[Mini-invasive interventions under magnetic resonance guidance in the clarifying diagnosis of small pelvic tumors]

OBJECTIVE

To perfect and estimate the possibilities of using a mini-invasive diagnostic procedure under magnetic resonance (MR) guidance in the complex anatomic situations in cases of pathological small pelvic changes of unknown origin.

MATERIAL AND METHODS

Ten small pelvic interventions were made under MR guidance. The indications for bone biopsy under MR guidance were poor visualization of bone changes or their absence during radiography, including computed tomography. Small pelvic organ and soft tissue biopsies were carried out in the situations of complex location of pathological changes adjacent to critical organs, large vascular and neural structures. All interventions were done using a high-field MR scanner. Freehand biopsy was performed in a stepwise fashion under axial and sagittal T2-weighted image control.

RESULTS

Informative histological material was obtained in 100% of cases. No complications were observed.

CONCLUSIONS

It became possible to verify the diagnosis based on morphological findings and to timely determine management tactics only by target biopsy under MR guidance in these 10 patients with small pelvic changes of unknown origin.

Tubal and ovarian pathways to pelvic epithelial cancer: a pathological perspective

Prolongation of ovarian epithelial cancer survival depends on early detection or improved responses to chemotherapy. Gains in either have been modest at best. Understanding the diverse pathogenesis of this disease is critical to early intervention or prevention. This review addresses six important variables, including (i) cell of origin, (ii) site of origin, (iii) initial genotoxic events, (iv) risks imposed by hereditary and other promoting conditions, (v) subsequent factors that promote different patterns of metastatic spread, and (vi) prospects for intervention. This review proposes two distinct pathways to pelvic epithelial cancer. The first initiates in ovarian surface epithelium (OSE), Mullerian inclusions or endometriosis in the ovary. The second arises from the endosalpinx and encompasses a subset of serous carcinomas. The serous carcinogenic sequence in the distal fallopian tube is described and contrasted with lower grade serous tumors based on tumour location, earliest genetic change and ability (or lack of) to undergo terminal (ciliated) differentiation. Ultimately, a clear understanding of tumour origin and the mechanism(s) leading to the earliest phases of the serous and endometrioid carcinogenic sequences may hold the greatest promise for designing prevention strategies and/or developing new therapies.

Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis?

OBJECTIVES

To determine which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings, and to determine if the use of logistic regression models for calculation of individual risk of malignancy would improve the diagnostic accuracy in difficult tumors.

METHODS

In a prospective, international, European multicenter study involving nine centers, 1066 women with a pelvic mass judged to be of extrauterine origin underwent transvaginal ultrasound examination by an experienced ultrasound examiner before surgery. A standardized examination technique and predefined definitions of ultrasound characteristics were used. On the basis of subjective evaluation of ultrasound findings, the examiner classified each mass as being certainly benign, probably benign, unclassifiable, probably malignant or certainly malignant. Even when the examiner found the mass unclassifiable (i.e. difficult mass) he or she was obliged to state whether the mass was more likely to be benign or malignant. Borderline tumors were classified as malignant.

RESULTS

There were 90 (8%) unclassifiable masses. Multiple logistic regression analysis showed papillary projections, >10 locules in a cyst without solid components, low-level echogenicity of cyst fluid, and moderate vascularization as assessed subjectively at color Doppler examination to be ultrasound variables independently associated with unclassifiable mass. Borderline malignant tumors (n = 55) proved to be most difficult to assess with only 47% being correctly classified (i.e. classified as malignant), 29% being incorrectly classified (i.e. classified as benign) and 24% being unclassifiable vs. 90% of non-borderline tumors being correctly classified, 3% being incorrectly classified and 8% being unclassifiable (P < 0.0001). Papillary cystadeno(fibro)mas, myomas and cases of struma ovarii were also more common among the unclassifiable masses than among the classifiable ones (5.6% vs. 1.1%, P = 0.008; 4.4% vs. 0.9%, P = 0.02; 4.4% vs. 0.2%, P = 0.0006). No ultrasound variable or clinical variable (including CA 125) entered a logistic regression model to predict malignancy in difficult masses. A model could be constructed for difficult masses containing papillary projections but this model performed no better than subjective evaluation of the ultrasound image. Sensitivity and specificity of subjective evaluation with regard to malignancy in the group of unclassifiable masses were 56% (14/25) and 77% (50/65) vs. 91% (220/241) and 97% (712/735) in the classifiable masses.

CONCLUSIONS

Borderline tumors cause great diagnostic difficulties, but so do papillary cystadeno(fibro)mas, struma ovarii and some myomas. Logistic regression models do not solve the diagnostic problem in difficult pelvic masses.

Tumors of the retrorectal space

PURPOSE

Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential.

METHODS

The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis.

RESULTS

Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions.

CONCLUSIONS

Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Presacral tumors: a practical classification and treatment of a unique and heterogeneous group of diseases

BACKGROUND

Presacral tumors are a rare and diverse group of diseases that originate from the different tissues that comprise the potential presacral space. Because of their relative rarity, confusion exists regarding their clinical presentation, natural history, and treatment. The aim of this study is to describe a single institution's experience with the management of presacral tumors and to suggest a practical method of classification.

METHODS

Records of all patients who underwent operation for presacral tumors from the years 1991 to 2001 were reviewed. Clinical, pathologic, treatment, and outcome variables were evaluated.

RESULTS

Forty-two patients were included in the study and were divided into 4 groups according to lesion pathology: benign congenital (n = 12), malignant congenital (n = 9), benign acquired (n = 9), and malignant acquired (n = 12). Symptoms were nonspecific, and 26% of the cases were completely asymptomatic. Diagnosis was made with rectal examination and confirmed with pelvic computerized tomographic scan. Surgical approach varied among the different groups, with the posterior approach used mainly for congenital tumors and the anterior approach for acquired. Complete surgical resection of the tumor was obtained in all cases of benign tumors and in 76% of malignant tumors. No postoperative mortality was seen, and complications occurred in 36% (15/42); most were reversible. None of the patients with benign tumors had recurrences, and all are alive at this time. The survival rate of patients with malignant tumors was significantly improved when complete resection was possible.

CONCLUSION

Classification of presacral tumors into congenital versus acquired and benign versus malignant is simple and efficient. Treatment is complete surgical resection, which can be performed safely with low morbidity and no mortality.

The management of presacral masses in the adult

Presacral (retrorectal) tumors are particularly rare in the adult. There is difficulty in the performance of diagnostic biopsy, and specialized imaging is required to plan surgical extirpation. This review assesses their incidence and classification as well as the principles involved in their diagnosis and surgical management.

MRI of the female and male pelvis: current and future applications of contrast enhancement

Magnetic resonance imaging (MRI) of the pelvis has proven to be a most valuable diagnostic tool to examine pathologies of various organ systems in the pelvis. For most conditions MRI was found to be superior to other imaging modalities, like ultrasound and computed tomography. Controversy still exists on the value of intraluminal and intravenous contrast enhancement. This article gives an overview on currently available intraluminal and intravenous contrast agents. The techniques and results for contrast-enhanced MRI in the female and male pelvis are discussed based on a review of the literature. New developments and upcoming techniques, such as lymph node specific contrast agents and breathhold volumetric MRI, are described and initial results are presented.

Low-grade fibromyxoid sarcoma: clinicopathologic case report with review of the literature

Low-grade fibromyxoid sarcoma is a rare, benign-appearing soft tissue neoplasm with an aggressive clinical course characterized by multiple local recurrences over several years, with ultimate spread to lung and occasionally to bone. Thus far, a total of 24 cases of low-grade fibromyxoid sarcoma have been reported in the literature. The authors present an additional case that grossly and microscopically emphasizes a pronounced lobular pattern of contrasting areas of cellularity showing high proliferative activity, as demonstrated by a proliferation marker, Ki 67 with MIB-1, and hypocellular areas with prominent myxoid component and abundant collagen fibrils. There was predominance of delicate capillary-sized stromal vessels with collagenized walls in both cellular and myxoid areas. The unusual features in this case were osseous metaplasia, prominent intranuclear pseudoinclusions, DNA tetraploidy, and membrane-bound intracytoplasmic fat vacuoles. The immunoprofile and cytologic and ultrastructural features are described. After the excision of the tumor, the patient was treated with radiotherapy without chemotherapy. The patient has been observed for 26 months and is alive without the evidence of disease. The postoperative follow-up with axial computed tomography at 24 months showed no evidence of disease, except postsurgical fibrotic changes.

Endometrioma: analysis and sonographic classification of 51 documented cases

We analyzed 51 proven cases of endometrioma and characterized the sonographic patterns as purely cystic, cystic with few septations or minimal debris, complex combinations of cystic and solid elements, and largely solid. In this series, 30% were purely cystic, 62% showed various degrees of complexity with septation or debris, and 8% appeared essentially solid. The broad spectrum of patterns is in keeping with the evolutionary process of endometriomas, which follow essentially the same transitions from homogeneous gelatinous (cystic) through partially resolved (liquified) complex and ultimately returning to nearly purely cystic, as do hematomas. The average diameter of endometriotic masses was 6.1 cm (range, 2.0 to 20.0 cm), and the average age of the patients at diagnosis was 31.3 years (range, 15 to 45 years). The diversity of sonographic appearance, the span of essentially all the child-bearing years, and the presence of endometriomas without a history of infertility or dysmenorrhea (and even after hysterectomy) keep this entity a constant differential diagnostic consideration in sonographically identified pelvic masses. We believe this to be the largest documented series of sonographically identified endometriomas in the literature.

Tumors in the lower pelvis as imaged by vaginal sonography

Ultrasound is a sensitive tool for the diagnosis of cystic tumors in the lower pelvis of women. Most knowledge about the ultrasound image of such tumors is based on abdominal scanning. The value of vaginal sonography for evaluation of such tumors has, to the best of our knowledge, so far not been studied. This study was aimed at relating the vaginal sonographic image of tumors in the lower pelvis with the results of macro- and microscopic examination of the tumor. Special interest was paid to establishing ultrasound criteria for classifying unilocular tumors as benign or malignant. One hundred and eighty women who were operated on for pelvic tumors were included in the study. All women were evaluated by vaginal sonography the day before surgery. Ninety-four women were postmenopausal and eighty-six were still menstruating. Vaginal ultrasound characterized the tumor correctly as related to macroscopic examination in 96% (172/180). The sensitivity of vaginal sonography in identifying benign and malignant tumors was 82%, and the specificity, 92%. None of the unilocular tumors was malignant. Papillary formations on the inside of the cyst wall indicated an increased chance of the tumor's being malignant. There was a clear correlation between size of tumor and malignancy except for unilocular tumors. Vaginal sonography was shown to be accurate in characterizing cystic tumors in the lower pelvis. The present results also indicate that the probability that unilocular tumors less than 10 cm in diameter and without papillary formations, are malignant is low, irrespective of the woman's age.

Endometriosis: treatment with gonadotropin-releasing hormone agonist Buserelin

Fifty-one women with pelvic endometriosis were treated with the gonadotropin-releasing hormone agonist (GnRHa) Buserelin (Hoechst Holland N.V., Amsterdam, The Netherlands) 300 micrograms three times a day intranasally for 6 months. Forty-nine women completed treatment; 42 were available for 6 months of follow-up following treatment. Symptoms showed prompt and significant improvement. Follow-up after treatment revealed persistent relief from dysmenorrhea and dyspareunia in, respectively, 58.6% and 88.2% of the women, whereas pelvic pain returned to pretreatment scores. Serum estradiol (E2) was suppressed to predominantly early follicular phase concentrations. Laparoscopy at the end of therapy showed significant reduction of scores for implants only. There was no relation between the degree of E2 suppression during therapy and the improvement of symptoms or the reduction of endometriosis. Statistical analysis in 22 infertile patients, of whom 7 conceived during follow-up, revealed no differences in E2 levels during therapy, improvement of symptoms, or reduction of endometriosis. Buserelin appears to be safe, well tolerated, and effective in the management of endometriosis and associated complaints.