- Email: [email protected]
Retained Myoma Fragment After LASH Procedure
777
CASE REPORT
REFERENCES 1 France CJ, O'Connell JP. Osseous metaplasia in the human mammary gland. Arch Surg 1970;100:238±239. 2 Gonzalez-Licea A, Yardley JH, Hartman WH. Malignant tumor of the breast with bone formation. Cancer 1967;20:1234±1247. 3 Hou MF, Chai CY, Huang TJ, Lin HJ. Metaplastic ossi®cation in the breast ± a case report. Kaohsiung J Med Sci 1995;11: 239±242. 4 Jernstrom P, Lindberg AL, Meland ON. Osteogenic sarcoma of the mammary gland. Am J Clin Path 1963;40:521±526. 5 Mayers MM, Evans P, MacVicar D. Case report: ossifying ®bromatosis of the breast. Clin Radiol 1994;49:211±212.
6 Smith BH, Taylor HB. The occurrence of bone and cartilage in mammary tumors. Am J Clin Pathol 1969;51:610±618. 7 Spagnolo DV, Shilkin KB. Breast neoplasms containing bone and cartilage. Virchows Arch A Pathol Anat 1983;400:287±295. 8 Zung A, Herzenberg JE, Chalew SA. Radiological case of the month. Ectopic ossi®cation and calci®cation in pseudohypoparathyrodism and pseudohypoparathyrodism. Arch Pediatr Adolesc Med 1996;150:643±644. 9 Yokoo H, Nakazato Y. Primary localized amyloid tumor of the breast with osseous metaplasia. Pathol Int 1998;48:545±548. 10 Lynch LA, Moriarty AT. Localized primary amyloid tumor associated with osseous metaplasia presenting as bilateral breast masses. Diagn Cytopathol 1993;9:570±575.
doi:10.1053/crad.1999.0288, available online at http://www.idealibrary.com on
Retained Myoma Fragment After LASH Procedure RO B E R T L . WO R T H I N G TO N - K I R S C H *, F R A N C I S L . H U TC H I N S , J R { *Interventional Radiology, Delaware Valley Imaging Ltd, Bala Cynwyd, and {Hutchins Institute for Women's Health, Bala Cynwyd, Pennsylvania, U.S.A.
CASE REPORT A 42-year-old woman presented to the gynaecologist with complaints of menorrhagia and dysmenorrhoea. Ultrasound examination revealed an enlarged uterus (14.2 8.5 7.8 cm) with a dominant fundal ®broid measuring 9.3 8.2 6.4 cm. The patient elected to have a laparoscopically assisted supracervical hysterectomy (LASH procedure). During this procedure the uterine corpus is removed through a laparoscopy port after being cut into fragments within the peritoneal cavity (morcellation). The procedure was performed without incident and the patient was discharged within 24 h. On post-surgery day 30 the patient complained of several days of increasing right abdominal pain. Ultrasound revealed a hypoechoic mass or collection with increased through sound transmission in the right peri-umbilical area. The patient was admitted to the hospital with a presumptive diagnosis of intra-abdominal haematoma or abscess associated with the peri-umbilical port site. Ultrasound-guided drainage was requested. At ultrasound a trans-sonic collection (approximately 7 5 3 cm) with good through sound transmission and with homogeneous low level internal echogenicity was demonstrated at the area of tenderness (Fig. 1a). Needle aspiration of the collection was attempted with an 18G thin-wall arteriography needle, but no ¯uid could be aspirated. Computed tomography examination showed a mass / collection in the peritoneal cavity measuring approximately 6 cm in diameter. The lesion was similar to bile in attenuation and showed no enhancement (Fig. 1b). Both the ultrasound and CT examinations showed a very small amount of free ¯uid surrounding the lesion. There was no safe Author for correspondence and guarantor: Robert L. WorthingtonKirsch, M.D. Section Head ± Interventional Radiology, Delaware Valley Imaging, Ltd, 301 City Avenue, Suite G1 Bala Cynwyd, PA 19004, U.S.A. Fax: 1 610 617 9252; E-mail: [email protected]
percutaneous path to the lesion by CT, as it was bordered on all sides by either bowel or the gall-bladder. Surgical consultation was then obtained and the patient underwent exploratory laparotomy. At surgery, a mass measuring 5.0 4.7 4.1 cm (Fig. 1c) was found in the right mid-abdomen. It was adjacent to the gall-bladder, small bowel, ascending colon and omentum, but was not adherent to any of these structures. Pathology con®rmed that this was a fragment of infarcted of leiomyoma. The patient had an uneventful recovery and was discharged on post-laparotomy day 4. She has remained well since that time.
DISCUSSION
As laparoscopically guided procedures for uterine surgery are introduced and become popular, the possibility arises for new complications to occur. Two of these new procedures are laparoscopic myomectomy and laparoscopically assisted supracervical hysterectomy (LASH procedure) [1]. In both procedures the tissue to be removed is cut into fragments (morcellated) in the peritoneal cavity, and the morcellated fragments removed through laparoscopy ports. Portions of the morcellated tissue may inadvertently be left behind in the abdominal cavity. While the loss of smaller fragments has been described without clinical sequelae [2], in this case the retained fragment caused symptoms. The clinical aspects of this case have been reported elsewhere [3]. It is important to note that in this case the retained fragment had imaging characteristics at both ultrasound
778
CLINICAL RADIOLOGY
Fig. 1 ± a Transverse ultrasound image just to the right of the umbilicus shows the lesion (*) with a small amount of surrounding ¯uid (arrowhead). Note homogeneous low-level internal echogenicity and good through sound transmission. (b) Image from contrastenhanced CT of the abdomen shows the lesion in the right abdomen (*). Note that the attenuation is similar to that of bile in the gallbladder (gb). In both the ultrasound and CT images there is a small amount of ¯uid surrounding the lesion (arrowheads). (c) Gross specimen of myoma fragment.
and CT that were suggestive of a ¯uid collection ± either an abscess or hematoma. However, the inability to aspirate any ¯uid from the collection, despite the use of a relatively large-bore needle, suggested the solid nature of the lesion. In this case the retained fragment was symptomatic; however, in the future, asymptomatic fragments may be found as incidental ®ndings and could be mistaken for more ominous pathology such as pelvic or abdominal malignancies. With the increase in laparascopic debulking procedures for uterine surgery, the incidence of retained morcellated fragments of myomatous uterus will probably increase. Knowledge of this potential complication and the
associated imaging ®ndings, as well as the clinical history, is essential for the proper diagnosis of these lesions, whether or not patients are symptomatic. REFERENCES 1 Chapron C, Dubuisson JB, Aubert V, et al. Total laparascopic hysterectomy: preliminary results. Hum Reprod 1994;9:2084±2089. 2 Hill DJ, Maher PJ, Wood EC. `Lost surgical specimens'. J Am Assoc Gynecol Laparosc 1997;4:277±279. 3 Hutchins FL, Reinoehl EM. Retained myoma after laparoscopic supracervical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc 1998;5:293±295.
CASE REPORT
REFERENCES 1 France CJ, O'Connell JP. Osseous metaplasia in the human mammary gland. Arch Surg 1970;100:238±239. 2 Gonzalez-Licea A, Yardley JH, Hartman WH. Malignant tumor of the breast with bone formation. Cancer 1967;20:1234±1247. 3 Hou MF, Chai CY, Huang TJ, Lin HJ. Metaplastic ossi®cation in the breast ± a case report. Kaohsiung J Med Sci 1995;11: 239±242. 4 Jernstrom P, Lindberg AL, Meland ON. Osteogenic sarcoma of the mammary gland. Am J Clin Path 1963;40:521±526. 5 Mayers MM, Evans P, MacVicar D. Case report: ossifying ®bromatosis of the breast. Clin Radiol 1994;49:211±212.
6 Smith BH, Taylor HB. The occurrence of bone and cartilage in mammary tumors. Am J Clin Pathol 1969;51:610±618. 7 Spagnolo DV, Shilkin KB. Breast neoplasms containing bone and cartilage. Virchows Arch A Pathol Anat 1983;400:287±295. 8 Zung A, Herzenberg JE, Chalew SA. Radiological case of the month. Ectopic ossi®cation and calci®cation in pseudohypoparathyrodism and pseudohypoparathyrodism. Arch Pediatr Adolesc Med 1996;150:643±644. 9 Yokoo H, Nakazato Y. Primary localized amyloid tumor of the breast with osseous metaplasia. Pathol Int 1998;48:545±548. 10 Lynch LA, Moriarty AT. Localized primary amyloid tumor associated with osseous metaplasia presenting as bilateral breast masses. Diagn Cytopathol 1993;9:570±575.
doi:10.1053/crad.1999.0288, available online at http://www.idealibrary.com on
Retained Myoma Fragment After LASH Procedure RO B E R T L . WO R T H I N G TO N - K I R S C H *, F R A N C I S L . H U TC H I N S , J R { *Interventional Radiology, Delaware Valley Imaging Ltd, Bala Cynwyd, and {Hutchins Institute for Women's Health, Bala Cynwyd, Pennsylvania, U.S.A.
CASE REPORT A 42-year-old woman presented to the gynaecologist with complaints of menorrhagia and dysmenorrhoea. Ultrasound examination revealed an enlarged uterus (14.2 8.5 7.8 cm) with a dominant fundal ®broid measuring 9.3 8.2 6.4 cm. The patient elected to have a laparoscopically assisted supracervical hysterectomy (LASH procedure). During this procedure the uterine corpus is removed through a laparoscopy port after being cut into fragments within the peritoneal cavity (morcellation). The procedure was performed without incident and the patient was discharged within 24 h. On post-surgery day 30 the patient complained of several days of increasing right abdominal pain. Ultrasound revealed a hypoechoic mass or collection with increased through sound transmission in the right peri-umbilical area. The patient was admitted to the hospital with a presumptive diagnosis of intra-abdominal haematoma or abscess associated with the peri-umbilical port site. Ultrasound-guided drainage was requested. At ultrasound a trans-sonic collection (approximately 7 5 3 cm) with good through sound transmission and with homogeneous low level internal echogenicity was demonstrated at the area of tenderness (Fig. 1a). Needle aspiration of the collection was attempted with an 18G thin-wall arteriography needle, but no ¯uid could be aspirated. Computed tomography examination showed a mass / collection in the peritoneal cavity measuring approximately 6 cm in diameter. The lesion was similar to bile in attenuation and showed no enhancement (Fig. 1b). Both the ultrasound and CT examinations showed a very small amount of free ¯uid surrounding the lesion. There was no safe Author for correspondence and guarantor: Robert L. WorthingtonKirsch, M.D. Section Head ± Interventional Radiology, Delaware Valley Imaging, Ltd, 301 City Avenue, Suite G1 Bala Cynwyd, PA 19004, U.S.A. Fax: 1 610 617 9252; E-mail: [email protected]
percutaneous path to the lesion by CT, as it was bordered on all sides by either bowel or the gall-bladder. Surgical consultation was then obtained and the patient underwent exploratory laparotomy. At surgery, a mass measuring 5.0 4.7 4.1 cm (Fig. 1c) was found in the right mid-abdomen. It was adjacent to the gall-bladder, small bowel, ascending colon and omentum, but was not adherent to any of these structures. Pathology con®rmed that this was a fragment of infarcted of leiomyoma. The patient had an uneventful recovery and was discharged on post-laparotomy day 4. She has remained well since that time.
DISCUSSION
As laparoscopically guided procedures for uterine surgery are introduced and become popular, the possibility arises for new complications to occur. Two of these new procedures are laparoscopic myomectomy and laparoscopically assisted supracervical hysterectomy (LASH procedure) [1]. In both procedures the tissue to be removed is cut into fragments (morcellated) in the peritoneal cavity, and the morcellated fragments removed through laparoscopy ports. Portions of the morcellated tissue may inadvertently be left behind in the abdominal cavity. While the loss of smaller fragments has been described without clinical sequelae [2], in this case the retained fragment caused symptoms. The clinical aspects of this case have been reported elsewhere [3]. It is important to note that in this case the retained fragment had imaging characteristics at both ultrasound
778
CLINICAL RADIOLOGY
Fig. 1 ± a Transverse ultrasound image just to the right of the umbilicus shows the lesion (*) with a small amount of surrounding ¯uid (arrowhead). Note homogeneous low-level internal echogenicity and good through sound transmission. (b) Image from contrastenhanced CT of the abdomen shows the lesion in the right abdomen (*). Note that the attenuation is similar to that of bile in the gallbladder (gb). In both the ultrasound and CT images there is a small amount of ¯uid surrounding the lesion (arrowheads). (c) Gross specimen of myoma fragment.
and CT that were suggestive of a ¯uid collection ± either an abscess or hematoma. However, the inability to aspirate any ¯uid from the collection, despite the use of a relatively large-bore needle, suggested the solid nature of the lesion. In this case the retained fragment was symptomatic; however, in the future, asymptomatic fragments may be found as incidental ®ndings and could be mistaken for more ominous pathology such as pelvic or abdominal malignancies. With the increase in laparascopic debulking procedures for uterine surgery, the incidence of retained morcellated fragments of myomatous uterus will probably increase. Knowledge of this potential complication and the
associated imaging ®ndings, as well as the clinical history, is essential for the proper diagnosis of these lesions, whether or not patients are symptomatic. REFERENCES 1 Chapron C, Dubuisson JB, Aubert V, et al. Total laparascopic hysterectomy: preliminary results. Hum Reprod 1994;9:2084±2089. 2 Hill DJ, Maher PJ, Wood EC. `Lost surgical specimens'. J Am Assoc Gynecol Laparosc 1997;4:277±279. 3 Hutchins FL, Reinoehl EM. Retained myoma after laparoscopic supracervical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc 1998;5:293±295.