GYNECOLOCIC
ONCOLOGY
47, 382-384 (1992)
CASE REPORT Hypogastric Artery Aneurysm Masquerading as an Ovarian Neoplasm JOAN L. WALKER, *University of Oklahoma Oklahoma 73190;
M.D.,*,’
ALBERTO
MANETTA,
M.D.,t
AND ROBERT S. MANNEL,
M.D.*
Health Sciences Center, Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, and tlJniversity of California, Irvine Medical Center, Division of Gynecologic Oncology, Department and Gynecqlogy, Orange, California 92668
Oklahoma
City,
of Obstetrics
Received January 16, 1992
Hypogastric artery aneurysmin womenis rare. The casepresenteddemonstrateshow this lesioncan easily mimic an ovarian neoplasm.The misseddiagnosiscan becatastrophicif the surgeon is unfamiliar with the retroperitonealanatomy and is confronted with arterial hemorrhage.Hypogastric artery aneurysmshould beincludedin the differential diagnosisof a pelvic massin elderly womenwith atheroscleroticdisease.The report reviews the literature on the presentation,diagnosis,and recommendedtreatments. 0 1992 Academic F’ms, Inc. INTRODUCTION
The usual differential diagnosis of an adnexal mass in a postmenopausal woman would ordinarily include a primary ovarian neoplasm, diverticular abscess, colon cancer, or a metastatic tumor [l]. This case presents an unusual and life-threatening adnexal mass which to our knowledge has not been previously reported in the gynecologic literature. CASE REPORT
An 82-year-old white female presented with complaints of abdominal swelling. Her gynecologic history included a total abdominal hysterectomy at the age of 38 for benign indications and a retropubic urethral suspension 1 year prior to presentation. Her past medical history was significant for hypertension, two myocardial infarctions, and peptic ulcer disease. She had undergone coronary artery bypass surgery 10 years prior to presentation. 1 To whom correspondence and reprint requests should be addressed at Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, P.O. Box 26901, 4SP-700, Oklahoma City, OK 73190. Fax: 405/271-8547. 382 OG90-825W92 $4.00 Copyright 0 1992 by Academic Press, Inc. AI1 rights of reproduction in any form reserved.
The review of systems was positive for urinary incontinence, but she denied any constipation, diarrhea, hematochezia, or melena. Physical exam demonstrated the previous surgical scars, no evidence of pleural effusion or ascites, and a fixed lo-cm left adnexal mass. Preoperative ultrasound (Fig. 1) and computed tomography (Fig. 2) demonstrateed a well circumscribed lo-cm cystic and solid left adnexal mass consistent with ovarian neoplasm or abscess. Mild left ureteral dilatation was noted and there was a small aneurysmal dilatation of the abdominal aorta between the renal arteries and the aortic bifurcation. A barium enema and upper gastrointestinal series demonstrated a hiatal hernia and small diverticuli in the colon. Exploratory laparotomy was performed and a lo-cm cystic mass was identified under the sigmoid colon filling the pararectal space. The mass was densely adherent to the left pelvic sidewall. The ovaries were normal and atrophic and did not appear to be the etiology of the mass. The retroperitoneal spaces were developed and the left infundibulopelvic ligament and ureter were identified. These structures were dissected free of the mass and the ovarian vessels were ligated and transected superior to the mass above the pelvic brim. The ureter and the external iliac artery and vein were noted to be densely adherent to the mass. In addition, the ureter was noted to be dilated proximal to the mass. Meticulous dissection of the retroperitoneal structures was performed and it was noted that the mass was originating from the common iliac artery where the hypogastric artery ordinarily is found. The mass was determined to be a hypogastric artery aneurysm. The ligation of the vessel at its origin was difficult due to the abundance of atherosclerotic plaque within the lumen causing
CASE
FIG. 1.
REPORT
Pelvic
the vessel to fracture when sutured. All distal branches of the hypogastric artery had to be individually ligated to effect removal of the mass. During the removal of the mass the external iliac vein was lacerated due to the dense adhesions between the aneurysm and the vein, and it was repaired without incident. The operative blood loss in this case was 1600 cc; however, the patient was stable throughout surgery. The pathologic diagnosis confirmed the mass to be a hypogastric artery aneurysm. The patient’s postoperative course was complicated by superficial wound disruption, but was otherwise uneventful. DISCUSSION Hypogastric artery aneurysm has not been included in the differential diagnosis of a pelvic or adnexal mass in the gynecologic literature [l]. The urologic literature describes this condition in association with ureteral obstruction in men, but the condition appears to be rare in women [2]. A review of reports in women is limited to pregnancy complications [3,4] and trauma to the vessel at the time of a radical hysterectomy [5]. Operative intervention in the community by the gynecologist could
383
ultrasound.
be catastrophic if the vascular etiology of the lesion is not appreciated. A report of two cases in elderly men and review of the literature by Perry and Leventhal in 1968 summarized the situation nicely [6]. These lesions are usually atherosclerotic in origin and associated with aneurysms in other systemic arteries. The patient is asymptomatic until pressure occurs on surrounding structures such as bladder, rectum, ureter, or iliac veins. The symptoms reported include pelvic pressure, back pain, leg pain, and numbness. Ureteral obstruction with its associated complications is not uncommon. Many patients (20%) present with rupture and may have life-threatening hypotension. An enlarging pelvic mass with hematochezia has been reported [7]. Approximately half of the masses are pulsatile to palpation. Intralumenal clots may prevent filling of the structure on angiogram and make the diagnosis difficult preoperatively. The presence of calcification in the wall of the aneurysm on X ray may be an important clue preoperatively. Aneurysm was not suspected preoperatively in this case. In retrospect, the patients age, history of coronary artery disease, the small aortic aneurysm, and the presence of calcium in the wall of the mass should
384
WALKER,
FIG.
MANETTA,
AND MANNEL
2. Computed tomography of the pelvis.
have made hypogastric artery aneurysm a possible preoperative diagnosis. The mass was not pulsatile which also failed to alert the clinicians. Silver et al. [7] noted only 3 cases of isolated hypogastric artery aneurysms in a report of 671 patients with systemic aneurysms. In an autopsy review of 12,000 patients by Lucke and Rea [8], 321 aneurysms were found and only one hypogastric aneurysm was found. Lucke also noted that the male to female ratio was 4 to 1 and aneurysms occur approximately 10 years earlier in Blacks than in Whites. Review of the recommended treatments include simple ligation of the hypogastric artery at its origin resection of the vessel with ligation of all distal branches [2,3]. Some surgeons have recommended dissection of the vessel from its attachments if the mass is causing obstruction of a structure such as the ureter. The inflammatory nature of the aneurysm may produce adhesions to the surrounding structures, making this dissection difficult. For this reason some authors recommend leaving the wall of the vessel attached to vital structures such as the external iliac vein or ureter to avoid injury to these structures during dissection. Removing the majority of the mass will decompress the obstruction.
In summary, hypogastric artery aneurysm should be considered in the differential diagnosis of a pelvic mass in older patients with severe atherosclerosis. REFERENCES 1.
2.
3. 4. 5. 6. 7. 8.
DiSaia, P. J., and Creasman, W. T. The adnexal mass and early ovarian cancer, in, DiSaia, P. J. and Creasman, W. T. eds. Clinical gynecologic oncology (P. J. DiSaia and W. T. Creasman, Eds.), Mosby, Washington, DC, 3rd ed., p. 293 (1989). Smith, H. W., Campbell, E. W., and Dagher, F. J. Bilateral ureteral obstruction secondary to hypogastric artery aneurysm: A case report, J. Ural. 117, 796-797 (1977). Brown, T. K., and Some, S. D. Aneurysm of the internal iliac artery (1934). complicating pregnancy, Am. J. Obstet. Gynecol. 27,766-767 MacLaren, A. Aneurism of the internal iliac, Ann. Surg. 58, 269270 (1913). Brin, B. J., and Busuttil, R. W. Isolated hypogastric artery aneurysms, Arch. Surg. 117, 1329-1333 (1982). Perry, M. O., and Leventhal, M. Ruptured hypogastric artery aneurysms, Am. J. Surg. 115, 828-829 (1968). Silver, D. E., Anderson, E. E., and Porter, J. M. Isolated hypogastric artery aneurysm, Arch. Surg. 95, 308 (1967). Lucke, B., and Rea, M. H. Studies on aneurysm. I. general statistical data on aneurysms, J. Am. Med. Assoc. 77, 935 (1921).
ONCOLOGY
47, 382-384 (1992)
CASE REPORT Hypogastric Artery Aneurysm Masquerading as an Ovarian Neoplasm JOAN L. WALKER, *University of Oklahoma Oklahoma 73190;
M.D.,*,’
ALBERTO
MANETTA,
M.D.,t
AND ROBERT S. MANNEL,
M.D.*
Health Sciences Center, Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, and tlJniversity of California, Irvine Medical Center, Division of Gynecologic Oncology, Department and Gynecqlogy, Orange, California 92668
Oklahoma
City,
of Obstetrics
Received January 16, 1992
Hypogastric artery aneurysmin womenis rare. The casepresenteddemonstrateshow this lesioncan easily mimic an ovarian neoplasm.The misseddiagnosiscan becatastrophicif the surgeon is unfamiliar with the retroperitonealanatomy and is confronted with arterial hemorrhage.Hypogastric artery aneurysmshould beincludedin the differential diagnosisof a pelvic massin elderly womenwith atheroscleroticdisease.The report reviews the literature on the presentation,diagnosis,and recommendedtreatments. 0 1992 Academic F’ms, Inc. INTRODUCTION
The usual differential diagnosis of an adnexal mass in a postmenopausal woman would ordinarily include a primary ovarian neoplasm, diverticular abscess, colon cancer, or a metastatic tumor [l]. This case presents an unusual and life-threatening adnexal mass which to our knowledge has not been previously reported in the gynecologic literature. CASE REPORT
An 82-year-old white female presented with complaints of abdominal swelling. Her gynecologic history included a total abdominal hysterectomy at the age of 38 for benign indications and a retropubic urethral suspension 1 year prior to presentation. Her past medical history was significant for hypertension, two myocardial infarctions, and peptic ulcer disease. She had undergone coronary artery bypass surgery 10 years prior to presentation. 1 To whom correspondence and reprint requests should be addressed at Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, P.O. Box 26901, 4SP-700, Oklahoma City, OK 73190. Fax: 405/271-8547. 382 OG90-825W92 $4.00 Copyright 0 1992 by Academic Press, Inc. AI1 rights of reproduction in any form reserved.
The review of systems was positive for urinary incontinence, but she denied any constipation, diarrhea, hematochezia, or melena. Physical exam demonstrated the previous surgical scars, no evidence of pleural effusion or ascites, and a fixed lo-cm left adnexal mass. Preoperative ultrasound (Fig. 1) and computed tomography (Fig. 2) demonstrateed a well circumscribed lo-cm cystic and solid left adnexal mass consistent with ovarian neoplasm or abscess. Mild left ureteral dilatation was noted and there was a small aneurysmal dilatation of the abdominal aorta between the renal arteries and the aortic bifurcation. A barium enema and upper gastrointestinal series demonstrated a hiatal hernia and small diverticuli in the colon. Exploratory laparotomy was performed and a lo-cm cystic mass was identified under the sigmoid colon filling the pararectal space. The mass was densely adherent to the left pelvic sidewall. The ovaries were normal and atrophic and did not appear to be the etiology of the mass. The retroperitoneal spaces were developed and the left infundibulopelvic ligament and ureter were identified. These structures were dissected free of the mass and the ovarian vessels were ligated and transected superior to the mass above the pelvic brim. The ureter and the external iliac artery and vein were noted to be densely adherent to the mass. In addition, the ureter was noted to be dilated proximal to the mass. Meticulous dissection of the retroperitoneal structures was performed and it was noted that the mass was originating from the common iliac artery where the hypogastric artery ordinarily is found. The mass was determined to be a hypogastric artery aneurysm. The ligation of the vessel at its origin was difficult due to the abundance of atherosclerotic plaque within the lumen causing
CASE
FIG. 1.
REPORT
Pelvic
the vessel to fracture when sutured. All distal branches of the hypogastric artery had to be individually ligated to effect removal of the mass. During the removal of the mass the external iliac vein was lacerated due to the dense adhesions between the aneurysm and the vein, and it was repaired without incident. The operative blood loss in this case was 1600 cc; however, the patient was stable throughout surgery. The pathologic diagnosis confirmed the mass to be a hypogastric artery aneurysm. The patient’s postoperative course was complicated by superficial wound disruption, but was otherwise uneventful. DISCUSSION Hypogastric artery aneurysm has not been included in the differential diagnosis of a pelvic or adnexal mass in the gynecologic literature [l]. The urologic literature describes this condition in association with ureteral obstruction in men, but the condition appears to be rare in women [2]. A review of reports in women is limited to pregnancy complications [3,4] and trauma to the vessel at the time of a radical hysterectomy [5]. Operative intervention in the community by the gynecologist could
383
ultrasound.
be catastrophic if the vascular etiology of the lesion is not appreciated. A report of two cases in elderly men and review of the literature by Perry and Leventhal in 1968 summarized the situation nicely [6]. These lesions are usually atherosclerotic in origin and associated with aneurysms in other systemic arteries. The patient is asymptomatic until pressure occurs on surrounding structures such as bladder, rectum, ureter, or iliac veins. The symptoms reported include pelvic pressure, back pain, leg pain, and numbness. Ureteral obstruction with its associated complications is not uncommon. Many patients (20%) present with rupture and may have life-threatening hypotension. An enlarging pelvic mass with hematochezia has been reported [7]. Approximately half of the masses are pulsatile to palpation. Intralumenal clots may prevent filling of the structure on angiogram and make the diagnosis difficult preoperatively. The presence of calcification in the wall of the aneurysm on X ray may be an important clue preoperatively. Aneurysm was not suspected preoperatively in this case. In retrospect, the patients age, history of coronary artery disease, the small aortic aneurysm, and the presence of calcium in the wall of the mass should
384
WALKER,
FIG.
MANETTA,
AND MANNEL
2. Computed tomography of the pelvis.
have made hypogastric artery aneurysm a possible preoperative diagnosis. The mass was not pulsatile which also failed to alert the clinicians. Silver et al. [7] noted only 3 cases of isolated hypogastric artery aneurysms in a report of 671 patients with systemic aneurysms. In an autopsy review of 12,000 patients by Lucke and Rea [8], 321 aneurysms were found and only one hypogastric aneurysm was found. Lucke also noted that the male to female ratio was 4 to 1 and aneurysms occur approximately 10 years earlier in Blacks than in Whites. Review of the recommended treatments include simple ligation of the hypogastric artery at its origin resection of the vessel with ligation of all distal branches [2,3]. Some surgeons have recommended dissection of the vessel from its attachments if the mass is causing obstruction of a structure such as the ureter. The inflammatory nature of the aneurysm may produce adhesions to the surrounding structures, making this dissection difficult. For this reason some authors recommend leaving the wall of the vessel attached to vital structures such as the external iliac vein or ureter to avoid injury to these structures during dissection. Removing the majority of the mass will decompress the obstruction.
In summary, hypogastric artery aneurysm should be considered in the differential diagnosis of a pelvic mass in older patients with severe atherosclerosis. REFERENCES 1.
2.
3. 4. 5. 6. 7. 8.
DiSaia, P. J., and Creasman, W. T. The adnexal mass and early ovarian cancer, in, DiSaia, P. J. and Creasman, W. T. eds. Clinical gynecologic oncology (P. J. DiSaia and W. T. Creasman, Eds.), Mosby, Washington, DC, 3rd ed., p. 293 (1989). Smith, H. W., Campbell, E. W., and Dagher, F. J. Bilateral ureteral obstruction secondary to hypogastric artery aneurysm: A case report, J. Ural. 117, 796-797 (1977). Brown, T. K., and Some, S. D. Aneurysm of the internal iliac artery (1934). complicating pregnancy, Am. J. Obstet. Gynecol. 27,766-767 MacLaren, A. Aneurism of the internal iliac, Ann. Surg. 58, 269270 (1913). Brin, B. J., and Busuttil, R. W. Isolated hypogastric artery aneurysms, Arch. Surg. 117, 1329-1333 (1982). Perry, M. O., and Leventhal, M. Ruptured hypogastric artery aneurysms, Am. J. Surg. 115, 828-829 (1968). Silver, D. E., Anderson, E. E., and Porter, J. M. Isolated hypogastric artery aneurysm, Arch. Surg. 95, 308 (1967). Lucke, B., and Rea, M. H. Studies on aneurysm. I. general statistical data on aneurysms, J. Am. Med. Assoc. 77, 935 (1921).
