British Journal of Obstetrics and Gynaecology September 1979. Vol. 86. pp 747-748

RETROPERITONEAL SARCOMAS OBSTRUCTING DELIVERY TWO CASE REPORTS BY

B. FORUHAN Department of' Obstetrics and Gynaecology All Saints' Hospital, Chatham, Kent

Summary Two patients with abnormal fetal lies underwent elective Caesarean section. Both abnormal lies were found 'to be due to retroperitoneal sarcomas overlying the bifurcation of the iliac vessels. One proved to be an inoperable and radioresistant fibrosarcoma. At seven and a half years after Caesarean section and following chemotherapy this patient is alive and well and has had two more children. The other tumour was a large myxoid liposarcoma which was completely removed at the time of Caesarean section. This patient is alive and well 18 months after operation. cytotoxic agents (cyclophosphamide, fluorouracil, vincristine, cytosine-arabinoside, methotrexate) plus largactil and folinic acid was given until May 1972. Two attempts to extirpate the tumour surgically during this time were unsuccessful, but regression occurred, and by August 1972 the tumour could no longer be felt, either abdominally or vaginally, and intravenous pyelography was normal. When seen at a routine follow-up examination in August 1974, the patient was pregnant again. The antenatal period passed uneventfully and she was delivered by elective Caesarean section on 28th January, 1975. A healthy male infant weighing 3.850 kg was born. A search for the retroperitoneal fibrosarcoma showed no sign of recurrence. She became pregnant for the third time, and after another uneventful antenatal period was delivered by elective Caesarean section and the tubes ligated on 17th July, 1978. Another healthy boy weighing 3.320 kg was born and again there was no sign of the retroperitoneal tumour. Three monthly follow-up continues to show complete regression of the tumour at seven and a half years after its discovery.

CASEREPORTS Patient I The first patient was seen during her first pregnancy at the age of 21 years in January 1970. Her expected date of delivery was 12th July, 1970. No abnormality was found until 36 weeks gestation when the fetus was found to be lying obliquely with the head in the left iliac fossa. Pelvic examination showed a right sided tumour which was thought to be of ovarian origin. Elective Caesarean section 'was done at term on 13th July, 1970 and a live male infant weighing 3.825 kg was delivered. The mass obstructing engagement of the head was found to be a right-sided retroperitoneal tumour 12 cm in diameter and centred on the bifurcation of the iliac vessels. Biopsy of the tumour showed it to be a fairly well differentiated fibrosarcoma. A post-operative intravenous pyelogram showed a right hydroureter with displacement and hydronephrosis. The patient was referred to the Royal Marsden Hospital, London, for further treatment under the care of Mr C. A. Simmons. As the tumour was thought to be radioresistant, chemotherapy with methotrexate, a combination of other 747

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Patient 2 This 28-year-old patient with a history of three normal hospital deliveries in 1971, 1973, and 1976 had no abnormal pelvic or abdominal masses detected during these pregnancies. She was seen during her fourth pregnancy on 28th April, 1977 in our hospital antenatal clinic and booked for hospital delivery. Her expected date of confinement was 2nd August, 1977. On 5th May, 1977, when 28 weeks pregnant by dates, the uterus was found to be large for dates and the fetus to be lying transversely. Multiple pregnancy was suspected but an abdominal X-ray on 30th June, 1977, showed a single fetus apparently in a transverse lie, pushed high out of the pelvis under the diaphragm. The patient was admitted to hospital for elective Caesarean section on 26th July, 1977. At operation a left sided retroperitoneal tumour about 30 cm in diameter was found to be pushing the uterus to the right. There was no free fluid in the peritonea1 cavity. A transverse lower uterine segment Caesarean section was performed and a live female infant weighing 4-280 kg was delivered as a breech after which tuba1 ligation was performed. The lobulated, semi-solid brain-like tumour was then easily dissected out and completely removed though it was located over the left iliac vessels. A corrugated drain was placed into the retroperitoneal space and the abdominal wall closed. The patient made a satisfactory recovery and was discharged home on the tenth postoperative day. She was readmitted two days later with a deep vein thrombosis of the right leg which was treated with heparin and warfarin. The tumour was 25 cm in diameter and weighed 2 678 kg. On histological examination it proved to be a myxoid liposarcoma. Three monthly postoperative follow-up has shown no sign of recurrence up to 18 months later.

DISCUSSION Foruhan and Jennings (1978) described two patients with presacral tumours diagnosed late in labour. In both of the patients I now present, the tumours were large enough and high enough to prevent the presenting part from entering the

pelvic brim. An abnormality was, therefore, recognised during pregnancy and both patients were delivered by planned Caesarean section. In his series of 97 cancer cases in pregnancy, Cade (1964) reported 12 sarcomas of mesodermal origin while Cantin and McNeer (1967), in their review of 375 women with soft tissue sarcomas, discovered 57 who between them had 83 pregnancies. In neither of these surveys were the sarcomas associated with pregnancy ever reported to have been situated retroperitoneally in the pelvis so as to obstruct vaginal delivery, and the patients I report may be unique in the literature. Fibrosarcomas are generally considered to be highly malignant (Clark and Martin, 1970), seldom radio-sensitive and usually resistant to chemotherapy (Das Gupta, 1973). The response of the tumour in my first patient to chemotherapy is therefore remarkable. The possibility that the tumour was in some way pregnancydependant is unlikely in view of its failure to recur during two subsequent pregnancies. As in my second patient, liposarcomas are commonly large, well differentiated and myxomatous. They are not as malignant as fibrosarcomas (Das Gupta and Ghosh, 1976) and are most satisfactorily treated by local excision (Brasfield and Das Gupta, 1970). ACKNOWLEDGEMENTS My thanks are due to Mr D. D. Mathews and Mr Clifford A. Simmons for their permission to publish these case reports. REFERENCES Brasfield, R. D., and Das Gupta, T. K. (1970): Cancer Journal for Clinicians, 20,3. Cade, S. (1964): Journal of Obstetrics and Gynaecology of the British Commonwealth, 71,341. Cantin, J., and McNeer, G . P. (1967): Surgery, Gynecology and Obstetrics, 125,28. Clark, R. L., and Martin, R. G . (1970): Si.uth National Cuncer Conference Proceedings. Lippincott, Philadelphia, p. 789. Das Gupta, T. K. (1973): Surgery, Gynecology and Obstetrics, 137, 1012. Das Gupta, T. K., and Ghosh, B. C. (1976): Surgery Annual, 7,115. Foruhan, B., and Jennings, P. J. (1978): British Journal of Obstetrics and Gynaecology, 85,231.

Retroperitoneal sarcomas obstructing delivery: two case reports.

British Journal of Obstetrics and Gynaecology September 1979. Vol. 86. pp 747-748 RETROPERITONEAL SARCOMAS OBSTRUCTING DELIVERY TWO CASE REPORTS BY...
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