Case report 133. Hemophilic pseudotumor of ilium and soft tissues

Surgical treatment of the haemophilic pseudotumour: a single centre experience

PURPOSE

Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.

METHODS

We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.

RESULTS

The mean age at surgery was 45.9 (range, 40-61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4-24) years, normal healing with no recurrence was observed.

CONCLUSIONS

The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.

Iliopsoas hemophilic pseudotumor with bowel fistulization

Haemophiliac pseudotumors are usually observed in the diaphysis of long bones. Pseudotumors due to psoas muscle hematoma are rare and surgical management is difficult. Surgical treatment of these lesions is usually associated with high morbidity and mortality rate. Here, we present a case with iliopsoas haemophiliac pseudotumors with bowel fistulization who underwent three abdominal operations and survived. Based on our experiences in this patient, we recommend to wait for the intraabdominal hematoma and adhesions to resolve and organise, so that the dissection can be kept to a minimum, which decreases the chances of iatrogenic injury and surgical bleeding (Fig. 3, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Hemophilic pseudotumor: multicenter experience over a 25-year period

Pseudotumor is an infrequent manifestation of bleeding diathesis seen in hemophiliacs, the management of which is still controversial. To ascertain the effectiveness of the main therapies of choice, we have reviewed 1,831 patients affected by hemophilias A (1,108) and B (172), von Willebrand's disease (329), and other miscellaneous coagulopathies (222) diagnosed between 1965 and 1990 in a multicentric, retrospective study. Pseudotumor was proven in 21 patients. Replacement therapy was given in 15 cases as the first therapeutic approach, with complete success attained in only two, whereas surgery, which was carried out in 14 patients, completely resolved the process in eight (P = 0.017). Patients over 40 years of age demonstrated worse prognosis than younger patients (P = 0.02), but no other clinical parameters were shown to have influenced the patients' evolution. Surgical management was the most effective treatment for pseudotumor, although more conservative therapies cannot be overlooked in selected cases.

Computed tomography and ultrasonography of the hemophilic pseudotumor and their use in surgical planning

Twenty-one hemophilic pseudotumors in 17 patients were evaluated radiologically to facilitate surgical planning. Plain radiography, angiography, intravenous urography, computerized tomography (CT), and ultrasonography (U/S) were the modalities used. CT proved to be the most efficient method in the detection of bone destruction and soft tissue lesions including additional daughter cysts. The combination of CT, intravenous urography, and angiography were used in pelvic pseudotumors, and that of CT and angiography for extremity pseudotumors, to determine the proper surgical approaches to the lesions. As a non-ionizing technique, U/S was usually preferable in visualizing soft tissue masses and, in sequential studies, to evaluate progress or recurrence of the lesion.

Haemophilic pseudotumours of the mandible: report of a case in a one-year-old child

Pseudotumours of bone are an uncommon complication of severe haemophilia and only seven cases occurring in the mandible have been reported previously in the English literature. If treated early the condition appears to have a better prognosis and so it should be included in the differential diagnosis of any slowly progressive swelling of hard and soft tissues occurring in a patient with severe haemophilia. However aspiration and biopsy should be avoided if possible. Previous authors have advocated a variety of invasive procedures for this condition. A further case is described which is unique in the age at which the bilateral lesions developed, in the successful outcome of conservative management and in the dental observations.

Computed tomography in hemophilic pseudotumor

Computed tomography was used in 4 cases of hemophilic pseudotumor. Three of the patients were operated upon. The method proved to make the differential diagnosis safe and to yield valuable information on the extent of the lesion and the involvement of the skeleton and contiguous organs. The information facilitated the decision whether surgery was indicated and the planning of the operation as well as the follow-up of the conservatively treated case.