to be symptom-free and her gcnvral condition was excelIent.
pronephric, mesonephric, metanephric and mtilIerian; (2) mesocolic, formed from pockets of peritoneum Ieft between opposite serous surfaces of the mesentery and parietaI peritoneum, and necessarily within the f,oundnries of the coIon; (3) dermoid, from imperfect closure of the abdominal pIates; (4) Iymphatic or chvlous,
from deveIopmenta1 or obstructive phenomena of the retroperitoneal and mesenteric Iymphatits, Iined f1.y fibrous tissue or endothcliun~; (3) traumatic; and (6) parasitic. Handfield-Jones described cysts of urogenital origin as bluish, thin-walled and rather fIabb>-, and never tense. When they are removed they are translucent and lose their bluish tinge. There are no visible vessels in their walls. Higgins and Llo?-d [.F] noted that complications of mesenteric cysts, peritonitis, such as intestina1 obstruction, hemorrhage, rupture, torsion and impaction in the pelvis, arc rare with respect to retroperitonea1 cysts. The treatment of retroperitoneal c>-sts is surgica1 excision. hlicroscopicaIIy, the cyst is lined with cuboidal, flattened or coIumnar epithelium, and contains serous, chyIous or other material, according to its type. Dermoid cysts ma)- be suspected during x-ray examination if a caIcified shadow is seen. These cysts may contain hair, sebaceous materiaI and other ectoderma1 derivatives. Various types of cysts have been reported by Landes and Ransom [fi], Nichols [;I and others.
COMMENTS SUMMARY
The higher
incidence of retroperitonea1 cysts in females than in maIes is probabIy due to retention of more woIfhan body remnants in
A case of an unusual histoIogica1 retroperitonea1 type of cyst is presented. The ciassification of retroperitonea1 cysts, with their surgica1 treatment, is discussed.
the female. In the maIe the mtiIIerian ducts usuaIIy degenerate and disappear, whereas in the femaIe they form the genital organs, with the exception of the ovaries. Remnants of this tissue couId give rise to formation of cystic tumors in the maIe. LIoyd and Bonnett [I] suggested that these cysts are formed from mesoderma1 rests.
REFERENCES
I. LLOYD, F. A. and RONNETT, D. MiilIerian ttuct cysts. J. Ural., 64: 777-782, 1950. 2. MELICOW, M. M. Primary tumors of retroperi751
KaIani, Kapp and Eitzen toneum: clinicopathoIogic anaIysis of 162 cases; reveiw of Iiterature and tables of cIass&cation. J. Znternat. Coil. Surgeons, 19: 401-449, 1953. 3. PACK, G. T. and TABAH, E. J. CoIIective review; primary retroperitonea1 tumors; study of IZO cases. Znternat. Abstr. Surg., 99: 209-231, 313-341, 1954. 4. HANDFIELD-JONES, R.
M.
RetroperitoneaI
cysts,
their pathology, diagnosis and treatment. Brit. J. SW&, 12: 119-134. 1924. 5. HIGGINS, T. T. and LLOYD, E. T. Mesenteric cysts. Brit. J. SUrg., 12: 95-105, 1924. 6. LANDES, R. R. and RANSOM, C. L. MiiIIerian duct cysts. J. Ural., 61: 1088-1093, 1949. 7. NICHOLS, H. M. RetroperitoneaI cysts. Ann. Surg., 126: 340-349. 1947.
752
Retroperitoneal
Pseudomucinous
HARJIWAN L. KALANI, M.D., Detroit, Michigan, ROBERT W. KAPP, OLIVER EITZEN, M.D., Lakewood, Ohio
From tbe Departments of General Surgery and Pathology, Lakewood City Hospital, Lakewood, Obio.
RIMARY retroperitoneal
tumors, defined as which arise independentIy in the retroperitonea1 space and have no apparent connection with any adult structure save by areoIar tissue, are of reIativeIy infrequent occurrence, aIthough not extremeIy rare. Because of their situation, size, shape and other characteristics, these tumors are sometimes treated by the genera1 or genitourinary surgeon and at other times by the gynecoIogist. They are often overIooked in the differentia1 diagnosis and hence may be recognized onIy at the time of
P those
FIG. I. Intravenous pyeIogram showing outIine of retroperitoneal cyst on left, sIight media1 dispIacement of left ureter and bIadder deformity due to fibromyomas of uterus.
Cyst
M.D., AND
operation. There are occasions when the surgica1 approach might have been improved if the true nature of the Iesion had been recognized beforehand. During the past year an unusua1 case of retroper?toneaI cyst, histoIogicaIIy of pseudomutinous type, was observed. A search of avaiIabIe hospitai records and a review of the literature did not revea1 a case histoIogicaIIy simiIar to the foIlowing. CASE REPORT A forty-seven year oId woman, admitted to Lakewood HospitaI on JuIy 2 I, 1957, had had excessive and irregular vagina1 bleeding for the past six months and was suffering from weakness and discomfort in the lower abdomen. For the past two years the patient had noted swelhng in the Iower abdomen, which had graduahy increased. She had occasiona cramps, which Iasted for two or three days, but there had been no pain or tenderness. Her appetite had remained good, but occasionahy she was constipated. There were no compIaints referabIe to the urinary tract. Her Iast menstrua1 period had occurred one week before admission. PhysicaI examination reveaIed that the heart and lungs were normaI. The blood pressure was 150/80 mm. Hg. PaIpation of the abdomen showed a mass in the Ieft abdomen and flank, and two peIvic masses. The peIvic masses were hard, rounded and smooth. The Ieft abdomina1 mass was soft and indefinite. On vaginal examination the peIvic masses were felt. The clinical impression was that of uterine hbromyomas and left retroperitonea1 mass. RoentgenoIogic studies, incIuding intravenous pyeIography, showed a Iarge peIvic mass consistent with a diagnosis of uterine tibromyomas and another Iarge mass situated in the Iumbar area on the left side. (Fig. I .) This was suggestive of peritonea1 cyst or ectopic spleen. The bIood count showed 10.5 gm. per cent erythrocytes and 6,350 hemoglobin, 3,8 I 0,000 Ieukocytes. Microscopic examination of the urine
Pseudomucinous
Cyst Cystic growths are not so common as s&l retroperitonea1 tumors. MeIicow [2] found ten cysts in 162 cases, and Pack and Tahah [j] found five (one a teratoma) in 120 cases. In his cIassic articIe on retroperitonea1 cysts, HancIfieid-Jones [4] in 1924 asserted that they were formed from urogenital remnants. He classified them as follows: (I) urogenital, including
showed 40 white and 15 red cells per high power held, with a few epitheIia1 ceIIs. Chemical constituents in the blood were normal. CervicaI biopsy showed chronic cervicitis, and uterine curettage showed secretory endometrium. At operation on JuIy 30, 1957, a Iarge uterus, containing multipIe fibromyomas and a Iarge peduncuIated fibromyoma, and a Iarge retroperitoneal cyst were removed. The cyst was found in the retroperitonea1 space, directIy posterior to the descending coIon and its mesentery. The superior poIe of the cyst was overIying the inferior pole of the Ieft kidney. The inferior poIe of the cyst extended to the Ieft iliac fossa. The cyst was removed by incising the peritoneum aIong the Ieft gutter, relIecting the left coIon and its mesentery from the anterior surface of the cyst. The cyst was then shelled out, tinding no attachment to any of the surrounding structures. The uterus weighed 714 gm. and measured 12 by 0.5 IQ- 7 cm. The attached peduncuIated fibromyoma measured 12 by IO by 7 cm. The cyst weighed 470 gm. and measured 14 by I I by 8 cm. Its surface was mostIy smooth, with a few fibrous tags attached. On section the cyst contained clear, slightly viscid fluid. The waI1 was of the membranous type; its Iining was generaIIy smooth but some trabecuIations were present. No secondary cysts wc’rc noted. HistoIogic examination showed that the cyst was lined by taI1 columnar epithelium, with paIe cytoplasm and small nucIei basaIIy Iocated in the cells, similar to that seen in a pseudomucinous cystadenoma of the ovary. There was no significant ceIIuIar proliferation nor actual gIand formation. NucIear pleomorphism and infiItration were absent. A mucin stain was negative. The remainder of the wall consisted of connective tissue. The patient’s postoperative course was uneventful and she was discharged from the hospita1 on August I o, 1957. Further examination one year later showed her to be symptom-free and her gcnvral condition was excelIent.
pronephric, mesonephric, metanephric and mtilIerian; (2) mesocolic, formed from pockets of peritoneum Ieft between opposite serous surfaces of the mesentery and parietaI peritoneum, and necessarily within the f,oundnries of the coIon; (3) dermoid, from imperfect closure of the abdominal pIates; (4) Iymphatic or chvlous,
from deveIopmenta1 or obstructive phenomena of the retroperitoneal and mesenteric Iymphatits, Iined f1.y fibrous tissue or endothcliun~; (3) traumatic; and (6) parasitic. Handfield-Jones described cysts of urogenital origin as bluish, thin-walled and rather fIabb>-, and never tense. When they are removed they are translucent and lose their bluish tinge. There are no visible vessels in their walls. Higgins and Llo?-d [.F] noted that complications of mesenteric cysts, peritonitis, such as intestina1 obstruction, hemorrhage, rupture, torsion and impaction in the pelvis, arc rare with respect to retroperitonea1 cysts. The treatment of retroperitoneal c>-sts is surgica1 excision. hlicroscopicaIIy, the cyst is lined with cuboidal, flattened or coIumnar epithelium, and contains serous, chyIous or other material, according to its type. Dermoid cysts ma)- be suspected during x-ray examination if a caIcified shadow is seen. These cysts may contain hair, sebaceous materiaI and other ectoderma1 derivatives. Various types of cysts have been reported by Landes and Ransom [fi], Nichols [;I and others.
COMMENTS SUMMARY
The higher
incidence of retroperitonea1 cysts in females than in maIes is probabIy due to retention of more woIfhan body remnants in
A case of an unusual histoIogica1 retroperitonea1 type of cyst is presented. The ciassification of retroperitonea1 cysts, with their surgica1 treatment, is discussed.
the female. In the maIe the mtiIIerian ducts usuaIIy degenerate and disappear, whereas in the femaIe they form the genital organs, with the exception of the ovaries. Remnants of this tissue couId give rise to formation of cystic tumors in the maIe. LIoyd and Bonnett [I] suggested that these cysts are formed from mesoderma1 rests.
REFERENCES
I. LLOYD, F. A. and RONNETT, D. MiilIerian ttuct cysts. J. Ural., 64: 777-782, 1950. 2. MELICOW, M. M. Primary tumors of retroperi751
KaIani, Kapp and Eitzen toneum: clinicopathoIogic anaIysis of 162 cases; reveiw of Iiterature and tables of cIass&cation. J. Znternat. Coil. Surgeons, 19: 401-449, 1953. 3. PACK, G. T. and TABAH, E. J. CoIIective review; primary retroperitonea1 tumors; study of IZO cases. Znternat. Abstr. Surg., 99: 209-231, 313-341, 1954. 4. HANDFIELD-JONES, R.
M.
RetroperitoneaI
cysts,
their pathology, diagnosis and treatment. Brit. J. SW&, 12: 119-134. 1924. 5. HIGGINS, T. T. and LLOYD, E. T. Mesenteric cysts. Brit. J. SUrg., 12: 95-105, 1924. 6. LANDES, R. R. and RANSOM, C. L. MiiIIerian duct cysts. J. Ural., 61: 1088-1093, 1949. 7. NICHOLS, H. M. RetroperitoneaI cysts. Ann. Surg., 126: 340-349. 1947.
752