SPONTANEOUS DRAINAGE OF A LARGE CYSTIC TUMOR b y M. A. Winston, MD; G. T. Krishnamurthy, MD; and Ronald D. Taylor, MD
ABSTRACT A case is described of a 58 year old male who presented with a large mass o n the left side of the abdomen which was found to be cystic by ultrasound. A presumptive diagnosis of pancreatic pseudocyst was made. Shortly thereafter, the mass drained spontaneously further suggesting this diagnosis. At surgery a month later, however, the mass was found to be a metastic leiomyosarcoma with cystic degeneration that had eroded into the gastric wall. This case serves t o illustrate that cystic abdominal masses, even ones that drain spontaneously into the gastrointestinal tract, may not be pancreatic pseudocysts.
Indexing Words; Leiom yosarcoma
Ultrasound
The use of B scanning t o detect and follow the progress of cystic abdominal masses has been well accepted. Pancreatic psuedocysts are probably the most commonly detected masses of this sort, and rapid spontaneous drainage of several pseudocysts has been documented by echography (1,2). We recently encountered a large cystic mass which drained spontaneously but proved to be a degenerated leiomyosarcoma arising in the gastric wall. CASE REPORT
A 58 year old male presented with fever, anemia, and abdominal swelling. A large mass was palpable on the left side of the abdomen. Iron deficiency anemia was found, related t o gastrointestinal bleeding. Endoscopy revealed a 1 cm gastric ulcer but biopsy of the area was unremarkable. Ultrasonography revealed a large cystic mass (Fig. 1,1/16). A presumptive diagnosis of pancreatic pseudocyst was made and medical treatment was recommended. Three weeks later, the patient’s From Nuclear Medicine and Research Services, Veterans Administration Wadsworth Hospital Center. Los Angeles. and University of California a t Los Angeles (UCLA) School o f Medicine. Received September 12. 1 9 7 5 : revision accepted December 11, 1975. For reprints contact: Dr. M. A. Winston, Nuclear Medicine Service (691/172).VA Wadsworth Hospital Center, Los Angeles. California 90073. VOLUME 4. NUMBER 2
Pancreatic pseudocyst
temperature rose and he passed large amounts of serosanguineous diarrheal fluid. The mass had become much smaller by palpation and this was confirmed by repeat ultrasonography (Fig. 1,4/10). Repeat endoscopy revealed the gastric ulcer t o be larger. From it issued the serosanguineous fluid. Upper gastrointestinal series revealed entry of barium into the cyst cavity (Fig. 2). Cytology and biopsies were again negative for malignancy. Fever and bleeding continued until surgery one month later. At this time multiple hemorrhagic nodules were noted involving the liver and mesentery. Biopsy of these nodules provided the diagnosis of metastic leiomyosarcoma. Bleeding continued postoperatively and the patient died several weeks later following a spontaneous pneumothorax. At postmortem, a large gastric ulcer was found in the posterior gastric wall communicating into a large cystic tumor. Multiple smaller cystic masses with hemorrhagic centers were noted in the liver. DISCUSSION
It is clear that while sonographic detection and followup of cystic masses is relatively easy, it is difficult and hazardous t o make an etiologic diagnosis. Although the pancreas is probably the most common source of rapidly developing abdominal cystic masses, cysts in other organs, 119
FIGURE 2. Upper gastrointestinal series shows barium filling large cyst at upper left. F = gastric fundus, C = cyst FIGURE 1. Transverse sections through cystic mass on dates recorded. Patient's left i s to the reader's left.
particularly the spleen, kidneys, and adrenal glands, must be considered. A cystic lymphoma and choledochal cysts that otherwise resembled echographically a series of pancreatic pseudocysts have been encountered at laparotomy (3,4). The ultrasonic findings for rapid and spontaneous disappearance of cystic masses have been described only for what were presumed to be pancreatic pseudocysts. This appeared t o occur in our patient, but subsequent events revealed that this was not the case. Cystic degeneration with hemorrhage is certainly a possibility in large tumors which outgrow their blood supply (5,6). When such tumors erode into, or, as in this case, arise from the wall of the gastrointestinal tract, spontaneous drainage may occur. With existing echographic techniques, it is unlikely that these types of masses may be distinguished definitively. The presence of a septa1 echo (Fig. 1) renders less likely the possibility of a pancreatic pseudocyst, which after all is not a true cyst but a collection of fluid walled
120
off by the mesentery, but does not exclude it. Under these circumstances, reports must be descriptive rather than d i a g n 0 s t i c . a
REFERENCES
1. Leopold GR, Berli RN, and Reinke R: Echographicradiographic documentation of spontaneous rupture of a pancreatic pseudocyst into the duodenum. Radiology 102: 699,1972. 2. Leopold GR: Pancreatic echography: A new dimension in the diagnosis of pseudocyst. Radiology 104: 365,1972. 3. Bradley EL and Clements JL: Implications of diagnostic ultrasound in the surgical management of pancreatic pseudocysts. Am J Surg 127: 163, 1974. 4. Stuber J , Templeton A, and Bishop K: Sonographic diagnosis of pancreatic lesions. Am J Roentgen01 16:406,1972. 5. Marshall S: Gastric leiomyosarcoma. Surg CIin N
North Am 39: 719,1959. 6. Stanley WM and Groshong LR: Leiomyosarcoma of the gastrointestinal tract. Am Surg (American Surgeon) 35: 809,1969.
J O U R N A L O F CLINICAL U L T R A S O U N D
ABSTRACT A case is described of a 58 year old male who presented with a large mass o n the left side of the abdomen which was found to be cystic by ultrasound. A presumptive diagnosis of pancreatic pseudocyst was made. Shortly thereafter, the mass drained spontaneously further suggesting this diagnosis. At surgery a month later, however, the mass was found to be a metastic leiomyosarcoma with cystic degeneration that had eroded into the gastric wall. This case serves t o illustrate that cystic abdominal masses, even ones that drain spontaneously into the gastrointestinal tract, may not be pancreatic pseudocysts.
Indexing Words; Leiom yosarcoma
Ultrasound
The use of B scanning t o detect and follow the progress of cystic abdominal masses has been well accepted. Pancreatic psuedocysts are probably the most commonly detected masses of this sort, and rapid spontaneous drainage of several pseudocysts has been documented by echography (1,2). We recently encountered a large cystic mass which drained spontaneously but proved to be a degenerated leiomyosarcoma arising in the gastric wall. CASE REPORT
A 58 year old male presented with fever, anemia, and abdominal swelling. A large mass was palpable on the left side of the abdomen. Iron deficiency anemia was found, related t o gastrointestinal bleeding. Endoscopy revealed a 1 cm gastric ulcer but biopsy of the area was unremarkable. Ultrasonography revealed a large cystic mass (Fig. 1,1/16). A presumptive diagnosis of pancreatic pseudocyst was made and medical treatment was recommended. Three weeks later, the patient’s From Nuclear Medicine and Research Services, Veterans Administration Wadsworth Hospital Center. Los Angeles. and University of California a t Los Angeles (UCLA) School o f Medicine. Received September 12. 1 9 7 5 : revision accepted December 11, 1975. For reprints contact: Dr. M. A. Winston, Nuclear Medicine Service (691/172).VA Wadsworth Hospital Center, Los Angeles. California 90073. VOLUME 4. NUMBER 2
Pancreatic pseudocyst
temperature rose and he passed large amounts of serosanguineous diarrheal fluid. The mass had become much smaller by palpation and this was confirmed by repeat ultrasonography (Fig. 1,4/10). Repeat endoscopy revealed the gastric ulcer t o be larger. From it issued the serosanguineous fluid. Upper gastrointestinal series revealed entry of barium into the cyst cavity (Fig. 2). Cytology and biopsies were again negative for malignancy. Fever and bleeding continued until surgery one month later. At this time multiple hemorrhagic nodules were noted involving the liver and mesentery. Biopsy of these nodules provided the diagnosis of metastic leiomyosarcoma. Bleeding continued postoperatively and the patient died several weeks later following a spontaneous pneumothorax. At postmortem, a large gastric ulcer was found in the posterior gastric wall communicating into a large cystic tumor. Multiple smaller cystic masses with hemorrhagic centers were noted in the liver. DISCUSSION
It is clear that while sonographic detection and followup of cystic masses is relatively easy, it is difficult and hazardous t o make an etiologic diagnosis. Although the pancreas is probably the most common source of rapidly developing abdominal cystic masses, cysts in other organs, 119
FIGURE 2. Upper gastrointestinal series shows barium filling large cyst at upper left. F = gastric fundus, C = cyst FIGURE 1. Transverse sections through cystic mass on dates recorded. Patient's left i s to the reader's left.
particularly the spleen, kidneys, and adrenal glands, must be considered. A cystic lymphoma and choledochal cysts that otherwise resembled echographically a series of pancreatic pseudocysts have been encountered at laparotomy (3,4). The ultrasonic findings for rapid and spontaneous disappearance of cystic masses have been described only for what were presumed to be pancreatic pseudocysts. This appeared t o occur in our patient, but subsequent events revealed that this was not the case. Cystic degeneration with hemorrhage is certainly a possibility in large tumors which outgrow their blood supply (5,6). When such tumors erode into, or, as in this case, arise from the wall of the gastrointestinal tract, spontaneous drainage may occur. With existing echographic techniques, it is unlikely that these types of masses may be distinguished definitively. The presence of a septa1 echo (Fig. 1) renders less likely the possibility of a pancreatic pseudocyst, which after all is not a true cyst but a collection of fluid walled
120
off by the mesentery, but does not exclude it. Under these circumstances, reports must be descriptive rather than d i a g n 0 s t i c . a
REFERENCES
1. Leopold GR, Berli RN, and Reinke R: Echographicradiographic documentation of spontaneous rupture of a pancreatic pseudocyst into the duodenum. Radiology 102: 699,1972. 2. Leopold GR: Pancreatic echography: A new dimension in the diagnosis of pseudocyst. Radiology 104: 365,1972. 3. Bradley EL and Clements JL: Implications of diagnostic ultrasound in the surgical management of pancreatic pseudocysts. Am J Surg 127: 163, 1974. 4. Stuber J , Templeton A, and Bishop K: Sonographic diagnosis of pancreatic lesions. Am J Roentgen01 16:406,1972. 5. Marshall S: Gastric leiomyosarcoma. Surg CIin N
North Am 39: 719,1959. 6. Stanley WM and Groshong LR: Leiomyosarcoma of the gastrointestinal tract. Am Surg (American Surgeon) 35: 809,1969.
J O U R N A L O F CLINICAL U L T R A S O U N D
