Retrovesical liposarcoma

RETROVESICAL

LIPOSARCOMA*

MAJ. M . SHELDON POLSKY, USA (MC) MAJ. JACK H . VITENSON, USAF (MC) MAJ. JAMES M . WILSON, USAF (MC) COL. DAVID M . WOODHEAD, USAF (MC)t LT. COL. CARL H . WEBER, USAF (MC) From the Urology Service, Department of Surgery, Wilford Hall USAF Medical Center, Lackland AFB (San Antonio), Texas

ABSTRACT-The second reported case of retrovesical liposarcoma is described in a thirty-five-yearold man with a three-year history of obstructive urinary symptoms . The mass was removed surgically and histologically was found to be myxoid liposarcoma . Adjunctive Cobalt-60 irradiation therapy was given postoperatively, and the patient is without apparent recurrence at one year . Liposarcoma, ass related to the retroperitoneal space, is briefly discussed .

Although the retroperitoneal space is involved in 12 to 19 per cent of liposarcomas, involvement of the retrovesical area has previously been reported but once .' -' A case of retrovesical liposarcoma is presented . Case Report A thirty-five-year-old Caucasian male patient was referred to the urology clinic at Tachikawa Air Base Hospital on April 4, 1972, because of difficulty with urination and an "enlarged prostate" found on examination by the dispensary physicians . The patient complained of frequent, small-volume urinations associated with severe straining, often requiring him to sit or squat to void . Over the preceding three years, his obstructive symptoms had gradually progressed . Ile reported no weight loss nor change in bowel habits . A pelvic mass was palpated, and he was referred to Wilford Hall USAF Medical Center . Physical examination disclosed a healthyappearing man . A firm hypogastric mass extending 11 cm . above the pubis was present . The bladder was palpated superiorly and somewhat *The views expressed herein are those of the authors and do not necessarily reflect the views of the U .S . Air Force, Army, or Deputrneni of Defense . t Deceased,

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to the right of the mass . Rectal examination re vealed a fixed, nontender, smooth, rubbery mash located in the area of the prostate gland . A noirnial prostate could not be felt . Results of urine analysis, urine culture, coin-' plete blood count, blood urea nitrogen, serum' creatinine and electrolytes, liver function studies,' bromsulphthalein, liver scan, and chest roeritgenogram were all normal . Excretory urogrant revealed normal upper tracts with the distal right ureter medially displaced and draped over a pelvic mass. The bladder was elevated out oftht pelvis and displaced anteriorly (Fig . LA) . Vo 4ing cystourethrogram demonstrated a markedly) distorted proximal urethra and bladder base f which was also superiorly displaced and cou'S pressed by an extrinsic mass (Fig . 1B) . Bariti enema showed the mass to be extrinsic to rectu"s and sigmoid colon . Lateral displacement of boilW iliac arteries and no evidence of tumor vesseib were seen on pelvic arteriography . Due to distortion and lengthening of thel) mal urethra, the vesical neck and bladder co not be visualized on attempted panendose despite general anesthesia . Transrectal V Silverman needle biopsy of the mass encoun a fibrous outer shell with a fatty core . histologic diagnosis was benign fibrous tisskl Bimanual examination showed that the nra`,>

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(A) Preoperative intravenous pyelograrn showing bladder elevated out of pelvis and displaced Iteriorly, and (B) voiding cystourethrograin showing markedly distorted proximal urethra and bladder base . ,: :. (C) Postoperative intravenous pyelogramm and (D) voiding cystourethrogram demonstrating normal findings .

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extended to both pelvic walls and appeared to be fixed inferiorly . On May 2, 1972, through a hypogastric midline incision, a 15 by 14 cm . encapsulated mass was found posterior and inferior to the bladder. There were adhesions to the posterior bladder wall, prostate, urethra, and pubis, and these were easily freed by blunt and sharp dissection . The final pathologic diagnosis, confirmed by the Armed Forces Institute of Pathology, was well-differentiated myxoid liposarcoma . This prompted institution of Cobalt-60 radiation therapy on May 24, 1972 . Five thousand rads tumor dose was delivered to the entire pelvis over a thirty-six-day period and was well tolerated by the patient, He was reevaluated one year postoperatively and was found to be free of turner recurrence and voiding well . Results of repeat intravenous pyelogram, voiding cystourethrogram, cystoscopy, and sigmoidoscopy were within normal limits (Figs . 1C and D) .

sites, whereas the more well-differentiated liposarcomas are more likely to be locally infiltrativ e. Survival figures also appear to be related to the site of origin of the tumor, that is, liposarcomas arising in other sites of the body have a more favorable prognosis than retroperitoneal tumors .^" Although surgical removal of the tumor is the treatment of choice, it appears that irradiation therapy has a definite place in the treatment of these tumors," ,8 with combined pre- and postoperative irradiation yet to be evaluated. Effective palliative treatment of m etastatic 1 ip o sarcoma utilizing chemotherapy has been reported in a few instances 9 .10 Lackland Air Force Base, Texas 78236 (DR_ WEBER)

References

Comment Liposarcoma, although rare, has an apparent affinity for developing in urologic areas, especially scrotal, inguinal, and perirenal retroperitoneil ."' 7 Although the classification of malignant adi'7 Enzinger and varied,'-a pose tissue tumors is •4 Winslow' have described well-differentiated adult, myxoid, round-cell, and pleomorphic types which appear to relate well to the prognosis . Thus, in their series, the more benign myxoid and well-differentiated adult liposarcomas had an average five- and ten-year survival rate of 76 and 42 per cent, respectively, whereas the pleomorphic and round-cell varieties had only a 20 and 2 per cent survival for similar time periods . The relationship of survival to tumor type has been noted by other reporters 4,1 presumably related to the propensity of the poorly differentiated tumors to metastasize to distant

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I . STOUT, A . P . : liposarcoma, the malignant tumor of lipoblasts, Ann . . Snrg . 119 : 86 (1944) . 2. PACK, G . T., and SoN, J . C . : Iiposarcoma, a study of 105 cases, Surgery 36 : 687 (1954) . 3. ENTERLINE, H . T., CULBERSON, J . D., ROCHLIN. D . B., and BRADY, L . W . : Liposarcm,lniadpthosc logic study of 53 cases, Cancer, 13 : 932 (1960) . 4. Des CupTA, T . K . : Tumors andd tumor-like conditions of the adipose tissue . Curr . Probl . Snrg. 7: 1-60 (1970) . . 3 . SPITTLE, M. F ., NEWTON, K . A ., and MACKFNZW, D . H.: : Liposarcoma, a review of 60 cases, Br . J . Cancer 24 : 696 (1970) . 6 . EnsoN, M ., FRTEDMAN, J ., and RICIL9RUSON, J . Fa Perivesical liposarcoma, a case report, J . Urol . 85: 767 (1961) . 7 . ENZINcFn, F . M ., and WINSLOw, D . J .: Liposarcoma, a study of 103 cases, Virehows Arch . Pathol . Anat . 33a:

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367 (1962) . 8 . DEWEERU, J . H . . and DOCKERTY, NI . B . : Lipomatou3 retroperitoneal tumors, Ain. J . Surg . 84 : 397 (1952). 9 . MOLANDER, D. W . : Palliative treatment of metastatie tumors of soft somatic tissues with irradiation and chemotherapy, Am. J . Roentgenol . 96 : 150 (1966) . 10 . JAMES, D . H ., JOHNSON, W. W ., and. WRENN, E . Effective chemotherapy of an abdominal liposarcoma,J' Pediat. 68 : 311 (1966) .

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