0:00

Here, we have a 44 year old female with past medical

0:03

history of hypertension pre-diabetes and uterine fibroids

0:06

present to a gynecologist for evaluation of syncable episodes

0:09

and menu. Metaraja.

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The patient reports frequent spells of dizziness and fading while

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also noting increased flow and frequency of

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our menstrual periods. So she had a tubal ligation

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of no two years prior after the birth of our

0:24

third child.

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Physical examination is particularly significant for

0:28

a large uterine, Mass. But otherwise she on a

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physical examination is within the limits of normal.

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So what is the next best step in the management of this abnormal uterine

0:38

bleeding?

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Would you say transvaginal ultrasound?

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Perhaps you'd say a pelvic MRI.

0:44

perhaps an endometrial biopsy

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or perhaps an abdominal x-ray

0:50

so if you said a transvaginal ultrasound maybe correct.

0:53

So with the history of fibroids and altered menstrual

0:56

bleeding a transviolent ultrasound will quickly evaluate the

0:59

uterus and it makes it in the office. However, what

1:02

I would say, is that a an MRI would

1:05

actually be particularly appropriate as well in this

1:08

setting.

1:10

So the impression on the initial ultrasound is

1:13

that there's a four centimeter intramural fibroid in

1:16

the anterior body of the uterus.

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There's a 7.6 centimeter lobular hypochoic

1:21

mass in the right upper quadrant. Incidentally noted

1:24

not fully characterized on the

1:27

study.

1:28

So with limitations of the ultrasound the mass is not showed definitely

1:31

relation to surrounding organs.

1:33

So friends, what is the next best step in

1:36

the management of this patient's instantly denoted?

1:39

not abdominal Mass Would You observe

1:42

Would you recommend the patient for pelvic MRI?

1:45

Would you refer the patient to oncology?

1:48

Or would you perform a CT of the abdomen and pelvis?

1:52

If you set a CT of the abdomen in pelvis you correct.

1:56

That the patient's unknown abdominal Mass must be

1:59

for the characterized with some cross-sectional Imaging

2:02

a CT scan is the most appropriate initial

2:05

modality.

2:07

It was opted to perform a CT without IV

2:10

contrast but with it oral contrast.

2:15

What do we see?

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If you noted this structure that's

2:23

rounded in the right lower quadrant, you'd

2:26

be spot on.

2:28

So here we see on the impression a 8.5

2:31

by 6.6 by 4.9 homogeneous

2:34

soft as you mass that is

2:37

lobulated in the right Hemi abdomen. So the

2:40

mass appears to be rooted in the mesentery posteriorly to

2:43

the cecum the appendix as well

2:46

as the distal small ball.

2:47

Now this retro-cecal Mass actually

2:50

likely corresponds to the prior ultrasound finding

2:53

that we partially visualize on that transvaginal ultrasound.

2:58

So what conditions are on the differential diagnosis of this patient's

3:01

retrocecal, Mass?

3:03

Could this be a gastrointestinal stromal tumor?

3:06

Could it be a sarcoma?

3:07

Could it be a lion or could it

3:10

be all of the above?

3:12

Well, the referential diagnosis of the soft tissue

3:15

Mass actually remains wide.

3:18

So biopsy is actually needed for characterization.

3:22

Next steps where do we go from here? So the

3:25

patient is scheduled for an ultrasound guide about see with ir.

3:28

Here we see a still image obtained of

3:31

the needle being Advanced under ultrasound

3:34

guidance into this right Hemi abdominal mass in

3:37

question. In order to perform this the patient was positioned Supine

3:40

and the ultrasound localized

3:43

the masking question relatively easily and

3:46

five corn needle biopsy specimens were obtained

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and submitted informally for

3:52

surgical pathology analysis introducer needle

3:55

removed still dressing was applied

3:58

and the patient was discharge the same day.

4:00

So what is the path report reveal from

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that ultrasound guided perhaps you well, the patient's path

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report revealed. They spindle cell lesion which

4:09

is positive for Desmond and a wild type pattern

4:12

for p53 with low proliferation pattern.

4:15

So what's the likely diagnosis of this Mass? My friends? Is it

4:18

a sarcoma?

4:20

Is it a just a gastrointestinal stromal tumor?

4:23

Is it a parasitic Lima?

4:26

Or is it a carcinoid tumor?

4:28

This actually ended up being a parasitic liamo

4:31

a parasitic lineman or

4:34

parasitic fibroid is actually a pedunculated subserosal

4:37

fibroid that undergoes torsion

4:40

and then ultimately detaches in the abdomen from

4:43

the uterus.

4:44

It sustains its growth interestingly enough

4:47

through neovascularization from adjacent

4:50

tissues. It's almost as if an apple falls from

4:53

the tree and continues to live and ripen on

4:56

the grass as it gains roots from the grass, very

4:59

similar analogy here a fibroid

5:02

falls off from the uterus and then sustains

5:05

its growth from new blood vessel growth

5:08

within this abdomen surrounded by the adjacent tissues.

5:12

So what are our next steps?

5:14

So the patient scheduled for a combined surgical operation in

5:17

which general surgery performs for section of the

5:20

retrocecal mass.

5:22

And then the gynecologic surgeon performs prophylactic total

5:25

hysterectomy.

5:27

An additional momental mass that was then resected during

5:30

the procedure as well. And in order to prevent urital

5:33

injury from occurring.

5:36

Inadvertently you read old stands

5:39

replaced retrograde, why are Urology colleagues as

5:42

a precautionary measure in order to ensure that the tumor was

5:45

recognized and removed and there was no consequence to

5:49

the urinary tract. I either ureters and that's particularly

5:52

important given the ratchet perennial extension from the messengering. The

5:55

operation was performed without complications and

5:58

the patient was discharged the next day.

6:01

So in conclusion, the surgical specimens

6:04

are compared to the biopsy samples from the percutaneous iron

6:07

guided biopsy both the Retro Sequel

6:10

and a mental samples confirm.

6:12

Hormonally influence extra uterine

6:15

liamoada a parasitic

6:18

fibroid was exactly what was found.

6:21

The patient is reassured.

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But scheduled for follow-up Imaging in three and six month

6:26

intervals given the significant potential for extra uterine fibroid recurrence.